{"paper_id":"4236adef-95bd-48c7-a399-3d3d039f192d","body_text":"A Retrospective Cohort Study Comparing Robot-Assisted and Conventional Fluoroscopy- guided Pedicle Screw Placement | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article A Retrospective Cohort Study Comparing Robot-Assisted and Conventional Fluoroscopy- guided Pedicle Screw Placement Hassan Seif, Emanuele Maragno, Marco Gallus, Michael Schwake, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6252242/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Pedicle screw placement is crucial for restoring stability. Emerging robot assisted technologies may offer enhanced precision and reduced radiation exposure This study aimed to compare the accuracy and clinical outcomes of robot-assisted versus conventional fluoroscopy-guided pedicle screw placements. Methods: This retrospective cohort study included 218 patients undergoing pedicle screw placement at a single spine centre between 2019 and 2023. Of these, 105 patients underwent robot-assisted surgery, and 113 underwent conventional fluoroscopy guided surgery. The primary outcome was screw placement accuracy according to the Gertzbein-Robbins classification. Secondary outcomes included estimated blood loss (EBL), radiation exposure, length of hospital stay (LOS), clinical outcome according to the Macnab classification, postoperative pain, and adverse events. Results: Robot-assisted surgery demonstrated significantly higher accuracy in screw placement, with 93.33% achieving Grade 0 accuracy versus 78.76% in the conventional group (p=0.002). The unadjusted relative risk (RR) for achieving Grade 0 screw placement in the robot-assisted group was 0.3139 (95% CI: 0.1412-0.6978, p=0.005). Moreover, robot-assisted procedures were associated with reduced EBL, shorter LOS, and lower radiation exposure times. Postoperative pain scores (VAS) and clinical outcomes were also more favourable in the robot-assisted group. Duration of surgery, adverse events, and revision rates were comparable between the two groups. Conclusion: This study supports the clinical benefits of robot-assisted pedicle screw placement, particularly in achieving higher accuracy and reducing EBL and LOS. Future research should explore long-term outcomes, cost-effectiveness, and the generalizability of these results to a broader patient population. Health sciences/Medical research/Study design/Clinical trials Health sciences/Medical research/Outcomes research Spinal fusion Robotics Navigation Figures Figure 1 Figure 2 Figure 3 Introduction Pedicle screw fixation is a cornerstone of spinal surgery, employed to restore spinal stability following trauma, tumors, or degenerative conditions [ 1 ]. Traditionally, pedicle screw placement has relied on freehand techniques or fluoroscopic guidance, which, despite their widespread use, present challenges in achieving high accuracy. The thoracic spine, with its smaller pedicles and proximity to vital neural structures, poses particular challenges, as screw misplacement can lead to severe complications, such as neurological injury or screw loosening, ultimately compromising patient outcomes [ 2 ]. In recent years, advances in surgical technology have introduced several methods aimed at improving pedicle screw placement accuracy. Among these, robot-assisted technology has emerged as a promising solution, offering precision through real-time imaging, intraoperative guidance, and robotic-arm-assisted positioning [ 3 – 6 ]. Robotic systems integrate surgical planning workstations, intraoperative imaging, and control software, enabling continuous trajectory verification and minimizing risks of misplacement, even in minimally invasive procedures [ 4 , 7 ]. Robot-assisted pedicle screw placement not only enhances precision but also standardizes techniques, reducing outcome variability and aiding less experienced surgeons in achieving consistent results [ 8 , 9 ]. Additionally, robotic systems reduce fluoroscopy use, thereby minimizing radiation exposure for both patients and surgical teams, a significant advantage over traditional methods [ 3 , 10 ]. Enhanced visualization provided by robotic systems is particularly beneficial in anatomically complex cases, aligning with the growing demand for spinal procedures [ 11 ]. Nevertheless, limitations such as increased infection and hematoma risks, possibly linked to additional incisions and reduced tactile feedback, remain concerns [ 12 , 13 ]. Conversely, freehand techniques guided by fluoroscopy may lower infection risks and utilize tactile feedback, but they remain prone to errors stemming from surgeon fatigue and higher radiation exposure [ 7 , 10 ]. These trade-offs underscore the need for a systematic comparison of robotic-assisted and conventional freehand methods. This study aims to compare the clinical and surgical outcomes of robot-assisted and conventional freehand pedicle screw placement. Key parameters include placement accuracy, complication rates, estimated blood loss, length of hospital stays, and infection rates. Furthermore, we aimed to investigate whether robotic guidance may reduce irradiation time in the operating room, minimizing the cumulative exposure of the surgical team. By elucidating the strengths and limitations of each approach, this study seeks to provide evidence to guide healthcare providers in selecting the most appropriate method based on patient needs, institutional capabilities, and surgeon expertise. Methods and Materials This retrospective cohort study was conducted to compare robot-assisted and conventional fluoroscopy-guided pedicle screw placement in spinal surgery. Data were collected from a single medical center between 01/2019 and 12/2023. Data were retrospectively extracted from the hospital’s electronic medical records, including surgery reports, anaesthesia protocol radiographic assessments, and postoperative follow-up notes. The study was conducted according to the declaration of Helsinki and approved by the institutional review board (Ethikkommission Westfalen-Lippe, Approval No. 2024 214-f-S). All procedures involving human participants were performed in accordance with institutional and national ethical guidelines. Given the retrospective design and use of anonymized patient data, the requirement for individual informed consent was waived by the Ethics Commission. Eligibility criteria: Eligible participants included patients aged 18 years and older who underwent pedicle screw placement for spinal stabilization due to fractures or degenerative conditions. Patients were categorized into two groups based on the surgical technique employed: robot-assisted or conventional fluoroscopy-guided pedicle screw placement. Patients under the age of 18 were excluded from the study. The allocation to each treatment group dependent on logistical reasons and resource availability at time of surgery. All surgeries were performed by, or under the supervision of two experienced surgeons HS and SS. Surgical methods: In the first cohort, percutaneous, fluoroscopic guided screw insertion technique was employed. The procedure began with the insertion of a Jamshidi needle to establish the pedicle trajectory, under fluoroscopic X-ray guidance (anteroposterior and lateral views) throughout the surgery to ensure accurate screw placement. In the second cohort, a robotic-assisted technique utilizing the Mazor X™ Stealth Edition (Medtronic, Minneapolis, MN, USA) was implemented. Preoperative imaging, including fluoroscopic X-rays and computed tomography (CT), was processed with specialized software on the Mazor X workstation. This enabled three-dimensional anatomical reconstruction, pedicle measurements, trajectory optimization, and implant selection. The finalized surgical plan was then transferred to the robotic system, which facilitated precise screw placement during the procedure, which was conducted in accordance with the manufacturer's guidelines, in a percutaneous and minimally invasive fashion. Data collection and outcomes: The primary outcome of this study was the accuracy of pedicle screw placement, assessed using the Gertzbein-Robbins classification system [ 14 ]. This system categorizes pedicle screw placement based on postoperative imaging into grades ranging from 0 to 3. Grade 0 indicates full containment within the pedicle with no cortical breach, representing optimal placement, while Grades 1 to 3 indicate breaches of increasing severity: less than 2 mm for Grade 1, 2–4 mm for Grade 2, and greater than 4 mm for Grade 3. Grades 1–3 were collectively categorized as suboptimal placements. This classification system is widely validated for evaluating pedicle screw placement in spinal surgeries [ 14 ]. The accuracy grade for each surgical case was determined by the highest screw grade observed, reflecting the expectation that experienced surgeons should place every screw with perfect accuracy. Postoperative imaging was independently reviewed by two study authors (HS, MS) to determine accuracy grades. In cases of discrepancies, additional author EM, was consulted for resolution. Because we assume that experienced surgeons would place pedicle screw very accurately [ 15 , 16 ] and we expected an additional value of robotic-assisted surgery, we compared Grade 0 placements - defined as optimal placement - to Grade 1–3 placements – defined as suboptimal placement. Secondary outcome variables included estimated blood loss (EBL), length of hospital stay (LOS), infection rates, hematoma occurrence, revision rates, and postoperative pain levels assessed by both the Visual Analog Scale (VAS) for pain intensity and the Macnab classification for overall functional improvement and patient satisfaction [ 17 ]. Risk of bias: Potential sources of bias were addressed by applying consistent eligibility criteria for all participants and reviewing radiological data uniformly. Additionally, selection bias was potentially minimized by using data from a single center, where the surgical approach—robot-assisted or conventional—was determined based on standard clinical practice rather than random assignment. Statistical Methods : The study population consisted of all eligible patients who underwent pedicle screw placement at the specialized spine unit during the study period. Given the retrospective design, no prior power calculation was conducted. Statistical analyses were carried out using IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY). Numeric variables were presented as means and standard deviations, with group comparisons conducted using two-sided t-tests. Ordinal variables were described using medians and interquartile ranges (IQR) and compared between groups using the Mann-Whitney U (MWU) test. Categorical variables were analyzed using chi-square (χ²) tests for variables with multiple categories, and Fisher’s exact test was applied for dichotomous variables. Statistical significance was defined as a p-value of < 0.05. Regression analysis was performed to calculate odd ratio (OR) relative risk (RR) and the corresponding 95% confidence intervals (CI) for associations between the surgical techniques and the outcomes. Loss to follow-up was not a concern due to the nature of the retrospective study design. Sensitivity and subgroup analyses were not performed due to sample size constraints, which limited the statistical power required for these additional analyses. The reporting of this study followed STROBE guidelines for cohort studies [ 18 ]. Results Participants: A total of 240 patients were initially screened for eligibility. After reviewing medical records, 22 patients were excluded due to missing follow-up data or failure to meet the inclusion criteria, such as not undergoing pedicle screw placement because of alternative medical interventions or incomplete surgical data. This resulted in a final cohort of 218 patients, of whom 105 underwent robot-assisted pedicle screw placement, and 113 underwent conventional fluoroscopy-guided screw placement. All 218 patients completed follow-up and were included in the final analysis. Baseline characteristics: The baseline characteristics of the study participants, including demographic, clinical, and surgical data, are presented in Table 1 . The mean age of participants was 67 years (± 13), and the majority were female, comprising 58% (n = 61) of the robot-assisted group and 66% (n = 75) of the conventional group. The mean body mass index (BMI) was significantly higher in the robot-assisted group (28.69 ± 5.017) compared to the conventional group (26.75 ± 4.096). The primary surgical indications included degenerative disc disease, spinal canal stenosis, spondylolisthesis, and vertebral fractures. No significant differences were observed between the groups regarding the distribution of surgical indications (p > 0.05). Further details on patient characteristics, including comorbidities and preoperative status, are outlined in Table 1 . There were no missing data for the primary outcome of pedicle screw placement accuracy. Additionally, all 218 patients had complete data for other variables, including EBL, LOS, and postoperative complications. Table 1 Demographic Characteristics Variable Robot-assisted (n = 105) Control Group (n = 113) P-value (Statistical Test used) Sex 0.212 (Fisher’s Exact) Female (n, %) 61 (58.1%) 75 (66.4%) Male (n, %) 44 (41.9%) 38 (33.6%) Age (Mean, SD) 64.72 (± 13,13) 66 (± 13,28) 0.873 (two tailed t-test) BMI (Mean, SD) 28.69 (± 5,017) 26.75 (± 4,096) 0.002 (two-tailed t-test) Repeated surgery (n, %) 36 (34.29%) 43 (38.05%) 0.576 (Fisher’s Exact) VAS pre-OP (Mean, SD) 7.72 (± 0,7) 7.6 (± 0.59) 0.1647 (Two-tailed t-test) Indication for surgery 0.628 (χ²-test) Degenerative Disc Disease (n, %) 31(29.52%) 34(30.08%) Spinal canal stenosis (n, %) 19(18.09%) 24(21.23%) Spondylolisthesis (n, %) 23(21.90%) 29(25.66%) Fracture (n, %) 32(30.47%) 26(23.00%) BM Score 0.404 (χ²-test) 1 (n, %) 9 (8.6%) 20 (17.70%) 2 (n, %) 53 (50.48%) 20 (17.70%) 3 (n, %) 