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Clinical application of spinal robot in cervical spine surgery: safety and accuracy of posterior pedicle screw placement in comparison with conventional freehand methods

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Abstract

The novel robot-assisted (RA) technique has been utilized increasingly to improve the accuracy of cervical pedicle screw placement. Although the clinical application of the RA technique has been investigated in several case series and comparative studies, the superiority and safety of RA over conventional freehand (FH) methods remain controversial. Meanwhile, the intra-pedicular accuracy of the two methods has not been compared for patients with cervical traumatic conditions. This study aimed to compare the rate and risk factors of intra-pedicular accuracy of RA versus the conventional FH approach for posterior pedicle screw placement in cervical traumatic diseases. A total of 52 patients with cervical traumatic diseases who received cervical screw placement using RA (26 patients) and FH (26 patients) techniques were retrospectively included. The primary outcome was the intra-pedicular accuracy of cervical pedicle screw placement according to the Gertzbin–Robbins scale. Secondary outcome parameters included surgical time, intraoperative blood loss, postoperative drainage, postoperative hospital stay, and complications. Moreover, the risk factors that possibly affected intra-pedicular accuracy were assessed using univariate analyses. Out of 52 screws inserted using the RA method, 43 screws (82.7%) were classified as grade A, with the remaining 7 (13.5%) and 2 (3.8%) screws classified as grades B and C. In the FH cohort, 60.8% of the 79 screws were graded A, with the remaining screws graded B (21, 26.6%), C (8, 10.1%), and D (2, 2.5%). The RA technique showed a significantly higher rate of optimal intra-pedicular accuracy than the FH method (P = 0.008), but there was no significant difference between the two groups in terms of clinically acceptable accuracy (P = 0.161). Besides, the RA technique showed remarkably longer surgery time, less postoperative drainage, shorter postoperative hospital stay, and equivalent intraoperative blood loss and complications than the FH technique. Furthermore, the univariate analyses showed that severe obliquity of the lateral atlantoaxial joint in the coronal plane (P = 0.003) and shorter width of the lateral mass at the inferior margin of the posterior arch (P = 0.014) were risk factors related to the inaccuracy of C1 screw placement. The diagnosis of HRVA (P < 0.001), severe obliquity of the lateral atlantoaxial joint in the coronal plane (P < 0.001), short pedicle width (P < 0.001), and short pedicle height (P < 0.001) were risk factors related to the inaccuracy of C2 screw placement. RA cervical pedicle screw placement was associated with a higher rate of optimal intra-pedicular accuracy to the FH technique for patients with cervical traumatic conditions. The severe obliquity of the lateral atlantoaxial joint in the coronal plane independently contributed to high rates of the inaccuracy of C1 and C2 screw placements. RA pedicle screw placement is safe and useful for cervical traumatic surgery.

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Funding

This study was supported by the National Key Research and Development Program of China (No. 2022YFC2407504) and the Research Fund of Anhui Institute of Translational Medicine (No. 2021zhyx-C34).

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Author notes

  1. Lu-Ping Zhou, Ren-Jie Zhang and Wen-Kui Zhang contributed equally to this work.

Authors and Affiliations

  1. Department of Orthopedics and Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China

    Lu-Ping Zhou, Ren-Jie Zhang, Wen-Kui Zhang, Liang Kang, Kai-Xuan Li, Hua-Qing Zhang, Chong-Yu Jia, Yin-Shun Zhang & Cai-Liang Shen

  2. Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, the First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China

    Lu-Ping Zhou, Ren-Jie Zhang, Wen-Kui Zhang, Liang Kang, Kai-Xuan Li, Hua-Qing Zhang, Chong-Yu Jia, Yin-Shun Zhang & Cai-Liang Shen

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Contributions

Lu-Ping Zhou: conceptualization, data curation, formal analysis, investigation, methodology, software, validation, visualization, writing – original draft, writing – editing. Ren-Jie Zhang: conceptualization, formal analysis, investigation, validation, visualization, writing – review. Wen-Kui Zhang: formal analysis, investigation, validation, visualization, writing – review. Liang Kang: formal analysis, investigation, methodology, visualization, writing – editing. Kai-Xuan Li: formal analysis, software, validation, visualization, investigation, investigation, software. Hua-Qing Zhang: data curation, writing – editing. Chong-Yu Jia: software, writing – editing. Yin-Shun Zhang: conceptualization, project administration, foundation, methodology, supervision, writing – review. Cai-Liang Shen: conceptualization, project administration, investigation, foundation, methodology, supervision, writing – review. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Yin-Shun Zhang or Cai-Liang Shen.

