Circumferential lumbar arthrodesis and decompression for degenerative disorders: robot- assisted exoscope with head-mounted display versus traditional microscope

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Circumferential lumbar arthrodesis and decompression are effective surgical treatments when conservative options fail. Recently, robotic-assisted exoscopes have emerged as an alternative to traditional operating microscopes (OMs), offering enhanced visualization, improved ergonomics, and better surgical maneuverability. This study evaluates our institutional experience using a robotic binocular digital visualization system with a head-mounted display (BHS RoboticScope®) in circumferential lumbar arthrodesis and decompression procedures. Materials and Methods A retrospective analysis was conducted on 32 patients undergoing single-level circumferential lumbar arthrodesis and decompression between October 2023 and November 2024. Patients were divided into two groups: Group A (RoboticScope®) and Group B (OM). Data collected included demographics, surgical time, intraoperative complications, and postoperative outcomes, assessed through the Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI). Ergonomic assessment was performed using the Rapid Upper Limb Assessment (RULA) score, while surgeons rated visualization quality and usability. Results Both groups showed significant postoperative improvement in NRS and ODI scores. The RoboticScope® group demonstrated comparable surgical outcomes with no significant increase in operative time (p=0,654). Surgeons reported improved ergonomics (lower RULA scores) and enhanced visualization with the RoboticScope, though challenges included an initial learning curve. Conclusions RoboticScope represents a promising alternative to traditional OMs in spinal surgery, offering improved ergonomics and comparable clinical outcomes. While limitations exist, continued technological advancements may further optimize their application in complex spinal procedures. robotic assisted surgery spinal canal decompression lumbar spine fusion spine arthrodesis new technologies in spine surgery Figures Figure 1 Figure 2 Figure 3 Introduction Within the aging society, the prevalence of spinal disorders is continuously raising [1], [2], [3]. Lumbar spinal stenosis, degenerative disc disease and spondylolisthesis are a part of a broader spectrum of degenerative disorders of the lumbar spine, characterized by a constellation of clinical symptoms, from low back pain to radiculopathy to neurogenic claudicatio. Chronic low back pain (LBP) imposes huge costs to society, either directly by health-care consumption or indirectly by lost productivity because of work absenteeism and early retirement[4], [5]. There is a wide range of available treatments for these patients, including both conservative and operative approaches: when conservative measures prove ineffective, surgical intervention is often warranted [6], [7], [8], [9], [10]. Circumferential arthrodesis and decompression represent an option, according to patient’s symptoms assessment and related tailored treatment. In recent years, exoscope-assisted spinal surgery has emerged as a promising advancement, facilitating precise visualization that is essential for successful surgical outcomes[11], [12], [13]. Although traditional surgical microscopes have historically been the predominant tool, they limit optimal visualization in deep fields and ergonomics. In contrast, exoscopes seem to offer enhanced visualization, superior magnification, and adjustable camera angles. Furthermore, exoscopes confer significant ergonomic advantages and may offer substantial educational benefits[14]. Nonetheless, there are notable limitations associated with their use, including the absence of stereoscopy, challenges related to light overexposure that result in reduced illumination in deeper fields, and the lack of a mouthpiece, which disrupts the conventional workflow. While many neurosurgeons are integrating these advanced visualization tools into their practice, the possibility of replacing conventional operating microscopes (OM) for various standardized procedures remains a topic of investigation[15], [16]. We present and evaluate our institutional experience in transitioning from the standard OM to a robotic binocular digital visualization system featuring a head-mounted display controller for circumferential lumbar arthrodesis and decompression procedures for lumbar degenerative diseases . Materials and Methods Patient Cohort and Data Collection In this retrospective study (October 2023–November 2024), we analysed 32 patients undergoing circumferential lumbar arthrodesis and decompression for single-level degenerative diseases (lumbar stenosis with