32 (30.48%) 34 (30.09%) 4 (n, %) 1 (0.95%) 1 (8.85%) ASA: American Society of Anaesthesiologists Physical Status Classification System; BMI: Body Mass Index; M/F: Male/Female; SD: Standard Deviation; OP: Operation; VAS: Visual Analogue Scale Primary Outcome: Accuracy of Pedicle Screw Placement The accuracy of pedicle screw placement, assessed using the Gertzbein-Robbins classification, was significantly higher in the robot-assisted group compared to the conventional group. In the robot-assisted cohort, 93.33% of patients got a perfect screw placement (n = 98), classified as Grade 0 (optimal placement), compared to 78.76% (n = 89) in the conventional group (p = 0.002; OR 0.265, 95% CI: 0.109–0.645) (Fig. 1 ). The unadjusted relative risk (RR) for achieving Grade 0 placement in individuals within the robot-assisted group was 0.3139 (95% CI: 0.1412–0.6978, p = 0.005). In terms of absolute risk reduction, the number needed to treat (NNT) to achieve a Grade 0 screw placement with robot assistance was 6.862 (95% CI: 4.229–18.191). This indicates that approximately seven patients need to undergo robot-assisted surgery to prevent one suboptimal screw placement (Grade 1 or higher). Nevertheless, revision surgery due to screw misplacement was not significantly higher in the control cohort (4 (3.54%) in comparison to 2 (1.9%); p = 0.684). Additionally, an analysis based on the placement per screw revealed comparable trends as mentioned in Table 2 . Secondary Outcomes The robot-assisted group demonstrated significantly lower estimated blood loss (EBL) compared to the conventional group. The mean EBL in the robot-assisted group was 156.43 ± 102.22 mL, significantly lower than the 563.72 ± 280.48 mL observed in the conventional group ( p < 0.001), with a large effect size (Cohen's d = 1.93). Radiation exposure time was also significantly reduced in the robot-assisted group, with a mean of 109.27 ± 45.01 seconds compared to 239.88 ± 103.17 seconds in the conventional group ( p < 0.001), demonstrating another large effect size (Cohen's d = 1.64). However, mean surgery time did not differ significantly between the groups. The length of hospital stay (LOS) was notably shorter in the robot-assisted group (6.12 ± 0.7 days) compared to the conventional group (7.6 ± 2.59 days; p < 0.0001). Postoperative pain, measured using the Visual Analog Scale (VAS), was significantly lower in the robot-assisted group (2.73 ± 0.72) than in the conventional group (2.94 ± 0.67; p = 0.013; Fig. 2 ). Patient-reported outcomes based on the Macnab classification showed that a higher proportion of patients in the robot-assisted group achieved “Excellent” or “Good” results (Macnab grades 4–5: 73.33%) compared to the conventional group (45.13%; p = 0.021, OR 0.544, 95% CI: 0.326–0.909). Conversely, “Fair” or “Poor” outcomes (Macnab grades 1–3) were more frequent in the conventional group (54.87%) than in the robot-assisted group (29.52%). An interesting finding was that the accuracy of screw placement in the robot-assisted cohort improved over time. Most suboptimal placements occurred within the first 40 procedures. Afterwards, only one case with a Gertzbein-Robbins Grade 1 placement was observed (Fig. 3 ). Postoperative Complications Postoperative complications and adverse events were generally similar between the robot-assisted and conventional groups, with comparable rates of revision surgeries, screw misplacements, and other adverse events, such as cerebrospinal fluid leaks and hematomas. Although surgical site infections were reported only in the robot-assisted group, this difference was not statistically significant. Overall, the complication profiles for both techniques appeared consistent. Further details of patients’ outcome are outlined in Table 2 . Table 2 Postoperative patient outcomes Variable Robot-assisted (n = 105) Control Group (n = 113) P-value (Statistical Test used) Estimated blood loss (ml, Mean, SD) 156.43 (± 102.22) 563.72 (± 280.48) < 0.001 (Two-tailed t-test) Cohen's D: 1.929434 Radiation time (Sec, Mean, SD) 109.27 (± 45.01) 239.88 (± 103.17) < 0.001 (Two-tailed t-test) Cohen's D: 1.641 Surgery time (min, Mean, SD) 221.51 (± 86.73) 236.93 (± 94.69) 0.212 (Two-tailed t-test) LOS (days, Mean, SD) 6.12 (± 0.7) 7.6 (± 2.59) < 0.0001 (Two-tailed t-test) VAS post-OP 2.73 (± 0.72) 2.94 (± 0.67) 0.013 (Two-tailed t-test) Number of screws implanted per patient (Sum) 508 570 0.698 (χ²-test) Four (n, %) 71 (67.62%) 68 (60.18%) Six (n, %) 25 (23.81%) 32 (28.32%) Eight (n, %) 8 (7.19%) 12 (10.62%) Ten (n, %) 1 (0.95%%) 1 (0.88%) Gertzbein-Robbins Classification per patient 0.029 (χ²-test) 0 (n, %) 98 (93.33%) 89 (78.76%) 1 (n, %) 4 (3.81%) 17 (15.04%) 2 (n, %) 3 (2.85%) 5 (4.42%) 3 (n, %) 0 2 (1.77%) Gertzbein-Robbins dichotomic per patient 0.007 (Fisher’s Exact) OR 0.265 (95% CI 0.109–0.645, P = 0.0034) Optimal (0) (n, %) 98 89 Suboptimal (1–3) (n, %) 6 25 Gertzbein-Robbins dichotomic, per screw 0.007 (Fisher’s exact) OR 0.1689 (95% CI 0.1689–0.7788, p = 0.009) Optimal (0) (n, %) 499 (98.23%) 543 (95.26%) Suboptimal (1–3) (n, %) 9 (1.77%) 27 (4.74%) Postoperative Macnab (points, Median, IQR) 4 (3–4) 3 (3–4) < 0.001 (MWU) 5 (n, %) 14 (13.33%) 3 (2.65%) 4 (n, %) 63 (59.05%) 48 (42.48%) 3 (n, %) 21 (20%) 57 (50.44%) 2 (n, %) 7 (6.67%) 3 (2.65%) 1 (n, %) 0 2 (1.77%) Macnab 4–5 (n, %) 77 (73.33%) 51 (45.13%) 0.021 (Fisher’s Exact) OR 0.544 (95% CI 0.326–0.909, P < 0.020) Macnab 1–3 (n, %) 51 (29.52%) 62 (54.87%) Revision Surgery (n, %) 7 (6.67%) 7 (6.19%) > 0.99 (Fisher’s Exact) Screw misplacement (n, %) 2 (1.9%) 4 (3.54%) 0.684 (Fisher’s Exact) Surgical site infection (n, %) 2 (1.9%) 0 > 0.99 (Fisher’s Exact) CSF leak (n, %) 2 (1.9%) 2 (1.77%) > 0.99 (Fisher’s Exact) Hematoma (n, %) 1 (0.95%) 1 (0.88%) > 0.99 (Fisher’s Exact) Medical Adverse events (n, %) 2 (1.9%) 3 (2.6%) > 0.99 (Fisher’s Exact) CI: Confidence Interval; CSF: Cerebrospinal fluid; IQR: Interquartile Range; LOS: Length of Stay; MWU: Mann-Whitney U test; OP: Operation; OR: Odds ratio; SD: Standard Deviation; VAS: Visual Analogue Scale Discussion Accuracy of Pedicle Screw Placement This study aimed to compare the accuracy and clinical outcomes of robot-assisted versus conventional fluoroscopy-guided pedicle screw placement in spinal surgery. The results demonstrated that robot-assisted techniques led to significantly higher accuracy rates in pedicle screw placement, as measured by the Gertzbein-Robbins classification, with 93.33% of screws in the robot group achieving an optimal placement (Grade 0) compared to 78.76% in the conventional group. These results are consistent with previous systematic reviews showing that robot-assisted techniques improve pedicle screw placement accuracy [ 3 , 4 ]. For example, the systematic review and meta-analysis of 19 studies by Fatima et al. found that robotic techniques significantly reduced misplacement rates compared to freehand methods, reinforcing the benefits we observed in our study [ 3 ]. Robotic assistance also standardizes screw placement techniques, reducing variability across practitioners [ 8 ], and provides essential support to less experienced surgeons who may face challenges in achieving precise placements with freehand methods [ 9 ]. The addition of advanced intraoperative navigation systems and digital volume tomography (DVT) technology further enhances the precision of robotic systems by offering real-time 3D imaging, which enables continuous verification of screw trajectory and reduces the risk of malposition, even in complex anatomical cases [ 19 ]. These imaging systems likely play a significant role in improving accuracy, as they decrease reliance on fluoroscopic guidance and provide detailed anatomical views during the procedure. In the past Li et al., demonstrated that both robot-assisted and navigation-assisted techniques significantly improve accuracy and safety of pedicle screw placement compared to freehand methods, however, the robotic systems showed superior precision over navigation-based approaches in scoliosis surgery. A systematic review further confirmed the enhanced accuracy and safety of robot-assisted techniques, underscoring their clinical advantages over navigation [ 20 , 21 ]. An additional noteworthy finding from this study was the observed increase in accuracy over time in the robotic cohort, with most suboptimal placements occurring within the first 40 procedures. After this initial phase, only one case with a Gertzbein-Robbins Grade 1 placement was recorded, indicating that as experience with the robotic system grew, placement accuracy reached consistently high levels. This learning curve effect suggests that proficiency with robotic systems can further optimize accuracy and underscores the importance of experience and training in maximizing the benefits of robotic-assisted surgery. A study by Torii et al. analyzed the learning curve of robotic-assisted pedicle screw placement by comparing the performance of junior and experienced surgeons. The findings revealed that experienced surgeons achieved a plateau in accuracy after 25 cases, while junior surgeons required approximately 40 cases to reach similar levels of accuracy. Additionally, regression analysis indicated that significant reductions in surgical time and radiation exposure were observed after 30 cases, highlighting the steep learning curve associated with robotic systems. These results emphasize the necessity of adequate training and case volume to optimize the outcomes of robotic-assisted spinal procedures [ 9 ]. Similar results were also demonstrated in a trial published by Han et al. [ 22 ] Length of Hospital Stay (LOS), Estimated Blood Loss (EBL), and Radiation Time In our study, robot-assisted pedicle screw placement resulted in significantly lower estimated blood loss (EBL) and shorter length of hospital stay (LOS) compared to conventional techniques, findings that are consistent with prior research. Asada et al. (2024), in their analysis of 1,633 lumbar fusion patients, observed that the robot-navigated group experienced significantly reduced EBL and LOS, with no substantial increase in operative time or reoperation rates [ 23 ]. This suggests that robotic guidance contributes to more efficient and minimally invasive procedures without compromising safety. Similarly, Li et al. (2023), through a meta-analysis, found that robot-assisted techniques consistently reduced intraoperative blood loss and hospitalization duration [ 24 ]. This reduction in EBL and shorter recovery times may be attributed to the increased precision and control offered by robotic systems, which minimize tissue disruption and optimize surgical trajectories. In addition, Mason et al. (2014) highlighted that advanced imaging systems, such as 3D fluoroscopic navigation, improve screw placement accuracy, which indirectly reduces EBL and speeds up recovery. Their findings suggest that the accuracy provided by these imaging systems reduces intraoperative complications, thereby improving postoperative outcomes like LOS [ 19 ]. Furthermore, robot-assisted pedicle screw placement resulted in a significantly reduced radiation time in the operation room. This goes in line with previous reports from Lin et al. that observed an inverse correlation of radiation time and experience with robotic surgery [ 12 ]. Reducing the radiation time during surgery is essential to minimize the cumulative dose received by employees during their work. Novel advancements like MRI-based 3D registration and augmented reality integration represent promising steps toward radiation-free yet highly accurate robotic surgery, enabling enhanced visualization and safety [ 25 , 26 ]. Clinical Outcomes Furthermore, the result of this study regarding clinical outcomes favored the robot-assisted group, showing lower postoperative VAS pain scores and a higher percentage of patients achieving “Excellent” or “Good” outcomes on the Macnab classification. The improved pain and functional outcomes in the robotic cohort may partially reflect the precision of screw placement, which optimizes spinal stability and can reduce postoperative discomfort, a benefit noted in Li et al. (2023), whose meta-analysis reported that robot-assisted procedures resulted in improved patient-reported outcomes such as VAS and Oswestry Disability Index (ODI) scores, likely due to reduced intraoperative trauma and optimized screw placement [ 24 ]. Complications and adverse events The occurrence of adverse events, such as revision surgeries, screw misplacements, CSF leaks, and hematomas, was comparable between the robot-assisted and conventional groups, indicating similar safety profiles. This aligns with Asada et al., who reported no significant differences in reoperation or readmission rates between techniques [ 23 ]. Furthermore, Mason et al. indicated that advanced image guidance, such as 3D fluoroscopic navigation, can help enhance screw accuracy and minimize intraoperative errors, indirectly contributing to favorable clinical outcomes and comparable safety between techniques [ 19 ]. Marcus et al. reviewed five studies and found some support for fluoroscopy-guided techniques in terms of lower infection and adverse event rates [ 5 ]. However, the high precision of robotic systems in preventing screw misplacement may outweigh the minor increases in complications like infections and hematomas, especially given that our study and others report lower overall complication rates with robotic systems [ 3 – 5 ]. Effect on Operating Time Operating times were comparable between the robot-assisted and conventional groups, suggesting that proficiency mitigates robotic setup and calibration delays. This is consistent with findings from Li et al., Asada et al., and Han et al., which showed no significant increases in operative times with robotic surgery [ 22 – 24 ]. However, our findings contrast with those of Fatima et al. and Gao et al., both meta-analyses that reported a notable increase in operative times for