Elsevier

World Neurosurgery

Volume 125, May 2019, Pages e1057-e1062
World Neurosurgery

Original Article
Effect of Robot-Assisted Surgery on Lumbar Pedicle Screw Internal Fixation in Patients with Osteoporosis

https://doi.org/10.1016/j.wneu.2019.01.243Get rights and content

Objective

We sought to compare clinical outcomes of robot-assisted versus conventional freehand fluoroscopy-assisted lumbar pedicle screw insertion in patients with osteoporosis.

Methods

This study included 80 patients with osteoporosis and lumbar disease treated with pedicle screw internal fixation in the Department of Spine Surgery, Beijing Jishuitan Hospital between June 2016 and July 2018. Patients were randomly assigned to receive either robot-assisted pedicle screw insertion (experimental group) or freehand fluoroscopy-assisted pedicle screw insertion (control group). The accuracy of screw placement was assessed with postoperative computed tomography. Operative time, pedicle screw placement time, radiation exposure to the medical team, and intraoperative blood loss were recorded.

Results

A total of 427 pedicle screws were inserted in 80 patients; 202 pedicle screws were placed in the experimental group, and 225 pedicle screws were placed in the control group. The accuracy of screw placement was significantly higher with robot-assisted pedicle screw insertion (98.5% [199/202]) compared with that achieved with the freehand technique (91.6% [206/225]) (P < 0.05). Robot-assisted pedicle screw insertion was associated with reductions in the mean total pedicle screw placement time (27.60 ± 8.58 vs. 32.26 ± 10.48 minutes), radiation exposure to the medical team (2.23 ± 0.62 vs. 3.35 ± 0.80 fluoroscopic images), and intraoperative blood loss (254.75 ± 115.34 vs. 356.25 ± 141.00 mL; P < 0.05). The mean operative time did not differ significantly between the groups.

Conclusions

Robot-assisted pedicle screw insertion is a more effective surgical option for patients with osteoporosis who present with various spine diseases compared with fluoroscopy-assisted freehand screw placement techniques.

Introduction

The aging population and improvements in life expectancy have led to a variety global public health issues.1, 2 Specifically, the annual incidence rates of osteoporosis and spinal degenerative diseases are increasing. Although pedicle screw internal fixation is a technique used for surgical treatment of spinal pathologies, complications with pedicle screw systems commonly arise in elderly patients. In particular, internal fixation failure and nerve injury can occur when the pedicle screws are placed in osteoporotic vertebrae, as screw insertion may breach the cortical wall.3, 4 Despite the availability of bone cements that can be used to enhance screw anchorage and the stability of internal fixation in osteoporotic vertebrae, microfracture of cortical bone can decrease the holding strength of the screw and increase the risk of bone cement leakage.

Previous studies have shown that achieving accurate screw placement by controlling the angle and trajectory of the pedicle screw without compromising the integrity of the cortical bone is important to enhance the safety of fixation in spinal disorders.5, 6, 7 Accordingly, new technologies provide new options for clinicians. The “TiRobot” orthopedic robot (TINAVI Medical Technologies Co., Ltd., Fenton, Missouri, USA) provides a new technology for the precise placement of pedicle screws. The emergence of this technology may improve the precision of surgical planning, shorten operative time, reduce intraoperative blood loss, and decrease intraoperative radiation exposure to the medical team. The objective of this study was to compare radiologic and clinical outcomes obtained with robot-assisted versus conventional freehand fluoroscopy-assisted pedicle screw insertion in patients with osteoporosis.

Section snippets

Study Population

Patients with osteoporosis and lumbar disease were enrolled in the Department of Spine Surgery, Beijing Jishuitan Hospital between June 2016 and July 2018. Inclusion criteria were 1) age ≥50 years; 2) bone mineral density <80 mg/cm3, evaluated using quantitative computed tomography; 3) diagnosis of a degenerative lumbar disease (e.g., degenerative disk disease, degenerative spondylolisthesis, spondylolytic listhesis, degenerative scoliosis); and 4) treatment with pedicle screw fixation.

Results

This study included 80 patients (25 men and 55 women) with a mean age of 67.71 years (range, 54–80 years). The patients' baseline characteristics are summarized in Table 1. Overall, 35 patients had lumbar spinal stenosis, 26 patients had lumbar disk herniation, and 19 patients had lumbar spondylolisthesis. In the experimental group, 40 patients (12 men and 28 women) with a mean age of 67.55 years (range, 54–78 years) underwent robot-assisted pedicle screw insertion. In the control group, 40

Discussion

The present study compared the radiologic and clinical outcomes of robot-assisted versus conventional freehand fluoroscopy-assisted pedicle screw insertion in patients with osteoporosis and degenerative lumbar disease. The results showed that 98.5% of pedicle screws had a perfect intrapedicular localization after robot-assisted insertion, compared with 91.6% after placement with the freehand technique. In accordance with these findings, previous studies showed that robot-assisted insertion of

Conclusion

The results of the present study show that robot-assisted pedicle screw insertion improves the accuracy of pedicle screw placement and decreases intraoperative blood loss, without increasing operative time, compared with traditional freehand fluoroscopy-assisted pedicle screw insertion in patients with osteoporosis and lumbar diseases. Furthermore, radiation exposure to the medical team was less during robot-assisted surgery. These data suggest that robot-assisted pedicle screw insertion is a

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      The subgroup analysis showed that the ROSA (MD, 74.00; [95% CI, 51.81 to 96.19]) robot-assisted technique was associated with longer operative time than the conventional freehand technique (Supplementary Figure 23). Two studies (92 participants, 661 pedicle screws) compared the differences in per pedicle screw time.28,39 The pooled estimates (Supplementary Figure 24) showed no difference in pedicle screw time between robotic-assisted techniques and the conventional freehand technique (MD, -1.20; [95% CI, -3.17 to 0.77]).

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    Conflict of interest statement: This work was supported by the National Key R&D Program of China [2016YFC0105800] and the National High Technology Research and Development Program of China [2015AA043201].

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