instability, degenerative spondylolisthesis, or discopathy). Patients were divided into Group A (robot-assisted exoscope with head-mounted display—RoboticScope®) and Group B (standard navigation with an operative microscope—Zeiss Kinevo® 900 S). Recorded data included age, gender, neurological status, NRS pain scores (back/leg), and medication intake (opioids, steroids, NSAIDs) in the four weeks before presentation. NRS >4 was classified as moderate-to-severe. Clinical assessments and Oswestry Disability Index (ODI) were evaluated at the last follow-up (≥3 months). Pre-operative imaging (MRI, CT, morpho-dynamic X-ray) was reviewed, along with degenerative disease type, affected level, Meyerding grade, surgical duration (distinguishing screws' placement from decompression/interbody fusion), and adverse events (SAVES v-2 grading)[17]. The RULA ergonomic assessment was performed for both groups. Surgeons rated illumination, magnification, manoeuvrability, focus, and 3D perception on a scale of 0–10. The RoboticScope The RoboticScope® (RS) is a fully digital 3D microscope providing stereoscopic visualization, comprising three meticulously coordinated main components: Head-Mounted Display (HMD), robotic arm, and microscopic camera. The robotic arm, with six axes, enables precise 3D movements of the robotic camera above the operational field. By pushing a footplate, the HMD detects the surgeon's head gestures, thereby controlling the robotic camera in response. Notably, all crucial functions and movements of the RS can be hands-free activated. With the HMD, the surgeon is equipped with two digital micro displays directly in front of their eyes, providing a real-time 3D image of the operational field. Sensors within the HMD interpret the head movements of the surgeon, and the robotic arm and camera head execute corresponding movements with high precision. (Figure 1). As previously reported, a 30 minutes training on cadaverlike models is recommended before surgery[19]. Operative Procedure All procedures were performed by the same surgical team (Z.R., C.B., M.D.R., A.B., E.S., M.P.T., M.F.) to reduce bias. Patients were prone on a Wilson frame, and the midline incision was planned with fluoroscopic landmarks. After skeletal dissection, a passive frame was placed on the cranial spinous process, followed by a 3D-CT scan (O-arm, Medtronic) interfaced with a neuro-navigation system (StealthStation S8, Medtronic). For Group A, surgeons wore the HMD, enabling screen transfer for navigation while maintaining a neutral head position. Pedicle screws were placed with intraoperative navigation and verified via a second 3D-CT scan. Contoured rods were inserted bilaterally, followed by distraction and, if necessary, vertebral reduction. Technical details have been already described by our group[19]. (Figure 2) Decompression was performed using the RS (Group A) or operative microscope (Group B). Surgeons stood opposite each other, with the RS camera 20–37 cm above the field. Laminotomy, arthrectomy, and foraminotomy were conducted to achieve neural decompression and enhance lordosis. For grade ≥2 spondylolisthesis with severe radicular compression, posterior element release preceded reduction to minimize nerve injury. Discectomy and endplate decortication facilitated interbody fusion. Bone chips from excised laminae were packed into the intervertebral space, and a hydroxyapatite pre-filled lordotic cage was inserted. The camera was positioned 60 cm above the field for precision. Compression maneuvers and final fixation were confirmed via intraoperative 2D scans. Posterolateral bone fusion was enhanced with autologous bone (Figure 3). Statistics Categorical data were expressed as numbers/percentages, continuous variables as means (SD). Variations in surgical time, NRS, and ODI scores were described with mean, SD, and 95% CI. Follow-up time was reported as median and range. Group differences were analyzed using the Chi-square test (categorical variables) or Mann-Whitney/Student t-tests (continuous variables), with significance set at p<0.05. Analyses were conducted using Stata v18. Ethics This retrospective technical assessment of a certified product was conducted per the Declaration of Helsinki and approved by the local ethics committee (CET Lombardia 5, study n. 17/25). Informed consent was obtained from all patients. Identifiable individuals consented to image publication. The case series follows the PROCESS guideline. Clinical trial number: not applicable. Results A total of 36 patients were enrolled in the study, with 16 patients in group A and 16 patients in group B. Males comprised 8 (50%) of the participants in both groups. The mean age of group A was 65.38 years (SD ± 9.01), while the mean age of group B was 65 years (SD ± 9.84). The L4-L5 intervertebral level was the most commonly affected in both groups. In group A, 3 patients (18.75%) presented with L5-S1 as the affected level, while the remaining 15 patients (93.75%) had L4-L5 involvement. In the Group B, L4-L5 represented 78.13%, L5-S1 18.75% and L3-L4 3.13% level involved, respectively. Six patients in group A (35.29%) and 3 patients (18.75%) in group B reported neurogenic claudication, whereas 11 patients (68.75%) in group A and all patients in group B experienced radicular pain. All patients in both groups reported chronic back pain (> 6 months). 