Robotic-assisted vs. fluoroscopy-assisted MIS-TLIF: improved screw accuracy and reduced early opioid use with comparable long-term outcomes

Introduction Robotic-assisted (RA) techniques are increasingly used in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). While technical advantages of RA have been demonstrated, it remains unclear whether they translate into improved patient-reported outcomes (PROs) or reduced opioid utilization compared to conventional fluoroscopy-assisted (FA) techniques. Given the growing emphasis on opioid stewardship in spine surgery, understanding differences in perioperative and long-term opioid use is critical. Methods A retrospective cohort study was conducted using a database of patients who underwent single-level MIS-TLIF for degenerative lumbar pathology by a single surgeon between 2019 and 2024. Patients were grouped based on pedicle screw placement technique (RA vs. FA). Primary outcomes included inpatient opioid consumption measured in morphine milligram equivalents (MME), long-term opioid use at 3, 6, and 12 months, and PROs including Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) scores. Secondary outcomes included operative time, length of stay (LOS), complications, and pedicle screw accuracy assessed by the Gertzbein and Robbins classification. Results A total of 87 patients met the inclusion criteria (FA: n = 39; RA: n = 48), with no significant differences in baseline characteristics. Operative time, anesthesia time, LOS, and complication rates were similar between groups. The RA group demonstrated significantly improved screw accuracy, with a higher proportion of grade A screws (91% vs. 57%, p < 0.001). Inpatient MME was significantly lower in the RA group on postoperative days 0–1 ( p = 0.002) and across total LOS ( p = 0.0015). After adjusting for age, BMI, and opioid naïve status, the RA approach remained independently associated with lower opioid use on postoperative days 0–1 ( β = −37.1; 95% CI, −63.6 to −10.6; p = 0.007) and total LOS ( β = −17.1; 95% CI, −29.6 to −4.7; p = 0.008). Long-term opioid use at 3, 6, and 12 months was similar between groups ( p > 0.05). Both groups demonstrated significant improvement in ODI and VAS scores at 6 and 12 months ( p < 0.05), with no between-group differences in PRO improvement or minimal clinically important difference or patient acceptable symptom state achievement. Conclusion RA MIS-TLIF had improved pedicle screw accuracy and reduced early postoperative opioid consumption compared to FA techniques; however, these advantages did not translate into reduced long-term opioid use or improved patient-reported outcomes.