The safety and precision of pedicle screw placement in treating upper cervical instability using a robotic system

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Methods The 134 patients were divided into two groups based on the surgical approach: the robotic-assisted group (RA group) and the traditional group (TR group). Imaging and clinical data from all patients were collected. Results The baseline data for the two groups was not significantly different (P > 0.05). The accuracy of screw placement was higher in the RA group than in the TR group (P < 0.05). The RA group had a lower incidence of facet joint violation compared to the TR group (P < 0.05). The radiation dose in the RA group was higher than that in the TR group (P < 0.05). The surgical duration, intraoperative blood loss, and incision length were reduced in the RA group compared to the TR group (P < 0.05). The VAS, NDI, SF-36, and JOA scores of both the RA group and TR group demonstrated postoperative improvement (P < 0.05). Conclusion The orthopedic robot-assisted pedicle screw internal fixation can enhance screw precision and minimize bleeding during the treatment of UCI. upper cervical instability robot-assisted surgery minimally invasive radiation safety Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Upper Cervical Instability (UCI) is the disruption of the relationship between the atlas (C1) and axis (C2), resulting in decreased stability of the cervical spine. Clinical presentations include cervical pain, neurological impairment, and vertigo[1]. In severe cases, the spinal cord can be damaged, which is life-threatening. The technology for fixing the atlantoaxial joint has changed a lot in recent decades[2]. The earliest cable and pedicle screw/hook techniques have gradually faded into history, and the rod-screw system composed of pedicle screws is currently the most popular choice for posterior fixation[3]. Currently, laminectomy and anterior cervical decompression and fixation can also be used for the treatment of UCI, but the theoretically most effective method remains posterior cervical pedicle screw fixation[4]. The atlas vertebra's unique and complex anatomy makes surgery challenging, requiring precise screw placement[5]. Traditional surgery has potential complications that are difficult to avoid, such as the risk of local soft tissue injury when exposing the vertebral body during open surgery. The venous sinus between C1-2 vertebrae may lead to significant bleeding. During the manual screw placement process, previous reports indicate that up to 73.9% of patients experienced vertebral artery injury, while 41.5% experienced nerve root injury[6]. The misplacement rate for traditional manual C2 pedicle screws ranges from 11–23%[5]. At present, a variety of robot-assisted systems are utilized in posterior cervical fusion surgery to assist surgeons in accurately locating and positioning screws. Fan et al. and Su et al. achieved accuracy rates of 87.6% and 90.6%, respectively, in the implantation of pedicle screws using the TINAVI robot[7], which differ from the accuracies of 84.1% for the Mazor X robot and 60.9% for the Cirq robot[8]. The robotic system can help improve preoperative planning and screw placement, leading to better surgical plans and outcomes for upper cervical spine surgery. However, additional data support is needed to verify the effectiveness with different brands and principles. This study aims to report the imaging differences and clinical outcomes of treatments robot-assisted pedicle screw internal fixation and traditional open surgery for condition UCI. Materials and methods The current retrospective study has received approval from the Ethics Committee (Approval number: Lunshen (Yan) 20240498). Gather the patient data of individuals who received surgical treatment for UCI at this hospital between January 2017 and May 2023. A total of 134 patients were enrolled, with 51 patients in the orthopedic robot-assisted pedicle screw internal fixation group (RA) and 83 patients in the traditional open surgery group (TR). All procedures were performed by a single, specialized team using standardized traditional and robotic techniques. Inclusion criteria: (1) Individuals with cervical instability due to birth defects, inflammation, or injury. (2) Patients with complete imaging data. Exclusion criteria: (1) Patients with mental disorders. (2) Congenital deformity of the upper cervical spine. (3) Patients in a severe state of infection. Surgical method Robot group: After the standard preoperative anesthesia and preoperative preparation are completed, start the TINAVI robotic system (Fig 1). Use a C-arm CT machine to scan the patient's spine. Then transfer the scanned images to the surgical planning system for registration, and design and plan the parameters and trajectory of the screws (Fig 2). After the plan is confirmed, the robotic arm with a guiding sleeve will automatically reach the target area. The surgical incision is made and pedicle screws are inserted along the guiding sleeve. After confirming their positions using fluoroscopy, all screws are tightened. Finally, all screws are connected and fixed with titanium rods. After completing all operations, the surgical incision is sutured and the surgery end (Fig 3; Fig 4). Traditional surgical group: After standard preoperative preparation, the surgery is carried out in accordance with established protocols and previous experience[9](Fig 5). Evaluation indicators Screw insertion accuracy: Two senior spine surgeons evaluated the screw placement using the Gertzbein-Robbins classification scale to ensure consistency and comparability of the research data. The assessment was conducted through CT scans (Fig 6)[10]. Violation of the facet joint: Evaluation of small joint involvement damage according to Seo's classification system[11]. Clinical data analysis: Baseline data, including surgical time, intraoperative blood loss, fluoroscopy dose, incision length, length of hospital stay and complications will be collected. In addition, follow-up assessments will include VAS score, SF-36 score, NDI score and JOA score at 3 days postoperatively, 3 months postoperatively and 12 months postoperatively. Statistical analysis SPSS 22.0 Windows software (IBM Co, Armonk, NY, USA) was used for statistical analysis. Descriptive statistics are reported as means ± standard deviations, frequencies, or percentages when appropriate. The unpaired Student’s t-test and paired sample t-test were used to compare two groups with Shapiro-Wilk test for normality test. And Mann-Whitney U test was used for non-normally distributed continuous data. Chissquare or Fisher exact tests were used for categorical variables. For VAS, SF-36, NDI and JOA data, after the normal test, data were all regularly distributed. Two-way repeated measurement ANOVA with the Bonferroni post-hoc test was used to assess VAS, SF-36, NDI and JOA data from the same group over multiple time points. P < 0.05 was considered statistically significant. Results Patients The demographic and perioperative information of the patients in the two groups are shown in Table 1 . The study enrolled a total of 134 patients, with 51 allocated to the RA group (male: female = 44 : 7; average age: 35.71 ± 11.56 years, BMI: 23.38 ± 3.36) and 83 to the TR group (male: female = 68 : 15; average age: 37.66 ± 8.18 years, BMI: 23.69 ± 3.60). There is no statistically significant disparity observed in the two sets of baseline data (P > 0.05). Table 1 Baseline characteristics of the patients RA TR P Number of patients 51 83 Age (years) 35.71 ± 11.56 37.66 ± 8.18 0.294 Sex (Male:Female) 44:7 68:15 0.510 BMI (kg/m 2 ) 23.38 ± 3.36 23.69 ± 3.60 0.626 Surgery time (min) 134.67 ± 34.81 111.23 ± 32.70 <0.001 Intraoperative bleeding (ml) 95.39 ± 30.15 149.52 ± 50.60 <0.001 Intraoperative fluoroscopic dose (mGy) 419.42 ± 55.57 236.54 ± 30.68 <0.001 Incision length (cm) 8.48 ± 2.30 11.92 ± 2.79 <0.001 Length of hospital stay (days) 4.45 ± 1.29 4.43 ± 1.87 0.950 Types of disease 0.110 Rheumatoid arthritis or Degenerative conditions 2 10 Traumatic instability 49 73 Note: 1. Significant values in bold; 2. Length of hospital stay: the first day after the operation to the end of the hospital; 3. The sample size for our study was determined as follows: We collected data on UCI patients who underwent surgery from January 2017 to May 2023 and screened cases based on predefined inclusion and exclusion criteria. A total of 134 eligible patients were included in the analysis. Accuracy of pedicle screw placement and facet process invasion The screw precision was 98.0% in the RA group and 83.4% in the TR group, with a statistically significant difference (P < 0.001). Regarding invasion of the adjacent facet joint, there was a significant difference between the RA group (Level 0, 1 and 2: 96.1%, 3.9% and 0%) and the TR group (Level 0, 1 and 2: 63.3%, 36.7% and 0%) (P < 0.001) Table 2 . Table 2 Rating of implanted screws and comparison of facet joint violation RA TR P Screw rating A 190 (93.1%) 186 (56.0%) < 0.001 B 10 (4.9%) 91 (27.4%) A + B 200 (98.0%) 277 (83.4%) < 0.001 C 4 (2.0%) 55 (16.6%) D 0 (0%) 0 (0%) E 0 (0%) 0 (0%) All 204 (100%) 332 (100%) Invasion of facet joint violation 0 level 196 (96.1%) 210 (63.3%) < 0.001 1 level 8 (3.9%) 122 (36.7%) 2 level 0 (0%) 0 (0%) Note:1. Significant values in bold; 2. This scale defines a grade A screw placement as 0 mm extraosseous position, grade B as ≤ 2 mm extraosseous position, grade C as ≤ 4 mm extraosseous position, grade D as ≤ 6 mm extraosseous position and grade E as > 6 mm extraosseous position. The A-grade and B-grade screws are considered as accuracy screws. Grade A was considered the “ideal screw position”, Grade A + B were considered “clinically acceptable” screw placement, and Grade D were considered “clinically unacceptable” screw placement. 