Spinal Robotics in Adult Spinal Deformity Surgery: Key Concepts and Technical Considerations

Abstract

Robotic assistance in spine surgery has long been pursued to innovate minimally invasive procedures and enhance patient safety, outcomes, operation time, and affordability. Over the past few decades, advancements in navigation and robotics have fundamentally transformed the role of technology in spine surgery, with their applications continuously expanding. In particular, this technology has made significant strides in the setting of adult spinal deformity (ASD), driving innovations for this technically challenging pathology. In this review, the authors explore key aspects of robotic assistance in ASD surgery, including software planning and construct design, pedicle screw placement, sacropelvic fixation, operative outcomes, and the learning curve associated with adopting this technology. Research articles for this qualitative review were indexed using PubMed and Google Scholar. The review also addresses the opportunities and challenges ahead in the field. Although this technology is in its relative infancy, the growing body of research is beginning to fully characterize its utility in surgery and its potential to redefine the standard of care.

 

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Keywords

adult spinal deformity - minimally invasive - pedicle screw - robotic assistance - robotic guidance - S2 alar-iliac screw

Introduction

Robotic assistance in spine surgery has long been sought to enhance minimally invasive procedures, improving patient safety, outcomes, operation time, and cost. Spinal robotics have notably advanced in adult spinal deformity (ASD), and they continue to innovate the standard of care for a technically challenging pathology. Recent studies estimate over 27 million individuals suffer from spinal deformity, creating a considerable disease burden, particularly among the aging population.[1] As life expectancy rises, the proportion of individuals older than 65 years in the United Staes is projected to increase from 12% in 2005 to 19% by 2050.[2] ASD treatment costs in the United States exceed $86 billion annually, and with increasing surgeries and complexity, these costs are expected to rise.[2] Thus, the application of robotics in this pathology to optimize care can profoundly impact overall medical outcomes and cost efficiency in ASD surgery.

As research on spinal robotics in ASD surgery grows, compiling and analyzing data to guide clinical decisions becomes essential. This review discusses key concepts in robotic-assisted ASD surgery, including software planning, construct designs, pedicle screw placement, sacropelvic fixation, and operative outcomes, while exploring future opportunities and challenges.

 

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Historical Context

Over the past century, surgical management of spinal deformity has achieved stepwise improvements in care. In 1995, the advent of computer-assisted navigation in spine surgery allowed for real-time intraoperative localization of surgical instruments in medical images.[3] Almost a decade later, the first spine robot, SpineAssist (Mazor Robotics Ltd), was approved in 2004 by the U.S. Food and Drug Administration.[4] Two years later, robotic guidance coopted navigation technology to provide mechanical support to orient instrumentation into preplanned positions.[5] Since then, several robotic platforms have been developed, including the Mazor X Stealth (Medtronic), ExcelsiusGPS (Globus Medical), TiRobot Orthopaedic Robotic System (TINAVI Medical Technologies), and the ROSA robot (Medtech).

Various technical challenges were encountered in the initial developmental process including improper synchronization of intraoperative fluoroscopic images with preoperative radiographs, excessive pressure on the guiding arm leading to altered accuracy, lengthy calculation times for screw instrumentation, and software crashes.[4] However, many of these problems have been addressed over the years, resulting in a wide array of highly sophisticated and user-friendly technology that has become common in the operating room.

 

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Materials and Methods

Research articles for this qualitative review were indexed using PubMed and Google Scholar. Keywords used included “adult spinal deformity,” “robotic guidance,” and “spinal robotics.” The reference lists of relevant articles were also manually searched to identify additional studies. Institutional Review Board and ethics committee approvals were not required as there was no direct involvement with human participants or new data collection. Data extraction was performed by recording study characteristics (e.g., author, year, setting, population) and key findings.

 

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Software Planning and Construct Design

Preoperative planning is critical when correcting a complex spinal deformity, and current robotic platforms integrate sophisticated planning software to organize construct designs. UNiD Hub by UNiD Adaptive Spine Intelligence (Medicrea) and Surgimap (Nemaris Inc) are such examples and have been developed to aid deformity correction. Both software options utilize radiographic images for display and manipulation to allow for geometrical calculations of instrument alignment. This allows not only for accurate placement of individual instrumented components but also for fine detailing of the entire spine construct designs.

