Robotics Reduces Radiation Exposure in Minimally Invasive Lumbar Fusion Compared With Navigation : Spine

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Robotics Reduces Radiation Exposure in Minimally Invasive Lumbar Fusion Compared With Navigation

Shahi, Pratyush MBBS, MS(Ortho)a; Vaishnav, Avani MBBSa; Araghi, Kasra BSa; Shinn, Daniel BSa; Song, Junho BSa; Dalal, Sidhant BSa; Melissaridou, Dimitra MDa; Mai, Eric BSa; Dupont, Marcel BSa; Sheha, Evan MDa; Dowdell, James MDa; Iyer, Sravisht MDa,b; Qureshi, Sheeraz A. MD, MBAa,b

Author Information
Spine 47(18):p 1279-1286, September 15, 2022. | DOI: 10.1097/BRS.0000000000004381
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Abstract

Spine surgery requires image guidance for localization of level and instrumentation. The reliance becomes even more vital in minimally invasive spine surgery (MISS) due to the limited ability to visualize and palpate anatomic landmarks.1 This leads to increased exposure to ionizing radiation to everyone in the operating room (OR), especially the surgeon and surgical staff where routine long-term exposure can lead to complications like cataract, leukemia, and other malignancies.2–5

The increased radiation exposure in MISS and its associated risks have driven the advent of newer technologies like navigation and robotics over the last two decades.6–9 These modalities decrease the dependence on fluoroscopy and thus, have been reported to reduce surgeons’ exposure to ionizing radiation. Although studies have been conducted comparing radiation exposure with robotics or navigation to that with traditional fluoroscopy,10–17 there has been no such comparative study between robotics and navigation.

The purpose of this study was, therefore, to compare robotics and navigation for minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) in terms of fluoroscopy time and radiation dose. A secondary objective was to compare the operative time demand with the two modalities.

MATERIALS AND METHODS

Study Design and Patient Cohort

This was an institutional review board–approved retrospective cohort study. Patients who had undergone primary or revision one-level or two-level MI-TLIF (Qureshi-Louie class 2)18 for the treatment of degenerative lumbar pathology between April 2017 and November 2021 were included. All procedures were performed by a fellowship-trained orthopedic spine surgeon at an academic institution. Patients were stratified into two cohorts based on the modality used for surgery: navigation and robotics (navigation 2017–2019, robotics 2019–2021, resulting in prospective cohorts of consecutive patients for each modality).

Navigation Workflow

Skin-based navigation (Stryker SpineMask; Stryker Corp., Kalamazoo, MI) was used as previously described in the literature.19,20 After OR setup and prepping/draping of the patient, the SpineMask was placed above the surgical field. The equipment and patient position were registered with the Ziehm Vision C-arm. After registration, a computed tomography (CT) scan was performed during which the surgeon and surgical staff stood behind lead barriers and hence, were not exposed to the radiation. The pedicle screws were then placed followed by MI-TLIF.

Robotics Workflow

The ExcelsiusGPS robotic system (Globus Medical Inc., Audubon, PA) was used as described previously in the literature.21 It is floor-mounted and equipped with integrated navigation and a rigid arm. After OR setup and prepping/draping of the patient, a dynamic reference base and a surveillance marker were placed in the posterior superior iliac spines through stab incisions. A temporary intraoperative CT fixture was attached to the surveillance marker. An intraoperative spin was done with the Ziehm Vision C-arm (the surgeon and surgical staff were not exposed to this radiation) and images were transferred to the robot. Planning of the pedicle screws and interbody was done on the screen after which headless screws were placed through the robotic rigid arm (Figure 1) followed by MI-TLIF.

F1
Figure 1:
(A) Intraoperative planning of pedicle screws (trajectory, diameter, and length) and interbody placement using the robot’s integrated navigation platform. (B) Placing of the screw through the rigid robotic arm.

MI-TLIF Technique

Surgical technique was performed as previously described in the literature.22–27 Briefly, MI-TLIF was performed through a tubular retractor with unilateral facetectomy, disk preparation, placement of an expandable interbody cage (Altera; Globus Medical Inc.) and bilateral percutaneous pedicle screw construct in all patients. Navigation (skin-based or robotic) was utilized in all cases to dock the tubular retractor and prepare the disk. The Globus Interbody Solutions update (August 2020) for the robot allows for planning of cage placement and superimposes the position of the cage while preparing the disk. This allows the surgeon to do the disk preparation in a more targeted and precise manner (Figure 2). Fluoroscopy was utilized to confirm the position of the pedicle screws, placement and expansion of the interbody cage, and rod passage.