3. Level 0 indicates no contact, Level 1 suggests screw head contact or suspected contact with the small joint, and Level 2 signifies obvious intrusion of screws into the small joint. Clinical results All patients experienced significant improvement in their clinical indicators after surgery, with an average follow-up duration of 12 months for all cases. The RA group demonstrated a longer surgical duration and higher intraoperative radiation exposure compared to the TR group (P < 0.001). The TR group experienced greater intraoperative blood loss and larger surgical incisions than the RA group (P 0.05). The VAS scores of the RA group at postoperative 3 days, 3 months, and 12 months were significantly lower than those of the TR group (P < 0.001). The SF-36 PCS score of the RA group at postoperative day 3 was significantly higher than that of the TR group (P 0.05) (Table 3 ). Moreover, both groups did not experience any serious complications such as wound infection, vertebral artery rupture, or nerve root damage (Table 4 ). Table 3 VAS, SF-36, NDI and JOA Score RA TR P VAS Preoperative 7.80 ± 1.46 7.88 ± 1.27 0.753 3 Days after surgery 3.24 ± 0.79* 4.80 ± 0.75* < 0.001 3 Months after surgery 2.06 ± 0.90 # 2.89 ± 0.73 # < 0.001 12 Months after surgery 1.20 ± 0.53 ※ 1.57 ± 0.65 ※ < 0.001 SF-36 PCS Preoperative 40.88 ± 7.03 40.17 ± 7.22 0.576 3 Days after surgery 48.01 ± 6.75* 44.82 ± 7.04* 0.011 3 Months after surgery 53.22 ± 4.97 # 51.65 ± 5.97 # 0.119 12 Months after surgery 55.06 ± 4.59 53.54 ± 6.16 0.105 MCS Preoperative 55.46 ± 7.93 56.24 ± 5.80 0.515 3 Days after surgery 63.04 ± 8.14* 63.17 ± 6.55* 0.917 3 Months after surgery 65.59 ± 8.26 65.83 ± 6.27 # 0.854 12 Months after surgery 66.13 ± 8.10 66.50 ± 6.31 0.769 NDI Preoperative 33.06 ± 3.76 33.05 ± 4.30 0.988 3 Days after surgery 21.14 ± 4.61* 21.27 ± 3.53* 0.857 3 Months after surgery 12.02 ± 4.09 # 12.41 ± 3.79 # 0.576 12 Months after surgery 10.24 ± 4.11 ※ 10.84 ± 3.80 ※ 0.385 JOA Preoperative 7.27 ± 1.71 7.29 ± 1.30 0.958 3 Days after surgery 12.10 ± 2.01* 11.81 ± 2.02* 0.419 3 Months after surgery 14.49 ± 1.35 # 14.46 ± 1.32 # 0.891 12 Months after surgery 15.78 ± 1.08 ※ 15.94 ± 1.17 ※ 0.445 Note: 1. Significant values in bold; 2. *The statistical significance of the difference between preoperative and postoperative day 3 within the same group is evident. (P < 0.05); 3. # The difference between 3 months and 3 days postoperatively within the same group is statistically significant (P < 0.05); 4. ※ The difference between 12 months and 3 months postoperatively within the same group is statistically significant (P < 0.05); 5. SF-36 (The medical outcomes study 36-item short from health survey): This is a very popular questionnaire used to evaluate health-related quality of life. Physical component summary (PCS) and mental component summary (MCS) can be calculated separately; 6. NDI (Neck disability index): This is a widely used clinical tool for evaluating the functional status of the cervical spine. This patient self-assessment questionnaire was developed by Vernon et al. in 1991, and it is based on modifications to the Oswestry Low Back Pain Disability Questionnaire; 7. JOA (Japanese orthopaedic association score): This is assessment methods developed by the Japanese orthopaedic association to evaluate the functional status of cervical spondylosis, including both cervical and lumbar JOA scores. Table 4 Complications related to surgery RA TR Neurologic deficit 0 0 Vertebral artery injury 0 0 Wound infection 0 0 Intraoperative adjustment screw 2 8 Discussion Unstable upper cervical spine conditions are generally treated conservatively; however, in cases of significant displacement and severe spinal cord compression, surgical intervention should be considered. Nonetheless, some reports have opted for conservative treatment, although the long-term follow-up outcomes are not ideal[12]. Due to the extremely narrow vertebral arch of the upper cervical vertebrae, and the inner side of the vertebral arch being constrained by the spinal cord, and the outer side being threatened by the vertebral artery, along with important physiological structures such as nerve roots passing through the vertebral body itself, implanting pedicle screws presents an exceptionally challenging task. There are reports indicating that during manual placement of screws, the rate of injury to critical structures can be as high as 11%-73.9%[12]. Manual nail placement faces objective challenges, but robotic-assisted surgery may offer a solution[8]. In 2016, Tian Wei reported the initial use of the TINAVI robot for atlantoaxial joint fixation, demonstrating its significant potential in upper cervical spine applications[13]. The Crip robot and StealthStation robot were also utilized in upper cervical spine procedures, with multiple surgical teams achieving successful outcomes using various robotic systems Table 5 [14–20]. This study revealed that the accuracy rate of screws in the RA group for patients with unstable upper cervical spine was 98.0% (200/204), which was significantly higher than the TR group at 83.4% (277/332). Furthermore, the proportion of Grade A screws in the RA group was notably higher at 93.1% (190/204), close to SU's findings, where the accuracy rate of Grade A screws in the RA group (90.6%) surpassed that in the TR group (71.1%) (P < 0.05)[14]. Furthermore, Fan and Su independently conducted a randomized controlled trial (RCT) and prospective cohort study utilizing the TINAVI robot to assess patients with degenerative and traumatic cervical spine lesions. The findings indicated that the accuracy rates in the RA group were 87.6% and 90.6%, respectively, surpassing those in the TR group (60.8% VS 86.6%) (P < 0.05)[7, 14]. It has been documented that manual implantation can result in a misplacement rate ranging from 14–23%[5]. The diameter of the pedicle screw ranges from approximately 3.5-4.0 mm, while the narrowest section of the pedicle root measures about 5.0–7.0 mm, presenting a significant challenge. Additionally, the presence of physiological deformities in the vertebrae poses an even greater obstacle to be addressed[21]. Table 5 Research on robotic-assisted surgery Author Time Types of Robots Number of screws Accuracy of screws C1-C2 C3-C7 C1-C2 C3-C7 Smith [27] 2016 StealthStation 8 - 50.0% (4/8) - Free hand - - - - Farah [26] 2020 Cirq 4 - 100.0% (4/4) - Free hand - - - - Farah [13] 2021 Cirq 2 19 100.0% (2/2) 78.9% (15/19) Free hand - - - - Zan [24] 2022 TINAVI 22 - 90.9% (20/22) - Free hand 28 - 85.7% (24/28) - Su [11] 2022 TINAVI 180 97.2% (175/180) Free hand 194 91.2% (177/194) Li [23] 2023 TINAVI 50 - 98.0% (49/50) - Free hand 70 - 74.2% (52/70) - Li [25] 2024 StealthStation 84 - 95.2% (80/84) - Free hand - - - - Li [25] 2024 TINAVI 116 - 95.7% (111/116) - Free hand - - - - Zhong 2024 TINAVI 120 - 98.0% (200/204) - Free hand 480 - 83.4% (277/332) - Note: Accuracy of screws: The ratio of "acceptable screws" to the total quantity of all screws. Based on our experience with robot-assisted spinal surgeries, even minor device movements can misalign screw trajectories. Any movement during data collection via the C-arm requires a rescan. The tracker’s position must be carefully set, as a distance greater than 30 cm from the surgical site can reduce accuracy. While this may not notably affect robot-assisted lumbar spine surgeries, it requires extra caution in UCI surgeries[14]. The RA team will monitor this and ensure that everything proceeds as planned. Fortunately, none of the patients in this study experienced serious complications such as cerebrospinal fluid leakage, vertebral artery rupture, or nerve root injury. Due to the instability of the upper cervical vertebrae, it seems difficult to completely avoid encroachment on adjacent facet joints during the process of implanting pedicle screws[22]. Some scholars argue that the intrusion of pedicle screws into the facet joint may expedite the degeneration of neighboring segments[23]. Hence, it is equally imperative to safeguard the neighboring small joints from infiltration during the screw implantation procedure. The present study demonstrates a lower incidence of small joint invasion in the RA group compared to the TR group (3.9% VS 36.7%). The results of this study indicate that compared to the TR group (111.23 ± 32.70 min), the RA group had a longer surgical time (134.67 ± 34.81 min) due to the use of the robot system, which requires connecting components such as the robotic arm system, optical positioning and tracking system, and surgical planning system, as well as performing registration operations on the robot system, all of which add extra time. The RA group demonstrated significantly reduced intraoperative blood loss (95.39 ± 30.15 ml) compared to the TR group (149.52 ± 50.60 ml), which can be attributed to the larger surgical incision, increased soft tissue damage, and greater surrounding tissue trauma during screw insertion in the TR group[24]. It is important to note that although traditional manual techniques require larger incisions to ensure sufficient visibility during surgery, the surrounding soft tissues are also a crucial component of upper cervical joint stability. Therefore, efforts should be made to minimize damage to the remaining stable structures during the actual procedure[6]. In this study, the TR group (236.54 ± 30.68 mGy) received a lower intraoperative radiation dose compared to the RA group (419.42 ± 55.57 mGy), as the RA group required additional data collection at the surgical site to meet the requirements of robot system analysis and design, resulting in a higher radiation dose than the TR group[25]. Despite the RA group experiencing higher levels of intraoperative radiation and longer surgical time, it