
==== Front
Brain Spine
Brain Spine
Brain & Spine
2772-5294
Elsevier

S2772-5294(24)00160-7
10.1016/j.bas.2024.102904
102904
Spine
Robotic-assisted surgery for adult spinal deformity. A systematic review
Lu Zimo mrluzimo@gmail.com
abc⁎
Tischer Thomas cd
Lutter Christoph c
Schnake Klaus John Klaus.Schnake@waldkrankenhaus.de
ae⁎⁎
a Center for Spinal and Scoliosis, Surgery Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
b The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine, Zunyi Medical University, China
c Department of Orthopedic Surgery, University Medicine Rostock, Rostock, Germany
d Department for Orthopaedic and Trauma, Surgery Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
e Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
⁎ Corresponding author. Center for Spinal and Scoliosis, Surgery Malteser Waldkrankenhaus St. Marien, Erlangen, Germany. mrluzimo@gmail.com
⁎⁎ Corresponding author. Center for Spinal and Scoliosis, Surgery Malteser Waldkrankenhaus St. Marien, Erlangen, Germany. Klaus.Schnake@waldkrankenhaus.de
31 7 2024
2024
31 7 2024
4 1029046 5 2024
15 7 2024
31 7 2024
© 2024 Published by Elsevier B.V. on behalf of EUROSPINE, the Spine Society of Europe, EANS, the European Association of Neurosurgical Societies.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Purpose

The goal of this systematic review is to offer a detailed summary of the present status of robotic-assisted surgery for adult spinal deformity.

Methods

This review is based on articles systematically searched in PubMed, Medline, and Web of Science Core Collection databases on robotic-assisted surgery for adult spinal deformity. Differences in the precision of pedicle screw placement, duration of surgery, and incidence of complications between robotic-assisted surgery and the conventional open surgery were considered.

Results

A total of 172 articles were retrieved from the literature search. A total of 168 articles were excluded. Therefore, this systematic review included the remaining four original articles, including accuracy of pedicle screw placement, operative time, radiation exposure, intraoperative and postoperative complications, respectively. The overall level of evidence in the studies was moderate to low.

Conclusion

Robotic-assisted surgery for adult spinal deformity demonstrates the potential to enhance the precision of screw placement, possibly reduce intraoperative and postoperative complications, and decrease radiation exposure. However, the impact on operation duration requires further investigation.

Highlights

• By synthesizing the available evidence from medical databases, journals, and studies, this review seeks to provide a comprehensive overview of the cur-rent state of robotic-assisted interventions for adult spinal deformity. The findings of this review have important implications for both clinicians and patients, as they can inform decision-making regarding the choice of surgical approach for adult spinal deformity.

Keywords

Adult spinal deformity
Robotic-assisted surgery
Accuracy of pedicle screw placement
Operative time
Radiation exposure
Complications
Handling Editor: Prof F Kandziora
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pmc1 Introduction

Adult spinal deformity(ASD)is characterized by abnormal curvature of the spine in individuals who are 18 years of age or older (Hiyama et al., 2018). It encompasses a wide range of conditions, including scoliosis, kyphosis, and lordosis, which can significantly impact a person's quality of life. Adult spinal deformity often requires extensive open surgeries in traditional treatment approaches, leading to increased risk of complications and longer recovery periods (Mundis et al., 2010). Robotic-assisted techniques have become a promising option for placing pedicle screws in spinal surgery (Toloza and Pow-Sang, 2015). These techniques utilize robotic systems to assist surgeons in performing precise and partially minimally invasive procedures. By enhancing surgical accuracy and reducing tissue trauma, robotic-assisted surgeries have the potential to improve patient outcomes and satisfaction (İyigün et al., 2017). The purpose of this systematic review is to assess the efficacy of robotic-assisted surgery in treating adult spinal deformities. It will analyze the clinical and radiological out-comes associated with these techniques, considering factors such as accuracy of pedicle screw placement, operative time, intra- and postoperative complications, and patient-reported outcomes. By synthesizing the available evidence from medical databases, journals, and studies, this review seeks to provide a comprehensive overview of the cur-rent state of robotic-assisted interventions for adult spinal deformity. The findings of this review have important implications for both clinicians and patients, as they can inform decision-making regarding the choice of surgical approach for adult spinal deformity (see Table 1, Table 2, Table 3, Table 4, Table 5, Fig. 1).Table 1 Studies dealing with accuracy of pedicle screw placement.