robot-assisted procedures—approximately 20.5 and 22.7 minutes longer, respectively. The prolonged duration in these studies is often attributed to the initial setup and calibration requirements unique to robotic systems, which may introduce more complexity compared to the straightforward preparation needed for freehand techniques [ 3 , 4 ]. Future Prospects: Enhanced Preoperative Planning with AI and Personalized Treatment Robotic precision in pedicle screw placement supports advanced preoperative planning, with AI poised to optimize trajectories based on patient-specific anatomy. This innovation could enhance accuracy, reduce complications, and minimize revisions. The integration of AI into robotic platforms represents a critical avenue for research, advancing individualized treatment approaches [ 27 , 28 ]. Cost-effectiveness Despite concerns over the high costs of robotic spine surgery, a study by Menger et al. supports its cost-effectiveness, citing reduced complications, fewer infections, and shorter hospital stays. Improved pedicle screw accuracy alone could prevent approximately 9.47 revision surgeries annually, saving $ 314,661. Additionally, converting open surgeries to minimally invasive procedures saved $ 608,546 annually in a single center [ 29 ]. As AI integrates into robotic systems, the potential for personalized, efficient, and cost-effective spinal surgeries increases, further addressing concerns about costs while enhancing precision and patient outcomes. Limitations Several limitations must be considered when interpreting the results of this study. First, as a single-center retrospective cohort study, the findings may be subject to selection bias and residual confounding from unmeasured factors, such as surgeon experience and variations in technique. Although variables like preoperative VAS scores and BMI were recognized as potential confounders, they were not fully adjusted due to the study’s exploratory scope and sample size limitations. Future studies with larger samples and multi-center designs should incorporate comprehensive adjustments for these confounding variables to confirm the findings. Additionally, the relatively small sample size may limit the generalizability of these results. Moreover, long-term outcomes, such as screw loosening or spinal stability over time, were not addressed in this study, which restricts our ability to draw conclusions on the long-term efficacy of robot-assisted techniques. Imprecision in measurements, such as intraoperative blood loss estimation, may have introduced variability. Infection rates were noted, but there was no standardized postoperative infection control protocol across all patients, which may have influenced results. Lastly, the high cost and required training for robotic systems could limit accessibility, particularly in smaller facilities. Financial constraints and the investment in training and infrastructure needed to proficiently use robotic systems must be weighed against the potential improvements in patient outcomes [ 30 ]. The patient population in this study consisted primarily of individuals with degenerative spinal conditions and vertebral fractures, which may not fully represent other demographics. Consequently, results may not be universally applicable, especially in settings with varied patient profiles or healthcare resources. Institutions lacking access to robotic technology or trained teams may not experience the same benefits observed in this study. Future research across multiple centers is needed to validate these findings in diverse healthcare settings. Conclusion This retrospective cohort study demonstrates that robot-assisted pedicle screw placement improves the accuracy of screw placement and reduces intraoperative blood loss and hospital stays compared to conventional fluoroscopy-guided techniques. These results add to the available evidence supporting the benefits of robotic assistance in spinal surgery, reinforcing findings from previous research on its precision and efficiency. While robotic systems provide significant short-term benefits in spinal surgery, future research should focus on long-term outcomes, cost-effectiveness, and the wider generalizability of these results. As surgical technologies continue to evolve, robot-assisted techniques are likely to play an increasingly important role in enhancing surgical precision and patient care. Abbreviations ASA – American Society of Anaesthesiologists BMI – Body Mass Index CI – Confidence Interval CSF – Cerebrospinal Fluid CT – Computed Tomography DVT – Digital Volume Tomography EBL – Estimated Blood Loss IQR – Interquartile Range LOS – Length of Hospital Stay MWU – Mann-Whitney U test NNT – Number Needed to Treat ODI – Oswestry Disability Index OR – Odds Ratio RR – Relative Risk SD – Standard Deviation SPSS – Statistical Package for the Social Sciences STROBE – Strengthening the Reporting of Observational Studies in Epidemiology VAS – Visual Analog Scale Declarations Acknowledgment This research received no external funding. The study was conducted without financial support from public, commercial, or not-for-profit funding agencies. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Author Contribution H.S. and E.M. contributed equally as first authors. H.S. and S.S. performed the surgical procedures and collected the data. H.S. also wrote the initial draft of the manuscript. E.M. and M.S. developed the study design and contributed to manuscript revision and improvement. M.G., E.M., and M.S. conducted the statistical analysis. E.M. and M.G. performed the literature review. M.S. supervised the study as the senior author and ensured methodological rigor. All authors contributed to data interpretation, manuscript editing, and critical revisions. M.G. prepared the figures and tables. All authors reviewed the manuscript, approved the final version, and take full responsibility for its content. References Peul, W. C. & Moojen, W. A. Fusion for Lumbar Spinal Stenosis–Safeguard or Superfluous Surgical Implant? N Engl. J. Med. 374 , 1478–1479. 10.1056/NEJME1600955 (2016). Reisener, M. J., Pumberger, M., Shue, J., Girardi, F. P. & Hughes, A. P. Trends in Lumbar Spinal Fusion-a Literature Review. J. Spine Surg. 6 , 752–776. 10.21037/JSS-20-492 (2020). Fatima, N., Massaad, E., Hadzipasic, M., Shankar, G. M. & Shin, J. H. Safety and Accuracy of Robot-Assisted Placement of Pedicle Screws Compared to Conventional Free-Hand Technique: A Systematic Review and Meta-Analysis. Spine J. 21 , 181–192. 10.1016/J.SPINEE.2020.09.007 (2021). Gao, S., Lv, Z. & Fang, H. Robot-Assisted and Conventional Freehand Pedicle Screw Placement: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Eur. Spine J. 27 , 921–930. 10.1007/S00586-017-5333-Y (2018). Marcus, H. J., Cundy, T. P., Nandi, D., Yang, G. Z. & Darzi, A. Robot-Assisted and Fluoroscopy-Guided Pedicle Screw Placement: A Systematic Review. Eur. Spine J. 23 , 291–297. 10.1007/S00586-013-2879-1 (2014). Barzilay, Y., Liebergall, M., Fridlander, A. & Knoller, N. Miniature Robotic Guidance for Spine Surgery–Introduction of a Novel System and Analysis of Challenges Encountered during the Clinical Development Phase at Two Spine Centres. Int. J. Med. Robot . 2 , 146–153. 10.1002/RCS.90 (2006). Su, X. J. et al. Comparison of Accuracy and Clinical Outcomes of Robot-Assisted Versus Fluoroscopy-Guided Pedicle Screw Placement in Posterior Cervical Surgery. Global Spine J. 12 , 620–626. 10.1177/2192568220960406 (2022). Lieberman, I. H., Kisinde, S. & Hesselbacher, S. Robotic-Assisted Pedicle Screw Placement During Spine Surgery. JBJS Essent. Surg. Tech. 10 10.2106/JBJS.ST.19.00020 (2020). Torii, Y. et al. Accuracy of Robotic-Assisted Pedicle Screw Placement Comparing Junior Surgeons with Expert Surgeons: Can Junior Surgeons Place Pedicle Screws as Accurately as Expert Surgeons? J. Orthop. Sci. 28 , 961–965. 10.1016/J.JOS.2022.06.012 (2023). Farber, S. H. et al. Robotics in Spine Surgery: A Technical Overview and Review of Key Concepts. Front. Surg. 8 10.3389/FSURG.2021.578674/FULL (2021). Chen, H. Y. et al. Results of Using Robotic-Assisted Navigational System in Pedicle Screw Placement. PLoS One . 14 10.1371/JOURNAL.PONE.0220851 (2019). Lin, S., Wang, F., Hu, J. & Tang, L. yi Comparison of the Accuracy and Safety of TiRobot-Assisted and Fluoroscopy-Assisted Percutaneous Pedicle Screw Placement for the Treatment of Thoracolumbar Fractures. Orthop. Surg. 14 , 2955–2963. 10.1111/OS.13504 (2022). Patel, N. A. et al. Robot-Assisted Percutaneous Pedicle Screw Placement Accuracy Compared with Alternative Guidance in Lateral Single-Position Surgery: A Systematic Review and Meta-Analysis. J. Neurosurg. Spine . 39 , 443–451. 10.3171/2023.3.SPINE2329 (2023). Gertzbein, S. & Robbins, S. Accuracy of Pedicular Screw Placement in Vivo. Spine (Phila Pa 1990, 15 , 11–14, (1976). 10.1097/00007632-199001000-00004 Samdani, A. F. et al. Accuracy of Free-Hand Placement of Thoracic Pedicle Screws in Adolescent Idiopathic Scoliosis: How Much of a Difference Does Surgeon Experience Make? Eur. Spine J. 19 , 91–95. 10.1007/S00586-009-1183-6 (2010). Schulze, C. J., Munzinger, E. & Weber, U. Clinical Relevance of Accuracy of Pedicle Screw Placement. A Computed Tomographic-Supported Analysis. Spine (Phila Pa. 1976) . 23 , 2215–2220. 10.1097/00007632-199810150-00014 (1998). Macnab, I., Negative Disc & Exploration An Analysis of the Causes of Nerve-Root Involvement in Sixty-Eight Patients. J. Bone Joint Surg. Am. 53 , 891–903. 10.2106/00004623-197153050-00004 (1971). von Elm, E. et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies. Lancet 370 , 1453–1457. 10.1016/S0140-6736(07)61602-X (2007). Mason, A. et al. The Accuracy of Pedicle Screw Placement Using Intraoperative Image Guidance Systems. J. Neurosurg. Spine . 20 , 196–203. 10.3171/2013.11.SPINE13413 (2014). Li, C. et al. Safety and Accuracy of Cannulated Pedicle Screw Placement in Scoliosis Surgery: A Comparison of Robotic-Navigation, O-Arm-Based Navigation, and Freehand Techniques. Eur. Spine J. 32 , 3094–3104. 10.1007/S00586-023-07710-8/METRICS (2023). Al-Naseem, A. O. et al. Robot-Assisted Pedicle Screw Insertion versus Navigation-Based and Freehand Techniques for Posterior Spinal Fusion in Scoliosis: A Systematic Review and Meta-Analysis. Spine Deform . 12 , 1203–1215. 10.1007/S43390-024-00879-Y/TABLES/3 (2024). Han, X. et al. Safety and Accuracy of Robot-Assisted versus Fluoroscopy-Assisted Pedicle Screw Insertion in Thoracolumbar Spinal Surgery: A Prospective Randomized Controlled Trial. J. Neurosurg. Spine . 30 , 615–622. 10.3171/2018.10.SPINE18487 (2019). Asada, T. et al. Robot-Navigated Pedicle Screw Insertion Can Reduce Intraoperative Blood Loss and Length of Hospital Stay: Analysis of 1,633 Patients Utilizing Propensity Score Matching. Spine J. 24 , 118–124. 10.1016/J.SPINEE.2023.09.004 (2024). Li, Y. et al. Comparison of Short-Term Clinical Outcomes between Robot-Assisted and Freehand Pedicle Screw Placement in Spine Surgery: A Meta-Analysis and Systematic Review. J. Orthop. Surg. Res. 18 10.1186/S13018-023-03774-W (2023). Altorfer, F. C. S. et al. Robotic Pedicle Screw Placement with 3D MRI Registration: Moving Towards Radiation Free Robotic Spine Surgery. Spine J. 10.1016/J.SPINEE.2024.10.020 (2024). Staartjes, V. E., Seevinck, P. R., Vandertop, W. P., van Stralen, M. & Schröder, M. L. Magnetic Resonance Imaging-Based Synthetic Computed Tomography of the Lumbar Spine for Surgical Planning: A Clinical Proof-of-Concept. Neurosurg. Focus . 50 , 1–7. 10.3171/2020.10.FOCUS20801 (2021). Ahmed, A. K. et al. First Spine Surgery Utilizing Real-Time Image-Guided Robotic Assistance. Comput. Assist. Surg. (Abingdon) . 24 , 13–17. 10.1080/24699322.2018.1542029 (2019). Ma, C. et al. A Novel Surgical Planning System Using an AI Model to Optimize Planning of Pedicle Screw Trajectories with Highest Bone Mineral Density and Strongest Pull-out Force. Neurosurg. Focus . 52 10.3171/2022.1.FOCUS21721 (2022). Menger, R. P., Savardekar, A. R., Farokhi, F. & Sin, A. A. Cost-Effectiveness Analysis of the Integration of Robotic Spine Technology in Spine Surgery. Neurospine 15 , 216–224. 10.14245/NS.1836082.041 (2018). D’Souza, M. et al. Robotic-Assisted Spine Surgery: History, Efficacy, Cost, And Future Trends. Robot Surg. 6 , 9–23. 10.2147/RSRR.S190720 (2019). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-6252242\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Article\",\"associatedPublications\":[],\"authors\":[{\"id\":439502368,\"identity\":\"b0db28f5-c54c-43a9-b10a-7eebdc0f279f\",\"order_by\":0,\"name\":\"Hassan Seif\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Brüder St. Josef Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Hassan\",\"middleName\":\"\",\"lastName\":\"Seif\",\"suffix\":\"\"},{\"id\":439502369,\"identity\":\"bc0d6b8f-1f46-44c3-89de-d15023bb524c\",\"order_by\":1,\"name\":\"Emanuele Maragno\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University Hospital Muenster\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Emanuele\",\"middleName\":\"\",\"lastName\":\"Maragno\",\"suffix\":\"\"},{\"id\":439502370,\"identity\":\"8ff3c4d5-8623-4179-b87d-af0d0a8a0a66\",\"order_by\":2,\"name\":\"Marco Gallus\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of California San Francisco\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Marco\",\"middleName\":\"\",\"lastName\":\"Gallus\",\"suffix\":\"\"},{\"id\":439502371,\"identity\":\"b59e061a-4a67-4be6-a0e7-a00c12ce20c7\",\"order_by\":3,\"name\":\"Michael Schwake\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIie3PMYvCMBTA8ZSCLgHXFsR+hZRARSp+EZdKwS6Js5vdugiu/RgFoXNKwCnSNXLT4epQN+XuuIsI6hL0Nof8IWT68d4DwGR6y6B6DIDO9btlPydueiP2iwTdRzwhXrbdOCcxHGNJK2YR3ut36mo/B2FPR5CYTd2lnNJSziJmlRwP8tj2BUiwljgwkLDhihDEf0o+KaTdUofxSapbLIfB7rv5peucoMuURVHz9lmRhY4ACYMPKBktnCuJEItbliKR/hbS/+qKmObicCGJX8gYuylKfO1imcD+YTOiq4zgxipDD9XV5zGdh55uinb6f4HJZDKZHvsD1yRfDGSRGOkAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"University Hospital Muenster\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Michael\",\"middleName\":\"\",\"lastName\":\"Schwake\",\"suffix\":\"\"},{\"id\":439502375,\"identity\":\"212fef5f-077a-4553-a4f0-fe6c1331f21c\",\"order_by\":4,\"name\":\"Szabolcs Szeöke\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Brüder St. Josef Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Szabolcs\",\"middleName\":\"\",\"lastName\":\"Szeöke\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-03-18 10:38:31\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-6252242/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-6252242/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":81699252,\"identity\":\"3ee539b9-eb78-41f2-b383-c707d78a399a\",\"added_by\":\"auto\",\"created_at\":\"2025-04-30 13:02:19\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":22760,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ea bar diagram showing the accuracy of pedicle screw placement in the two cohorts. In the robot-assisted cohort optimal pedicle screw placement (Gertzbein-Robbins 0) was achieved in 93.33% of cases (n=98), whereas in control cohort optimal placement was achieved in 78.76% of the cases (n=89; p=0.002; OR 0.265, 95% CI: 0.109–0.645).