During preoperative planning, software can predict pedicle screw trajectory for optimal placement. Using machine learning algorithms, this technology can predict the interrelations of adjacent screws and global complex construct designs when correcting ASD. Using normalized values for the sagittal vertical axis (SVA), pelvic tilt (PT), and pelvic incidence–lumbar lordosis (PI-LL) mismatch, these software programs help plan and execute technically challenging procedures.[6] PI-LL may be measured intraoperatively; however, SVA and PT can only be measured when the patient is standing, which presents a challenge for intraoperative correction and places heavier weight on proper algorithms in the software. Langella et al evaluated the predictive power of Surgimap in 40 nonconsecutive patients by calculating their postoperative alignment and found the use of Surgimap enabled the surgeons to achieve proper postoperative sagittal alignment in 42% of patients.[7]

While the software developments have been monumental in the field of ASD surgery, UNiD has developed patient-specific rods (PSRs) to be used in combination with the planning software to better enhance the clinical and radiographic outcomes. Barton et al retrospectively examined the impact of using a planning software and PSR in 18 cases of ASD correction and found that the combination gave them complete specificity and positive predictive value for quantifying postoperative outcomes.[8] Another study provided a longitudinal analysis of 60 patients after 1 year and found that the combination of planning software and PSR was 2.6 times superior to sufficiently correct the PI-LL mismatch when compared to other studies.[9] Kleck et al conducted a similar study and found a correction withstanding 2 years postoperatively.[10] The study cited preoperative planning as a considerable limitation for the efficacy of the PSR and suggested that patient-specific optimal spinopelvic parameters for correction may further enhance the capabilities of the PSR.

Construct design has evolved to use multiple-rod constructs (MRCs) to enhance stability and rigidity in deformity correction. MRCs promote bone fusion and rigidity with the use of accessory rods to support areas of increased stress.[11] With better surgical outcomes due to MRC implementation, patient satisfaction and pain relief follow. Bourghli et al reported that MRCs for pedicle subtraction osteotomies were associated with higher scores in a health-related quality-of-life survey 6 months and 2 years after surgery.[12] Concordantly, while minimally invasive surgery (MIS) helps improve patient outcomes, there is little in the literature describing its use with MRCs. MRCs have previously been utilized in open deformity corrections, but Pham et al recently reported a six-patient case series utilizing preoperative software planning to implement MRCs in a minimally invasive setting.[13] The combination of MIS, preoperative planning software, robotic aid, and MRC enabled a mean complete rod passage time of 8.5 minutes and low blood loss.

A recent study by Pham et al demonstrated this key concept of the utility of preoperative robotics planning for minimally invasive ASD surgery.[14] [15] In their cohort of 12 patients with either adult degenerative scoliosis or sagittal imbalance, mean values consisted of 9.9 levels instrumented, 3.3 iliac fixation points used, 3.3 rods passed, and 18.7 screws placed per patient. These demonstrated complex constructs are usually reserved for open surgery but were facilitated by robotics planning software and design and implemented in an MIS fashion. Future studies may include extended follow-up and patient quality-of-life surveys to report significance of surgery strategy combination.

 

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Pedicle Screw Placement

A standard procedure of vertebral interbody fusion and scoliosis correction is the use of pedicle screws to stabilize the spine during the fusion process or rod placement. Percutaneous pedicle screws carry the advantages of smaller incisions and decreased operative time, postoperative pain, hospital length of stay (LOS), and blood loss compared to open screw placement.[16] [17] [18] [19]