Table 1	Purpose	Study design	N	Main message	Ev- L	
Chen et al. (Fan et al., 2018)	To compare the accuracy of pedicle screw placement in adult degen- erative scoliosis surgery between robot-assisted and freehand tech- niques.	Retrospective cohort study	97	Robot-assisted surgery offers higher screw placement accuracy than the traditional freehand method	III	
Fan et al. (Gertzbein and Robbins, 1990)	Evaluate the preci- sion of screw place- ment using robotic- assisted navigation, drill guide template and CT-based navi- gation.	Retrospective cohort study	267	The robot-assisted method achieved the highest accuracy in screw insertion (91.3% perfect insertion)	III	
Li et al. (Li et al., 2022)	Compare the ac- curacy of pedicle screw placement in scoliosis surgery us- ing robotic-assisted navigation with an O-arm, robotic- assisted navigation with a 3D C-arm, and the fluoroscopy- assisted free-hand technique.	Retrospective cohort study	144	Robotic-assisted nav- igation using either an O-arm or a 3D C-arm can effectively improve the accuracy and safety of pedicle screw placement.	III	
Li et al. (Li et al., 2023)	Compare the safety and accuracy of cannulated pedicle screw placement in scoliosis surgery using three different techniques: robotic- navigation, O-arm- based navigation, and freehand.	Retrospective cohort study	106	Robotic-navigation showed the highest accuracy in screw placement (96.7%), fol- lowed by O-arm-based navigation (93.0%), and then the freehand technique (80.4%).	II	

Table 2 Studies dealing with time of operation.

Table 2	Purpose	Study de- N sign	Main message	Ev- L	
Chen et al. (Fan et al., 2018)	To evaluate if there is a significant difference in the time required to perform the surgery us- ing the robot-assisted technique compared to the traditional freehand technique.	Retrospective97 cohort study	The operative time between the robot- assisted (RA) and freehand (FH) groups showed no significant difference (283.1 vs. 291.9 min; P = 0.31).	III	
Fan et al. (Gertzbein and Robbins, 1990)	To assess the efficiency of three different as- sisted technologies used in the pedicle screw fix- ation of adult degener- ative scoliosis.	Retrospective267 cohort study	The study found that the patient-specific drill guide template group (Group B) had the shortest surgical time compared to the spine robot (Group A) and CT-based navigation (Group C) groups.	III	
Li et al. (Li et al., 2022)	To determine if there is a significant differ- ence in the duration of surgery when us- ing robotic-assisted navigation with an O-arm or a 3D C- arm, compared to the traditional fluoroscopy- assisted free-hand technique.	Retrospective144 cohort study	The use of robotic- assisted navigation with a 3D C-arm resulted in longer operation times, while the O-arm robotic- assisted navigation proved to be more effi- cient intraoperatively, resulting in shorter surgery times.	III	
Li et al. (Li et al., 2023)	To evaluate whether the incorporation of robotic-navigation and O-arm-based navi- gation technologies affects the duration of surgery when com- pared to the freehand technique.	Retrospective106 cohort study	The operation times for Group 1 (robotic- navigation-assisted pedicle screw in- sertion) and Group 2 (O-arm-based navigation-guided pedicle screw inser- tion) were significantly longer than that for Group 3 (freehand pedicle screw inser-tion) (P < 0.05).	II	

Table 3 Studies dealing with radiation exposure.