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6252242/v1/1e98fc0e212dd5d12453bc93.png\"},{\"id\":81699153,\"identity\":\"27315bcc-b3ef-4f27-8a7a-69feed5b9491\",\"added_by\":\"auto\",\"created_at\":\"2025-04-30 13:01:20\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":216176,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ethe whisker plots demonstrate the significance reduction in radiation time, length of hospital stay (LOS), and estimated blood loss in the robotic-assisted cohort (magenta) in comparison to the control cohort (green, all \\u003cem\\u003ep\\u003c/em\\u003e\\u0026lt;0.5)\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6252242/v1/08768c6968ab866de517d8ff.png\"},{\"id\":81699150,\"identity\":\"793a8577-0deb-449e-b591-a0bb1a528062\",\"added_by\":\"auto\",\"created_at\":\"2025-04-30 13:01:18\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":43932,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe run chart illustrates the accuracy of screw placement according to the Gertzbein-Robbins classification over time (Y-axis), comparing the conventional and robot-assisted cohorts. The green line represents the control cohort, while the continuous magenta line represents the robot-assisted cohort. Notably, in the robot-assisted cohort, there was a marked improvement in accuracy over time, with only one suboptimal screw placement occurring after the 40\\u003csup\\u003eth\\u003c/sup\\u003e procedure. In contrast, the accuracy in the conventional cohort did not show a significant improvement over time, maintaining a relatively stable rate of suboptimal placements throughout the study period. This highlights a potential learning curve benefit associated with the robot-assisted technique.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6252242/v1/89b214a55a8dce0789adca8e.png\"},{\"id\":83821491,\"identity\":\"0a32fed4-3c11-4fb2-8a89-0937e59c0645\",\"added_by\":\"auto\",\"created_at\":\"2025-06-03 09:02:11\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1218942,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6252242/v1/7786afaa-f385-484d-a2b7-15457be4c036.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"A Retrospective Cohort Study Comparing Robot-Assisted and Conventional Fluoroscopy- guided Pedicle Screw Placement\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003ePedicle screw fixation is a cornerstone of spinal surgery, employed to restore spinal stability following trauma, tumors, or degenerative conditions [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. Traditionally, pedicle screw placement has relied on freehand techniques or fluoroscopic guidance, which, despite their widespread use, present challenges in achieving high accuracy. The thoracic spine, with its smaller pedicles and proximity to vital neural structures, poses particular challenges, as screw misplacement can lead to severe complications, such as neurological injury or screw loosening, ultimately compromising patient outcomes [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn recent years, advances in surgical technology have introduced several methods aimed at improving pedicle screw placement accuracy. Among these, robot-assisted technology has emerged as a promising solution, offering precision through real-time imaging, intraoperative guidance, and robotic-arm-assisted positioning [\\u003cspan additionalcitationids=\\\"CR4 CR5\\\" citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. Robotic systems integrate surgical planning workstations, intraoperative imaging, and control software, enabling continuous trajectory verification and minimizing risks of misplacement, even in minimally invasive procedures [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eRobot-assisted pedicle screw placement not only enhances precision but also standardizes techniques, reducing outcome variability and aiding less experienced surgeons in achieving consistent results [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. Additionally, robotic systems reduce fluoroscopy use, thereby minimizing radiation exposure for both patients and surgical teams, a significant advantage over traditional methods [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]. Enhanced visualization provided by robotic systems is particularly beneficial in anatomically complex cases, aligning with the growing demand for spinal procedures [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. Nevertheless, limitations such as increased infection and hematoma risks, possibly linked to additional incisions and reduced tactile feedback, remain concerns [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eConversely, freehand techniques guided by fluoroscopy may lower infection risks and utilize tactile feedback, but they remain prone to errors stemming from surgeon fatigue and higher radiation exposure [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]. These trade-offs underscore the need for a systematic comparison of robotic-assisted and conventional freehand methods.\\u003c/p\\u003e \\u003cp\\u003eThis study aims to compare the clinical and surgical outcomes of robot-assisted and conventional freehand pedicle screw placement. Key parameters include placement accuracy, complication rates, estimated blood loss, length of hospital stays, and infection rates. Furthermore, we aimed to investigate whether robotic guidance may reduce irradiation time in the operating room, minimizing the cumulative exposure of the surgical team. By elucidating the strengths and limitations of each approach, this study seeks to provide evidence to guide healthcare providers in selecting the most appropriate method based on patient needs, institutional capabilities, and surgeon expertise.\\u003c/p\\u003e\"},{\"header\":\"Methods and Materials\",\"content\":\"\\u003cp\\u003eThis retrospective cohort study was conducted to compare robot-assisted and conventional fluoroscopy-guided pedicle screw placement in spinal surgery. Data were collected from a single medical center between 01/2019 and 12/2023. Data were retrospectively extracted from the hospital\\u0026rsquo;s electronic medical records, including surgery reports, anaesthesia protocol radiographic assessments, and postoperative follow-up notes. The study was conducted according to the declaration of Helsinki and approved by the institutional review board (Ethikkommission Westfalen-Lippe, Approval No. 2024 214-f-S). All procedures involving human participants were performed in accordance with institutional and national ethical guidelines. Given the retrospective design and use of anonymized patient data, the requirement for individual informed consent was waived by the Ethics Commission.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eEligibility criteria:\\u003c/h2\\u003e \\u003cp\\u003eEligible participants included patients aged 18 years and older who underwent pedicle screw placement for spinal stabilization due to fractures or degenerative conditions. Patients were categorized into two groups based on the surgical technique employed: robot-assisted or conventional fluoroscopy-guided pedicle screw placement. Patients under the age of 18 were excluded from the study. The allocation to each treatment group dependent on logistical reasons and resource availability at time of surgery. All surgeries were performed by, or under the supervision of two experienced surgeons HS and SS.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eSurgical methods:\\u003c/h3\\u003e\\n\\u003cp\\u003eIn the first cohort, percutaneous, fluoroscopic guided screw insertion technique was employed. The procedure began with the insertion of a Jamshidi needle to establish the pedicle trajectory, under fluoroscopic X-ray guidance (anteroposterior and lateral views) throughout the surgery to ensure accurate screw placement. In the second cohort, a robotic-assisted technique utilizing the Mazor X\\u0026trade; Stealth Edition (Medtronic, Minneapolis, MN, USA) was implemented. Preoperative imaging, including fluoroscopic X-rays and computed tomography (CT), was processed with specialized software on the Mazor X workstation. This enabled three-dimensional anatomical reconstruction, pedicle measurements, trajectory optimization, and implant selection. The finalized surgical plan was then transferred to the robotic system, which facilitated precise screw placement during the procedure, which was conducted in accordance with the manufacturer's guidelines, in a percutaneous and minimally invasive fashion.\\u003c/p\\u003e\\n\\u003ch3\\u003eData collection and outcomes:\\u003c/h3\\u003e\\n\\u003cp\\u003eThe primary outcome of this study was the accuracy of pedicle screw placement, assessed using the Gertzbein-Robbins classification system [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. This system categorizes pedicle screw placement based on postoperative imaging into grades ranging from 0 to 3. Grade 0 indicates full containment within the pedicle with no cortical breach, representing optimal placement, while Grades 1 to 3 indicate breaches of increasing severity: less than 2 mm for Grade 1, 2\\u0026ndash;4 mm for Grade 2, and greater than 4 mm for Grade 3. Grades 1\\u0026ndash;3 were collectively categorized as suboptimal placements. This classification system is widely validated for evaluating pedicle screw placement in spinal surgeries [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. The accuracy grade for each surgical case was determined by the highest screw grade observed, reflecting the expectation that experienced surgeons should place every screw with perfect accuracy. Postoperative imaging was independently reviewed by two study authors (HS, MS) to determine accuracy grades. In cases of discrepancies, additional author EM, was consulted for resolution.\\u003c/p\\u003e \\u003cp\\u003eBecause we assume that experienced surgeons would place pedicle screw very accurately [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e] and we expected an additional value of robotic-assisted surgery, we compared Grade 0 placements - defined as optimal placement - to Grade 1\\u0026ndash;3 placements \\u0026ndash; defined as suboptimal placement.\\u003c/p\\u003e \\u003cp\\u003eSecondary outcome variables included estimated blood loss (EBL), length of hospital stay (LOS), infection rates, hematoma occurrence, revision rates, and postoperative pain levels assessed by both the Visual Analog Scale (VAS) for pain intensity and the Macnab classification for overall functional improvement and patient satisfaction [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e].\\u003c/p\\u003e\\n\\u003ch3\\u003eRisk of bias:\\u003c/h3\\u003e\\n\\u003cp\\u003ePotential sources of bias were addressed by applying consistent eligibility criteria for all participants and reviewing radiological data uniformly. Additionally, selection bias was potentially minimized by using data from a single center, where the surgical approach\\u0026mdash;robot-assisted or conventional\\u0026mdash;was determined based on standard clinical practice rather than random assignment.\\u003c/p\\u003e\\u003cdiv class=\\\"Heading\\\"\\u003e\\u003cb\\u003eStatistical Methods\\u003c/b\\u003e:\\u003c/div\\u003e \\u003cp\\u003eThe study population consisted of all eligible patients who underwent pedicle screw placement at the specialized spine unit during the study period. Given the retrospective design, no prior power calculation was conducted. Statistical analyses were carried out using IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY). Numeric variables were presented as means and standard deviations, with group comparisons conducted using two-sided t-tests. Ordinal variables were described using medians and interquartile ranges (IQR) and compared between groups using the Mann-Whitney U (MWU) test. Categorical variables were analyzed using chi-square (χ\\u0026sup2;) tests for variables with multiple categories, and Fisher\\u0026rsquo;s exact test was applied for dichotomous variables. Statistical significance was defined as a p-value of \\u0026lt;\\u0026thinsp;0.05. Regression analysis was performed to calculate odd ratio (OR) relative risk (RR) and the corresponding 95% confidence intervals (CI) for associations between the surgical techniques and the outcomes. Loss to follow-up was not a concern due to the nature of the retrospective study design. Sensitivity and subgroup analyses were not performed due to sample size constraints, which limited the statistical power required for these additional analyses.\\u003c/p\\u003e \\u003cp\\u003eThe reporting of this study followed STROBE guidelines for cohort studies [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e].