Understanding the Use of Robotics in Spine Surgery

In recent years, the use of robotic systems in surgery has increased in popularity, including in spine surgery. Pedicle screw placement is a crucial aspect of spine surgery that can benefit from the use of robotic technology.

However, accuracy is paramount, as screw malposition can result in severe complications. Robotic systems must offer comparable accuracy to established methods of screw placement. Early reports suggest that robotic systems offer equivalent accuracy and reduced radiation exposure.

Over the last ten years, surgical robotics have gained popularity in specialties like general surgery, urology, and gynecology for manipulating tissue in body cavities. The early adoption of robotic systems in these fields has driven innovation and their use in other subspecialties, including spine surgery.

Spinal pathologies often require pedicle screw placement for fixation, which has evolved with navigated techniques since the late 1950s. Robotics is now an area of opportunity for accurate pedicle screw placement in spine surgery, reducing potential complications and improving outcomes.

Efficient and accurate screw placement is crucial for robotic systems to be widely adopted in spine surgery. Robotic technologies can automate repetitive tasks and reduce human error, with early reports showing similar accuracy to established methods. Several FDA-approved robotic systems, including

ExcelsiusGPS, Mazor X Stealth Edition, and ROSA ONE Spine, are commercially available. However, direct comparison between these systems is difficult due to the cost and time associated with adoption.

Operative Technique

Robotic systems can be used for spinal fusion procedures that require pedicle screw fixation. The integration of robotics has mainly been observed in lumbar fusion surgeries, which include anterior lumbar interbody fusion, lateral lumbar interbody fusion, and transforaminal lumbar interbody fusion.

Percutaneous technique has been the prevalent method for pedicle screw fixation, although open screw placement has also been conducted. Moreover, depending on the surgery being performed, patients may be positioned in either the prone or lateral stance.

  • The patient is made ready and covered using established sterile techniques.
  • At first, two minor cuts are created on both sides over the posterior superior iliac spine.
  • The dynamic reference base array and surveillance marker are then placed onto the posterior superior iliac spine bilaterally in a superolateral direction.
  • The intraoperative CT registration fixture is connected to the dynamic reference base array.
  • An intraoperative CT scan is conducted using O-arm to co-register with the preoperative imaging.
  • A trajectory plan may be created for each pedicle screw or pre planned before surgery to reduce intraoperative time.
  • The robotic end effector arm is then positioned to direct all subsequent actions along the planned trajectory.

All subsequent steps can be accomplished via the end effector arm.

  • To place a pedicle screw, a small incision is made and the skin is dissected using an electrocautery tool. The fascia is also cut, which is important to ensure the screw goes in the right direction.
  • A bur is then used to create a pilot hole in the bone, which helps the drill to go in smoothly.
  • The trajectory is planned using navigation and the screw is placed using the same system.
  • The surgeon is notified when the screw is in the right position, and a force meter confirms that the instruments are being used correctly.
  • Finally, a CT scan is performed to ensure the screw is in the right place.

Other Surgical Considerations

Screws are most commonly placed through small incisions in the skin. Nevertheless, in some situations, such as when a spinal decompression is required for degenerative conditions, open screw placement may be necessary.

When an open procedure is performed, instead of positioning the dynamic reference base array and intraoperative CT registration fixture on the posterior superior iliac spine, they are placed on a spinous process above and below the region being operated on.

All future procedures can be carried out as mentioned earlier, with the exception of ensuring that the dynamic reference base array is not disturbed in the surgical area. During an open exposure, the screw entry site can be directly visualized, and it may be necessary to drill away cortical bone to facilitate the screw placement.

The usual application of this method is for patients in the conventional prone position. Nevertheless, there has been growing interest in conducting lumbar fusion surgery with the patient in a single position, which is the lateral position. These involve surgeries such as anterior lumbar interbody fusion and lateral lumbar interbody fusion with pedicle screw fixation, both of which can also incorporate the use of a robotic system.

These techniques involve inserting an interbody either through an incision made in the front or the side of the body, and then using pedicle screws for fixation. If the lateral approach is used, modifications are made to the trajectory of the screws on the lower side to reduce the chance of infection. All other steps remain unchanged.

Accuracy of Pedicle Screw Placement

Our doctors at Complete Orthopedics want to ensure the safety and accuracy of pedicle screw placement during surgery. There are now robotic systems available to aid in this procedure, and research has shown that they can achieve a high level of accuracy, typically between 94% to 98%. Nevertheless, there is conflicting evidence in the literature regarding the precision of robot-assisted screw placement in comparison to conventional freehand methods.

While certain research has found that the accuracy of pedicle screw placement with robotic assistance is subpar, other studies have demonstrated that it is either just as good or even better than freehand methods. Recent meta-analyses support this, revealing that robot-assisted pedicle screw placement is typically more precise than freehand placement.

Navigation with intraoperative CT scan is another commonly used method for pedicle screw fixation. Some surgeons contend that the precision of screw placement with navigation is sufficiently high that a robotic arm is unnecessary. However, literature supports the use of a robotic arm for several reasons.

One reason to support the use of a robotic arm is that preoperative CT scanning permits screw planning prior to the operation, which leads to reduced surgery time and improves the precision of screw placement. Another factor is that the robotic arm can minimize the human error that is often associated with manual tasks. Additionally, employing a robotic arm can be less physically demanding for the surgeon.

Operative Time

Incorporating robotic technology into spine surgery can increase the time it takes to perform the procedure. Studies have shown that this may be due to the steep learning curve associated with using this technology.

Nevertheless, as surgeons become more experienced and technology improves, it is expected that the additional operative time will decrease. Previous studies have shown that after an initial learning period, there is an improvement in accuracy with the use of robotics.

Radiation Exposure

Robotic systems in spine surgery can offer decreased radiation exposure to both the surgeon and patient. The use of a preoperative CT scan and fluoroscopy during surgery to register the robotic system allows for minimal intraoperative radiation. Multiple studies have shown that the overall and per-screw radiation exposure times are lower with the use of robotic systems.

Future Directions

Rapid advancements are being made in the use of robotic systems in spine surgery, but there is a need for further enhancement of efficiency and surgical workflow to encourage broader implementation. Enhancing imaging software is crucial in reducing errors and aiding with trajectory planning both before and during surgery.

By automating repetitive tasks and decreasing human error, robotic systems strive for more uniform patient outcomes. Although existing research primarily concentrates on fixing the thoracolumbar spine, robotics has the potential to be employed in cervical and pelvic fixation in the future, along with more intricate procedures like decompression and complex deformity surgeries.

Assessing various robotic systems against one another may aid in identifying their particular advantages and drawbacks. Cost is another factor to bear in mind, and the feasibility of implementing these systems more broadly will depend on their economic viability.

The utilization of robotic systems in spine surgery has gained popularity, offering advantages such as enhanced precision of screw placement, shorter operation time, and lowered radiation exposure.

Yet, mastering the use of these systems effectively poses challenges, and further technical progress is necessary to boost their efficacy. Adopting a well-rounded approach is crucial in evaluating the implementation of robotic systems versus conventional techniques for screw placement.

If you are interested in knowing more about Robotics in Spine Surgery you have come to the right place!

Call Us Now!

Based on 107 reviews
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.

Please take a look at my profile page and don't hesitate to come in and talk.