Table 3	Purpose	Study design	N	Main message	Ev- L	
Li et al. (Li et al., 2022)	To evaluate the trade-offs between the increased accu- racy and safety in pedicle screw place- ment provided by advanced navigation technologies and their potential to cause higher radi- ation exposure to patients.	Retrospective cohort study	144	Robotic-assisted naviga- tion increased radiation exposure compared to the free-hand technique.	III	
Li et al. (Li et al., 2023)	To evaluate the risk associated with each technique, as high levels of radiation ex- posure during surgi- cal procedures could pose a risk to both the patient and the surgical team.	Retrospective cohort study	106	The cumulative radia- tion dose for patients decreased in the order of Group 1 (robotic-navigation- assisted pedicle screw insertion) > Group 2 (O-arm-based navigation-guided pedi- cle screw insertion) > Group 3 (freehand pedicle screw insertion). The cumulative radia- tion dose for surgeons in Group 1 and Group 2 was signifcantly lower than that in Group 3	II	

Table 4 Studies dealing with intraoperative complications.

Table 4	Purpose	Study design	N	Main message	Ev- L	
Chen et al. (Fan et al., 2018)	To determine if the RA technique results in less intraoperative blood loss, which can be an in- dicator of less surgical trauma and may con- tribute to faster recov- ery and reduced surgical risks for patients.	Retrospective cohort study	97	The robotic-assisted method demon- strated a notable advantage in reduc- ing intraoperative blood loss compared to the freehand technique.	III	
Fan et al. (Gertzbein and Robbins, 1990)	To determine the ef- ficacy, safety, and potential advantages of newer robotic-assisted methods in comparison to the conventional technique.	Retrospective cohort study	267	Robotic-assisted surgery showed reduced intra-op radiation but didn't specifically reduce surgery time or blood loss compared to other methods.	III	
Li et al. (Li et al., 2022)	To assess whether the use of advanced navi- gation technologies im- pacts the safety of sco- liosis surgery in terms of bleeding. technique.	Retrospective cohort study	144	No significant dif- ferences in blood loss between robotic- assisted and free- hand pedicle screw placement in scoliosis surgery.	III	
Li et al. (Li et al., 2023)	To evaluate whether the incorporation of robotic-navigation and O-arm-based navigation technologies affects the duration of surgery when compared to the freehand technique.	Retrospective cohort study	106	There were no sig- nificant differences in blood loss among the three groups (robotic-navigation, O-arm-based navi- gation, and freehand techniques) during scoliosis surgery.	II	

Table 5 Studies dealing with postoperative complications.

Table 5	Purpose	Study design	N	Main message	Ev- L	
Chen et al. (Fan et al., 2018)	To provide insights into which method offers a safer alter- native and results in fewer postoperative complications	Retrospective cohort study	97	The study found fewer complications in the robot-assisted group, with only one case of pressure sores, com- pared to two cases of dural tears in the free- hand group.	III	
Fan et al. (Gertzbein and Robbins, 1990)	To assess and de- termine the clinical safety and efficacy of the three advanced guided technologies used in pedicle screw fixation for adult degenerative scoliosis.	Retrospective cohort study	267	There were no sig- nificant disparities in postoperative com- plication observed among the three groups	III	
Li et al. (Li et al., 2023)	To identify which of the techniques offers the highest precision in screw placement, thus po- tentially minimizing the risk of postoper- ative complications.	Retrospective cohort study	106	Postoperative com- plications were not significantly differ- ent among the three groups	II	

Fig. 1 Fig. 1

2 Methods

The study involved investigating adult spinal deformity in connection with robotics. To ensure thoroughness, we conducted a meticulous examination of the literature, encompassing all articles published from January 2000 to September 2023. In order to gather relevant information, the investigators thoroughly examined and searched the PubMed, Medline, and Web of Science Core Collection databases. To maintain the focus of our research, we specifically excluded articles that discussed spinal deformities in non-adults, such as adolescent scoliosis. More-over, this analysis did not take into account any case reports, reviews, or animal studies. Due to the fact that data collection had already concluded before PROSPERO registration, this review was ineligible for registration with PROSPERO. The review questions were defined by utilizing the PICO scheme.• Can we observe any disparities in the precision of pedicle screw placement, duration of surgery, and incidence of complications between robotic-assisted surgery and the conventional open surgery?