\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eParticipants:\\u003c/h2\\u003e \\u003cp\\u003eA total of 240 patients were initially screened for eligibility. After reviewing medical records, 22 patients were excluded due to missing follow-up data or failure to meet the inclusion criteria, such as not undergoing pedicle screw placement because of alternative medical interventions or incomplete surgical data. This resulted in a final cohort of 218 patients, of whom 105 underwent robot-assisted pedicle screw placement, and 113 underwent conventional fluoroscopy-guided screw placement. All 218 patients completed follow-up and were included in the final analysis.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eBaseline characteristics:\\u003c/h3\\u003e\\n\\u003cp\\u003eThe baseline characteristics of the study participants, including demographic, clinical, and surgical data, are presented in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. The mean age of participants was 67 years (\\u0026plusmn;\\u0026thinsp;13), and the majority were female, comprising 58% (n\\u0026thinsp;=\\u0026thinsp;61) of the robot-assisted group and 66% (n\\u0026thinsp;=\\u0026thinsp;75) of the conventional group. The mean body mass index (BMI) was significantly higher in the robot-assisted group (28.69\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;5.017) compared to the conventional group (26.75\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.096).\\u003c/p\\u003e \\u003cp\\u003eThe primary surgical indications included degenerative disc disease, spinal canal stenosis, spondylolisthesis, and vertebral fractures. No significant differences were observed between the groups regarding the distribution of surgical indications (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05). Further details on patient characteristics, including comorbidities and preoperative status, are outlined in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThere were no missing data for the primary outcome of pedicle screw placement accuracy. Additionally, all 218 patients had complete data for other variables, including EBL, LOS, and postoperative complications.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eDemographic Characteristics\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariable\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRobot-assisted (n\\u0026thinsp;=\\u0026thinsp;105)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eControl Group (n\\u0026thinsp;=\\u0026thinsp;113)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eP-value (Statistical Test used)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSex\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.212 (Fisher\\u0026rsquo;s Exact)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFemale (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e61 (58.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e75 (66.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMale (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e44 (41.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e38 (33.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAge (Mean, SD)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e64.72 (\\u0026plusmn;\\u0026thinsp;13,13)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e66 (\\u0026plusmn;\\u0026thinsp;13,28)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.873 (two tailed t-test)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBMI (Mean, SD)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e28.69 (\\u0026plusmn;\\u0026thinsp;5,017)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e26.75\\u0026nbsp;(\\u0026plusmn;\\u0026thinsp;4,096)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.002 (two-tailed t-test)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRepeated surgery (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e36 (34.29%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e43 (38.05%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.576 (Fisher\\u0026rsquo;s Exact)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVAS pre-OP (Mean, SD)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7.72 (\\u0026plusmn;\\u0026thinsp;0,7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7.6 (\\u0026plusmn;\\u0026thinsp;0.59)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.1647 (Two-tailed t-test)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIndication for surgery\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.628 (χ\\u0026sup2;-test)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDegenerative Disc Disease (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e31(29.52%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e34(30.08%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSpinal canal stenosis (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e19(18.09%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e24(21.23%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSpondylolisthesis (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e23(21.90%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e29(25.66%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFracture (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e32(30.47%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e26(23.00%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBM Score\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.404 (χ\\u0026sup2;-test)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e9 (8.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e20 (17.70%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e53 (50.48%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e20 (17.70%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e32 (30.48%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e34 (30.09%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e4 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (0.95%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1 (8.85%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003eASA: American Society of Anaesthesiologists Physical Status Classification System; BMI: Body Mass Index; M/F: Male/Female; SD: Standard Deviation; OP: Operation; VAS: Visual Analogue Scale\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePrimary Outcome: Accuracy of Pedicle Screw Placement\\u003c/h2\\u003e \\u003cp\\u003eThe accuracy of pedicle screw placement, assessed using the Gertzbein-Robbins classification, was significantly higher in the robot-assisted group compared to the conventional group. In the robot-assisted cohort, 93.33% of patients got a perfect screw placement (n\\u0026thinsp;=\\u0026thinsp;98), classified as Grade 0 (optimal placement), compared to 78.76% (n\\u0026thinsp;=\\u0026thinsp;89) in the conventional group (p\\u0026thinsp;=\\u0026thinsp;0.002; OR 0.265, 95% CI: 0.109\\u0026ndash;0.645) (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). The unadjusted relative risk (RR) for achieving Grade 0 placement in individuals within the robot-assisted group was 0.3139 (95% CI: 0.1412\\u0026ndash;0.6978, p\\u0026thinsp;=\\u0026thinsp;0.005). In terms of absolute risk reduction, the number needed to treat (NNT) to achieve a Grade 0 screw placement with robot assistance was 6.862 (95% CI: 4.229\\u0026ndash;18.191). This indicates that approximately seven patients need to undergo robot-assisted surgery to prevent one suboptimal screw placement (Grade 1 or higher). Nevertheless, revision surgery due to screw misplacement was not significantly higher in the control cohort (4 (3.54%) in comparison to 2 (1.9%); p\\u0026thinsp;=\\u0026thinsp;0.684). Additionally, an analysis based on the placement per screw revealed comparable trends as mentioned in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eSecondary Outcomes\\u003c/h2\\u003e \\u003cp\\u003eThe robot-assisted group demonstrated significantly lower estimated blood loss (EBL) compared to the conventional group. The mean EBL in the robot-assisted group was 156.43\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;102.22 mL, significantly lower than the 563.72\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;280.48 mL observed in the conventional group (\\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), with a large effect size (Cohen's \\u003cem\\u003ed\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;1.93). Radiation exposure time was also significantly reduced in the robot-assisted group, with a mean of 109.27\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;45.01 seconds compared to 239.88\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;103.17 seconds in the conventional group (\\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), demonstrating another large effect size (Cohen's \\u003cem\\u003ed\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;1.64). However, mean surgery time did not differ significantly between the groups.\\u003c/p\\u003e \\u003cp\\u003eThe length of hospital stay (LOS) was notably shorter in the robot-assisted group (6.12\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.7 days) compared to the conventional group (7.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.59 days; \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.0001). Postoperative pain, measured using the Visual Analog Scale (VAS), was significantly lower in the robot-assisted group (2.73\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.72) than in the conventional group (2.94\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.67; \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.013; Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003ePatient-reported outcomes based on the Macnab classification showed that a higher proportion of patients in the robot-assisted group achieved \\u0026ldquo;Excellent\\u0026rdquo; or \\u0026ldquo;Good\\u0026rdquo; results (Macnab grades 4\\u0026ndash;5: 73.33%) compared to the conventional group (45.13%; \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.021, OR 0.544, 95% CI: 0.326\\u0026ndash;0.909). Conversely, \\u0026ldquo;Fair\\u0026rdquo; or \\u0026ldquo;Poor\\u0026rdquo; outcomes (Macnab grades 1\\u0026ndash;3) were more frequent in the conventional group (54.87%) than in the robot-assisted group (29.52%).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eAn interesting finding was that the accuracy of screw placement in the robot-assisted cohort improved over time. Most suboptimal placements occurred within the first 40 procedures. Afterwards, only one case with a Gertzbein-Robbins Grade 1 placement was observed (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePostoperative Complications\\u003c/h2\\u003e \\u003cp\\u003ePostoperative complications and adverse events were generally similar between the robot-assisted and conventional groups, with comparable rates of revision surgeries, screw misplacements, and other adverse events, such as cerebrospinal fluid leaks and hematomas. Although surgical site infections were reported only in the robot-assisted group, this difference was not statistically significant. Overall, the complication profiles for both techniques appeared consistent. Further details of patients\\u0026rsquo; outcome are outlined in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003ePostoperative patient outcomes\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariable\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRobot-assisted (n\\u0026thinsp;=\\u0026thinsp;105)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eControl Group (n\\u0026thinsp;=\\u0026thinsp;113)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eP-value (Statistical Test used)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEstimated blood loss\\u003c/p\\u003e \\u003cp\\u003e(ml, Mean, SD)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e156.43 (\\u0026plusmn;\\u0026thinsp;102.22)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e563.72\\u003c/p\\u003e \\u003cp\\u003e(\\u0026plusmn;\\u0026thinsp;280.48)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001 (Two-tailed t-test)\\u003c/p\\u003e \\u003cp\\u003eCohen's D: 1.929434\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRadiation time (Sec, Mean, SD)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e109.27 (\\u0026plusmn;\\u0026thinsp;45.01)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e239.88 (\\u0026plusmn;\\u0026thinsp;103.17)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001 (Two-tailed t-test)\\u003c/p\\u003e \\u003cp\\u003eCohen's D: 1.641\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSurgery time (min, Mean, SD)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e221.51 (\\u0026plusmn;\\u0026thinsp;86.73)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e236.93 (\\u0026plusmn;\\u0026thinsp;94.69)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.212 (Two-tailed t-test)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLOS (days, Mean, SD)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6.12 (\\u0026plusmn;\\u0026thinsp;0.