Robotic assistance has improved spinal procedures by increasing the accuracy of pedicle screw placement. Accuracy is commonly measured after operation with a CT scan using the Gertzbein and Robbins classification ([Table 1]).[20] Pedicle screw placement, regardless of technique used, has historically had an impressive accuracy rate of approximately 90%, and the use of robotic assistance results in similarly accurate to greater accuracy with additional benefits.[21] [22] [23] [24] [25] [26] [27] Zhang et al compared the freehand and robotic-assisted techniques and found that the robotic pedicle screw placement was significantly more accurate (94% grade A placement) than freehand (87% grade A placement).[27] Huntsman et al found in their single-institution study a pedicle screw placement accuracy rate of 99% for lateral lumbar interbody fusions (LLIFs), posterior lumbar interbody fusions (PLIFs), and anterior lumbar interbody fusions (ALIFs) in the first 100 cases of adopting the technology.[28] Some studies, like that of Jiang et al, have not demonstrated this superiority.[29] In their research involving 56 consecutive patients undergoing one- or two-level lumbar fusion for degenerative disease, they observed comparable accuracy rates between patients who received robotic-assisted instrumentation and those who underwent freehand techniques. However, none of the patients were treated for ASD, and all freehand screws were placed by fellowship-trained surgeons, a group that might benefit the least from robotic assistance.[29] However, a recent systematic review by Khalifeh et al described robotic pedicle screw placement in ASD surgery ranging from 95.5 to 98.7%, supporting the application of robotics in ASD surgery as safe and effective.[30]

Table 1 Gertzbein and Robbins scale classification

Grade	Classification
A[*]	Screw in fully intrapedicular position without breach of the pedicle cortex
B[*]	Screw exceeding the pedicle cortex by <2 mm
C	Screw exceeding the pedicle cortex by 2–4 mm
D	Screw exceeding the pedicle cortex by 4–6 mm
E	Screw exceeding the pedicle cortex by >6 mm or is outside of the pedicle

^* Grades A and B are considered clinically acceptable.

Prevention of facet joint violations (FJVs) is clinically pertinent when placing pedicle screws in surgical spinal deformity correction because they are associated with facet arthrosis, adjacent segment disease, and increased likelihood for future additional procedures.[31] [32] Similar to the pedicle screw placement scale mentioned earlier, the Babu method of grading FJV uses postoperative CT scans to rank FJV severity from 0 to 3 ([Table 2]).[33] One retrospective study found robotic-assisted percutaneous pedicle screw placement had similar screw trajectory to fluoroscopy-guided procedures, but the robot cohort demonstrated significantly fewer FJVs.[19] Zhang et al reported similar findings, with robotic pedicle screw placement having significantly fewer superior level FJVs compared to freehand techniques.[27] These consistent findings of reduced FJVs support the advantages of robotic guidance for pedicle screw placement and the application to ASD surgery.

Table 2 Facet joint violation grading scale

Grade	Classification
0	Screw not in facet
1	Screw in lateral facet but not in facet articulation
2	Penetration of facet articulation by screw
3	Screw travels within facet articulation

 

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Sacropelvic Fixation

Fixation of the lumbosacral junction has historically presented challenges due to the intense forces the junction faces. The traditional route of fixation with S1 screws needs additional pelvic screws for support to decrease likelihood of fixation compromise and S1 screw strain.[34] The S2 alar-iliac (S2AI) screw technique has become increasingly popular over the years due to its advantageous stability and reduced complication rate compared to the classical S1 screw technique.[35] Freehand placement of S2AI screws has been successful due to diligent training and placement confirmation with imaging. Shillingford et al reviewed the freehand placement of 45 S2AI screws and found an overall accuracy rate of 95%.[36]

Robotic guidance has similarly found potential in aiding the placement of S2AI screws. Laratta et al found in their case series that robotic guidance achieved an accuracy rate of 95.7% when performing 46 S2AI screw placements with zero intraoperative neurologic or vascular complications.[37] Lee et al examined the generalizability of robotic guidance for S2AI screw placement in a retrospective multi-institutional study where they found 93.8% placement accuracy across 65 screws and 31 patients.[38] Limited studies have described the accuracy rates of robotically placed S2AI screws in ASD surgery. Among them, Khalifeh et al reported 100% accuracy rates across three studies and 51 robotically placed S2AI screws.[30] The accuracy rates using both the freehand and robotic guidance techniques in ASD surgery appear similar; nevertheless, further studies including retrospective reviews and randomized trial directly comparing the techniques are needed to determine specific advantages.

 

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Single-Stage Deformity Surgery

Robotic platforms in spine surgery have expanded minimally invasive techniques for treating spine pathology. In mild deformities, they efficiently perform single-position long segment posterior fixation with positive clinical outcomes. Although literature on this technique is limited, its potential to optimize metrics such as operative time, hospital stay, and total costs is significant.