The subsequent keywords were employed in the search: ("robotics"[Title/Abstract] OR "robot-guided"[Title/Abstract] OR "robot-assisted"[Title/Abstract] OR "robotic-assisted"[Title/Abstract] OR "navigation"[Title/Abstract]) AND ("adult spinal deformity"[Title/Abstract] OR "scoliosis"[Title/Abstract] OR "kyphosis"[Title/Abstract] OR "lor-dosis"[Title/Abstract] OR "degenerative scoliosis"[Title/Abstract] OR "secondary scoliosis"[Title/Abstract]) NOT "adolescent idiopathic scoliosis" NOT "AIS" NOT ("case reports"[Publication Type] OR "review"[Publication Type])

Later on, we proceeded to analyze all the relevant original articles, carefully considering their levels of evidence and drawing the appropriate conclusions accordingly.• Accuracy of pedicle screw placement

• Time of operation

• Radiation exposure

• Intraoperative complication

• Postoperative complications

3 Results

In total, we managed to gather 172 abstracts from the literature research. Out of these, a total of 146 articles were eliminated from consideration due to issues found in their abstracts or titles. A significant portion of the studies that were not included in the analysis were those that overlapped with the literature databases, involved animal subjects, lacked original content, or explored topics unrelated to the intended pathologies or limited to robotic surgery. In our analysis, we delved into a comprehensive set of 26 articles. Thirteen articles were ruled out from the selection as they did not pertain to adult spinal deformity or not involve robotic-assisted technology in surgery. This brings the final count of articles to 4. Summaries are provided for all four of the original articles that have been preserved from the period spanning 2000 to 2023.

3.1 Accuracy of pedicle screw placement

Four papers analyzed the safety and accuracy of pedicle screw implantation. In the context of treating adult degenerative scoliosis(ADS), a study carried out by Chen (Chen et al., 2020) shed light on the comparison between robotic-assisted (RA) and free hand (FH) techniques. This single-center retrospective cohort study revealed intriguing findings regarding screw implantation accuracy. The research showed that the RA group had a notably higher level of accuracy in comparison to the FH group. Specifically, the screw implantation accuracy in the RA group

was 98.7%, while the FH group achieved a slightly lower accuracy rate of 92.2% (P < 0.001).

Fan et al. (2018) assessed retrospectively the accuracy of screw implantation based on postoperative CT scans according to the Gertzbein and Robbins classification (Gertzbein and Robbins, 1990). In the study, 83 patients in Group A had 1012 pedicle screws implanted with robotic-assisted navigation, 75 patients in Group B had 886 screws implanted using a drill guide template, and 109 patients in Group C had 1276 screws implanted with CT-based navigation. The accuracy of screw implantation was 91.3%for Group A, 81.3%for Group B, and 84.1%for Group C, respectively. The "clinically acceptable" accuracy (Grade A + B) was 96.0%, 90.6%, and 93.0% (P < 0.05) respectively. Group A significantly outperformed groups B and C in accuracy.

Li et al. (2022) compared retrospectively the safety and accuracy of pedicle screw implantation in patients with scoliosis using surgical techniques assisted by robotic-assisted navigation, the O-arm or 3D C-arm, and a fluoroscopy-assisted free-hand technique. Among 92 patients who received robotic navigation assistance during surgery, the pedicle screws were found to be misplaced at a rate of 3.7%. Interestingly, the misplacement rate was slightly higher on the concave side at 5.1%, while it was lower on the convex side at 2.3%. When utilizing the O-arm or 3D C-arm alongside robotic support, the rates of misplaced pedicle screws stood at 5.1% and 5.2% correspondingly. With the application of fluoroscopic-guided surgical technique, the occurrence of pedicle screws being positioned incorrectly stood at 14.1% in 52 patients (P < 0.05).