12 (75%) patients of group A and 14 of group B (87.5%) presented with spondylolisthesis on pre-operative imaging. Within group A, 4 (25%) patients exhibited Meyerding grade II spondylolisthesis, while in group B, 1 (6.25%) patient had grade II and 1 (6.25%) patient had grade III spondylolisthesis. The remaining cases in both groups were classified as grade I. At baseline, the mean Numeric Rating Scale (NRS) back pain scores were 6.25 (SD ± 1.73) for group A and 7.13 (SD ± 1.59) for group B (p= 0.147), while the mean NRS leg pain scores were 6.88 (SD ± 2.75) for group A and 7.25 (SD ± 1.24) for group B (p=0,623). Most patients in both groups with moderate-to-severe pain were prescribed opioid medications and steroids, particularly in cases of radicular pain. At discharge, the mean NRS back pain scores were 3.5 (SD ± 1.03) for group A and 3.94 (SD ± 1.24) for group B (p=0,286), while the mean NRS leg pain scores were 2.63 (SD ± 1.20) for group A and 2.5 (SD ± 1.46) for group B (p=0,896). The mean surgical operative time was 148.19 min (SD ± 30.16 min) for group A and 143.25 min (SD ± 31.55 min) for group B (p=0,654); the mean screws’ placement interval time was 32.31 min (SD ± 7.26) for group A and 31.75 min (SD ± 7.97) for group B (p=0,836), while the mean decompression/interbody fusion time interval was 87.19 min (SD ± 22.07) for group A and 82.38 min (SD ± 20.42) for group B (p=0,526) . RULA score was 2 for group A and 6 for group B. Table 1 reports the mean scores, ranging from 0 to 10, assigned by each surgeon for each item related to the utilization of the RS. (Table 3) The length of hospital stay was 3 days for all patients. No intraoperative adverse events were reported. Postoperatively, group A experienced one case of urinary tract infection and one of mild residual radiculopathy, both graded as 1 according to the SAVES-v2 classification. Group B reported a superficial wound infection (grade 2). All cases were managed conservatively. The median follow-up time was 8.5 months (range, 3-12) for both groups. At the last follow-up, all patients demonstrated favorable outcomes, with a mean Oswestry Disability Index (ODI) score of 17 (SD ± 7.75) for group A and 20.06 (SD ± 11.1) for group B (p=0,372). The mean NRS back pain scores were 2.13 (SD ± 0.96) for group A and 3 (SD ± 1.55) for group B (p=0,064), while the mean NRS leg pain scores were 1.81 (SD ± 2.01) for group A and 1.19 (SD ± 1.52) for group B (p=0,328). (Table 2) The mean scores regarding illumination, magnification, maneuverability, focus, and 3D perception, measured with a Visual Analogue Scale (VAS) ranging from 0 to 10, have been reported in Table 3. Finally, the participants estimated as minimum procedures number to reach a proficient user level 13±5 cases. Discussion This study represents the first comparative analysis between patients undergoing surgery for spondylolisthesis utilizing the RoboticScope® versus a conventional operating microscope (OM). In Table 4, a technical comparison between RS and OM has been resumed. (Table 4) In literature, some authors have already investigated the effects of exosope in spinal procedures.[20] According to Ferreira T et al., the main benefits of exoscopes in spine surgery is enhanced visualisation, improved ergonomics, improved surgical precision, reduced operation times and postoperative infection rates. The authors advocate the integration of robotics in exoscope-assisted spine surgery to enable autofocus function, ensuring the integrity of the sterile field, providing superior image quality, resolution and three-dimensional perception[13]. Similar benefits have been reported by Abunimer AL et al., who however recognize as a limit the lack of stereopsis and advocate the implementation with 3D modules[21]. Reporting their experience with 40 cases of spinal canal decompression using VITOM 3D (KARL STORZ SE & Co. KG), Siller S et al. rated intraoperative process flow and surgical situs to be superior to the OM. However, they reported inferior visualization/illumination quality compared with the OM[22], [23]. From a technical perspective, the RS seems to provide the same advantages but also to overcome the limitations of the exoscopes. From