F2
Figure 2:
Disk preparation (A) and interbody placement using robotic navigation (B).

Data Collection

Following data were collected and managed using REDCap (Research Electronic Data Capture)28,29 hosted at Weill Cornell Medicine Clinical and Translational Science Center supported by the National Center For Advancing Translational Science of the National Institute of Health under award number: UL1 TR002384:

  • Preoperative data: patient demographics (age, sex, body mass index, American Society of Anesthesiologists class, age-adjusted Charlson Comorbidity Index).
  • Operative data: type of surgery (primary/revision), number of fusion levels, operative time (time of incision to time of closure), time for setup and image capture (induction end time to incision time), total OR time (in room to out of room time), radiation exposure (fluoroscopy time for surgical procedure, fluoroscopy time for image capture, total fluoroscopy time, % of radiation for surgical procedure, % of radiation for image capture, and total radiation dose).

Statistical Analysis

The two cohorts were compared using the χ2 test and Fisher exact test for categorical variables, and the Student t test and Mann-Whitney U test for normally and non-normally distributed continuous variables respectively. Significance was defined at P-value ≤0.05, and all analyses were performed using the IBM Statistical Package for the Social Sciences (SPSS), version 25 (IBM Corp., Armonk, NY).

RESULTS

A total of 244 patients (111 patients in the robotics cohort, 133 patients in the navigation cohort) were included in the study. There was no significant difference between the cohorts in terms of age, sex, body mass index, age-adjusted Charlson Comorbidity Index, American Society of Anesthesiologists class, number of primary/revision surgeries, and number of fusion levels (Table 1).

TABLE 1 - Comparison Between the Robotics and Navigation Cohorts in Terms of Demographics, Surgery Type, and Number of Fusion Levels
Robotics Navigation P
Age (mean±SD) (yr) 59.45±12.81 57.81±13.25 0.327
Sex [n (%)] 0.343
 Female 56 (50.4) 59 (44.4)
 Male 55 (49.6) 74 (55.6)
BMI (mean±SD) (kg/m2) 27.6±5.1 27.88±6.21 0.701
ASA class [n (%)] 0.775
 I 10 (9) 14 (10.5)
 II 96 (86.5) 115 (86.5)
 III 5 (4.5) 4 (3)
Age-adjusted CCI (mean±SD) 2.11±1.63 2±1.79 0.595
Surgery type [n (%)] 0.194
 Primary 79 (71.2) 94 (70.7)
 Revision 27 (28.8) 21 (29.3)
Fusion levels [n (%)] 0.385
 1 86 (77.5) 109 (81.2)
 2 25 (22.5) 24 (18.8)
ASA indicates American Society of Anesthesiologists; BMI, body mass index; CCI, Charlson Comorbidity Index.

For one-level transforaminal lumbar interbody fusion (TLIF), the fluoroscopy time for surgical procedure, total fluoroscopy time, total radiation dose, and % of radiation for surgical procedure were significantly less with robotics compared with navigation (11 vs. 15 s, P<0.001; 20 vs. 25 s, P<0.001; 38 vs. 42 mGy, P=0.05; 58% vs. 65%, P=0.021). There was no significant difference between the two groups in fluoroscopy time for image capture (9 vs. 9 s, P=0.399) (Table 2). Although the time for setup and image capture was significantly less with robotics (22 vs. 25 min, P<0.001) and operative time was significantly greater with robotics (103 vs. 93 min, P<0.001), there was no significant difference in the total OR time (145 vs. 141 min, P=0.25) (Table 3).