Li et al. (2023) provided additional support for this standpoint in another article. A retrospective cohort study was conducted on 106 individuals who underwent scoliosis surgery, with a total of 2035 pedicle screws being implanted. The first placement of the pedicle screw showed a noteworthy disparity in accuracy between the robotic-assisted navigation group, with an rate of 94.7%, and the O-arm navigation group, which achieved 89.2% (P < 0.001). Following the surgery, the precision of pedicle screw placement was as follows the robotic-assisted navigation group achieved the highest rate at 96.7%, trailed by the O-arm navigation group at 93.0%, with the free hand techniques group exhibiting the lowest rate at 80.4% (P < 0.01).

3.2 Time of operation

The surgical time for different surgical techniques in spine deformity surgery was the subject of analysis in four articles. Among them, Chen et al. (2020) found that the surgical time between the two groups compared in the study—robot-assisted (RA) group and freehand (FH) group—was not significantly different (P = 0.31). The average operative time for the RA group was 283.1 min, while for the FH group it was 291.9 min. According to Fan et al. (2018) the comparison of surgery times among the three groups (Robotic-assisted navigation (group A), Drill guide template (group B), CT-based navigation (group C)) revealed significant differences. For the group A, the average surgery time was 239 ± 52 min. For the group B, it was 191 ± 48 min, and for the group C, it was 228 ± 43 min group A vs group B had a P-value of <0.001, indicating a significant difference. The comparison between group A vs group C resulted in a P-value of 0.111, and group B vs group C had a P-value of <0.001, demonstrating significant differences in surgery times between the groups.

In the study results of Li et al. (2022), the comparison of operation times among the groups revealed that subgroup AII (n = 44; robotic-assisted navigation with a 3D C-arm) had a significantly longer surgery duration compared to both subgroup AI (n = 48; robotic-assisted navigation with an O-arm) and group B (n = 52; free hand). The mean operation time for subgroup AII was 7.1 ± 2.2 h, while for subgroup AI it was 6.7 ± 2.3 h, and for group B it was 5.5 ± 1.6 h. The differences in operation time were statistically significant with a P value of 0.016 when comparing subgroup AII to subgroup AI, and 0.032 when comparing subgroup AII to group B, indicating that the robotic-assisted navigation with a 3D C-arm (subgroup AII) increased the operation time. There was no significant difference in operation time between subgroup AI and group B (P = 0.084), Another study by Li et al. (2023) showed that group 1 (robotic-navigation-assisted) had an operation time of 6.55 ± 0.99 h, group 2 (O-arm-based navigation) had 6.12 ± 0.92 h, and group 3 (freehand) had the shortest operation time with 5.56 ± 0.99 h. The statistical analysis indicates that the operation times for group 1 and group 2 were significantly longer than that of group 3 (P < 0.05).

3.3 Radiation exposure

Two studies mentioned the issue of radiation exposure in adult spinal deformity surgery. Li et al. (2022) showed that patients which underwent robotic-assisted pedicle screw insertion with either O-arm or 3D C-arm navigation, had higher radiation exposure than those in the group undergoing the freehand fluoroscopy-guided technique (P < 0.005). Additionally, within in the subgroup using the robotic-assisted navigation with an O-arm patients experienced higher radiation exposure than in the in subgroup with 3D C-arm-assisted navigation (P < 0.005). Another study by Li et al. (2023) showed that the cumulative radiation dose for patients was highest the robotic-navigation-assisted group with 44.22 ± 5.34 μSv, followed by the O-arm-based navigation group with 32.81 ± 4.22 μSv, and the lowest in the freehand group with 2.89E-3 ± 0.72E-3 μSv. The statistical significance for this comparison was P < 0.001.

