What You Need to Know About Robotic Spine Surgery

Robotic spine surgery, also called robot-assisted spine surgery, is an emerging technology that involves the use of robots to assist in surgical procedures on the spine.

Spine Surgery with Robotic Technology: The Potential Advantages

When compared to traditional surgeries, robot-assisted surgeries may provide the following potential advantages ¹ D'Souza M, Gendreau J, Feng A, Kim LH, Ho AL, Veeravagu A. Robotic-Assisted Spine Surgery: History, Efficacy, Cost, And Future Trends [published correction appears in Robot Surg. 2019 Dec 23;6:25]. Robot Surg. 2019;6:9-23. Published 2019 Nov 7. doi:10.2147/RSRR.S190720 :

• Real-time surgical navigation
• Lower radiation exposure
• Higher precision
• Lower complication rates
• Shorter surgical time
• Faster recovery

As with any new technology, there are several challenges that need to be addressed for robotic spine surgery to reach its full potential. These challenges include the high cost of robotic systems, the need for specialized training for surgeons and operating room staff, and the demand for more research to validate the safety and effectiveness of these procedures.

Understanding Robotic Spine Surgery

Robotic spine surgeries are minimally invasive or open surgeries where a robotic arm assists the surgeon in performing the surgery. The goal of this specialized surgery is to improve the accuracy and precision of the surgery, with reduced risk of complications and faster recovery times for patients. ² Vadalà G, De Salvatore S, Ambrosio L, Russo F, Papalia R, Denaro V. Robotic Spine Surgery and Augmented Reality Systems: A State of the Art. Neurospine. 2020;17(1):88-100. doi:10.14245/ns.2040060.030

The key difference between traditional spine surgery and robotic spine surgery is that the traditional method is hands-on, meaning the surgeon uses his/her hands and instruments to access and treat the spine, but in robotic surgery, the procedure is implemented by the robot, which is guided by a surgeon.

A popular misconception about robotic spine surgery is that the robot performs the surgery ³ Fiani B, Quadri SA, Farooqui M, et al. Impact of robot-assisted spine surgery on health care quality and neurosurgical economics: A systemic review. Neurosurg Rev. 2020;43(1):17-25. doi:10.1007/s10143-018-0971-z —which is not true. The robotic arm is not capable of moving on its own. During the entire procedure, a surgeon controls every movement of the robotic arm using a console that is connected to the robot’s apparatus.

Types of Robots Used in Spine Surgery

Surgical robots can be divided into three categories ³ Fiani B, Quadri SA, Farooqui M, et al. Impact of robot-assisted spine surgery on health care quality and neurosurgical economics: A systemic review. Neurosurg Rev. 2020;43(1):17-25. doi:10.1007/s10143-018-0971-z :

Tele-surgical systems

These robots have a command station from where the surgeon can control the motion of the machine. The surgeon does not stay close to the robot in this setup but controls every movement of the machine.

Supervisory controlled systems

These robots are preprogrammed with actions that are performed by the robot itself, but they are done under the close supervision of the surgeon.

Co-autonomy system

These robots are shared-control models, in which both the surgeon and the robot control motions together.

Types of Spine Surgeries Performed with Robotic Assistance

The following types of spine surgeries may be performed using robotic assistance:

• Spinal fusion. Robotic tools can assist in the placement of pedicle screws and other spinal instrumentation in a spinal fusion surgery. With the use of real-time imaging and 3-D models of the patient’s spine, the robot can help the surgeon determine the optimal screw trajectory and depth, reducing the risk of complications, such as incorrect screw placement and post-surgical infection. ⁴ Karasin B, Rizzo G, Hardinge T, Grzelak M, Eskuchen L, Watkinson J. Robotic-Assisted Lumbar Fusion: An Effective Technique for Pedicle Screw Placement. AORN J. 2022;115(3):251-260. doi:10.1002/aorn.13612 Common indications for spinal fusion surgeries are lumbar degenerative disc disease, scoliosis, and isthmic spondylolisthesis. ⁵ Li T, Shi L, Luo Y, Chen D, Chen Y. One-Level or Multilevel Interbody Fusion for Multilevel Lumbar Degenerative Diseases: A Prospective Randomized Control Study with a 4-Year Follow-Up. World Neurosurg. 2018;110:e815-e822. doi:10.1016/j.wneu.2017.11.109
• Discectomy. Robotic technology can assist in the surgical removal of a part or all of a herniated disc. Lumbar discectomy surgery performed with robotic assistance can help improve the accuracy of the surgical procedure and reduce radiation exposure to the surgeon and operating room staff. ⁶ Wang Z, Tan Y, Fu K, Meng Z, Wang L. Minimally invasive trans-superior articular process percutaneous endoscopic lumbar discectomy with robot assistance. BMC Musculoskelet Disord. 2022;23(1):1144. Published 2022 Dec 31. doi:10.1186/s12891-022-06060-8
• Vertebroplasty. Robot-assisted bone cement injection in vertebroplasty procedures (the procedure to stabilize the vertebral compression fracture) have shown to reduce the rate of bone cement leakage and minimize radiation exposure time throughout the procedure. ⁷ Zhang Y, Peng Q, Sun C, et al. Robot Versus Fluoroscopy-Assisted Vertebroplasty and Kyphoplasty for Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta-analysis. World Neurosurg. 2022;166:120-129. doi:10.1016/j.wneu.2022.07.083
• Scoliosis surgery. Robotic technology may help provide safer, less invasive, and more accurate placement of spinal instrumentation, such as pedicle screws, in the surgical treatment of scoliosis. ⁸ Chen H, Zhu X, Dong L, Liu T. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2021;35(11):1457-1462. doi:10.7507/1002-1892.202106072