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7.6 (\\u0026plusmn;\\u0026thinsp;2.59)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.0001 (Two-tailed t-test)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVAS post-OP\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2.73 (\\u0026plusmn;\\u0026thinsp;0.72)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2.94 (\\u0026plusmn;\\u0026thinsp;0.67)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.013 (Two-tailed t-test)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNumber of screws implanted per patient (Sum)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e508\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e570\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.698 (χ\\u0026sup2;-test)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFour (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e71 (67.62%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e68 (60.18%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSix (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e25 (23.81%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e32 (28.32%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEight (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8 (7.19%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e12 (10.62%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTen (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (0.95%%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1 (0.88%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGertzbein-Robbins Classification per patient\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.029 (χ\\u0026sup2;-test)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e0 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e98 (93.33%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e89 (78.76%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4 (3.81%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e17 (15.04%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3 (2.85%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5 (4.42%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (1.77%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGertzbein-Robbins\\u003c/p\\u003e \\u003cp\\u003edichotomic per patient\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.007 (Fisher\\u0026rsquo;s Exact)\\u003c/p\\u003e \\u003cp\\u003eOR 0.265 (95% CI 0.109\\u0026ndash;0.645, P\\u0026thinsp;=\\u0026thinsp;0.0034)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOptimal (0) (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e98\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e89\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSuboptimal (1\\u0026ndash;3) (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e25\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGertzbein-Robbins dichotomic, per screw\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.007 (Fisher\\u0026rsquo;s exact) \\u003c/p\\u003e \\u003cp\\u003eOR 0.1689 (95% CI 0.1689\\u0026ndash;0.7788, p\\u0026thinsp;=\\u0026thinsp;0.009)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOptimal (0) (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e499 (98.23%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e543 (95.26%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSuboptimal (1\\u0026ndash;3) (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e9 (1.77%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e27 (4.74%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostoperative Macnab (points, Median, IQR)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4 (3\\u0026ndash;4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3 (3\\u0026ndash;4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001 (MWU)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e5 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e14 (13.33%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3 (2.65%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e4 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e63 (59.05%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e48 (42.48%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e21 (20%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e57 (50.44%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7 (6.67%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3 (2.65%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (1.77%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMacnab 4\\u0026ndash;5 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e77 (73.33%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e51 (45.13%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.021 (Fisher\\u0026rsquo;s Exact)\\u003c/p\\u003e \\u003cp\\u003eOR 0.544 (95% CI 0.326\\u0026ndash;0.909, P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.020)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMacnab 1\\u0026ndash;3 (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e51 (29.52%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e62 (54.87%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRevision Surgery (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7 (6.67%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7 (6.19%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026gt;\\u0026thinsp;0.99 (Fisher\\u0026rsquo;s Exact)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eScrew misplacement\\u0026nbsp;(n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2 (1.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4 (3.54%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.684 (Fisher\\u0026rsquo;s Exact)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSurgical site infection (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2 (1.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026gt;\\u0026thinsp;0.99 (Fisher\\u0026rsquo;s Exact)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCSF leak (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2 (1.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (1.77%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026gt;\\u0026thinsp;0.99 (Fisher\\u0026rsquo;s Exact)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHematoma (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (0.95%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1 (0.88%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026gt;\\u0026thinsp;0.99 (Fisher\\u0026rsquo;s Exact)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMedical Adverse events (n, %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2 (1.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3 (2.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026gt;\\u0026thinsp;0.99 (Fisher\\u0026rsquo;s Exact)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003eCI: Confidence Interval; CSF: Cerebrospinal fluid; IQR: Interquartile Range; LOS: Length of Stay; MWU: Mann-Whitney U test; OP: Operation; OR: Odds ratio; SD: Standard Deviation; VAS: Visual Analogue Scale\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAccuracy of Pedicle Screw Placement\\u003c/h2\\u003e \\u003cp\\u003eThis study aimed to compare the accuracy and clinical outcomes of robot-assisted versus conventional fluoroscopy-guided pedicle screw placement in spinal surgery. The results demonstrated that robot-assisted techniques led to significantly higher accuracy rates in pedicle screw placement, as measured by the Gertzbein-Robbins classification, with 93.33% of screws in the robot group achieving an optimal placement (Grade 0) compared to 78.76% in the conventional group. These results are consistent with previous systematic reviews showing that robot-assisted techniques improve pedicle screw placement accuracy [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. For example, the systematic review and meta-analysis of 19 studies by Fatima et al. found that robotic techniques significantly reduced misplacement rates compared to freehand methods, reinforcing the benefits we observed in our study [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eRobotic assistance also standardizes screw placement techniques, reducing variability across practitioners [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e], and provides essential support to less experienced surgeons who may face challenges in achieving precise placements with freehand methods [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. The addition of advanced intraoperative navigation systems and digital volume tomography (DVT) technology further enhances the precision of robotic systems by offering real-time 3D imaging, which enables continuous verification of screw trajectory and reduces the risk of malposition, even in complex anatomical cases [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e]. These imaging systems likely play a significant role in improving accuracy, as they decrease reliance on fluoroscopic guidance and provide detailed anatomical views during the procedure.\\u003c/p\\u003e \\u003cp\\u003eIn the past Li et al., demonstrated that both robot-assisted and navigation-assisted techniques significantly improve accuracy and safety of pedicle screw placement compared to freehand methods, however, the robotic systems showed superior precision over navigation-based approaches in scoliosis surgery. A systematic review further confirmed the enhanced accuracy and safety of robot-assisted techniques, underscoring their clinical advantages over navigation [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eAn additional noteworthy finding from this study was the observed increase in accuracy over time in the robotic cohort, with most suboptimal placements occurring within the first 40 procedures. After this initial phase, only one case with a Gertzbein-Robbins Grade 1 placement was recorded, indicating that as experience with the robotic system grew, placement accuracy reached consistently high levels. This learning curve effect suggests that proficiency with robotic systems can further optimize accuracy and underscores the importance of experience and training in maximizing the benefits of robotic-assisted surgery.\\u003c/p\\u003e \\u003cp\\u003eA study by Torii et al. analyzed the learning curve of robotic-assisted pedicle screw placement by comparing the performance of junior and experienced surgeons. The findings revealed that experienced surgeons achieved a plateau in accuracy after 25 cases, while junior surgeons required approximately 40 cases to reach similar levels of accuracy. Additionally, regression analysis indicated that significant reductions in surgical time and radiation exposure were observed after 30 cases, highlighting the steep learning curve associated with robotic systems. These results emphasize the necessity of adequate training and case volume to optimize the outcomes of robotic-assisted spinal procedures [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. Similar results were also demonstrated in a trial published by Han et al. [\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e]\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eLength of Hospital Stay (LOS), Estimated Blood Loss (EBL), and Radiation Time\\u003c/h2\\u003e \\u003cp\\u003eIn our study, robot-assisted pedicle screw placement resulted in significantly lower estimated blood loss (EBL) and shorter length of hospital stay (LOS) compared to conventional techniques, findings that are consistent with prior research. Asada et al. (2024), in their analysis of 1,633 lumbar fusion patients, observed that the robot-navigated group experienced significantly reduced EBL and LOS, with no substantial increase in operative time or reoperation rates [\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e]. This suggests that robotic guidance contributes to more efficient and minimally invasive procedures without compromising safety. Similarly, Li et al. (2023), through a meta-analysis, found that robot-assisted techniques consistently reduced intraoperative blood loss and hospitalization duration [\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e]. This reduction in EBL and shorter recovery times may be attributed to the increased precision and control offered by robotic systems, which minimize tissue disruption and optimize surgical trajectories.\\u003c/p\\u003e \\u003cp\\u003eIn addition, Mason et al. (2014) highlighted that advanced imaging systems, such as 3D fluoroscopic navigation, improve screw placement accuracy, which indirectly reduces EBL and speeds up recovery. Their findings suggest that the accuracy provided by these imaging systems reduces intraoperative complications, thereby improving postoperative outcomes like LOS [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eFurthermore, robot-assisted pedicle screw placement resulted in a significantly reduced radiation time in the operation room. This goes in line with previous reports from Lin et al. that observed an inverse correlation of radiation time and experience with robotic surgery [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. Reducing the radiation time during surgery is essential to minimize the cumulative dose received by employees during their work. Novel advancements like MRI-based 3D registration and augmented reality integration represent promising steps toward radiation-free yet highly accurate robotic surgery, enabling enhanced visualization and safety [\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e].\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eClinical Outcomes\\u003c/h2\\u003e \\u003cp\\u003eFurthermore, the result of this study regarding clinical outcomes favored the robot-assisted group, showing lower postoperative VAS pain scores and a higher percentage of patients achieving \\u0026ldquo;Excellent\\u0026rdquo; or \\u0026ldquo;Good\\u0026rdquo; outcomes on the Macnab classification. The improved pain and functional outcomes in the robotic cohort may partially reflect the precision of screw placement, which optimizes spinal stability and can reduce postoperative discomfort, a benefit noted in Li et al. (2023), whose meta-analysis reported that robot-assisted procedures resulted in improved patient-reported outcomes such as VAS and Oswestry Disability Index (ODI) scores, likely due to reduced intraoperative trauma and optimized screw placement [\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e].