Recent studies describing the use of robotics in single-position posterior fixation have illustrated its application in oblique lumbar interbody fusion (OLIF). Originally introduced in 1997, the OLIF procedure has become a popular technique employed by surgeons to treat degenerative spine conditions and takes advantage of the oblique anatomical corridor between the psoas muscle and the aorta/inferior vena cava to access the spine.[39] This technique is often accompanied by posterior spinal fixation using pedicle screws to limit the incidence of interbody graft subsidence, which traditionally requires repositioning the patient. However, several studies have described the application of robotic single-position OLIF with posterior fixation in the lateral decubitus position. In an operative video by Pham and Hirshman, the authors portray the procedure in detail, highlighting the use of robotics for a single-position L2–S1 OLIF with L2–ilium posterior spinal fixation in a 59-year-old man with sagittal malalignment and spinopelvic imbalance.[40] This technique was also described in a case series by Diaz-Aguilar et al in which the authors illustrate how the robotic platform and patient positioning enable a simultaneous two-surgeon workflow.[41] This consists of an anterior surgeon responsible for incision and exposure to the disk spaces and placement of interbody cages as well as a posterior surgeon responsible for incision and placement of all pedicle screws with robotic guidance and rod placement. Thirteen patients (6 males; mean age: 64.1 years) with degenerative spine disease underwent simultaneous robotic single-position surgery with OLIF. A total of 60 pedicle screws were placed bilaterally in the lateral position with an accuracy rate of 95% (3 lateral breaches with no medial or inferior breaches). The average operative duration was 111.2 ± 25.2 minutes. There was one complication (postoperative seroma) and one reoperation at 3 months postoperatively due to a fall. The authors reported no instances of intraoperative neurologic injury, implant failure, or wound infections.

Single-position OLIF, also termed lateral ALIF, at L5–S1 was also shown to dramatically improve regional alignment and the lumbar distribution index (LDI) in a series of 17 patient as described by Hernandez et al.[42] In this report, 17 patients with abnormal LDI were treated with a single-level lateral ALIF using robotic assistance and achieved correction into a normal distribution. This highlighted the correctional power of performing a single-level fusion using lateral ALIF with robotic assistance.

Robotic-assisted single-position pedicle screw placement has also been described in prone lateral fusion. In a recent technical paper, Yeo et al describe their technique and the nuances of performing single-position robotic-assisted prone lateral lumbar fusion on a 64-year-old woman with lumbar spondylosis with mild degenerative scoliosis.[43] A 2023 cadaveric study and retrospective clinical series was also performed for patients who had undergone robot-assisted placement of S2AI screws in the lateral decubitus position.[44] A total of 126 screws were placed with robotic assistance in 12 cadavers, of which 24 were S2AI screws. There were four breaches from pedicle screws and none with S2AI screws for an overall accuracy rate of 96.8%. In the clinical series, four patients (all male, mean age of 65.8 years) underwent single-position lateral surgery with S2AI distal fixation. A total of 42 screws were placed, of which 8 were S2AI screws. There were two breaches from pedicle screws and none from S2AI screws for an overall accuracy rate of 95.2%. No repositioning or salvage techniques were required for the S2AI screws.

Robotic-assisted and single-position spine surgeries have gained attention due to their numerous benefits in spinal fusion. Combining these techniques eliminates the need for repositioning, potentially reducing anesthesia time, operating room duration, and hospital costs while maintaining high accuracy. These advantages are especially relevant in ASD surgery, where complex anatomy often hampers efficiency. However, studies on robotic-assisted single-position fixation in ASD are limited.