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Ethics approval

This study was conducted according to the guidelines of the Declaration of Helsinki and approved by the hospital institutional review board (Ethics Approval Number PJ2022-04-49). Written consent was obtained from the study participants.

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The authors declare no competing interests.

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Supplementary information

Supplementary file 1.

The high-riding vertebral artery (HRVA) was defined on the sagittal section(A) as an internal height (a) ≤ 2 mm, isthmus height (b) of the axis ≤5 mm, or both. The sagittal section was identified with the coronal section(B) transecting the mid-portion of the C1–2 facet joint. (ZIP 2141 kb)

Supplementary file 2.

The estimation of ideal sample size of the screw number included in RA and FH groups. In the PASS 15.0.5 software, the parameters were set as: α= 0.05, 1-β= 0.90, group allocation= equal (N1=N2), the estimated RA group portion= 0.876, and the estimated FH group portion= 0.608. Finally, the result showed that the number of included screws in RA group should be 51, and number of included screws in FH group should also be 51. (TIF 999 kb)

Supplementary file 3.

The estimation of sample size of the screw number included in FH group when the screw number in RA group set as 52 and “1-β” as 0.90. In the PASS 15.0.5 software, the parameters were set as: α= 0.05, 1-β= 0.90, group allocation= “enter N1=52, solve for N2”, the estimated RA group portion= 0.876, and the estimated FH group portion= 0.608. Finally, the result showed that if the number of included screws in RA group was 52, the number of included screws in FH group should be 51. (TIF 996 kb)

Supplementary file 4.

The estimation of sample size of the screw number included in FH group when the screw number in RA group set as 52 and “1-β” as 0.99. In the PASS 15.0.5 software, the parameters were set as: α= 0.05, 1-β= 0.99, group allocation= “enter N1=52, solve for N2”, the estimated RA group portion= 0.876, and the estimated FH group portion= 0.608. Finally, the result showed that if the number of included screws in RA group was 52, the number of included screws in FH group should be 131. (TIF 1061 kb)

Supplementary file 5.

Descriptive statistics of the number of screws on inserted segments in RA and FH groups (DOCX 53 kb) (DOCX 30 kb)

Supplementary file 6.

Descriptive statistics of the number of screws inserted in axis with HRVA between RA and FH groups (DOCX 12 kb)

Supplementary file 7.

Inter-observer consistency for the assessment of the accuracy of cervical pedicle screw placement (DOCX 12 kb)

Supplementary file 8.

Inter-observer consistency for the radiographic measurements (DOCX 12 kb)

Supplementary file 9.

Assessment of posterior C1 screw placement accuracy according to Gertzbein–Robbins scale for RA and FH approaches (DOCX 13 kb)

Supplementary file 10.

Assessment of posterior C2 screw placement accuracy according to Gertzbein–Robbins scale for RA and FH approaches (DOCX 13 kb)

Supplementary file 11.

Assessment of posterior subaxial screw placement accuracy according to Gertzbein–Robbins scale for RA and FH approaches (DOCX 13 kb)

Supplementary file 12.

Univariate analyses of factors associated with intra-pedicular accuracy of subaxial screw placement. (DOCX 13 kb)

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Zhou, LP., Zhang, RJ., Zhang, WK. et al. Clinical application of spinal robot in cervical spine surgery: safety and accuracy of posterior pedicle screw placement in comparison with conventional freehand methods. Neurosurg Rev 46, 118 (2023). https://doi.org/10.1007/s10143-023-02027-y

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