It is important to note that not all spine surgeries can be performed with the assistance of robots. A surgeon with expertise in robotic spine surgeries can help determine if the patient’s underlying condition is treatable with robotic surgery after carefully considering the potential risks and benefits.

How Robotic Spine Surgery Works: Steps Involved in the Planning

In the planning stage, the surgeon first creates a 3D model of the patient's spine using computed tomography (CT) scans or magnetic resonance imaging (MRI) scans. The surgeon then uploads this 3D model into the robotic system. The robot assesses the model to reconstruct the surgical field and independently registers each component of the patient’s spine. ⁹ Hu X, Scharschmidt TJ, Ohnmeiss DD, Lieberman IH. Robotic assisted surgeries for the treatment of spine tumors. Int J Spine Surg. 2015;9:1. Published 2015 Feb 3. doi:10.14444/2001

Robotic Spine Surgery Procedure: Preparation, Anesthesia, Surgical Time, Hospital Stay, and More

Depending on the condition being treated and the surgeon’s preference, robotic spine surgery can be performed as an inpatient or an outpatient procedure.

• For inpatient surgeries, patients are required to stay in the hospital for 1-4 days after the surgery to monitor their recovery and manage any potential complications.
• For outpatient surgeries, the patient can return home on the same day as the surgery.

Open surgeries, such as some multilevel spinal fusions or scoliosis surgeries may be performed on an inpatient basis and the length of hospital stay depends on the type and complexity of the surgery. Minimally invasive surgeries, such as discectomies, may be performed on an outpatient basis.

Surgical procedure

Eating and drinking are typically not allowed for 6 hours before the procedure. The procedure begins with the patient being placed under anesthesia (complex procedures and open surgeries require general anesthesia).

• The surgeon makes several small incisions in the patient's back.
• The robotic guidance system is positioned over the surgical site.
• The robotic arm (which is controlled by the surgeon) is equipped with a camera and surgical instruments that are inserted through the small incisions in the patient's back.
• The surgeon uses the robotic arm to maneuver the instruments and perform the surgery.
• Throughout the surgery, the robotic guidance system provides real-time images of the patient's spine, allowing the surgeon to visualize the surgical site with clarity and precision.

Once the surgery is complete, the surgical instruments are removed, and the small incisions are sutured. The patient is then moved to a recovery area where his/her vital signs are monitored.

Recovery After Robotic Spinal Surgery

The rate and time of recovery after a robot-assisted surgery depends on the complexity of the procedure. Lumbar spinal fusion or multilevel spinal fusion surgeries may take longer to recover compared to a discectomy surgery.

• What happens when the anesthesia wears off? After the effect of anesthesia wears off, most patients experience some degree of pain and drowsiness from the surgical procedure. Intravenous or injectable pain-relieving medication is administered initially, and as the severity of pain decreases, oral medication is started.
• How to care for the surgical site? The surgical incision site needs to be cleaned daily and checked for signs of infection. It is recommended to strictly follow the surgeon’s instructions for at least the first two weeks post-surgery.
• When is it possible to walk or move around? Walking is encouraged as early as possible. Patients work with physical and occupational therapists to learn the safest ways to walk, dress, sit, stand, and take part in other activities without putting added stress on the back. Even getting out of bed requires a special technique—known as log-rolling—to avoid twisting the spine.

Any concerning symptoms that emerge during the recovery period must be discussed with the surgeon as soon as possible.

The Future of Robotic Spine Surgery

Robot-assisted surgery has been described as an enabling technology (which means that it helps the surgeon perform surgery better). Robotic technology in surgery can be helpful in several ways, including pre-surgical planning, automatically generated alignment calculations, and precise and accurate intraoperative guidance.

To justify the high cost, robotic capabilities will need to expand beyond placing pedicle screws in fusion surgery. More research is needed in exploring the capabilities of the spine robot in assisting with faster and safer spinal cord and nerve decompressions, more accurate artificial disc and inter-body fusion implantation, safe and accurate tumor resection and reconstruction, and spinal osteotomies.