On the other hand, the radiation exposure for surgeons was lower in in the robotic-navigation-assisted group (0.26E-3 ± 0.08E-3 μSv) and and O-arm based navigation group (0.29E-3 ± 0.08E-3 μSv) compared to the free-hand group (1.14E-3 ± 0.20E-3 μSv), with a P value of <0.001.

3.4 Intraoperative complications

A total of 4 articles mentioned intraoperative complications. Common intraoperative complications in adult spinal deformity surgery include nerve root or spinal cord injury, bleeding, and anesthesia-related complications.

Chen et al. (2020) observed that the robot-assisted surgery group (RA group) exhibited significantly reduced blood loss in comparison to the traditional freehand group (FH group). In terms of blood loss, the RA group showed an average of 499 ml, while the FH group had a slightly higher average of 573 ml (P < 0.001), indicating a statistically significant difference in favor of the robotic-assisted technique.

According to Fan et al. (2018) the comparison of intraoperative blood loss across the three groups–Robotic-assisted navigation (group A), Drill guide template (group B), CT-based navigation (group C)-robotic-assisted posterior lumbar interbody fusion (robot-PLIF), CT-based PLIF, and template-PLIF-shows that there were no significant differences in the amount of blood loss during surgery. The mean blood loss was as follows: group A had 681 ± 277 ml, group B had 669 ± 250 ml, and group C had 611 ± 272 ml (all non-significant).

Li et al., 2022, 2023conducted two studies that lent further support to this point. One of the results of the comparison of intraoperative blood loss between the different groups showed no significant differences. The robotic-assisted navigation with an O-arm group had 623 ± 42 ml, the robotic-assisted navigation with a 3D C-arm group had 631.

± 82 ml. In comparison, the freehand fluoroscopy-guided group had a slightly but not significant higher average blood loss at 643 ± 85 ml. Similarly, there was no significant difference between the robotic-navigation, and O-arm-based navigation, and freehand technique group) with a P-value greater than 0.05 (P > 0.05). This suggests that the variation in blood loss among the different techniques used in the surgery was not statistically significant, and thus, the choice of technique did not markedly affect the amount of blood loss experienced during surgery.

3.5 Postoperative complications

Three studies analyzed postoperative complications in adult spinal deformity surgery. Common postoperative complications include incisional infections, breakage or displacement of screws or other fixation devices, persistent pain that could not be alleviated, pulmonary infections, bedsores, and deep vein thrombosis. Chen et al. (2020) mentioned postoperative complications, including one case of pressure sores in the robot-assisted group and two cases of dural tears in the freehand group. But neither group required another surgery. In the study by Li et al. (2023)no related complications were observed in the pedicle screw placement for both the robotic-assisted and O-arm assisted groups. However, in the freehand group, two patients experienced postoperative abnormal sensations and weakness in the lower limbs due to the screw penetrating the inner wall of the pedicle and compressing the nerve root. One patient recovered with steroid treatment, while the other required surgery to remove and reinsert the screw.

Fan et al. (2018) analyzed the postoperative complications observed in patients with these three surgical approaches based on robotic-assisted navigation, drill guide templates and CT-based navigation. The incidence of postoperative complications was 7.23%, 12.00% and 8.23%, respectively. No significant disparities in postoperative complication observed among the three groups.

4 Discussion

The objective of this study was to assess the effectiveness of robotic-assisted surgeries for adult spinal deformities, specifically examining the precision of pedicle screw placement, surgical duration, incidence of intraoperative and postoperative complications, as well as radiation exposure.

The aggregated data indicate a significant advantage of robotic-assisted surgery in enhancing the precision of screw placement. Researchers revealed that when it came to the precision of pedicle screw placement, the robot system excelled with an accuracy rate of 97.3%, surpassing the 92% accuracy achieved through the conventional freehand approach (Li et al., 2020a). Compared to traditional surgical methods, such as navigation surgery, or even freehand technology, robotic-assisted in surgery has shown to position screws more accurately, thereby reducing the risk of neurological damage and postoperative complications (Yongqi et al., 2020). These results are consistent with prior research that highlights the advantages of robotic-assisted surgeries in terms of accuracy.