is fortunate that no radiation-related complications occurred following robot-assisted surgery in this study, and there was no increase in the incidence of other complications. Operators are generally not exposed to the radiation environment during the data collection process. The TR group exhibited a significantly larger incision length compared to the RA group. No disparity in hospital stay duration was observed between the TR and RA groups. In the present study, surgical intervention resulted in significant improvements in clinical pain and functional indicators including VAS, SF-36, NDI, and JOA. On the 3rd day after surgery, there was a statistically significant difference in VAS and PCS between the RA group and the TR group. This may be due to the extensive muscle and soft tissue dissection during the traditional open surgery for posterior cervical exposure, leading to more pain symptoms during recovery. There were no significant differences in NDI and JOA between the two groups during follow-up. While the RA group has shown significant potential for practical application in providing a more reliable implantation plan for screw insertion during surgery and precise guidance, surgeons must still exercise a high degree of caution during the screw insertion process due to the possibility of slight deviations in the tip of the screw caused by soft tissues or other structures, which may impact its trajectory. Furthermore, while robotic systems are an optimal choice for patients with challenging issues such as delicate pedicles, variation of position of vertebral artery, or congenital anomalies of the vertebrae, the relatively steep costs associated with acquiring and maintaining these systems contribute to the financial burden on patients. Fortunately, as the system becomes more widely utilized in various clinical settings, it is anticipated that production costs will decrease, ultimately making treatment with robotic systems more accessible to a larger number of patients in need[7]. This study has several limitations. Due to the early stage of robot-assisted therapy, the number of UCI patients undergoing such treatment is limited. Therefore, recruiting more patients in later stages is essential to strengthen the credibility of our conclusions. Retrospective methods result in some clinical data loss; thus, future prospective studies should focus on collecting additional data and including more comprehensive assessment indicators. Additionally, future research should involve longer follow-up periods, randomized controlled trials, and multicenter studies. Conclusions Traditional open posterior cervical pedicle screw fixation surgery still holds significant importance in the treatment of UCI. However, using orthopedic robotic-assisted pedicle screw fixation for UCI can significantly improve screw placement accuracy and reduce intraoperative blood loss. Overall, robotic-assisted pedicle screw fixation represents a surgical approach with considerable clinical potential and promising application prospects in orthopedic surgery. Declarations Author Contribution Wenjie Zhong: Writing – review & editing, Writing – original draft, Visualization, Methodology, Investigation, Data curation, Conceptualization. Niezhenghao He: Methodology, Investigation, Data curation. Zongdong Zhu: Methodology. Lingcong Xu: Methodology, Investigation. Wenao Liao: Investigation. Caiyuan Liu: Investigation. Ke Xu: Investigation. Fei Wang: Writing – review & editing, Investigation. Xu Lan: Investigation. Wei Zhang: Investigation. Jiang Hu: Writing – review & editing, Funding acquisition. Haowen Cui: Writing – review & editing, Supervision, Project administration, Funding acquisition, Conceptualization. Acknowledgement This work was supported by National Natural Science Foundation 65 of China (Grant No. 82302754) and Sichuan Provincial Department of Science and Technology Project (No.2024NSFSC1807). All data needed to evaluate the conclusions in the paper are present in the paper and/or the Supplementary Materials. References Ma Z, Zhang YN, Ma X, Chen C, Feng HY (2023) Comparison of the clinical efficacy of unilateral and bilateral pedicle screw short-segment fixation and fusion in the treatment of atlantoaxial fracture-dislocation. Technol Health Care 31:1619-1629. doi: 10.3233/THC-220721 Singh DK, Shankar D, Singh N, Singh RK, Chand VK (2022) C2 Screw fixation techniques in atlantoaxial instability: A technical review. 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Spine (Phila Pa 1976) 45:E1532-E1540. doi: 10.1097/BRS.0000000000003632 Malik AT, Drain JP, Jones J, Karnes J, Brewster J, Ryu R, Singh V, Kim J, Khan SN, Yu E (2021) Robotic-Assisted Versus Conventional Posterior Lumbar Fusion-An Analysis of 90-Day Complications and Readmissions. World Neurosurg 152:e168-e174. doi: 10.1016/j.wneu.2021.05.072 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. 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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-6336718","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":445068245,"identity":"8a9095ed-cb90-4758-ad71-e0d93f38dae6","order_by":0,"name":"Wenjie Zhong","email":"","orcid":"","institution":"Department of Orthopedics, Sichuan Provincial People’s Hospital; School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China","correspondingAuthor":false,"prefix":"","firstName":"Wenjie","middleName":"","lastName":"Zhong","suffix":""},{"id":445068246,"identity":"dc3924d2-5647-46e9-b3ea-1ce8a7a06f28","order_by":1,"name":"Niezhenghao He","email":"","orcid":"","institution":"Department of Orthopedics, Sichuan Provincial People’s Hospital; School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China","correspondingAuthor":false,"prefix":"","firstName":"Niezhenghao","middleName":"","lastName":"He","suffix":""},{"id":445068247,"identity":"dfb694ba-7edd-4564-ae89-cbc26185ff57","order_by":2,"name":"Zongdong Zhu","email":"","orcid":"","institution":"Department of Orthopedics, Sichuan Provincial People’s Hospital; School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China","correspondingAuthor":false,"prefix":"","firstName":"Zongdong","middleName":"","lastName":"Zhu","suffix":""},{"id":445068248,"identity":"1baf8595-c2f5-4d5c-a9f2-99d8a4910cf3","order_by":3,"name":"lingcong Xu","email":"","orcid":"","institution":"Department of Orthopedics, Sichuan Provincial People’s Hospital; School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China","correspondingAuthor":false,"prefix":"","firstName":"lingcong","middleName":"","lastName":"Xu","suffix":""},{"id":445068249,"identity":"90c36255-3685-47dd-8d6c-52d1689b4bb9","order_by":4,"name":"Wenao Liao","email":"","orcid":"","institution":"Department of Orthopedics, Sichuan Provincial People’s Hospital; School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China","correspondingAuthor":false,"prefix":"","firstName":"Wenao","middleName":"","lastName":"Liao","suffix":""},{"id":445068250,"identity":"7062f750-ce66-4074-9b2a-ff1c4915c3e1","order_by":5,"name":"caiyuan Liu","email":"","orcid":"","institution":"Department of Orthopedics, Sichuan Provincial People’s Hospital; School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China","correspondingAuthor":false,"prefix":"","firstName":"caiyuan","middleName":"","lastName":"Liu","suffix":""},{"id":445068251,"identity":"ba08e886-bae9-43a1-81d9-8adb83406b44","order_by":6,"name":"Ke Xu","email":"","orcid":"","institution":"Department of Orthopedics, Sichuan Provincial People’s Hospital; School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China","correspondingAuthor":false,"prefix":"","firstName":"Ke","middleName":"","lastName":"Xu","suffix":""},{"id":445068252,"identity":"f5921391-c05f-4696-852f-c8d23c917509","order_by":7,"name":"Fei Wang","email":"","orcid":"","institution":"Department of Orthopedics, Sichuan Provincial People’s Hospital; School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China","correspondingAuthor":false,"prefix":"","firstName":"Fei","middleName":"","lastName":"Wang","suffix":""},{"id":445068253,"identity":"72d22464-4651-483b-a0ae-346deead6d9f","order_by":8,"name":"xu Lan","email":"","orcid":"","institution":"Department of Orthopedics, Sichuan East Hospital, Sichuan Provincial People's Hospital · The First People's Hospital of Dazhou, Dazhou, 635000, China","correspondingAuthor":false,"prefix":"","firstName":"xu","middleName":"","lastName":"Lan","suffix":""},{"id":445068254,"identity":"e0337df8-ab8d-4f90-904c-8b776a586956","order_by":9,"name":"wei Zhang","email":"","orcid":"","institution":"Department of Orthopedics, Sichuan Provincial People’s Hospital; School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China","correspondingAuthor":false,"prefix":"","firstName":"wei","middleName":"","lastName":"Zhang","suffix":""},{"id":445068255,"identity":"b62313cd-a52d-4a1d-877d-2b3081128c49","order_by":10,"name":"jiang Hu","email":"","orcid":"","institution":"Department of Orthopedics, Sichuan Provincial People’s Hospital; School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China","correspondingAuthor":false,"prefix":"","firstName":"jiang","middleName":"","lastName":"Hu","suffix":""},{"id":445068256,"identity":"43b05b75-8c0a-413a-a220-cd779c286a28","order_by":11,"name":"Haowen Cui","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIiWNgGAWjYFACxjYIzd7AwMADF2UjRgvPAagWNoJaYLISCURq4Z+R3PbgR8VhOXPJ14kP3jAclpOf3/yA4UPZYQb+2Q1YtUjcSGw37Dlz2Nhydu5mwzkMh40NjrEZMM44d5hB4s4BrFoMJBLbJHjbbiduuJ27TZqH4XDiBjYeBmbetsNAqQScWiT/tt2u33Dz7PbfQC3189uAWv4S0CINtCXB4AbvNmaglgSGY0AtjHi0SJx52CYtc+a/4YYzuZsl5xikG244lmZwsOdcOo/EDexa+NvTn0m+qUiTNzh+duOHNxXW8vLNhx8++FFmLcc/A7sWdHdCqAMMyClhFIyCUTAKRgHJAAB7+l1826txfwAAAABJRU5ErkJggg==","orcid":"","institution":"Department of Orthopedics, Sichuan Provincial People’s