TABLE 2 - Comparison Between the Robotics and Navigation Cohorts in Terms of Fluoroscopy Time and Radiation Dose for One-level and Two-level TLIF Surgeries
Fluoroscopy Time for Surgical Procedure (s) Fluoroscopy Time for Image Capture (s) Total Fluoroscopy Time (s) % of Radiation for Surgical Procedure % of Radiation for Image Capture Total Radiation Dose (mGy)
One-level TLIF
 Robotics (n=86) 11 (8–14) 9 (9–9) 20 (17–23) 58% (22 mGy) 42% 38 (23.15–53.75)
 Navigation (n=109) 15 (10–22) 9 (9–9) 24.5 (20–31) 65.5% (31 mGy) 34.5% 41.7 (33.05–63.3)
P <0.001 0.399 <0.001 0.021 0.047 0.005
Two-level TLIF
 Robotics (n=25) 18 (13–20.5) 9 (9–9) 25 (18.5–34.5) 73% (29 mGy) 27% 40.4 (31.15–57.9)
 Navigation (n=24) 30 (14–40) 9 (8–9) 39 (29–49) 76% (50 mGy) 24% 66.4 (55.8–85.3)
P 0.003 0.690 0.001 0.992 0.992 0.001
Bold values are significant at P < 0.05.
TLIF indicates transforaminal lumbar interbody fusion.

TABLE 3 - Comparison Between the Robotics and Navigation Cohorts in Terms of Time Demand for One-level and Two-level TLIF Surgeries
One-level (Robotics: n=86 Navigation: n=109) Two-level (Robotics: n=25 Navigation: n=24) Overall (Robotics: n=111 Navigation: n=133)
Time for Setup and Image Capture Operative Time Total OR Time Time for Setup and Image Capture Operative Time Total OR Time Time for Setup and Image Capture Operative Time Total OR Time
Robotics 22 (17.75–25) 103.5 (89.75–79) 145 (132–157.5) 24 (20.5–26) 145 (131.5–171.5) 193 (166–213.5) 22 (19–25) 108 (94–131) 151 (134–174)
Navigation 25 (21–30) 93 (79–104) 141 (125.5–154) 25 (22.25–28.75) 132.5 (122–159.25) 176 (167–214.5) 25 (21.5–30) 96 (80.5–121.5) 146 (129.5–169.5)
P <0.001 <0.001 0.25 0.11 0.141 0.645 <0.001 <0.001 0.165
Bold values are significant at P < 0.05.
OR indicates operating room; TLIF, transforaminal lumbar interbody fusion.

Analysis of two-level TLIFs also showed similar findings. The fluoroscopy time for surgical procedure, total fluoroscopy time, and total radiation dose were significantly less with robotics compared with navigation (18 vs. 30 s, P=0.003; 25 vs. 39 s, P<0.001; 38 vs. 42 mGy, P=0.05; 58% vs. 65%, P=0.021). However, the % of radiation for surgical procedure, although less with robotics compared with navigation, was not significantly different (73% vs. 76%, P=0.992). There was no significant difference between the two groups in fluoroscopy time for image capture (9 vs. 9 s, P=0.690) (Table 2). Comparing the time demand for two-level TLIFs between the two groups, no significant difference was found in the time for setup and image capture, operative time, or total OR time (24 vs. 25 min, P=0.110; 145 vs. 132 min, P=0.141; 193 vs. 176 min, P=0.645) (Table 3).

Analysis of the robotics cases was done separately to compare the radiation exposure before (n=51) and after (n=60) the Interbody Solutions update. No significant difference was found between the two groups for both one-level and two-level TLIFs (Table 4).

TABLE 4 - Comparison of the Robotics Cases Before and After the Interbody Solutions Update in Terms of Fluoroscopy Time and Radiation Dose for One-level and Two-level Transforaminal Lumbar Interbody Fusion Surgeries
One-level (Before: n=45; After: n=41) Two-level (Before: n=6; After: n=19)
Fluoroscopy time for surgical procedure (s) Before: 10.96±6.49 After: 12.78±4.36 P=0.134 Before: 14.67±4.08 After: 17.53±6.67 P=0.335
Fluoroscopy time for image capture (s) Before: 8.84±2.36 After: 8.34±3.11 P=0.399 Before: 6.17±4.4 After: 10.42±4.63 P=0.127
Total fluoroscopy time (s) Before: 19.61±5.3 After: 21.07±4.28 P=0.062 Before: 21±4.29 After: 28.16±9.66 P=0.095
Total radiation dose (mGy) Before: 40.19±16.51 After: 49.13±72 P=0.415 Before: 33.16±11.67 After: 42.24±22.12 P=0.08

