Does the application of robotics improve outcomes of pedicle screw insertion in spine surgery compared to conventional fluoroscopy guidance? A systematic review and meta-analysis of RCTs

Purpose: Pedicle screw insertion is a commonly performed procedure in spine surgery that has conventionally been carried out under fluoroscopy guidance. In order to improve the accuracy of screw placement, robotic guidance has recently gained popularity. However, it is unclear whether the use of robotics alters the accuracy of screw placement or clinical outcomes and this study aims to clear this controversy. Methods: A systematic literature search was carried out in the electronic databases of PubMed, Embase, Scopus and Ovid. Relevant RCTs that directly compared pedicle screw placement under fluoroscopy guidance with those placed under robotic guidance were included. A meta-analysis was conducted on the outcomes including accuracy of screw placement, mean surgical duration, intraoperative blood loss, radiation exposure, rate of complications and rate of screw revision. Results: The use of robotic techniques led to a significant decrease in the rate of severely misplaced screws (Gertzbein-Robbins grade C, D, E) (OR 0.59 [0.38, 0.92; P –0.02]). Robotically placed pedicle screws were also associated relatively increased mean surgical duration, lower mean blood loss, lesser radiation exposure, lesser incidence of complications and lower rate of screw revision, although not statistically significant. Conclusion: The use of robotic guidance leads to a significant decrease in the incidence of severely misplaced pedicle screws that are mainly responsible for causing injury to adjacent structures leading to complications.