Hospital; School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China","correspondingAuthor":true,"prefix":"","firstName":"Haowen","middleName":"","lastName":"Cui","suffix":""}],"badges":[],"createdAt":"2025-03-30 04:23:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6336718/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6336718/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81932254,"identity":"51746baf-8f99-4b7f-967c-fa199b594000","added_by":"auto","created_at":"2025-05-05 05:34:44","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":139478,"visible":true,"origin":"","legend":"\u003cp\u003ePhysical and operational schematics of the robot\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6336718/v1/bd8a7208abf77e1be8cad47b.jpg"},{"id":81932255,"identity":"ecf2130d-11c7-4e85-b824-44eec7caa66c","added_by":"auto","created_at":"2025-05-05 05:34:44","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":116839,"visible":true,"origin":"","legend":"\u003cp\u003eRobots flow chart\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6336718/v1/c3ddd3ff33e607d8768d621c.jpg"},{"id":81932259,"identity":"9d2461a4-78bd-48a0-8b93-093f483f28bf","added_by":"auto","created_at":"2025-05-05 05:34:44","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":108135,"visible":true,"origin":"","legend":"\u003cp\u003eRobot navigation map\u003c/p\u003e\n\u003cp\u003eNote: 1. C1 screw layout diagram (a-c); 2. C2 screw layout diagram(d-f); 3. Check and confirm before implanting the screw (g-h); 4. Deg: The angle parameters between the designed screw and the preset screw.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6336718/v1/115a8b16a9a22fde6b594a89.jpg"},{"id":81932258,"identity":"fec5f91e-9b90-4435-8aa6-26857110907e","added_by":"auto","created_at":"2025-05-05 05:34:44","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":87131,"visible":true,"origin":"","legend":"\u003cp\u003eCase 1\u003c/p\u003e\n\u003cp\u003eNote: This case involves a 37-year-old female patient diagnosed with upper cervical injury (UCI) after trauma. According to the Anderson-D'AJonzo classification, the type of axis vertebral injury is IIC, and according to the Gehweiler classification, the type of atlas vertebral injury is type 1. Considering the overall condition of the patient, posterior C1-C2 fixation should be performed. The patient underwent upper cervical internal fixation surgery assisted by TINAVI system. (a) Preoperative X-ray; (b, c): Sagittal and transverse CT images before surgery; (d) 3D reconstructed cervical spine image from preoperative CT; (e,f) Preoperative MRI images; (g) Postoperative X-ray image; (h,i): Postoperative CT images; Yellow arrows indicate the main injured areas in the patient.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6336718/v1/e8cdb60ff9d928878e8208f2.jpg"},{"id":81932257,"identity":"81ac014e-2768-4fe4-80da-ebd5fe554559","added_by":"auto","created_at":"2025-05-05 05:34:44","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":79947,"visible":true,"origin":"","legend":"\u003cp\u003eCase 2\u003c/p\u003e\n\u003cp\u003eThis case is a 45-year-old female patient who suffered upper cervical spine injury due to trauma, Anderson-D'AJonzo type IIc, requiring posterior C1-C2 fixation. The patient underwent manual internal fixation surgery of the upper cervical spine. (a) Preoperative X-ray examination; (b, c): Preoperative CT sagittal and transverse images; (d) Preoperative CT three-dimensional reconstruction of the cervical spine image; (e, f) Preoperative MRI images; (g) Postoperative X-ray imaging; (h, i): Postoperative CT images; The yellow arrows indicate the main injured area of the patient.\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6336718/v1/0c63f113d357bb2bba697a59.jpg"},{"id":81933980,"identity":"45971e43-6a91-4f3a-a423-403727c42f87","added_by":"auto","created_at":"2025-05-05 05:42:44","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":23770,"visible":true,"origin":"","legend":"\u003cp\u003eGertzbin-Robbins grading diagram\u003c/p\u003e\n\u003cp\u003eNote: Intra-pedicular accuracy according to the Gertzbin–Robbins scale. (a) “perfect” screw (two screws); (b) “clinically acceptable” screw; (c) “clinically unacceptable” screw.\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6336718/v1/08fb45af5b0ab33a3e952073.jpg"},{"id":82032247,"identity":"88c09c34-a758-4b11-a7db-c17b3b75b85c","added_by":"auto","created_at":"2025-05-06 07:31:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1429180,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6336718/v1/2e8214e8-c0be-4bfa-a494-5c046bbb9ad6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The safety and precision of pedicle screw placement in treating upper cervical instability using a robotic system","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUpper Cervical Instability (UCI) is the disruption of the relationship between the atlas (C1) and axis (C2), resulting in decreased stability of the cervical spine. Clinical presentations include cervical pain, neurological impairment, and vertigo[1]. In severe cases, the spinal cord can be damaged, which is life-threatening. The technology for fixing the atlantoaxial joint has changed a lot in recent decades[2]. The earliest cable and pedicle screw/hook techniques have gradually faded into history, and the rod-screw system composed of pedicle screws is currently the most popular choice for posterior fixation[3]. Currently, laminectomy and anterior cervical decompression and fixation can also be used for the treatment of UCI, but the theoretically most effective method remains posterior cervical pedicle screw fixation[4]. The atlas vertebra's unique and complex anatomy makes surgery challenging, requiring precise screw placement[5].\u003c/p\u003e \u003cp\u003eTraditional surgery has potential complications that are difficult to avoid, such as the risk of local soft tissue injury when exposing the vertebral body during open surgery. The venous sinus between C1-2 vertebrae may lead to significant bleeding. During the manual screw placement process, previous reports indicate that up to 73.9% of patients experienced vertebral artery injury, while 41.5% experienced nerve root injury[6]. The misplacement rate for traditional manual C2 pedicle screws ranges from 11\u0026ndash;23%[5].\u003c/p\u003e \u003cp\u003eAt present, a variety of robot-assisted systems are utilized in posterior cervical fusion surgery to assist surgeons in accurately locating and positioning screws. Fan et al. and Su et al. achieved accuracy rates of 87.6% and 90.6%, respectively, in the implantation of pedicle screws using the TINAVI robot[7], which differ from the accuracies of 84.1% for the Mazor X robot and 60.9% for the Cirq robot[8].\u003c/p\u003e \u003cp\u003eThe robotic system can help improve preoperative planning and screw placement, leading to better surgical plans and outcomes for upper cervical spine surgery. However, additional data support is needed to verify the effectiveness with different brands and principles. This study aims to report the imaging differences and clinical outcomes of treatments robot-assisted pedicle screw internal fixation and traditional open surgery for condition UCI.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThe current retrospective study has received approval from the Ethics Committee (Approval number: Lunshen (Yan) 20240498). Gather the patient data of individuals who received surgical treatment for UCI at this hospital between January 2017 and May 2023. A total of 134 patients were enrolled, with 51 patients in the orthopedic robot-assisted pedicle screw internal fixation group (RA) and 83 patients in the traditional open surgery group (TR). All procedures were performed by a single, specialized team using standardized traditional and robotic techniques.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria:\u003c/strong\u003e (1) Individuals with cervical instability due to birth defects, inflammation, or injury. (2) Patients with complete imaging data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria:\u0026nbsp;\u003c/strong\u003e(1) Patients with mental disorders. (2) Congenital deformity of the upper cervical spine. (3) Patients in a severe state of infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical method\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRobot group:\u0026nbsp;\u003c/strong\u003eAfter the standard preoperative anesthesia and preoperative preparation are completed, start the TINAVI robotic system (Fig 1). Use a C-arm CT machine to scan the patient's spine. Then transfer the scanned images to the surgical planning system for registration, and design and plan the parameters and trajectory of the screws (Fig 2). After the plan is confirmed, the robotic arm with a guiding sleeve will automatically reach the target area. The surgical incision is made and pedicle screws are inserted along the guiding sleeve. After confirming their positions using fluoroscopy, all screws are tightened. Finally, all screws are connected and fixed with titanium rods. After completing all operations, the surgical incision is sutured and the surgery end (Fig 3; Fig 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTraditional surgical group:\u0026nbsp;\u003c/strong\u003eAfter standard preoperative preparation, the surgery is carried out in accordance with established protocols and previous experience[9](Fig 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluation indicators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eScrew insertion accuracy:\u0026nbsp;\u003c/strong\u003eTwo senior spine surgeons evaluated the screw placement using the Gertzbein-Robbins classification scale to ensure consistency and comparability of the research data. The assessment was conducted through CT scans (Fig 6)[10].