DISCUSSION

Over the last few decades, spine surgery has advanced from fluoroscopy to navigation and now to robotics.30,31 Newer robotic platforms offer integrated navigation and a rigid arm to place the screws and hence, have been reported to increase pedicle screw accuracy. A recent systematic review by Naik et al32 found robot-assisted pedicle screw insertion to be superior in accuracy compared with other modalities like CT navigation, 2-dimensional and 3-dimensional fluoroscopy, and freehand techniques. Another meta-analysis by Zhou et al33 demonstrated a significantly higher screw accuracy with robotic guidance using the Mazor platform compared with computer-assisted navigation. A recent comparative study of robotics and navigation conducted by the senior author demonstrated the ability to place pedicle screws with greater diameter and length with robotic assistance, although with similar accuracy.34 Although a few studies have been conducted comparing robotics and navigation in terms of pedicle screw accuracy and size, literature is still void on the topic of radiation exposure, which happens to be a major area of concern surrounding MISS. To the best of our knowledge, this is the first study comparing radiation exposure with robotics and navigation in minimally invasive elective lumbar fusion.

MISS relies heavily on image guidance due to a lack of direct visualization and increases the radiation-related risks for the surgeon and surgical staff as a result of the cumulative radiation exposure.35–38 Robotics and navigation have been reported to reduce radiation exposure during spine surgery but no study has been conducted to date comparing the two modalities. We, in the current study, found that the fluoroscopy time for the surgical procedure, total fluoroscopy time, and total radiation dose were significantly less with robotics compared with navigation for both one-level and two-level MI-TLIFs. The % of radiation for the surgical procedure was significantly less with robotics (58% vs. 66% with navigation) for one-level TLIFs and although less for two-level TLIFs as well (73% vs. 76% with navigation), the difference was not statistically significant. This reduction in radiation exposure is beneficial to both the surgeon and the patient. Possible explanations for reduction in radiation exposure with robotics compared with navigation are the following: (1) Navigation without a rigid robotic arm allows for more potential shifts in registration as well as skive which can sometimes require the reliance on fluoroscopy intraoperatively. (2) Robotics can possibly lead to more accurate docking of the tubular retractor and interbody cage compared with navigation. (3) There seems to be more intraoperative reliability on the robotic technology compared with navigation (probably because it is more upgraded, advanced, and accurate) that possibly can lead to a decrease in the requirement for fluoroscopy. However, we do address that these reasons might be dependent on the surgeon and the subjective comfort with either imaging modality.

No significant difference was found in the radiation exposure before and after the Interbody Solutions update in the robotics cohort. A possible explanation is that although the update does allow for more targeted disk preparation (as the planned location of the cage in the disk space can be visualized on the screen), the interbody cage is still placed and expanded under fluoroscopic guidance.

A drawback of robotics in spine surgery frequently reported is the increase in time demand. Most of the studies comparing robotics to traditional fluoroscopy have shown an increase in the operative time with the former.39–42 However, a conclusion regarding this cannot be drawn because of the following issues with these studies: (a) variables in terms of approach (open vs. percutaneous), surgeon experience, and the definition of operative time, (b) use of older robotic systems, and (c) unaccountability of the learning experience of the surgeon with the new technology. The operative time previously reported by the senior author using fluoroscopy for one-level MI-TLIF was 112 minutes.43 The current study found that for one-level MI-TLIFs, although the time for setup and image capture is significantly lesser with robotics (22 vs. 25 min with navigation) and the operative time is significantly greater with robotics (103 vs. 93 min with navigation), the total OR time had no significant difference. The increased operative time with robotics compared with navigation can be explained by the time taken to plan the pedicle screws and interbody on the screen before placing them in the patient and also the initial learning curve of the surgeon. Although the same trend was seen in two-level MI-TLIFs, the difference between robotics and navigation was not significant for any of the three variables. Recently, the meta-analysis by Zhou et al33 had also demonstrated no significant difference in the intraoperative time when comparing Mazor robotic guidance to navigation.