Nonetheless, given the disparities in the anatomy of adult spinal deformities, a plethora of issues continue to exist that cannot be circumvented. Screw misalignment during robotic navigation is a common issue among scoliosis patients, particularly those with concave pedicle dysplasia, and it can be attributed as one of the primary factors causing this problem. However, most misplaced pedicle screws are clinically acceptable. Moreover, thorough management of the patient's tidal volume and reduction of lumbar spine and back movement during robotic-assisted navigation can greatly improve the accuracy of pedicle screw placement (Li et al., 2022).

However, the impact on operation time presented mixed results. Chen et al. (2020)argue that there is no significant disparity in surgical duration between robotic-assisted surgery and freehand surgery. The results of Fan et al. (2018) study showed that the operation times for robotic-assisted navigation and O-arm-based navigation-guided were significantly longer than that for freehand. This increase in duration can be attributed to the additional time required for setting up and operating the robotic system, as well as the extra steps necessary for precise placement. However, as technology advances and surgeons become more adept with robotic systems, it’ s anticipated that the duration of these surgeries will decrease.

While Chen et al. (2020) argued that robotic-assisted surgery resulted in less intraoperative bleeding than freehand surgery, Fan (Fan et al., 2018) and Li (Li et al., 2022, 2023) stated that there was no significant difference in the amount of intraoperative bleeding between robotic-assisted surgery and traditional navigational surgery. This aspect seems to be influenced by a variety of factors including surgical technique, patient-specific conditions, and the complexity of the surgery, rather than the surgical approach itself.

In the included studies, there were few descriptions of postoperative complications.Chen et al. (2020)

reported only one case of pressure sore after robotic-assisted surgery and two cases of dural tear after freehand surgery. Fan et al. (2018)demonstrated that there was no notable disparity in postoperative complications regardless of the surgical technique employed. However, in other aspects of robot-assisted surgery, it demonstrates potential for minimizing postoperative complications(NAITO et al., 2015). The enhanced precision and reduced likelihood of human error in robotic surgeries may lead to fewer incidents of nerve damage and incorrect screw placement. Furthermore, achieving more precise placement can enhance long-term results and reduce the necessity for subsequent corrective surgeries.

Both studies conducted by Li et al., 2022, 2023 focused on radiation exposure, and one of these studies indicated that the utilization of robotic-assisted navigation led to an increase in radiation exposure in comparison to the free-hand technique. But another study calculated radiation exposure for surgeons and patients separately. Robotic-assisted surgery resulted in more radiation for patients than freehand surgery. But for doctors, the results are completely reversed. It is well documented that traditional spinal surgeries often expose both the surgeon and the patient to higher levels of radiation due to frequent use of X-rays for guiding screw placement. In contrast, robot-assisted surgeries can reduce reliance on radiation as the robotic systems can utilize pre-acquired imaging and precise navigation, thereby diminishing radiation exposure (Wu et al., 2019) (Li et al., 2020b).

Nonetheless, the review also revealed some limitations: only four studies were included, the level of evidence for all studies was relatively low, the sample size of the studies was limited, and there was a lack of long-term follow-up data. Future studies should focus on large-scale, multicenter, randomized controlled trials to further validate the effectiveness and safety of surgical robots in spinal deformity surgery.

5 Conclusion

Robotic-assisted surgery for adult spinal deformity demonstrates the potential to enhance the precision of screw placement, possibly reduce intraoperative and postoperative complications, and decrease radiation exposure. How-ever, the impact on operation duration requires further investigation. With ongoing technological advancements and more clinical data accumulation, robotic-assisted technology is poised to play a more significant role in spinal surgeries.

Conflict of interest

No confict of interests exists.

Open access

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appro-priate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Funding

Funding Financial support from the program of China Scholarships Council (No.202308520054 ).
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