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eViolation of the facet joint:\u003c/strong\u003e Evaluation of small joint involvement damage according to Seo's classification system[11].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical data analysis:\u0026nbsp;\u003c/strong\u003eBaseline data, including surgical time, intraoperative blood loss, fluoroscopy dose, incision length, length of hospital stay and complications will be collected. In addition, follow-up assessments will include VAS score, SF-36 score, NDI score and JOA score at 3 days postoperatively, 3 months postoperatively and 12 months postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSPSS 22.0 Windows software (IBM Co, Armonk, NY, USA) was used for statistical analysis. Descriptive statistics are reported as means ± standard deviations, frequencies, or percentages when appropriate. The unpaired Student’s t-test and paired sample t-test were used to compare two groups with Shapiro-Wilk test for normality test. And Mann-Whitney U test was used for non-normally distributed continuous data. Chissquare or Fisher exact tests were used for categorical variables. For VAS, SF-36, NDI and JOA data, after the normal test, data were all regularly distributed. Two-way repeated measurement ANOVA with the Bonferroni post-hoc test was used to assess VAS, SF-36, NDI and JOA data from the same group over multiple time points. P \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThe demographic and perioperative information of the patients in the two groups are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The study enrolled a total of 134 patients, with 51 allocated to the RA group (male: female\u0026thinsp;=\u0026thinsp;44 : 7; average age: 35.71\u0026thinsp;\u0026plusmn;\u0026thinsp;11.56 years, BMI: 23.38\u0026thinsp;\u0026plusmn;\u0026thinsp;3.36) and 83 to the TR group (male: female\u0026thinsp;=\u0026thinsp;68 : 15; average age: 37.66\u0026thinsp;\u0026plusmn;\u0026thinsp;8.18 years, BMI: 23.69\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60). There is no statistically significant disparity observed in the two sets of baseline data (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\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\u003eBaseline characteristics of the patients\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83\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 (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.71\u0026thinsp;\u0026plusmn;\u0026thinsp;11.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.66\u0026thinsp;\u0026plusmn;\u0026thinsp;8.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.294\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (Male:Female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44:7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68:15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.510\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.38\u0026thinsp;\u0026plusmn;\u0026thinsp;3.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.69\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.626\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e134.67\u0026thinsp;\u0026plusmn;\u0026thinsp;34.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e111.23\u0026thinsp;\u0026plusmn;\u0026thinsp;32.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative bleeding (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.39\u0026thinsp;\u0026plusmn;\u0026thinsp;30.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e149.52\u0026thinsp;\u0026plusmn;\u0026thinsp;50.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative fluoroscopic dose (mGy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e419.42\u0026thinsp;\u0026plusmn;\u0026thinsp;55.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e236.54\u0026thinsp;\u0026plusmn;\u0026thinsp;30.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncision length (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.48\u0026thinsp;\u0026plusmn;\u0026thinsp;2.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.45\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.950\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypes of disease\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRheumatoid arthritis or Degenerative conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\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\u003eTraumatic instability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\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\"\u003eNote: 1. Significant values in bold; 2. Length of hospital stay: the first day after the operation to the end of the hospital; 3. The sample size for our study was determined as follows: We collected data on UCI patients who underwent surgery from January 2017 to May 2023 and screened cases based on predefined inclusion and exclusion criteria. A total of 134 eligible patients were included in the analysis.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAccuracy of pedicle screw placement and facet process invasion\u003c/h2\u003e \u003cp\u003eThe screw precision was 98.0% in the RA group and 83.4% in the TR group, with a statistically significant difference (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Regarding invasion of the adjacent facet joint, there was a significant difference between the RA group (Level 0, 1 and 2: 96.1%, 3.9% and 0%) and the TR group (Level 0, 1 and 2: 63.3%, 36.7% and 0%) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) 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\u003eRating of implanted screws and comparison of facet joint violation\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScrew rating\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\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e190 (93.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e186 (56.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (4.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (27.4%)\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\u003eA\u0026thinsp;+\u0026thinsp;B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e200 (98.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e277 (83.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (16.6%)\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\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\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\u003eE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\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\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e204 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e332 (100%)\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\u003eInvasion of facet joint violation\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\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0 level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e196 (96.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e210 (63.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e122 (36.7%)\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 level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\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\"\u003eNote:1. Significant values in bold; 2. This scale defines a grade A screw placement as 0 mm extraosseous position, grade B as \u0026le;\u0026thinsp;2 mm extraosseous position, grade C as \u0026le;\u0026thinsp;4 mm extraosseous position, grade D as \u0026le;\u0026thinsp;6 mm extraosseous position and grade E as \u0026gt;\u0026thinsp;6 mm extraosseous position. The A-grade and B-grade screws are considered as accuracy screws. Grade A was considered the \u0026ldquo;ideal screw position\u0026rdquo;, Grade A\u0026thinsp;+\u0026thinsp;B were considered \u0026ldquo;clinically acceptable\u0026rdquo; screw placement, and Grade D were considered \u0026ldquo;clinically unacceptable\u0026rdquo; screw placement. 3. Level 0 indicates no contact, Level 1 suggests screw head contact or suspected contact with the small joint, and Level 2 signifies obvious intrusion of screws into the small joint.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical results\u003c/h3\u003e\n\u003cp\u003eAll patients experienced significant improvement in their clinical indicators after surgery, with an average follow-up duration of 12 months for all cases. The RA group demonstrated a longer surgical duration and higher intraoperative radiation exposure compared to the TR group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The TR group experienced greater intraoperative blood loss and larger surgical incisions than the RA group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, there was no statistically significant difference in length of hospital stay between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The VAS scores of the RA group at postoperative 3 days, 3 months, and 12 months were significantly lower than those of the TR group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The SF-36 PCS score of the RA group at postoperative day 3 was significantly higher than that of the TR group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, there were no statistically significant differences in NDI and JOA scores between the two groups at each postoperative time point (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Moreover, both groups did not experience any serious complications such as wound infection, vertebral artery rupture, or nerve root damage (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVAS, SF-36, NDI and JOA Score\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=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e7.