A major barrier in adopting robotics for spine surgery is the high initial and maintenance costs. Although robotic assistance has been associated with increased pedicle screw accuracy and size compared with navigation, data regarding hospital costs and long-term clinical outcomes is still scarce. Hence, the cost-effectiveness of the utilization of robotics in spine surgery is still unclear.44 Although more future work on this topic is required, the current study definitely helps to justify the high cost of the robotic platform by demonstrating a significant reduction in radiation exposure compared with navigation. Addressing a major concern around MISS, this finding can eventually motivate more surgeons to adopt this technology.

This study has a few limitations. Radiation was measured as the absorbed dose (mGy) and not the effective dose (mSv). The absorbed dose is the amount of energy deposited by radiation in a person and is a measurable physical quantity, whereas the effective dose is the addition of equivalent doses to all organs and reflects the overall radiation-related health risk.45 The study was conducted at a single center and included patients operated by one surgeon. This made the findings less generalizable as intraoperative radiation exposure can tend to depend on the surgeon, workflow, technique, and subjective comfort with either imaging modality. While generalizability is a limitation of the study, the potential benefit of a single-surgeon study specifically when considering radiation exposure with two different intraoperative imaging platforms is that it controls for differences in surgical technique-related radiation usage. We also believe that with the significant risks of radiation exposure in minimally invasive procedures, this study does highlight overall low rates of radiation exposure and provides surgeons with intraoperative workflow and techniques utilizing both navigation and robotics that can help reduce radiation exposure to themselves and other OR personnel. The learning curve of the surgeon for robotics was not accounted for. The surgeon had been using navigation for MI-TLIF since 2010 and the cohort included in this study was from 2017 to 2021. This suggests that the significantly greater radiation exposure with navigation compared with robotics was not a result of the learning curve of the surgeon for navigation. In fact, we believe that had the learning curve for robotics been accounted for, the difference might have been even more significant with our technique of MI-TLIF. Although the time for setup and image capture, operating time, and the total OR time were separately assessed, we lacked the data for time per screw that could have allowed for a more detailed analysis.

From our findings, we can conclude that robotics compared with navigation leads to a significant reduction in radiation exposure both for the surgeon and the patient. Although it does lead to a slight increase in the OR time, it is not statistically significant. However, multicenter prospective trials are required to establish these findings.

Key Points

  • This study aimed to compare robotics and navigation in terms of radiation exposure in minimally invasive elective lumbar fusion.
  • A secondary objective was to compare the operative time demand with the two modalities.
  • Patients who had undergone one-level or two-level MI-TLIF were included.
  • Robotics was found to cause a significant reduction in radiation exposure both to the surgeon and patient compared with navigation.
  • No significant difference was seen between the two modalities in the OR time.

