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What Is the Learning Curve for Robotic-assisted Pedicle Screw Placement in Spine Surgery?

  • Symposium: Minimally Invasive Spine Surgery
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Some early studies with robotic-assisted pedicle screw implantation have suggested these systems increase accuracy of screw placement. However, the relationship between the success rate of screw placement and the learning curve of this new technique has not been evaluated.

Questions/purposes

We determined whether, as a function of surgeon experience, (1) the success rate of robotic-assisted pedicle screw placement improved, (2) the frequency of conversion from robotic to manual screw placement decreased, and (3) the frequency of malpositioned screws decreased.

Methods

Between June 2010 and August 2012, the senior surgeon (IHL) performed 174 posterior spinal procedures using pedicle screws, 162 of which were attempted with robotic assistance. The use of the robotic system was aborted in 12 of the 162 procedures due to technical issues (registration failure, software crash, etc). The robotic system was successfully used in the remaining 150 procedures. These were the first procedures performed with the robot by the senior surgeon, and in this study, we divided the early learning curve into five groups: Group 1 (Patients 1–30), Group 2 (Patients 31–60), Group 3 (Patients 61–90), Group 4 (Patients 91–120), and Group 5 (Patients 121–150). One hundred twelve patients (75%) had spinal deformity and 80 patients (53%) had previous spine surgery. The accuracy of screw placement in the groups was assessed based on intraoperative biplanar fluoroscopy and postoperative radiographs. The results from these five groups were compared to determine the effect on the learning curve. The numbers of attempted pedicle screw placements were 359, 312, 349, 359, and 320 in Groups 1 to 5, respectively.

Results

The rates of successfully placed screws using robotic guidance were 82%, 93%, 91%, 95%, and 93% in Groups 1 to 5. The rates of screws converted to manual placement were 17%, 7%, 8%, 4%, and 7%. Of the robotically placed screws, the screw malposition rates were 0.8%, 0.3%, 1.4%, 0.8%, and 0%.

Conclusions

The rate of successfully placed pedicle screws improved with increasing experience. The rate of the screws that were converted to manual placement decreased with increasing experience. The frequency of screw malposition was similar over the learning curve at 0% to 1.4%. Future studies will need to determine whether this finding is generalizable to others.

Level of Evidence

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

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Authors and Affiliations

  1. Scoliosis and Spine Tumor Center, Texas Back Institute, Texas Health Presbyterian Hospital Plano, 6020 West Parker Road, #200a, Plano, TX, 75093, USA

    Xiaobang Hu MD, PhD & Isador H. Lieberman MD, MBA, FRCSC

Authors
  1. Xiaobang Hu MD, PhD
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  2. Isador H. Lieberman MD, MBA, FRCSC
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Corresponding author

Correspondence to Isador H. Lieberman MD, MBA, FRCSC.

Additional information

One of the authors certifies that he (XH), or a member of his or her immediate family, has received or may receive payments or benefits, during the study period, an amount of less than USD 10,000 from Mazor Robotics Ltd (Caesarea, Israel). One of the authors certifies that he (IHL), or a member of his or her immediate family, has received or may receive payments or benefits, during the study period, an amount of USD 10,000 to USD 100,000 from Mazor Robotics Ltd.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

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Hu, X., Lieberman, I.H. What Is the Learning Curve for Robotic-assisted Pedicle Screw Placement in Spine Surgery?. Clin Orthop Relat Res 472, 1839–1844 (2014). https://doi.org/10.1007/s11999-013-3291-1

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  • DOI: https://doi.org/10.1007/s11999-013-3291-1

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