\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec18\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eComplications and adverse events\\u003c/h2\\u003e \\u003cp\\u003eThe occurrence of adverse events, such as revision surgeries, screw misplacements, CSF leaks, and hematomas, was comparable between the robot-assisted and conventional groups, indicating similar safety profiles. This aligns with Asada et al., who reported no significant differences in reoperation or readmission rates between techniques [\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e]. Furthermore, Mason et al. indicated that advanced image guidance, such as 3D fluoroscopic navigation, can help enhance screw accuracy and minimize intraoperative errors, indirectly contributing to favorable clinical outcomes and comparable safety between techniques [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e]. Marcus et al. reviewed five studies and found some support for fluoroscopy-guided techniques in terms of lower infection and adverse event rates [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. However, the high precision of robotic systems in preventing screw misplacement may outweigh the minor increases in complications like infections and hematomas, especially given that our study and others report lower overall complication rates with robotic systems [\\u003cspan additionalcitationids=\\\"CR4\\\" citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec19\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eEffect on Operating Time\\u003c/h2\\u003e \\u003cp\\u003eOperating times were comparable between the robot-assisted and conventional groups, suggesting that proficiency mitigates robotic setup and calibration delays. This is consistent with findings from Li et al., Asada et al., and Han et al., which showed no significant increases in operative times with robotic surgery [\\u003cspan additionalcitationids=\\\"CR23\\\" citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e]. However, our findings contrast with those of Fatima et al. and Gao et al., both meta-analyses that reported a notable increase in operative times for robot-assisted procedures\\u0026mdash;approximately 20.5 and 22.7 minutes longer, respectively. The prolonged duration in these studies is often attributed to the initial setup and calibration requirements unique to robotic systems, which may introduce more complexity compared to the straightforward preparation needed for freehand techniques [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e].\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec20\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eFuture Prospects: Enhanced Preoperative Planning with AI and Personalized Treatment\\u003c/h2\\u003e \\u003cp\\u003eRobotic precision in pedicle screw placement supports advanced preoperative planning, with AI poised to optimize trajectories based on patient-specific anatomy. This innovation could enhance accuracy, reduce complications, and minimize revisions. The integration of AI into robotic platforms represents a critical avenue for research, advancing individualized treatment approaches [\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e].\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec21\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCost-effectiveness\\u003c/h2\\u003e \\u003cp\\u003eDespite concerns over the high costs of robotic spine surgery, a study by Menger et al. supports its cost-effectiveness, citing reduced complications, fewer infections, and shorter hospital stays. Improved pedicle screw accuracy alone could prevent approximately 9.47 revision surgeries annually, saving \\u003cspan\\u003e$\\u003c/span\\u003e314,661. Additionally, converting open surgeries to minimally invasive procedures saved \\u003cspan\\u003e$\\u003c/span\\u003e608,546 annually in a single center [\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e]. As AI integrates into robotic systems, the potential for personalized, efficient, and cost-effective spinal surgeries increases, further addressing concerns about costs while enhancing precision and patient outcomes.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec22\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eLimitations\\u003c/h2\\u003e \\u003cp\\u003eSeveral limitations must be considered when interpreting the results of this study. First, as a single-center retrospective cohort study, the findings may be subject to selection bias and residual confounding from unmeasured factors, such as surgeon experience and variations in technique. Although variables like preoperative VAS scores and BMI were recognized as potential confounders, they were not fully adjusted due to the study\\u0026rsquo;s exploratory scope and sample size limitations. Future studies with larger samples and multi-center designs should incorporate comprehensive adjustments for these confounding variables to confirm the findings.\\u003c/p\\u003e \\u003cp\\u003eAdditionally, the relatively small sample size may limit the generalizability of these results. Moreover, long-term outcomes, such as screw loosening or spinal stability over time, were not addressed in this study, which restricts our ability to draw conclusions on the long-term efficacy of robot-assisted techniques. Imprecision in measurements, such as intraoperative blood loss estimation, may have introduced variability. Infection rates were noted, but there was no standardized postoperative infection control protocol across all patients, which may have influenced results.\\u003c/p\\u003e \\u003cp\\u003eLastly, the high cost and required training for robotic systems could limit accessibility, particularly in smaller facilities. Financial constraints and the investment in training and infrastructure needed to proficiently use robotic systems must be weighed against the potential improvements in patient outcomes [\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e]. The patient population in this study consisted primarily of individuals with degenerative spinal conditions and vertebral fractures, which may not fully represent other demographics. Consequently, results may not be universally applicable, especially in settings with varied patient profiles or healthcare resources. Institutions lacking access to robotic technology or trained teams may not experience the same benefits observed in this study. Future research across multiple centers is needed to validate these findings in diverse healthcare settings.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003e This retrospective cohort study demonstrates that robot-assisted pedicle screw placement improves the accuracy of screw placement and reduces intraoperative blood loss and hospital stays compared to conventional fluoroscopy-guided techniques. These results add to the available evidence supporting the benefits of robotic assistance in spinal surgery, reinforcing findings from previous research on its precision and efficiency. While robotic systems provide significant short-term benefits in spinal surgery, future research should focus on long-term outcomes, cost-effectiveness, and the wider generalizability of these results. As surgical technologies continue to evolve, robot-assisted techniques are likely to play an increasingly important role in enhancing surgical precision and patient care.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eASA \\u0026ndash; American Society of Anaesthesiologists\\u003cbr\\u003e\\u0026nbsp;BMI \\u0026ndash; Body Mass Index\\u003cbr\\u003e\\u0026nbsp;CI \\u0026ndash; Confidence Interval\\u003cbr\\u003e\\u0026nbsp;CSF \\u0026ndash; Cerebrospinal Fluid\\u003cbr\\u003e\\u0026nbsp;CT \\u0026ndash; Computed Tomography\\u003cbr\\u003e\\u0026nbsp;DVT \\u0026ndash; Digital Volume Tomography\\u003cbr\\u003e\\u0026nbsp;EBL \\u0026ndash; Estimated Blood Loss\\u003cbr\\u003e\\u0026nbsp;IQR \\u0026ndash; Interquartile Range\\u003cbr\\u003e\\u0026nbsp;LOS \\u0026ndash; Length of Hospital Stay\\u003cbr\\u003e\\u0026nbsp;MWU \\u0026ndash; Mann-Whitney U test\\u003cbr\\u003e\\u0026nbsp;NNT \\u0026ndash; Number Needed to Treat\\u003cbr\\u003e\\u0026nbsp;ODI \\u0026ndash; Oswestry Disability Index\\u003cbr\\u003e\\u0026nbsp;OR \\u0026ndash; Odds Ratio\\u003cbr\\u003e\\u0026nbsp;RR \\u0026ndash; Relative Risk\\u003cbr\\u003e\\u0026nbsp;SD \\u0026ndash; Standard Deviation\\u003cbr\\u003e\\u0026nbsp;SPSS \\u0026ndash; Statistical Package for the Social Sciences\\u003cbr\\u003e\\u0026nbsp;STROBE \\u0026ndash; Strengthening the Reporting of Observational Studies in Epidemiology\\u003cbr\\u003e\\u0026nbsp;VAS \\u0026ndash; Visual Analog Scale\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgment\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research received no external funding. The study was conducted without financial support from public, commercial, or not-for-profit funding agencies.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData Availability\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eH.S. and E.M. contributed equally as first authors. H.S. and S.S. performed the surgical procedures and collected the data. H.S. also wrote the initial draft of the manuscript. E.M. and M.S. developed the study design and contributed to manuscript revision and improvement. M.G., E.M., and M.S. conducted the statistical analysis. E.M. and M.G. performed the literature review. M.S. supervised the study as the senior author and ensured methodological rigor. All authors contributed to data interpretation, manuscript editing, and critical revisions. M.G. prepared the figures and tables. All authors reviewed the manuscript, approved the final version, and take full responsibility for its content.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003ePeul, W. C. \\u0026amp; Moojen, W. A. Fusion for Lumbar Spinal Stenosis\\u0026ndash;Safeguard or Superfluous Surgical Implant? \\u003cem\\u003eN Engl. J. Med.\\u003c/em\\u003e \\u003cb\\u003e374\\u003c/b\\u003e, 1478\\u0026ndash;1479. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1056/NEJME1600955\\u003c/span\\u003e\\u003cspan address=\\\"10.1056/NEJME1600955\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2016).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eReisener, M. J., Pumberger, M., Shue, J., Girardi, F. P. \\u0026amp; Hughes, A. P. Trends in Lumbar Spinal Fusion-a Literature Review. \\u003cem\\u003eJ. Spine Surg.\\u003c/em\\u003e \\u003cb\\u003e6\\u003c/b\\u003e, 752\\u0026ndash;776. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.21037/JSS-20-492\\u003c/span\\u003e\\u003cspan address=\\\"10.21037/JSS-20-492\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2020).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFatima, N., Massaad, E., Hadzipasic, M., Shankar, G. M. \\u0026amp; Shin, J. H. Safety and Accuracy of Robot-Assisted Placement of Pedicle Screws Compared to Conventional Free-Hand Technique: A Systematic Review and Meta-Analysis. \\u003cem\\u003eSpine J.\\u003c/em\\u003e \\u003cb\\u003e21\\u003c/b\\u003e, 181\\u0026ndash;192. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/J.SPINEE.2020.09.007\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/J.SPINEE.2020.09.007\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2021).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGao, S., Lv, Z. \\u0026amp; Fang, H. Robot-Assisted and Conventional Freehand Pedicle Screw Placement: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. \\u003cem\\u003eEur. Spine J.\\u003c/em\\u003e \\u003cb\\u003e27\\u003c/b\\u003e, 921\\u0026ndash;930. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1007/S00586-017-5333-Y\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/S00586-017-5333-Y\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2018).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMarcus, H. J., Cundy, T. P., Nandi, D., Yang, G. Z. \\u0026amp; Darzi, A. Robot-Assisted and Fluoroscopy-Guided Pedicle Screw Placement: A Systematic Review. \\u003cem\\u003eEur. Spine J.\\u003c/em\\u003e \\u003cb\\u003e23\\u003c/b\\u003e, 291\\u0026ndash;297. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1007/S00586-013-2879-1\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/S00586-013-2879-1\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2014).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBarzilay, Y., Liebergall, M., Fridlander, A. \\u0026amp; Knoller, N. Miniature Robotic Guidance for Spine Surgery\\u0026ndash;Introduction of a Novel System and Analysis of Challenges Encountered during the Clinical Development Phase at Two Spine Centres. \\u003cem\\u003eInt. J. Med. Robot\\u003c/em\\u003e. \\u003cb\\u003e2\\u003c/b\\u003e, 146\\u0026ndash;153. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1002/RCS.90\\u003c/span\\u003e\\u003cspan address=\\\"10.1002/RCS.90\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2006).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSu, X. J. et al. Comparison of Accuracy and Clinical Outcomes of Robot-Assisted Versus Fluoroscopy-Guided Pedicle Screw Placement in Posterior Cervical Surgery. \\u003cem\\u003eGlobal Spine J.\\u003c/em\\u003e \\u003cb\\u003e12\\u003c/b\\u003e, 620\\u0026ndash;626. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1177/2192568220960406\\u003c/span\\u003e\\u003cspan address=\\\"10.1177/2192568220960406\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2022).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLieberman, I. H., Kisinde, S. \\u0026amp; Hesselbacher, S. Robotic-Assisted Pedicle Screw Placement During Spine Surgery. \\u003cem\\u003eJBJS Essent. Surg. Tech.\\u003c/em\\u003e \\u003cb\\u003e10\\u003c/b\\u003e \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.2106/JBJS.ST.19.00020\\u003c/span\\u003e\\u003cspan address=\\\"10.2106/JBJS.ST.19.00020\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2020).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTorii, Y. et al. Accuracy of Robotic-Assisted Pedicle Screw Placement Comparing Junior Surgeons with Expert Surgeons: Can Junior Surgeons Place Pedicle Screws as Accurately as Expert Surgeons? \\u003cem\\u003eJ. Orthop. Sci.\\u003c/em\\u003e \\u003cb\\u003e28\\u003c/b\\u003e, 961\\u0026ndash;965. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/J.JOS.2022.06.012\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/J.JOS.2022.06.012\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2023).