 

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Operative Outcomes

Hospital LOS is an important operative metric in surgery as prolonged time has been associated with complications including deep venous thrombosis and hospital-acquired infections.[45] Hyun et al compared peri- and postoperative results in robotic-assisted MIS versus fluoroscopy-guided open surgery and found that even when under similar operative time and total transfusion events, the use of robotic-assisted MIS techniques significantly decreased the mean hospital LOS from 9.4 to 6.8 days.[46] Chen et al found comparable results when juxtaposing robotic-assisted MIS transforaminal lumbar interbody fusion (TLIF) against fluoroscopy-guided open TLIFs (10.5 vs. 6.9 days).[47]

Risk of postoperative infection is another significant consideration for patient outcomes. A few studies have examined and compared infection rates between robotic-assisted and nonrobotic procedures. Kantelhardt et al observed an infection rate of 2.7% with the use of robotic-guided procedures compared to 10.7% in fluoroscopic techniques.[48] Menger et al similarly found that the incorporation of robotics in spinal procedures decreased postoperative infections.[49]

The literature also suggests that incorporation of robotic assistance in spinal procedures is associated with less estimated blood loss (EBL) in patients. Chen et al reported a significant decrease in intraoperative blood loss using robotic-assisted MIS TLIF compared to traditional open approaches (92 vs. 261 mL).[47] Li et al found a similar trend but an insignificant difference in EBL for the use of robots in cortical bone trajectory screw placement for the correction of degenerative lumbar spine disease.[50] Interestingly, Schatlo et al found that regardless of open or percutaneous approach for robotic involvement, both techniques were associated with significantly less EBL than fluoroscopy-guided pedicle screw placement in the lumbar spine.[51]

 

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Radiation Exposure

Several studies have suggested that robotic assistance may decrease the amount of radiation patients are exposed to compared to fluoroscopy-assisted procedures. Hyun et al found a decrease in fluoroscopic time per screw of 13.3 to 3.5 seconds using robotic assistance compared to fluoroscopy-guided open surgery.[46] Kantelhardt et al found a reduction in X-ray exposure per screw from 77 seconds in fluoroscopic-guided procedures to 34 seconds in robotic-guided procedures.[48] However, there appears to be some discrepancy as other studies have found insignificant differences in fluoroscopic time for patients with robotic assistance when propensity score matched for body mass index.[52]

Studies suggest that there are clearer benefits of reduced comprehensive radiation exposure to spine surgeons and their teams when using robotic platforms. The classic approach to pedicle screw instrumentation utilizes fluoroscopic techniques to visualize the trajectory and placement of the screw. However, this is largely done with retrospective imaging to verify placement before proceeding.[21] Fluoroscopic-guided procedures may or may not significantly increase the amount of radiation exposure a patient receives, but it does significantly impact the cumulative exposure to the surgical team.[5] [19] [21] [52] [53] Smith et al found that robotic assistance enabled a significant decrease to radiation exposure during pedicle screw placement to the torsos of spine surgeons compared to fluoroscopy assistance (0.33 rem vs. 4.33 mrem).[54] Another study found similar results in a randomized control trial with surgeons in fluoroscopy-guided procedures exposed to an order of magnitude more radiation that surgeons performing robotic-assisted ones.[55]

 

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Conversion to Manual Instrumentation

Several studies report significant rates of conversion from robotic assistance to manual instrumentation due to various reasons. This obstruction in workflow can be frustrating for the operating team as it can impair efficiency and prolong operative time. In a systematic review by McKenzie et al, the authors outlined 19 studies that reported this problem, citing technical difficulties as the top reason for conversion.[56] Devito et al provided more detail for conversion rates, reporting a total conversion rate of 16.4% with 9.2% for registration issues, 4.2% for unspecified reasons at the surgeon's discretion, 1.8% for device failure, 1.1% for physical limitations of robot, and 0.1% for mechanical movement.[57] Body habitus, image referencing problems, and high pedicle angulation have also been reported as reasons for conversion.[56]

 

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Learning Curve

One of the major challenges for adopting use of robotic-guided techniques is that surgeons are limited to work in more restricted visual fields. These determinants are heightened in MIS procedures, and thus the learning curve in using robotics is a reasonable concern. One study evaluating the proficiency of a single surgeon who had never previously used robotic guidance for pedicle screw placement found greater than 90% accuracy rate after completing the first 30 cases, to which their reported accuracy consistently remained greater than 93% through the following 120 patients.[58] Furthermore, the percentage of screws converted to manual placement decreased from 17% in the first 30 patients to 7% by their 150th case. Similarly, a systematic review by Pennington et al found that most studies on spine robot learning curves report a threshold ranging from approximately 20 to 30 cases before the learning curve is surpassed.[59] However, it is necessary to consider the potential complications associated with the learning process and evaluate the risks encountered during the time needed to properly adapt and become proficient.

