Robotic-assisted spine surgery: hype or game-changer?

Robotic-assisted spine surgery (RASS) has emerged as a potential advancement in spinal instrumentation, yet its comparative efficacy remains debated. This meta-analysis aimed to evaluate the accuracy, safety, and operative efficiency of RASS versus conventional freehand/navigation techniques, assess the impact of surgeon experience and robotic systems, and analyze secondary outcomes, such as complications and revision rates. A systematic review and meta-analysis followed PRISMA guidelines, incorporating 13 studies (5 RCTs, 3 prospective trials, 5 retrospective analyses) from PubMed, Embase, and other databases. Eligibility criteria included adult patients undergoing thoracolumbar/cervical pedicle screw placement. Primary outcomes were screw accuracy (Gertzbein-Robbins Grade A) and breach rates (> 2 mm); secondary outcomes included neurological injury, infection, revision surgery, and operative time. Data were analyzed using fixed/random-effects models, with subgroup analyses by pathology, robotic system, and surgeon experience. RASS demonstrated significantly higher perfect screw accuracy (94.2% vs. 85.1%; OR 2.41, p < 0.001) and lower breach rates (3.8% vs. 11.4%; OR 0.32, p < 0.001). Neurological injuries (1.9% vs. 4.3%; OR 0.45, p = 0.001) and revision surgeries (3.1% vs. 5.2%; OR 0.59, p = 0.02) were reduced, though operative times were longer (+ 12.4 min, p = 0.001). SSI rates showed a non-significant trend favouring RASS (2.5% vs. 3.7%; OR 0.67, p = 0.09). Subgroup analyses revealed greater benefits in deformity cases (OR 2.67), with Mazor systems (OR 2.55) and experienced surgeons (OR 4.55 after > 30 cases) achieving the best outcomes. RASS significantly improves screw accuracy and reduces complications compared to conventional techniques, particularly in complex cases and with surgeon proficiency. While operative times are marginally longer, the clinical benefits support its adoption, pending cost-effectiveness evaluations and individualized training programs.