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.753\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Days after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.89\u0026thinsp;\u0026plusmn;\u0026thinsp;0.73\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 Months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003csup\u003e※\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003csup\u003e※\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSF-36\u003c/b\u003e\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\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCS\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\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e40.88\u0026thinsp;\u0026plusmn;\u0026thinsp;7.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e40.17\u0026thinsp;\u0026plusmn;\u0026thinsp;7.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.576\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Days after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e48.01\u0026thinsp;\u0026plusmn;\u0026thinsp;6.75*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e44.82\u0026thinsp;\u0026plusmn;\u0026thinsp;7.04*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e53.22\u0026thinsp;\u0026plusmn;\u0026thinsp;4.97\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e51.65\u0026thinsp;\u0026plusmn;\u0026thinsp;5.97\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.119\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 Months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e55.06\u0026thinsp;\u0026plusmn;\u0026thinsp;4.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e53.54\u0026thinsp;\u0026plusmn;\u0026thinsp;6.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCS\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\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e55.46\u0026thinsp;\u0026plusmn;\u0026thinsp;7.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e56.24\u0026thinsp;\u0026plusmn;\u0026thinsp;5.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.515\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Days after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e63.04\u0026thinsp;\u0026plusmn;\u0026thinsp;8.14*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e63.17\u0026thinsp;\u0026plusmn;\u0026thinsp;6.55*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.917\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e65.59\u0026thinsp;\u0026plusmn;\u0026thinsp;8.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e65.83\u0026thinsp;\u0026plusmn;\u0026thinsp;6.27\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.854\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 Months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e66.13\u0026thinsp;\u0026plusmn;\u0026thinsp;8.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e66.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.769\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNDI\u003c/b\u003e\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\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e33.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e33.05\u0026thinsp;\u0026plusmn;\u0026thinsp;4.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.988\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Days after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e21.14\u0026thinsp;\u0026plusmn;\u0026thinsp;4.61*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.27\u0026thinsp;\u0026plusmn;\u0026thinsp;3.53*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.857\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e12.02\u0026thinsp;\u0026plusmn;\u0026thinsp;4.09\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e12.41\u0026thinsp;\u0026plusmn;\u0026thinsp;3.79\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.576\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 Months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e10.24\u0026thinsp;\u0026plusmn;\u0026thinsp;4.11\u003csup\u003e※\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.84\u0026thinsp;\u0026plusmn;\u0026thinsp;3.80\u003csup\u003e※\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.385\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eJOA\u003c/b\u003e\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\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e7.29\u0026thinsp;\u0026plusmn;\u0026thinsp;1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.958\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Days after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e12.10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e11.81\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.419\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e14.49\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.891\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 Months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e15.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08\u003csup\u003e※\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003csup\u003e※\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.445\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: 1. Significant values in bold; 2. *The statistical significance of the difference between preoperative and postoperative day 3 within the same group is evident. (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); 3. \u003csup\u003e#\u003c/sup\u003eThe difference between 3 months and 3 days postoperatively within the same group is statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); 4. \u003csup\u003e※\u003c/sup\u003eThe difference between 12 months and 3 months postoperatively within the same group is statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); 5. SF-36 (The medical outcomes study 36-item short from health survey): This is a very popular questionnaire used to evaluate health-related quality of life. Physical component summary (PCS) and mental component summary (MCS) can be calculated separately; 6. NDI (Neck disability index): This is a widely used clinical tool for evaluating the functional status of the cervical spine. This patient self-assessment questionnaire was developed by Vernon et al. in 1991, and it is based on modifications to the Oswestry Low Back Pain Disability Questionnaire; 7. JOA (Japanese orthopaedic association score): This is assessment methods developed by the Japanese orthopaedic association to evaluate the functional status of cervical spondylosis, including both cervical and lumbar JOA scores.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplications related to surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurologic deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertebral artery injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative adjustment screw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eUnstable upper cervical spine conditions are generally treated conservatively; however, in cases of significant displacement and severe spinal cord compression, surgical intervention should be considered. Nonetheless, some reports have opted for conservative treatment, although the long-term follow-up outcomes are not ideal[12]. Due to the extremely narrow vertebral arch of the upper cervical vertebrae, and the inner side of the vertebral arch being constrained by the spinal cord, and the outer side being threatened by the vertebral artery, along with important physiological structures such as nerve roots passing through the vertebral body itself, implanting pedicle screws presents an exceptionally challenging task. There are reports indicating that during manual placement of screws, the rate of injury to critical structures can be as high as 11%-73.9%[12]. Manual nail placement faces objective challenges, but robotic-assisted surgery may offer a solution[8].\u003c/p\u003e \u003cp\u003eIn 2016, Tian Wei reported the initial use of the TINAVI robot for atlantoaxial joint fixation, demonstrating its significant potential in upper cervical spine applications[13]. The Crip robot and StealthStation robot were also utilized in upper cervical spine procedures, with multiple surgical teams achieving successful outcomes using various robotic systems Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e[14\u0026ndash;20]. This study revealed that the accuracy rate of screws in the RA group for patients with unstable upper cervical spine was 98.0% (200/204), which was significantly higher than the TR group at 83.4% (277/332). Furthermore, the proportion of Grade A screws in the RA group was notably higher at 93.1% (190/204), close to SU's findings, where the accuracy rate of Grade A screws in the RA group (90.6%) surpassed that in the TR group (71.1%) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05)[14]. Furthermore, Fan and Su independently conducted a randomized controlled trial (RCT) and prospective cohort study utilizing the TINAVI robot to assess patients with degenerative and traumatic cervical spine lesions. The findings indicated that the accuracy rates in the RA group were 87.6% and 90.6%, respectively, surpassing those in the TR group (60.8% VS 86.6%) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05)[7, 14]. It has been documented that manual implantation can result in a misplacement rate ranging from 14\u0026ndash;23%[5]. The diameter of the pedicle screw ranges from approximately 3.5-4.0 mm, while the narrowest section of the pedicle root measures about 5.0\u0026ndash;7.0 mm, presenting a significant challenge. Additionally, the presence of physiological deformities in the vertebrae poses an even greater obstacle to be addressed[21].