References

1. Carlson BB, Saville P, Dowdell J, et al. Restoration of lumbar lordosis after minimally invasive transforaminal lumbar interbody fusion: a systematic review. Spine J. 2019;19:951–958.
2. Srinivasan D, Than KD, Wang AC, et al. Radiation safety and spine surgery: systematic review of exposure limits and methods to minimize radiation exposure. World Neurosurg. 2014;82:1337–1343.
3. Kumar A, Merrill RK, Overley SC, et al. Radiation exposure in minimally invasive transforaminal lumbar interbody fusion: the effect of the learning curve. Int J Spine Surg. 2019;13:39–45.
4. Mountford PJ, Temperton DH. Recommendations of the International Commission on Radiological Protection (ICRP) 1990. Eur J Nucl Med. 1992;19:77–79.
5. Mroz TE, Abdullah KG, Steinmetz MP, Klineberg EO, Lieberman IH. Radiation exposure to the surgeon during percutaneous pedicle screw placement. J Spinal Disord Tech. 2011;24:264–267.
6. Qureshi S, Lu Y, McAnany S, Baird E. Three-dimensional intraoperative imaging modalities in orthopaedic surgery: a narrative review. J Am Acad Orthop Surg. 2014;22:800–809.
7. Sivaganesan A, Clark NJ, Alluri RK, Vaishnav AS, Qureshi SA. Robotics and spine surgery: lessons from the personal computer and industrial revolutions. Int J Spine Surg. 2021;15(suppl 2):S21–S27.
8. Alluri RK, Avrumova F, Sivaganesan A, Vaishnav AS, Lebl DR, Qureshi SA. Overview of robotic technology in spine surgery. HSS J. 2021;17:308–316.
9. Urakawa H, Sivaganesan A, Vaishnav AS, Sheha E, Qureshi SA. The feasibility of 3D intraoperative navigation in lateral lumbar interbody fusion: perioperative outcomes, accuracy of cage placement and radiation exposure. Global Spine J. 2021. [Epub ahead of print].
10. Kim CW, Lee YP, Taylor W, Oygar A, Kim WK. Use of navigation-assisted fluoroscopy to decrease radiation exposure during minimally invasive spine surgery. Spine J. 2008;8:584–590.
11. Arif S, Brady Z, Enchev Y, Peev N, Encheva E. Minimising radiation exposure to the surgeon in minimally invasive spine surgeries: a systematic review of 15 studies. Orthop Traumatol Surg Res. 2021;107:102795.
12. Klingler JH, Scholz C, Hohenhaus M, et al. Radiation exposure to scrub nurse, assistant surgeon, and anesthetist in minimally invasive spinal fusion surgery comparing 2D conventional fluoroscopy with 3D fluoroscopy-based navigation: a randomized controlled trial. Clin Spine Surg. 2021;34:E211–E215.
13. Jamshidi AM, Massel DH, Liounakos JI, et al. Fluoroscopy time analysis of a prospective, multi-centre study comparing robotic- and fluoroscopic-guided placement of percutaneous pedicle screw instrumentation for short segment minimally invasive lumbar fusion surgery. Int J Med Robot. 2021;17:e2188.
14. De Biase G, Gassie K, Garcia D, et al. Perioperative comparison of robotic-assisted versus fluoroscopically guided minimally invasive transforaminal lumbar interbody fusion. World Neurosurg. 2021;149:e570–e575.
15. Good CR, Orosz L, Schroerlucke SR, et al. Complications and revision rates in minimally invasive robotic-guided versus fluoroscopic-guided spinal fusions: the MIS ReFRESH prospective comparative study. Spine (Phila Pa 1976). 2021;46:1661–1668.
16. Tarawneh AM, Salem KM. A systematic review and meta-analysis of randomized controlled trials comparing the accuracy and clinical outcome of pedicle screw placement using robot-assisted technology and conventional freehand technique. Global Spine J. 2021;11:575–586.
17. Vaishnav AS, Merrill RK, Sandhu H, et al. A review of techniques, time demand, radiation exposure, and outcomes of skin-anchored intraoperative 3D navigation in minimally invasive lumbar spinal surgery. Spine (Phila Pa 1976). 2020;45:E465–E476.
18. Louie PK, Vaishnav AS, Gang CH, et al. Development and initial internal validation of a novel classification system for perioperative expectations following minimally invasive degenerative lumbar spine surgery. Clin Spine Surg. 2021;34:E537–E544.
19. Bovonratwet P, Gu A, Chen AZ, et al. Computer-assisted navigation is associated with decreased rates of hardware-related revision after instrumented posterior lumbar fusion. Glob Spine J. 2021. [Epub ahead of print].
20. Virk S, Qureshi S. Navigation in minimally invasive spine surgery. J Spine Surg. 2019;5(suppl 1):S25–S30.
21. Avrumova F, Sivaganesan A, Alluri RK, Vaishnav A, Qureshi S, Lebl DR. Workflow and efficiency of robotic-assisted navigation in spine surgery. HSS J. 2021;17:302–307.
