Spine Surgical Robotics

Currently, surgical robots are increasingly recognized as a prominent example of artificial intelligence technology. Moreover, utilizing surgical robots for medical procedures is seen as a direction for future advancements in surgery.

Surgical robots, such as the Da Vinci, which consist of a combination of advanced medical technologies, have been widely utilized in general surgery. Furthermore, various generations of robots specifically designed for spine orthopedics have also been developed.

The purpose of designing these robots is not limited to providing greater precision to surgeons. They also aim to eliminate errors caused by human intervention, enhance the efficiency of surgeries, and fulfill the requirements of minimizing postoperative complications.

Limited Application In Spine Surgery

Some of the most commonly occurring spine disorders include disc herniation, degenerative changes to the spine, spondylolisthesis, and vertebral fractures. These conditions typically require surgical intervention using a nail-stick fixation system.

Although the morbidity rate is not very high, the conventional method of freehand pedicle screw insertion can result in pedicle damage and screw dislocation, which can lead to significant clinical complications like dural bruising, neurovascular injury, and damage to the muscles and internal organs.

The development of robotic assistance for spine surgery was primarily intended to improve the precision and convenience of pedicle screw placement while reducing the occurrence of manual errors and postoperative complications. As reported by the literature, it appears that robots are primarily used for the insertion of screws in spinal internal fixation procedures, and there are not many other applications of this technology that have been introduced yet.

It is certain that in the future, spine robots will have a wider range of applications beyond simply assisting surgeons with pedicle screw placement. The use of spine robots should also contribute to a comprehensive and multidimensional approach to performing different surgical methods for various diseases.

Limited Operation Site Of Spine Robots

Most of the research on robot-assisted spine surgery has focused on the lumbar or lumbosacral vertebrae, with only a small percentage of studies examining other segments of the spine. One possible reason for the lack of attention to clinical studies on robot-assisted surgery for the cervical and thoracic vertebrae could be that this technology is still in a relatively early stage and the accuracy and stability of robot execution cannot yet be guaranteed.

Additionally, the vital importance of the peripheral nerves, blood vessels, and other anatomical structures in these regions may also contribute to researchers’ hesitation to conduct more extensive clinical studies.

Assuming that the accuracy and stability of the robot can be ensured, there is immense potential for the application of robot-assisted surgery in the cervical and thoracic vertebrae segments. Robotic assistance is expected to improve the accuracy, speed, and convenience of cervical and thoracic spine surgery in some manner.

Furthermore, the upper cervical vertebrae are closely connected to the anatomy of the skull base, and surgeries in this segment are often closely associated with neurosurgery. The application of the Mazor Robotics™ system is being expanded to include brain surgeries, such as the placement of deep brain stimulation (DBS) electrodes.

Errors That Occur Before, During, And After Surgery, And Compound Each Other

Robots designed for surgical assistance aim to enhance accuracy, stability, convenience, and minimize human error by utilizing the latest technologies at every stage. Despite the intended benefits of surgical robots, errors can still occur during the actual clinical use.

Errors can occur at any stage of surgery, including before, during, or after the procedure, and these errors can accumulate, leading to larger deviations and potential risks that may impact the quality of the operation and even threaten the safety of the patient.

This issue is particularly significant in spine surgery, where the accuracy of pedicle screw fixation is crucial, as an incorrect screw placement can result in severe damage to the spinal cord, nerves, and critical vessels. In contrast to the flexible and manual adjustments made by humans, robots are not as effective at avoiding errors due to their higher stability and complex parameters, and there are various factors that can reduce the precision of robotics.

An example of this is when the casing is positioned at the inlet, which could result in lateral skidding. During the drilling process, the pressure applied can potentially cause displacement of the vertebral body being measured. The robot’s software may introduce errors due to parameter settings, and the manner in which the robot is attached to the spine should also be taken into account.

It’s important to be aware that the bed mount fixation may not be strong enough, which can lead to movement between the robot and the patient. This error in mounting could result in lateral deviation. Soft-tissue pressure should also be considered as a factor that can cause deviation on the robotic arm. Thick and tough tissues can cause the robot’s drill to deviate due to the high pressure applied by the robot.

Questioning The Advantage Of Spine Surgery Robots

Currently, the assessment outcomes of robot-assisted pedicle screw insertion predominantly consist of factors such as screw placement accuracy, radiation exposure/time, surgical duration, blood loss, and so on.

While literature has shown positive results for robot-assisted pedicle screw placement, with the experimental group outperforming the control group (which may use methods such as fluoroscopy or freehand techniques), there are still some articles that present different opinions on the matter. Surgeons may find robot-assisted systems less attractive when the anatomy is already clear, as there is no advantage in accuracy over conventional freehand surgery.

One randomized controlled trial found that the use of the Mazor™ robot for screw placement actually decreased accuracy. A question regarding the precision of the robot may arise from various factors such as preoperative planning, quality of imaging, and intraoperative manipulation. Most robotic systems still require the surgeon to verify, fine-tune or manually plan the automatic calculation of the robot’s parameters.

The accuracy and efficiency of planning are dependent on the processing of image correction and the pattern of the image. Currently, the fusion of 2D and 3D multi-mode images can be achieved automatically, but it may be time-consuming or may not achieve high precision for complex cases.

The design of screw insertion mainly depends on manual evaluation, and it does not have the ability to plan or verify based on a combination of physical condition and kinematics. One of the main factors that affects accuracy during surgery is the lateral sliding of the locating pin, which is often considered a significant problem and typically occurs at the facet of the herringbone groove.

Therefore, the positioning of the guidance rail could be affected by an incorrect entry point caused by the lateral sliding of the locating pin, resulting in deviation from the planned path. Additionally, minor changes in body position due to surgeon’s manipulation and patient’s respiratory motion, especially at the thoracic and lumbar vertebra, can also have an impact on the accuracy of the robot’s position.

Another concern in spine surgery is the radiation exposure that occurs during intraoperative fluoroscopy, which can be particularly problematic for surgeons and other staff involved in minimally invasive procedures. Surgical robots are designed to minimize the need for intraoperative radiation, which is one of their advantages.

Currently, robot-assisted surgery has not demonstrated a clear advantage in minimizing radiation exposure. Our doctors’ confidence and experience are the main factors that determine radiation exposure.

Need for Further Research on Postoperative Complications and Cost-Effectiveness of Robot-Assisted Surgery

When a new surgical technique is introduced and advocated, it is essential to assess not only its impact on surgical outcomes but also its effects on postoperative recovery, complications, social factors, and other relevant factors. The use of robotic technology for pedicle screw placement can potentially reduce the risk of adjacent-segment destruction, a common complication in spine surgery, by avoiding the need for surgeons to invade proximal facet joints.

Maybe due to the fact that spine surgery robots are still in the development phase, patients may have to pay more to undergo robot-assisted surgery. As a result, it may be perceived as a costly or a lucrative business tool.

The potential future application of spine surgical robotics is still widely regarded as promising. It holds significant potential for application in both horizontal and vertical fields.

Spinal surgery robots seem to offer better accuracy in placing pedicle screws compared to freehand placement or placement using fluoroscopy. Once the major limitations and drawbacks of the spine surgical robots are addressed and improved, their use is expected to become widespread in clinical practice.

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