Schatlo et al reviewed 1,265 robotic-assisted pedicle screw placements across multiple surgeons and found that proper proficiency could be achieved in 25 cases.[60] However, this study also noted the trends of increasing misplacement rates during robotic adaptation. They found that misplacement rates rose to 7.1% during the first 10 to 20 cases. The authors proposed that this was likely due to the transition from decreased supervision to increasing, perhaps premature, confidence in the surgeon. Thus, they recommend competent supervision through the first 25 cases while a surgeon adapts using this technology.

Although experience is the key to gaining precision and competence in a successful spine surgery, the adoption of robotics may present a considerable aid for new spine surgeons gaining experience. Urakov et al examined the learning curves and proficiencies between senior residents and fellows compared to their junior residents.[61] Although the sample size was limited to a single institution and 306 pedicle screws, the authors found that no significant difference regarding the speed of pedicle instrumentation was detected between the operators' years of experience or dedication to spine surgery. However, there was a trend toward improved efficiency with more cases performed.[61] One potential adverse effect regarding the introduction of robotics into the operating room is the overreliance on this technology by trainees, limiting their ability to adapt in the cases where problems arise with the robotic system. However, the literature describing this phenomenon is scant as the technology is still in its relative infancy.

 

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Financial Implications

One of the major drawbacks to utilizing robotics in ASD correction is the initial cost of equipment. The Renaissance is one of the most cited surgical robotics in the literature and until recently cost near $1 million. However, with increase in demand and accessibility of private innovation in a competitive market, prices are expected to drop in accordance. The launch of the Mazor X was met with the price drop of the Renaissance to $550,000.[62] [63]

Despite the upfront cost of these robotics, their precision and improved patient outcomes have major financial benefits in the long term. Menger et al described many of these financial incentives in a study retrospectively analyzing the medico-economic factors in 557 patients who underwent robotic spine surgery.[49] Overall, they found that robotic-guided procedures led to lower infection rates, revision surgeries, and operation times. Reduction in operation time of 3.4 minutes per MIS level resulted in an annual saving of approximately $5,700. Furthermore, by utilizing robotics, many patients were converted from open to minimally invasive strategies, which saved over $250,000. The savings at the academic center totaled $608,546 in 1 year, over half of which was attributed to the reduced number of revisions from increased accuracy.[49] Similarly, Kantelhardt et al found using the SpineAssist to be associated with a 46% reduction in revision surgeries and decreased hospital LOS for patients.[48] The reduction in peri- and postoperative adverse events will likely increase as technology and training expertise continue to improve.

One major limitation to this technology is its implementation in developing countries with constrained health care budgets. Owing to the steep initial costs of robotic platforms, lower-resourced settings often prioritize more cost-effective solutions, resulting in limited availability of robotic systems and experienced neurosurgeons in robotic spine surgery. Other factors limiting the implementation of this technology include the lack of trained staff with expertise to operate the robotic platforms and inadequate hospital infrastructure. As such, the high upfront expenses may not justify the benefits in settings where resources are scarce. However, Menger et al highlighted the long-term financial incentives of adopting this equipment.[49] As technology advances and manufacturing costs decrease, these systems may become more feasible for developing health care systems, particularly with strategic investments in training and infrastructure

 

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Conclusion

Robotic guidance in spine surgery has made significant strides in the last two decades and has demonstrated impressive capabilities in the operating room by improving outcomes and preserving patient safety. In particular, the utility of robotics in ASD correction has gained traction in recent years as the technology offers innovative solutions for navigating challenging pathology requiring intricate constructs. Despite the relative infancy of spinal robotics, the body of research involving this topic is expanding to fully characterize its utility in surgery and potential in redefining the standard of care.

 

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Conflict of Interest

M.H.P. receives consulting fees from Medtronic, Globus, Thomas Surgical, and NovApproach outside the submitted work.

Authors' Contributions

K.K. contributed to conceptualization, writing of the original draft, review, and editing, and visualization. C.P.M. contributed to conceptualization and writing of the original draft. N.S.H. contributed to writing—review and editing. M.H.P. contributed to writing—review and editing, supervision, and project administration.

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Publication History

Article published online:
31 March 2025