title: Robotic-assisted pedicle screw placement: lessons learned from the first 102 patients.
abstract: BACKGROUND
  Surgeons' interest in image and/or robotic guidance for spinal implant placement is increasing. This technology is continually improving and may be particularly useful in patients with challenging anatomy. Only through careful clinical evaluation can its successful applications, limitations, and areas for improvement be defined. This study evaluates the outcomes of robotic-assisted screw placement in a consecutive series of 102 patients.
  
  
  METHODS
  Data were recorded from technical notes and operative records created immediately following each surgery case, in which the robotic system was used to guide pedicle screw placement. All cases were performed at the same hospital by a single surgeon. The majority of patients had spinal deformity and/or previous spine surgery. Each planned screw placement was classified as: (1) successful/accurately placed screw using robotic guidance; (2) screw malpositioned using robot; (3) use of robot aborted and screw placed manually; (4) planned screw not placed as screw deemed non essential for construct stability. Data from each case were reviewed by two independent researchers to indentify the diagnosis, number of attempted robotic guided screw placements and the outcome of the attempted placement as well as complications or reasons for non-placement.
  
  
  RESULTS
  Robotic-guided screw placement was successfully used in 95 out of 102 patients. In those 95 patients, 949 screws (87.5 % of 1,085 planned screws) were successfully implanted. Eleven screws (1.0 %) placed using the robotic system were misplaced (all presumably due to "skiving" of the drill bit or trocar off the side of the facet). Robotic guidance was aborted and 110 screws (10.1 %) were manually placed, generally due to poor registration and/or technical trajectory issues. Fifteen screws (1.4 %) were not placed after intraoperative determination that the screw was not essential for construct stability. The robot was not used as planned in seven patients, one due to severe deformity, one due to very high body mass index, one due to extremely poor bone quality, one due to registration difficulty caused by previously placed loosened hardware, one due to difficulty with platform mounting and two due to device technical issues.
  
  
  CONCLUSIONS
  Of the 960 screws that were implanted using the robot, 949 (98.9 %) were successfully and accurately implanted and 11 (1.1 %) were malpositioned, despite the fact that the majority of patients had significant spinal deformities and/or previous spine surgeries. "Tool skiving" was thought to be the inciting issue with the misplaced screws. Intraoperative anteroposterior and oblique fluoroscopic imaging for registration is critical and was the limiting issue in four of the seven aborted cases.
authors.affiliation: Scoliosis and Spine Tumor Center, Texas Back Institute, Texas Health Presbyterian Hospital Plano, Plano, TX 75093, USA.
authors.forename: Xiaobang
authors.initials: X
authors.lastname: Hu
authors.forename: Donna D
authors.initials: DD
authors.lastname: Ohnmeiss
authors.forename: Isador H
authors.initials: IH
authors.lastname: Lieberman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001863:Bone Screws; D002648:Child; D005260:Female; D005471:Fluoroscopy; D006801:Humans; D021621:Imaging, Three-Dimensional; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012371:Robotics; D013122:Spinal Diseases / Q000000981:diagnostic imaging / Q000601:surgery*; D013123:Spinal Fusion / Q000295:instrumentation / Q000379:methods*; D013131:Spine / Q000000981:diagnostic imaging / Q000601:surgery*; D025321:Surgery, Computer-Assisted / Q000295:instrumentation / Q000379:methods*; D016896:Treatment Outcome