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Oh: Commentary on “A Propensity Score-Matched Cohort Study Comparing 3 Different Spine Pedicle Screw Fixation Methods: Freehand, Fluoroscopy-Guided, and Robot-Assisted Techniques”
The landscape of spine surgery has undergone a remarkable transformation with the emergence of advanced technologies. While robotics in spine surgery made its debut in the early 2000s, the past decade has seen a resurgence of interest in robotic-assisted procedures, likely driven by improved technology and refinements in technique [1].
The integration of robotics into spine surgery promises numerous opportunities. One of its foremost advantages lies in its capacity to guide pedicle screw insertion with real-time navigation based on preoperative planning. This precision not only minimizes tissue trauma but also reduces radiation [2]. Additionally, it has been used to complement lateral interbody fusion surgery, percutaneous iliac screw fixation, spinal endoscopy, and sacroiliac joint fusion, further enhancing its applicability across various spinal procedures [3,4].
In the March special issue of Neurospine, Hwang et al. [5] conducted a comprehensive comparative analysis of 3 pedicle screw fixation methods in their article titled “A Propensity Score-Matched Cohort Study Comparing 3 Different Spine Pedicle Screw Fixation Methods: Freehand, Fluoroscopy-Guided, and Robot-Assisted Techniques”. To date, most studies have been single- or double-arm studies, with few clinical outcomes reported [6,7]. This article sheds more light through a deeper comparative analysis.
The authors performed a retrospective cohort study utilizing propensity score matching to compare the efficacy of robotic-assisted surgery with conventional techniques. Specifically, they analyzed C-arm guided minimally invasive transforaminal lumbar interbody fusion and freehand open posterior lumbar interbody fusion involving 162 patients with lumbar degenerative disease. Each group comprised 54 patients after propensity score matching. The study evaluated various parameters, including surgical accuracy, radiological outcomes, clinical improvement, and complications for a mean of 2.2-year follow-up.
The findings highlighted the superiority of robotic-assisted surgery in achieving precise pedicle screw placement compared to conventional methods. Notably, the robotic-assisted group demonstrated significantly higher rates of grade A and B screws (> 98%), indicating optimal positioning as per the Gertzbein-Robbins scale. Moreover, the incidence of facet joint violation, as evaluated by the Babu scale, was notably lower in the robotic-assisted group (84.3%) compared to the other groups, reinforcing the precision afforded by robotic guidance.
The study also explored the impact on clinical outcomes, including postoperative pain, functional improvement, and the occurrence of clinical adjacent segmental disease. While no significant differences were observed among the 3 surgical cohorts in this 2.2-year follow-up, the study emphasized the critical role of accurate screw placement in adverting possible longer-term complications.
Overall, these findings underscore the benefit of robotic technology in spine surgery. While the widespread use of robotics is currently not mainstream, I am optimistic that more studies like this will prove invaluable in reshaping the future of robotic spine surgery, offering safer, more effective interventions and superior outcomes for patients.


Conflict of Interest

The author has nothing to disclose.


1. Perfetti DC, Kisinde S, Rogers-LaVanne MP, et al. Robotic spine surgery: past, present, and future. Spine (Phila Pa 1976) 2022;47:909-21.
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2. Staartjes VE, Klukowska AM, Schröder ML. Pedicle screw revision in robot-guided, navigated, and freehand thoracolumbar instrumentation: a systematic review and meta-analysis. World Neurosurg 2018;116:433-43.
crossref pmid
3. Tabarestani TQ, Sykes D, Murphy KR, et al. Beyond placement of pedicle screws - new applications for robotics in spine surgery: a multi-surgeon, single-institution experience. Front Surg 2022;9:889906.
crossref pmid pmc
4. Pham MH, Diaz-Aguilar LD, Shah V, et al. Simultaneous robotic single position oblique lumbar interbody fusion with bilateral sacropelvic fixation in lateral decubitus. Neurospine 2021;18:406-12.
crossref pmid pmc pdf
5. Hwang YH, Ha BJ, Kim HC, et al. A propensity score-matched cohort study comparing 3 different spine pedicle screw fixation methods: freehand, fluoroscopy-guided, and robot-assisted techniques. Neurospine 2024;21:83-94.
crossref pmid pmc pdf
6. Joseph JR, Smith BW, Liu X, et al. Current applications of robotics in spine surgery: a systematic review of the literature. Neurosurg Focus 2017;42:E2.
7. Lopez IB, Benzakour A, Mavrogenis A, et al. Robotics in spine surgery: systematic review of literature. Int Orthop 2023;47:447-56.
crossref pmid pdf

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