title: Biomechanical advantages of robot-assisted pedicle screw fixation in posterior lumbar interbody fusion compared with freehand technique in a prospective randomized controlled trial-perspective for patient-specific finite element analysis.
abstract: There have been conflicting results on the surgical outcome of lumbar fusion surgery using two different techniques: robot-assisted pedicle screw fixation and conventional freehand technique. In addition, there have been no studies about the biomechanical issues between both techniques.
  
  
  
  This study aimed to investigate the biomechanical properties in terms of stress at adjacent segments using robot-assisted pedicle screw insertion technique (robot-assisted, minimally invasive posterior lumbar interbody fusion, Rom-PLIF) and freehand technique (conventional, freehand, open approach, posterior lumbar interbody fusion, Cop-PLIF) for instrumented lumbar fusion surgery.
  
  
  
  This is an additional post-hoc analysis for patient-specific finite element (FE) model.
  
  
  
  The sample is composed of patients with degenerative lumbar disease.
  
  
  
  Intradiscal pressure and facet contact force are the outcome measures.
  
  
  
  Patients were randomly assigned to undergo an instrumented PLIF procedure using a Rom-PLIF (37 patients) or a Cop-PLIF (41), respectively. Five patients in each group were selected using a simple random sampling method after operation, and 10 preoperative and postoperative lumbar spines were modeled from preoperative high-resolution computed tomography of 10 patients using the same method for a validated lumbar spine model. Under four pure moments of 7.5 Nm, the changes in intradiscal pressure and facet joint contact force at the proximal adjacent segment following fusion surgery were analyzed and compared with preoperative states.
  
  
  
  The representativeness of random samples was verified. Both groups showed significant increases in postoperative intradiscal pressure at the proximal adjacent segment under four moments, compared with the preoperative state. The Cop-PLIF models demonstrated significantly higher percent increments of intradiscal pressure at proximal adjacent segments under extension, lateral bending, and torsion moments than the Rom-PLIF models (p=.032, p=.008, and p=.016, respectively). Furthermore, the percent increment of facet contact force was significantly higher in the Cop-PLIF models under extension and torsion moments than in the Rom-PLIF models (p=.016 under both extension and torsion moments).
  
  
  
  The present study showed the clinical application of subject-specific FE analysis in the spine. Even though there was biomechanical superiority of the robot-assisted insertions in terms of alleviation of stress increments at adjacent segments after fusion, cautious interpretation is needed because of the small sample size.
authors.affiliation: Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam, 463-707, Republic of Korea.
authors.forename: Ho-Joong
authors.initials: HJ
authors.lastname: Kim
authors.affiliation: Department of Mechanical Engineering, Yonsei University, 134 Sinchon-dong, Seodaemun-gu, Seoul, 03722, Republic of Korea.
authors.forename: Kyoung-Tak
authors.initials: KT
authors.lastname: Kang
authors.affiliation: Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam, 463-707, Republic of Korea.
authors.forename: Sung-Cheol
authors.initials: SC
authors.lastname: Park
authors.affiliation: Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam, 463-707, Republic of Korea.
authors.forename: Oh-Hyo
authors.initials: OH
authors.lastname: Kwon
authors.affiliation: Department of Mechanical Engineering, Yonsei University, 134 Sinchon-dong, Seodaemun-gu, Seoul, 03722, Republic of Korea.
authors.forename: Juhyun
authors.initials: J
authors.lastname: Son
authors.affiliation: Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, 110-744, Republic of Korea.
authors.forename: Bong-Soon
authors.initials: BS
authors.lastname: Chang
authors.affiliation: Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, 110-744, Republic of Korea.
authors.forename: Choon-Ki
authors.initials: CK
authors.lastname: Lee
authors.affiliation: Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam, 463-707, Republic of Korea. Electronic address: highcervical@gmail.com.
authors.forename: Jin S
authors.initials: JS
authors.lastname: Yeom
authors.affiliation: Columbia University Department of Orthopedic Surgery, Division of Spinal Surgery, Spine Hospital at New York-Presbyterian/The Allen Hospital, 5141 Broadway, 3 Field West, New York, NY 10034, USA.
authors.forename: Lawrence G
authors.initials: LG
authors.lastname: Lenke
mesh_terms: D000328:Adult; D001696:Biomechanical Phenomena; D005260:Female; D020342:Finite Element Analysis; D006801:Humans; D008159:Lumbar Vertebrae / Q000601:surgery; D008297:Male; D008875:Middle Aged; D065289:Pedicle Screws / Q000009:adverse effects*; D016059:Range of Motion, Articular; D012371:Robotics / Q000379:methods*; D013123:Spinal Fusion / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*
keywords: Biomechanical analysis; Freehand technique; Patient-specific finite element model; Posterior lumbar interbody fusion; Proximal facet joint violation; Robot-assisted pedicle screw fixation