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFarber, S. H. et al. Robotics in Spine Surgery: A Technical Overview and Review of Key Concepts. \\u003cem\\u003eFront. Surg.\\u003c/em\\u003e \\u003cb\\u003e8\\u003c/b\\u003e \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3389/FSURG.2021.578674/FULL\\u003c/span\\u003e\\u003cspan address=\\\"10.3389/FSURG.2021.578674/FULL\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2021).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChen, H. Y. et al. Results of Using Robotic-Assisted Navigational System in Pedicle Screw Placement. \\u003cem\\u003ePLoS One\\u003c/em\\u003e. \\u003cb\\u003e14\\u003c/b\\u003e \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1371/JOURNAL.PONE.0220851\\u003c/span\\u003e\\u003cspan address=\\\"10.1371/JOURNAL.PONE.0220851\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2019).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLin, S., Wang, F., Hu, J. \\u0026amp; Tang, L. yi Comparison of the Accuracy and Safety of TiRobot-Assisted and Fluoroscopy-Assisted Percutaneous Pedicle Screw Placement for the Treatment of Thoracolumbar Fractures. \\u003cem\\u003eOrthop. Surg.\\u003c/em\\u003e \\u003cb\\u003e14\\u003c/b\\u003e, 2955\\u0026ndash;2963. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1111/OS.13504\\u003c/span\\u003e\\u003cspan address=\\\"10.1111/OS.13504\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2022).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePatel, N. A. et al. Robot-Assisted Percutaneous Pedicle Screw Placement Accuracy Compared with Alternative Guidance in Lateral Single-Position Surgery: A Systematic Review and Meta-Analysis. \\u003cem\\u003eJ. Neurosurg. Spine\\u003c/em\\u003e. \\u003cb\\u003e39\\u003c/b\\u003e, 443\\u0026ndash;451. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3171/2023.3.SPINE2329\\u003c/span\\u003e\\u003cspan address=\\\"10.3171/2023.3.SPINE2329\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2023).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGertzbein, S. \\u0026amp; Robbins, S. Accuracy of Pedicular Screw Placement in Vivo. \\u003cem\\u003eSpine (Phila Pa\\u003c/em\\u003e 1990, \\u003cem\\u003e15\\u003c/em\\u003e, 11\\u0026ndash;14, (1976). \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1097/00007632-199001000-00004\\u003c/span\\u003e\\u003cspan address=\\\"10.1097/00007632-199001000-00004\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSamdani, A. F. et al. Accuracy of Free-Hand Placement of Thoracic Pedicle Screws in Adolescent Idiopathic Scoliosis: How Much of a Difference Does Surgeon Experience Make? \\u003cem\\u003eEur. Spine J.\\u003c/em\\u003e \\u003cb\\u003e19\\u003c/b\\u003e, 91\\u0026ndash;95. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1007/S00586-009-1183-6\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/S00586-009-1183-6\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2010).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSchulze, C. J., Munzinger, E. \\u0026amp; Weber, U. Clinical Relevance of Accuracy of Pedicle Screw Placement. A Computed Tomographic-Supported Analysis. \\u003cem\\u003eSpine (Phila Pa. 1976)\\u003c/em\\u003e. \\u003cb\\u003e23\\u003c/b\\u003e, 2215\\u0026ndash;2220. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1097/00007632-199810150-00014\\u003c/span\\u003e\\u003cspan address=\\\"10.1097/00007632-199810150-00014\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (1998).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMacnab, I., Negative Disc \\u0026amp; Exploration An Analysis of the Causes of Nerve-Root Involvement in Sixty-Eight Patients. \\u003cem\\u003eJ. Bone Joint Surg. Am.\\u003c/em\\u003e \\u003cb\\u003e53\\u003c/b\\u003e, 891\\u0026ndash;903. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.2106/00004623-197153050-00004\\u003c/span\\u003e\\u003cspan address=\\\"10.2106/00004623-197153050-00004\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (1971).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003evon Elm, E. et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies. \\u003cem\\u003eLancet\\u003c/em\\u003e \\u003cb\\u003e370\\u003c/b\\u003e, 1453\\u0026ndash;1457. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/S0140-6736(07)61602-X\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/S0140-6736(07)61602-X\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2007).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMason, A. et al. The Accuracy of Pedicle Screw Placement Using Intraoperative Image Guidance Systems. \\u003cem\\u003eJ. Neurosurg. Spine\\u003c/em\\u003e. \\u003cb\\u003e20\\u003c/b\\u003e, 196\\u0026ndash;203. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3171/2013.11.SPINE13413\\u003c/span\\u003e\\u003cspan address=\\\"10.3171/2013.11.SPINE13413\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2014).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLi, C. et al. Safety and Accuracy of Cannulated Pedicle Screw Placement in Scoliosis Surgery: A Comparison of Robotic-Navigation, O-Arm-Based Navigation, and Freehand Techniques. \\u003cem\\u003eEur. Spine J.\\u003c/em\\u003e \\u003cb\\u003e32\\u003c/b\\u003e, 3094\\u0026ndash;3104. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1007/S00586-023-07710-8/METRICS\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/S00586-023-07710-8/METRICS\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2023).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAl-Naseem, A. O. et al. Robot-Assisted Pedicle Screw Insertion versus Navigation-Based and Freehand Techniques for Posterior Spinal Fusion in Scoliosis: A Systematic Review and Meta-Analysis. \\u003cem\\u003eSpine Deform\\u003c/em\\u003e. \\u003cb\\u003e12\\u003c/b\\u003e, 1203\\u0026ndash;1215. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1007/S43390-024-00879-Y/TABLES/3\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/S43390-024-00879-Y/TABLES/3\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2024).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHan, X. et al. Safety and Accuracy of Robot-Assisted versus Fluoroscopy-Assisted Pedicle Screw Insertion in Thoracolumbar Spinal Surgery: A Prospective Randomized Controlled Trial. \\u003cem\\u003eJ. Neurosurg. Spine\\u003c/em\\u003e. \\u003cb\\u003e30\\u003c/b\\u003e, 615\\u0026ndash;622. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3171/2018.10.SPINE18487\\u003c/span\\u003e\\u003cspan address=\\\"10.3171/2018.10.SPINE18487\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2019).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAsada, T. et al. Robot-Navigated Pedicle Screw Insertion Can Reduce Intraoperative Blood Loss and Length of Hospital Stay: Analysis of 1,633 Patients Utilizing Propensity Score Matching. \\u003cem\\u003eSpine J.\\u003c/em\\u003e \\u003cb\\u003e24\\u003c/b\\u003e, 118\\u0026ndash;124. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/J.SPINEE.2023.09.004\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/J.SPINEE.2023.09.004\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2024).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLi, Y. et al. Comparison of Short-Term Clinical Outcomes between Robot-Assisted and Freehand Pedicle Screw Placement in Spine Surgery: A Meta-Analysis and Systematic Review. \\u003cem\\u003eJ. Orthop. Surg. Res.\\u003c/em\\u003e \\u003cb\\u003e18\\u003c/b\\u003e \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1186/S13018-023-03774-W\\u003c/span\\u003e\\u003cspan address=\\\"10.1186/S13018-023-03774-W\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2023).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAltorfer, F. C. S. et al. Robotic Pedicle Screw Placement with 3D MRI Registration: Moving Towards Radiation Free Robotic Spine Surgery. \\u003cem\\u003eSpine J.\\u003c/em\\u003e \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/J.SPINEE.2024.10.020\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/J.SPINEE.2024.10.020\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2024).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eStaartjes, V. E., Seevinck, P. R., Vandertop, W. P., van Stralen, M. \\u0026amp; Schr\\u0026ouml;der, M. L. Magnetic Resonance Imaging-Based Synthetic Computed Tomography of the Lumbar Spine for Surgical Planning: A Clinical Proof-of-Concept. \\u003cem\\u003eNeurosurg. Focus\\u003c/em\\u003e. \\u003cb\\u003e50\\u003c/b\\u003e, 1\\u0026ndash;7. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3171/2020.10.FOCUS20801\\u003c/span\\u003e\\u003cspan address=\\\"10.3171/2020.10.FOCUS20801\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2021).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAhmed, A. K. et al. First Spine Surgery Utilizing Real-Time Image-Guided Robotic Assistance. \\u003cem\\u003eComput. Assist. Surg. (Abingdon)\\u003c/em\\u003e. \\u003cb\\u003e24\\u003c/b\\u003e, 13\\u0026ndash;17. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1080/24699322.2018.1542029\\u003c/span\\u003e\\u003cspan address=\\\"10.1080/24699322.2018.1542029\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2019).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMa, C. et al. A Novel Surgical Planning System Using an AI Model to Optimize Planning of Pedicle Screw Trajectories with Highest Bone Mineral Density and Strongest Pull-out Force. \\u003cem\\u003eNeurosurg. Focus\\u003c/em\\u003e. \\u003cb\\u003e52\\u003c/b\\u003e \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3171/2022.1.FOCUS21721\\u003c/span\\u003e\\u003cspan address=\\\"10.3171/2022.1.FOCUS21721\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2022).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMenger, R. P., Savardekar, A. R., Farokhi, F. \\u0026amp; Sin, A. A. Cost-Effectiveness Analysis of the Integration of Robotic Spine Technology in Spine Surgery. \\u003cem\\u003eNeurospine\\u003c/em\\u003e \\u003cb\\u003e15\\u003c/b\\u003e, 216\\u0026ndash;224. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.14245/NS.1836082.041\\u003c/span\\u003e\\u003cspan address=\\\"10.14245/NS.1836082.041\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2018).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eD\\u0026rsquo;Souza, M. et al. Robotic-Assisted Spine Surgery: History, Efficacy, Cost, And Future Trends. \\u003cem\\u003eRobot Surg.\\u003c/em\\u003e \\u003cb\\u003e6\\u003c/b\\u003e, 9\\u0026ndash;23. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.2147/RSRR.S190720\\u003c/span\\u003e\\u003cspan address=\\\"10.2147/RSRR.S190720\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (2019).\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Spinal fusion, Robotics, Navigation\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6252242/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6252242/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground:\\u003c/strong\\u003e Pedicle screw placement is crucial for restoring stability. Emerging robot assisted technologies may offer enhanced precision and reduced radiation exposure \\u003cbr\\u003e\\nThis study aimed to compare the accuracy and clinical outcomes of robot-assisted versus conventional fluoroscopy-guided pedicle screw placements.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods:\\u003c/strong\\u003e This retrospective cohort study included 218 patients undergoing pedicle screw placement at a single spine centre between 2019 and 2023. Of these, 105 patients underwent robot-assisted surgery, and 113 underwent conventional fluoroscopy guided surgery. The primary outcome was screw placement accuracy according to the Gertzbein-Robbins classification. Secondary outcomes included estimated blood loss (EBL), radiation exposure, length of hospital stay (LOS), clinical outcome according to the Macnab classification, postoperative pain, and adverse events.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults:\\u003c/strong\\u003e Robot-assisted surgery demonstrated significantly higher accuracy in screw placement, with 93.33% achieving Grade 0 accuracy versus 78.76% in the conventional group (p=0.002). The unadjusted relative risk (RR) for achieving Grade 0 screw placement in the robot-assisted group was 0.3139 (95% CI: 0.1412-0.6978, p=0.005). Moreover, robot-assisted procedures were associated with reduced EBL, shorter LOS, and lower radiation exposure times. Postoperative pain scores (VAS) and clinical outcomes were also more favourable in the robot-assisted group. Duration of surgery, adverse events, and revision rates were comparable between the two groups.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion:\\u003c/strong\\u003e This study supports the clinical benefits of robot-assisted pedicle screw placement, particularly in achieving higher accuracy and reducing EBL and LOS. Future research should explore long-term outcomes, cost-effectiveness, and the generalizability of these results to a broader patient population.\\u003c/p\\u003e\",\"manuscriptTitle\":\"A Retrospective Cohort Study Comparing Robot-Assisted and Conventional Fluoroscopy- guided Pedicle Screw Placement\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-04-30 12:06:44\",\"doi\":\"10.21203/rs.3.rs-6252242/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"ea346f71-3216-4a61-ad4d-72a9b2b64ace\",\"owner\":[],\"postedDate\":\"April 30th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[{\"id\":46788441,\"name\":\"Health sciences/Medical research/Study design/Clinical trials\"},{\"id\":46788442,\"name\":\"Health sciences/Medical research/Outcomes research\"}],\"tags\":[],\"updatedAt\":\"2025-06-03T08:53:52+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-04-30 12:06:44\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6252242\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6252242\",\"identity\":\"rs-6252242\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}