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResearch on robotic-assisted surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTypes of Robots\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eNumber of screws\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eAccuracy of screws\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC1-C2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eC3-C7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC1-C2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eC3-C7\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmith [27]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eStealthStation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e50.0% (4/8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFree hand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFarah [26]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCirq\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e100.0% (4/4)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFree hand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFarah [13]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCirq\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e100.0% (2/2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e78.9% (15/19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFree hand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZan [24]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTINAVI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e90.9% (20/22)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFree hand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85.7% (24/28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSu [11]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTINAVI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e97.2% (175/180)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFree hand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e91.2% (177/194)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLi [23]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTINAVI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e98.0% (49/50)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFree hand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e74.2% (52/70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLi [25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eStealthStation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e95.2% (80/84)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFree hand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLi [25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTINAVI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e95.7% (111/116)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFree hand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZhong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTINAVI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e98.0% (200/204)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFree hand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e480\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83.4% (277/332)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: Accuracy of screws: The ratio of \"acceptable screws\" to the total quantity of all screws.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBased on our experience with robot-assisted spinal surgeries, even minor device movements can misalign screw trajectories. Any movement during data collection via the C-arm requires a rescan. The tracker\u0026rsquo;s position must be carefully set, as a distance greater than 30 cm from the surgical site can reduce accuracy. While this may not notably affect robot-assisted lumbar spine surgeries, it requires extra caution in UCI surgeries[14]. The RA team will monitor this and ensure that everything proceeds as planned. Fortunately, none of the patients in this study experienced serious complications such as cerebrospinal fluid leakage, vertebral artery rupture, or nerve root injury.\u003c/p\u003e \u003cp\u003eDue to the instability of the upper cervical vertebrae, it seems difficult to completely avoid encroachment on adjacent facet joints during the process of implanting pedicle screws[22]. Some scholars argue that the intrusion of pedicle screws into the facet joint may expedite the degeneration of neighboring segments[23]. Hence, it is equally imperative to safeguard the neighboring small joints from infiltration during the screw implantation procedure. The present study demonstrates a lower incidence of small joint invasion in the RA group compared to the TR group (3.9% VS 36.7%).\u003c/p\u003e \u003cp\u003eThe results of this study indicate that compared to the TR group (111.23\u0026thinsp;\u0026plusmn;\u0026thinsp;32.70 min), the RA group had a longer surgical time (134.67\u0026thinsp;\u0026plusmn;\u0026thinsp;34.81 min) due to the use of the robot system, which requires connecting components such as the robotic arm system, optical positioning and tracking system, and surgical planning system, as well as performing registration operations on the robot system, all of which add extra time. The RA group demonstrated significantly reduced intraoperative blood loss (95.39\u0026thinsp;\u0026plusmn;\u0026thinsp;30.15 ml) compared to the TR group (149.52\u0026thinsp;\u0026plusmn;\u0026thinsp;50.60 ml), which can be attributed to the larger surgical incision, increased soft tissue damage, and greater surrounding tissue trauma during screw insertion in the TR group[24]. It is important to note that although traditional manual techniques require larger incisions to ensure sufficient visibility during surgery, the surrounding soft tissues are also a crucial component of upper cervical joint stability. Therefore, efforts should be made to minimize damage to the remaining stable structures during the actual procedure[6].\u003c/p\u003e \u003cp\u003eIn this study, the TR group (236.54\u0026thinsp;\u0026plusmn;\u0026thinsp;30.68 mGy) received a lower intraoperative radiation dose compared to the RA group (419.42\u0026thinsp;\u0026plusmn;\u0026thinsp;55.57 mGy), as the RA group required additional data collection at the surgical site to meet the requirements of robot system analysis and design, resulting in a higher radiation dose than the TR group[25]. Despite the RA group experiencing higher levels of intraoperative radiation and longer surgical time, it is fortunate that no radiation-related complications occurred following robot-assisted surgery in this study, and there was no increase in the incidence of other complications. Operators are generally not exposed to the radiation environment during the data collection process. The TR group exhibited a significantly larger incision length compared to the RA group. No disparity in hospital stay duration was observed between the TR and RA groups. In the present study, surgical intervention resulted in significant improvements in clinical pain and functional indicators including VAS, SF-36, NDI, and JOA. On the 3rd day after surgery, there was a statistically significant difference in VAS and PCS between the RA group and the TR group. This may be due to the extensive muscle and soft tissue dissection during the traditional open surgery for posterior cervical exposure, leading to more pain symptoms during recovery. There were no significant differences in NDI and JOA between the two groups during follow-up.\u003c/p\u003e \u003cp\u003eWhile the RA group has shown significant potential for practical application in providing a more reliable implantation plan for screw insertion during surgery and precise guidance, surgeons must still exercise a high degree of caution during the screw insertion process due to the possibility of slight deviations in the tip of the screw caused by soft tissues or other structures, which may impact its trajectory. Furthermore, while robotic systems are an optimal choice for patients with challenging issues such as delicate pedicles, variation of position of vertebral artery, or congenital anomalies of the vertebrae, the relatively steep costs associated with acquiring and maintaining these systems contribute to the financial burden on patients. Fortunately, as the system becomes more widely utilized in various clinical settings, it is anticipated that production costs will decrease, ultimately making treatment with robotic systems more accessible to a larger number of patients in need[7].\u003c/p\u003e \u003cp\u003eThis study has several limitations. Due to the early stage of robot-assisted therapy, the number of UCI patients undergoing such treatment is limited. Therefore, recruiting more patients in later stages is essential to strengthen the credibility of our conclusions. Retrospective methods result in some clinical data loss; thus, future prospective studies should focus on collecting additional data and including more comprehensive assessment indicators. Additionally, future research should involve longer follow-up periods, randomized controlled trials, and multicenter studies.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTraditional open posterior cervical pedicle screw fixation surgery still holds significant importance in the treatment of UCI. However, using orthopedic robotic-assisted pedicle screw fixation for UCI can significantly improve screw placement accuracy and reduce intraoperative blood loss. Overall, robotic-assisted pedicle screw fixation represents a surgical approach with considerable clinical potential and promising application prospects in orthopedic surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eWenjie Zhong: Writing \u0026ndash; review \u0026amp; editing, Writing \u0026ndash; original draft, Visualization, Methodology, Investigation, Data curation, Conceptualization. Niezhenghao He: Methodology, Investigation, Data curation. Zongdong Zhu: Methodology. Lingcong Xu: Methodology, Investigation. Wenao Liao: Investigation. Caiyuan Liu: Investigation. Ke Xu: Investigation. Fei Wang: Writing \u0026ndash; review \u0026amp; editing, Investigation. Xu Lan: Investigation. Wei Zhang: Investigation. Jiang Hu: Writing \u0026ndash; review \u0026amp; editing, Funding acquisition. Haowen Cui: Writing \u0026ndash; review \u0026amp; editing, Supervision, Project administration, Funding acquisition, Conceptualization.