Workflow and Efficiency of Robotic-Assisted Navigation in Spine Surgery.

Abstract

The increasing interest in improving intraoperative workflow and efficiency is evident from the growing body of literature on spinal robotics. The first robotic-assisted system for adult spine surgery received US Food and Drug Administration (FDA) clearance in 2004 [4]. Newer robotic systems with integrated surgical navigation have shown the potential for improved accuracy, shorter time-per-screw placement, less fluoroscopy/radiation time, and shorter hospital stays over freehand techniques [8,9]. One early iteration, the Mazor SpineAssist system, provided 6° of freedom of mobility for surgical instrumentation in addition to close to optimal screw positioning and placement [5]. Mazor Robotics released the second generation (Renaissance Guidance System) in 2011, which was followed by the third generation (Mazor X) in 2016. (Mazor Robotics was purchased by Medtronic in 2018.) The most recent version is the Mazor X Stealth Edition; first used in 2019, it combines navigation and robotics in a single platform [5]. Recent competitors include ExcelsiusGPS (Globus Medical, Inc., Audubon, PA, USA), ROSA Spine (Zimmer Biomet Robotics, formerly Medtech SA, Montpellier, France), and Cirq (BrainLab, Munich, Germany) [12]. While multiple studies have examined the operative metrics of robotic-assisted surgery, few have offered a practical understanding of the types of surgeries that can be performed using various systems and the intraoperative workflows required. Here we review these issues, with the aim of providing a foundation for surgeons seeking to incorporate robotics into their practice in an efficient manner. We focus on the Mazor X Robotic Guidance System and the ExcelsiusGPS Robotic Navigation Platform; each has a different physical relationship to the operating room table. The Mazor X is a table-mounted system while the ExcelsiusGPS is a freestanding system with optical arrays. The Mazor X has an inherent stability due to its physical connection to the patient but, due to the weight of the bedmounted arm, it cannot maintain that stability if the patient’s position changes. In addition, a 2 to 3 mm incision must be made on the patient’s right side for posterior superior iliac spine (PSIS) pin placement. In contrast, the ExcelsiusGPS is a freestanding system that does not attach to either the bed or the patient. This allows the patient to change positions without interfering with robotic arm stability. The ROSA Spine received FDA clearance in 2016, and BrainLab’s Cirq received FDA clearance in 2019. Similar to the ExcelsiusGPS, ROSA is a freestanding system that uses a robotic arm and navigation camera, each mounted to mobile bases. BrainLab Cirq is similar to the Mazor X, as it is table-mounted.