22. Vaishnav AS, Saville P, McAnany S, et al. Retrospective review of immediate restoration of lordosis in single-level minimally invasive transforaminal lumbar interbody fusion: a comparison of static and expandable interbody cages. Oper Neurosurg (Hagerstown). 2020;18:518–523.
23. Lovecchio FC, Vaishnav AS, Steinhaus ME, et al. Does interbody cage lordosis impact actual segmental lordosis achieved in minimally invasive lumbar spine fusion? Neurosurg Focus. 2020;49:E17.
24. Overley SC, McAnany SJ, Anwar MA, et al. Predictive factors and rates of fusion in minimally invasive transforaminal lumbar interbody fusion utilizing rhBMP-2 or mesenchymal stem cells. Int J Spine Surg. 2019;13:46–52.
25. Qureshi S. Pearls: improving upon minimally invasive transforaminal lumbar interbody fusion. Clin Orthop Relat Res. 2019;477:501–505.
26. Virk S, Vaishnav AS, Sheha E, et al. Combining expandable interbody cage technology with a minimally invasive technique to harvest iliac crest autograft bone to optimize fusion outcomes in minimally invasive transforaminal lumbar interbody fusion surgery. Clin Spine Surg. 2021;34:E522–E530.
27. Verma R, Virk S, Qureshi S. Interbody fusions in the lumbar spine: a review. HSS J. 2020;16:162–167.
28. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381.
29. Harris PA, Taylor R, Minor BL, et al. REDCap Consortium, The REDCap consortium: building an international community of software partners. J Biomed Inform. 2019;95:103208.
30. Cong T, Sivaganesan A, Mikhail CM, et al. Facet violation with percutaneous pedicle screw placement: impact of 3D navigation and facet orientation. HSS J. 2021;17:281–288.
31. Virk S, Qureshi S, Sandhu H. History of spinal fusion: where we came from and where we are going. HSS J. 2020;16:137–142.
32. Naik A, Smith AD, Shaffer A, et al. Evaluating robotic pedicle screw placement against conventional modalities: a systematic review and network meta-analysis. Neurosurg Focus. 2022;52:E10.
33. Zhou LP, Zhang RJ, Sun YW, Zhang L, Shen CL. Accuracy of pedicle screw placement and four other clinical outcomes of robotic guidance technique versus computer-assisted navigation in thoracolumbar surgery: a meta-analysis. World Neurosurg. 2021;146:e139–e150.
34. Shafi KA, Pompeu YA, Vaishnav AS, et al. Does robot-assisted navigation influence pedicle screw selection and accuracy in minimally invasive spine surgery? Neurosurg Focus. 2022;52:E4.
35. Skovrlj B, Belton P, Zarzour H, Qureshi SA. Perioperative outcomes in minimally invasive lumbar spine surgery: a systematic review. World J Orthop. 2015;6:996–1005.
36. Perez AA, Yoon ES, Iyer S, et al. Computed tomography and magnetic resonance imaging overlay in the spine for surgical planning: a technical report. HSS J. 2022;18:439–447.
37. Alluri RK, Sivaganesan A, Vaishnav AS, Qureshi SA. Robotic guided minimally invasive spine surgery. IntechOpen. 2021.
38. Vaishnav AS, Othman YA, Virk SS, Gang CH, Qureshi SA. Current state of minimally invasive spine surgery. J Spine Surg. 2019;5(suppl 1):S2–S10.
39. Keric N, Doenitz C, Haj A, et al. Evaluation of robot-guided minimally invasive implantation of 2067 pedicle screws. Neurosurg Focus. 2017;42:E11.
40. Kantelhardt SR, Martinez R, Baerwinkel S, Burger R, Giese A, Rohde V. Perioperative course and accuracy of screw positioning in conventional, open robotic-guided and percutaneous robotic-guided, pedicle screw placement. Eur Spine J. 2011;20:860–868.
41. Solomiichuk V, Fleischhammer J, Molliqaj G, et al. Robotic versus fluoroscopy-guided pedicle screw insertion for metastatic spinal disease: a matched-cohort comparison. Neurosurg Focus. 2017;42:E13.
42. Farber SH, Pacult MA, Godzik J, et al. Robotics in spine surgery: a technical overview and review of key concepts. Front Surg. 2021;8:578674.
43. Vaishnav AS, Gang CH, Qureshi SA. Time-demand, radiation exposure and outcomes of minimally invasive spine surgery with the use of skin-anchored intraoperative navigation: the effect of the learning curve. Clin Spine Surg. 2022;35:E111–E120.
44. Wang TY, Park C, Dalton T, et al. Robotic navigation in spine surgery: where are we now and where are we going? J Clin Neurosci. 2021;94:298–304.
45. Fisher DR, Fahey FH. Appropriate use of effective dose in radiation protection and risk assessment. Health Phys. 2017;113:102–109.
Keywords:

robotics; navigation; radiation exposure; time demand; minimally invasive; lumbar fusion; TLIF; 3

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