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis work was supported by National Natural Science Foundation 65 of China (Grant No. 82302754) and Sichuan Provincial Department of Science and Technology Project (No.2024NSFSC1807). All data needed to evaluate the conclusions in the paper are present in the paper and/or the Supplementary Materials.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMa Z, Zhang YN, Ma X, Chen C, Feng HY (2023) Comparison of the clinical efficacy of unilateral and bilateral pedicle screw short-segment fixation and fusion in the treatment of atlantoaxial fracture-dislocation. Technol Health Care 31:1619-1629. doi: 10.3233/THC-220721\u003c/li\u003e\n\u003cli\u003eSingh DK, Shankar D, Singh N, Singh RK, Chand VK (2022) C2 Screw fixation techniques in atlantoaxial instability: A technical review. J Craniovertebr Junction Spine 13:368-377. doi: 10.4103/jcvjs.jcvjs_128_22\u003c/li\u003e\n\u003cli\u003eGelalis ID, Paschos NK, Pakos EE, Politis AN, Arnaoutoglou CM, Karageorgos AC, Ploumis A, Xenakis TA (2012) Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques. Eur Spine J 21:247-255. doi: 10.1007/s00586-011-2011-3\u003c/li\u003e\n\u003cli\u003eZhang HX, Zhu Y, Shi XQ (2023) [Posterior cervical pedicle screw rod short-segment internal fixation for the treatment of atlantoaxial fracture and dislocation]. Zhongguo Gu Shang 36:490-494. doi: 10.12200/j.issn.1003-0034.2023.05.018\u003c/li\u003e\n\u003cli\u003ePunyarat P, Buchowski JM, Klawson BT, Peters C, Lertudomphonwanit T, Riew KD (2018) Freehand technique for C2 pedicle and pars screw placement: is it safe? Spine J 18:1197-1203. doi: 10.1016/j.spinee.2017.11.010\u003c/li\u003e\n\u003cli\u003eLudwig SC, Kramer DL, Vaccaro AR, Albert TJ (1999) Transpedicle screw fixation of the cervical spine. Clin Orthop Relat Res:77-88. doi: 10.1097/00003086-199902000-00009\u003c/li\u003e\n\u003cli\u003eFan M, Liu Y, He D, Han X, Zhao J, Duan F, Liu B, Tian W (2020) Improved Accuracy of Cervical Spinal Surgery With Robot-Assisted Screw Insertion: A Prospective, Randomized, Controlled Study. Spine (Phila Pa 1976) 45:285-291. doi: 10.1097/BRS.0000000000003258\u003c/li\u003e\n\u003cli\u003eKisinde S, Hu X, Hesselbacher S, Satin AM, Lieberman IH (2022) Robotic-guided placement of cervical pedicle screws: feasibility and accuracy. Eur Spine J 31:693-701. doi: 10.1007/s00586-022-07110-4\u003c/li\u003e\n\u003cli\u003eResnick DK, Lapsiwala S, Trost GR (2002) Anatomic suitability of the C1-C2 complex for pedicle screw fixation. Spine (Phila Pa 1976) 27:1494-1498. doi: 10.1097/00007632-200207150-00003\u003c/li\u003e\n\u003cli\u003eBuchmann N, Schweizer C, Kirschke JS, Rienmuller A, Gempt J, Ringel F, Meyer B, Ryang YM (2020) C1-C2 posterior screw fixation in atlantoaxial fractures revisited: technical update based on 127 cases. Eur Spine J 29:1036-1042. doi: 10.1007/s00586-019-06244-2\u003c/li\u003e\n\u003cli\u003eOh HS, Seo HY (2021) The Relationship between Adjacent Segment Pathology and Facet Joint Violation by Pedicle Screw after Posterior Lumbar Instrumentation Surgery. J Clin Med 10. doi: 10.3390/jcm10132911\u003c/li\u003e\n\u003cli\u003eElMiligui Y, Koptan W, Emran I (2010) Transpedicular screw fixation for type II Hangman\u0026apos;s fracture: a motion preserving procedure. Eur Spine J 19:1299-1305. doi: 10.1007/s00586-010-1401-2\u003c/li\u003e\n\u003cli\u003eTian W (2016) Robot-Assisted Posterior C1-2 Transarticular Screw Fixation for Atlantoaxial Instability: A Case Report. Spine (Phila Pa 1976) 41 Suppl 19:B2-B5. doi: 10.1097/BRS.0000000000001674\u003c/li\u003e\n\u003cli\u003eSu XJ, Lv ZD, Chen Z, Wang K, Zhu C, Chen H, Han YC, Song QX, Lao LF, Zhang YH, Li Q, Shen HX (2022) 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. doi: 10.1177/2192568220960406\u003c/li\u003e\n\u003cli\u003eFarah K, Meyer M, Prost S, Albader F, Dufour H, Blondel B, Fuentes S (2021) Robotic Assistance for Minimally Invasive Cervical Pedicle Instrumentation: Report on Feasibility and Safety. World Neurosurg 150:e777-e782. doi: 10.1016/j.wneu.2021.03.150\u003c/li\u003e\n\u003cli\u003eLi S, Du J, Huang Y, Hao D, Zhao Z, Chang Z, Zhu J, Wang X, Duan Y, He B (2023) Comparison of the efficacies of TINAVI robot-assisted surgery and conventional open surgery for Levine-Edward type IIA (postreduction) hangman fractures. Sci Rep 13:15934. doi: 10.1038/s41598-023-43136-4\u003c/li\u003e\n\u003cli\u003eZhan J, Xu W, Lin J, Luan J, Hou Y, Wang Y, Li Y, Chen B, Lin D, Chen S (2022) Accuracy and Safety of Robot-Assisted versus Fluoroscopy-Guided Posterior C1 Lateral Mass and C2 Pedicle Screw Internal Fixation for Atlantoaxial Dislocation: A Preliminary Study. Biomed Res Int 2022:8508113. doi: 10.1155/2022/8508113\u003c/li\u003e\n\u003cli\u003eLi S, Du J, Huang Y, Hao D, Zhao Z, Chang Z, Zhang X, Gao S, He B (2024) Comparison of the S8 navigation system and the TINAVI orthopaedic robot in the treatment of upper cervical instability. Sci Rep 14:6487. doi: 10.1038/s41598-024-55610-8\u003c/li\u003e\n\u003cli\u003eFarah K, Meyer M, Prost S, Dufour H, Blondel B, Fuentes S (2020) Cirq(R) Robotic Assistance for Minimally Invasive C1-C2 Posterior Instrumentation: Report on Feasibility and Safety. Oper Neurosurg (Hagerstown) 19:730-734. doi: 10.1093/ons/opaa208\u003c/li\u003e\n\u003cli\u003eSmith JD, Jack MM, Harn NR, Bertsch JR, Arnold PM (2016) Screw Placement Accuracy and Outcomes Following O-Arm-Navigated Atlantoaxial Fusion: A Feasibility Study. Global Spine J 6:344-349. doi: 10.1055/s-0035-1563723\u003c/li\u003e\n\u003cli\u003eKaraikovic EE, Daubs MD, Madsen RW, Gaines RW, Jr. (1997) Morphologic characteristics of human cervical pedicles. Spine (Phila Pa 1976) 22:493-500. doi: 10.1097/00007632-199703010-00005\u003c/li\u003e\n\u003cli\u003eLee CS, Hwang CJ, Lee SW, Ahn YJ, Kim YT, Lee DH, Lee MY (2009) Risk factors for adjacent segment disease after lumbar fusion. Eur Spine J 18:1637-1643. doi: 10.1007/s00586-009-1060-3\u003c/li\u003e\n\u003cli\u003eKim TH, Lee BH, Moon SH, Lee SH, Lee HM (2013) Comparison of adjacent segment degeneration after successful posterolateral fusion with unilateral or bilateral pedicle screw instrumentation: a minimum 10-year follow-up. Spine J 13:1208-1216. doi: 10.1016/j.spinee.2013.07.431\u003c/li\u003e\n\u003cli\u003eZhou LP, Zhang RJ, Li HM, Shen CL (2020) Comparison of Cranial Facet Joint Violation Rate and Four Other Clinical Indexes Between Robot-assisted and Freehand Pedicle Screw Placement in Spine Surgery: A Meta-analysis. Spine (Phila Pa 1976) 45:E1532-E1540. doi: 10.1097/BRS.0000000000003632\u003c/li\u003e\n\u003cli\u003eMalik AT, Drain JP, Jones J, Karnes J, Brewster J, Ryu R, Singh V, Kim J, Khan SN, Yu E (2021) Robotic-Assisted Versus Conventional Posterior Lumbar Fusion-An Analysis of 90-Day Complications and Readmissions. World Neurosurg 152:e168-e174. doi: 10.1016/j.wneu.2021.05.072\u003c/li\u003e\n\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":"[email protected]","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":"upper cervical instability, robot-assisted surgery, minimally invasive, radiation safety","lastPublishedDoi":"10.21203/rs.3.rs-6336718/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6336718/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe objective of this study is to assess the clinical efficacy and safety of orthopedic robot-assisted pedicle screw internal fixation as compared to traditional open surgery for the treatment of upper cervical instability (UCI).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe 134 patients were divided into two groups based on the surgical approach: the robotic-assisted group (RA group) and the traditional group (TR group). Imaging and clinical data from all patients were collected.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe baseline data for the two groups was not significantly different (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The accuracy of screw placement was higher in the RA group than in the TR group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The RA group had a lower incidence of facet joint violation compared to the TR group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The radiation dose in the RA group was higher than that in the TR group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The surgical duration, intraoperative blood loss, and incision length were reduced in the RA group compared to the TR group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The VAS, NDI, SF-36, and JOA scores of both the RA group and TR group demonstrated postoperative improvement (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe orthopedic robot-assisted pedicle screw internal fixation can enhance screw precision and minimize bleeding during the treatment of UCI.\u003c/p\u003e","manuscriptTitle":"The safety and precision of pedicle screw placement in treating upper cervical instability using a robotic system","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-05 05:18:38","doi":"10.21203/rs.3.rs-6336718/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","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":"1b874e8c-f317-44c0-86ba-b8f7ecf34469","owner":[],"postedDate":"May 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-06T07:23:09+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-05 05:18:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6336718","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6336718","identity":"rs-6336718","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}