CT-Based Image-Guided Navigation and the DaVinci Robot in Spine Oncology: Changing Surgical Paradigms.

The benefits of image-guided navigation and robotics in spine surgery include improving accuracy of pedicle screw placement compared with freehand techniques, serving as a critical adjunct to minimal access surgery (MAS), and reducing radiation exposure for operating room personnel. Whereas these modalities have been beneficial for degenerative conditions, deformity, and trauma, they are becoming transformational in the treatment of primary malignant, metastatic, and benign spine tumors. Integration of these techniques has been a critical development in reducing morbidity for an often medically frail cancer population and improving targeted tumor resection. Navigation has aided the transition from long-segment to short-segment polymethyl methacrylate (PMMA)-augmented pedicle screw fixation used both for percutaneous reconstruction of unstable spines and more recently in open separation surgery for spinal cord decompression. Navigated instruments are becoming important adjuncts in the development of MAS for separation surgery, creating osteotomy trajectories to achieve wide or marginal en bloc excisions for primary malignant tumors and targeting intraosseous benign tumors. In tumor surgery, robotic integration with navigation may offer additional benefits to accurate placement of pedicle screws, but interest in this domain is focused on the da Vinci surgical system (Intuitive, Sunnyvale, CA) for roboticassisted resection of benign paraspinal nerve sheath tumors, principally schwannomas and ganglioneuromas.