an ergonomic perspective, the RoboticScope® provides a significant advantage over traditional OM. The head-mounted display (HMD) allows the surgeon to maintain a comfortable and neutral posture, reducing physical strain and fatigue. The ability to control the robotic camera using head movements further enhances ergonomic benefits by minimizing the need for repetitive manual adjustments[19], [24]. Moreover, the stereopsis provided by two 4K cameras enhance the 3D perception and visualization quality. In addition, thanks to the double illumination system coming both from the camerahead and from the HMD, the lighthness can be tailored according to surgeon preference, allowing to increase the visual perception of deep structures[19], [25], [26], [27]. One of the key advantages of the RoboticScope® lies in its integration of a picture-in-picture (PIP) system, which enables the visualization of multiple intraoperative elements on a single screen. This feature allows for better control of the surgical field and auxiliary tools within the operating room, enhancing workflow efficiency and situational awareness for the surgical team[19], [25]. In instrumented spine surgery, when using different tools, like Neuronavigation interfaced with the OArm, we found that the PiP function guarantees an efficacious integration of different information provided to the surgeon, who continues to maintain his vision focused to the surgical field. Our findings indicate that clinical outcomes and surgical duration are comparable between the two groups, demonstrating that the RoboticScope® is a safe and effective tool for spinal procedures. Our clinical results, assessed through NRS and ODI scores, showed significant improvement in both groups, with no statistically significant differences in pain reduction and disability scores at discharge and follow-up. Likewise, the mean surgical duration did not significantly differ between the two groups, confirming that the integration of the RoboticScope® does not prolong operative time. This supports the hypothesis that the RoboticScope® is a viable alternative to traditional OM, providing similar clinical efficacy and safety. Another important finding concerns the potential for improved surgical times with increasing experience using the RoboticScope®. As demonstrated in our previous study, surgeons with greater familiarity with the system required less time for intraoperative camera repositioning, as the hands-free control via head gestures eliminated the need for manual adjustments[19]. This suggests that the RoboticScope® may further optimize surgical efficiency over time as surgeons become more proficient with its functionalities. Limits Despite its advantages, the RoboticScope® still has certain limitations that should be acknowledged. First, the system requires an additional screen to ensure proper visualization for all members of the surgical team, which may add logistical complexity. Second, intraoperative radiological checks necessitate disconnecting and reconnecting the HMD, leading to minor workflow interruptions. A direct cable input on the HMD would be a more efficient solution. Third, the RoboticScope® requires predefined positioning before surgery, which, while not problematic in our specific procedure, may limit flexibility in other spinal surgeries. Conclusion In conclusion, our study highlights that the RoboticScope® is a safe and effective alternative to traditional OM for decompression and arthrodesis in spondylolisthesis surgery. Its comparable clinical outcomes, potential for improved efficiency with experience, and superior ergonomic benefits make it a valuable tool for spinal surgeons. However, some technical limitations remain, and further refinements in system design could enhance its usability and flexibility in different surgical contexts. Future studies with larger cohorts and longer follow-up periods will be necessary to further validate these findings and explore additional applications of this technology in spinal surgery. Abbreviations RS (RoboticScope); OM (Operative Microscope); ODI (Oswestry Disability Index); RULA (Rapid Upper Limb Assessment); SAVES v-2 (Spinal Adverse Events Severity System, version 2) Declarations Submission statement : This manuscript is original and has not been submitted elsewhere in part or in whole Previous Presentations: No previous presentation Authors contribution Mario De Robertis: Conceptualization, Methodology, Writing Original Draft . Emanuele Stucchi : Data curation, Writing- Original draft, Writing – Review and Editing. Ali Baram : Visualization, Data Curation. Andrea Franzini : Supervision, Data Curation, Investigation. Maria Pia Tropeano : Data Curation, Investigation, Validation.: Beatrice Bono: Data Curation, Investigation, Validation. Carlo Brembilla : Supervision, Visualization, Data Curation. Maurizio Fornari: Supervision, Visualization. Federico Pessina : Supervision, Visualization. Zefferino Rossini , Conceptualization, Writing – Review and Editing, Supervision. Funding This study did not receive any funding or financial support. Disclosures Z.R. reports a Consulting relationship with BHS Technologies a nonfinancial (personal) relationship with BHS Technologies. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. References Ferreira ML et al (2023) ‘Global, regional, and national burden of low back pain, 1990–2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021’, Lancet Rheumatol , vol. 5, no. 6, pp. e316–e329, Jun. 10.1016/S2665-9913(23)00098-X Parenteau CS, Lau EC, Campbell IC, Courtney A (Mar. 2021) Prevalence of spine degeneration diagnosis by type, age, gender, and obesity using Medicare data. 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J Robot Surg 18(1). 10.1007/s11701-023-01777-7 Rossini Z et al (2023) ‘Minimally invasive microsurgical decompression of the lumbar spine using a novel robotised digital microscope: A preliminary experience’, The International Journal of Medical Robotics and Computer Assisted Surgery , vol. 19, no. 2, Apr. 10.1002/rcs.2498 Ahmetspahic A et al (2023) ‘RoboticScope-Assisted Microanastomosis in a Chicken Leg Model’, Asian J Neurosurg , vol. 18, no. 04, pp. 782–789, Dec. 10.1055/s-0043-1776794 Piloni M, Bailo M, Gagliardi F, Mortini P (2021) ‘Resection of Intracranial Tumors with a Robotic-Assisted Digital Microscope: A Preliminary Experience with Robotic Scope’, World Neurosurg , vol. 152, pp. e205–e211, Aug. 10.1016/j.wneu.2021.05.075 Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations Competing interest reported. Z.R. reports a Consulting relationship with BHS Technologies a nonfinancial (personal) relationship with BHS Technologies. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Supplementary Files Table1.docx Table2.docx Table3.docx Table4.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6501351","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":455669555,"identity":"3be5d807-b138-496e-9912-c24dcefdcbf0","order_by":0,"name":"Mario Robertis","email":"","orcid":"","institution":"Humanitas University","correspondingAuthor":false,"prefix":"","firstName":"Mario","middleName":"","lastName":"Robertis","suffix":""},{"id":455669559,"identity":"600900dc-21d5-4790-ab5e-c4704cf97062","order_by":1,"name":"Emanuele Stucchi","email":"data:image/png;base64,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","orcid":"","institution":"Humanitas University","correspondingAuthor":true,"prefix":"","firstName":"Emanuele","middleName":"","lastName":"Stucchi","suffix":""},{"id":455669562,"identity":"96667c59-060e-4197-b979-244c65ea75b8","order_by":2,"name":"Ali Baram","email":"","orcid":"","institution":"Humanitas University","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Baram","suffix":""},{"id":455669564,"identity":"5eb4d184-8523-422c-9a69-435f17e5e104","order_by":3,"name":"Andrea Franzini","email":"","orcid":"","institution":"IRCCS Humanitas Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Franzini","suffix":""},{"id":455669565,"identity":"cbd73ee5-73b0-4ada-bc29-12b615810e05","order_by":4,"name":"Maria Pia Tropeano","email":"","orcid":"","institution":"IRCCS Humanitas Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Pia","lastName":"Tropeano","suffix":""},{"id":455669568,"identity":"9f673392-8095-4d34-9116-8503a0792daf","order_by":5,"name":"Beatrice Bono","email":"","orcid":"","institution":"IRCCS Humanitas Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Beatrice","middleName":"","lastName":"Bono","suffix":""},{"id":455669569,"identity":"66dea983-88ab-4cd3-8430-f1fca4eb9613","order_by":6,"name":"Carlo Brembilla","email":"","orcid":"","institution":"IRCCS Humanitas Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Carlo","middleName":"","lastName":"Brembilla","suffix":""},{"id":455669570,"identity":"112c0ca3-0081-406d-af2a-72fe9dfb6424","order_by":7,"name":"Maurizio Fornari","email":"","orcid":"","institution":"Humanitas University","correspondingAuthor":false,"prefix":"","firstName":"Maurizio","middleName":"","lastName":"Fornari","suffix":""},{"id":455669573,"identity":"1bce27d2-a1a7-4035-be7e-dfc6c59830e0","order_by":8,"name":"Federico Pessina","email":"","orcid":"","institution":"Humanitas University","correspondingAuthor":false,"prefix":"","firstName":"Federico","middleName":"","lastName":"Pessina","suffix":""},{"id":455669574,"identity":"761f789a-470b-424f-8e40-ec15f2deff4a","order_by":9,"name":"Zefferino Rossini","email":"","orcid":"","institution":"IRCCS Humanitas Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zefferino","middleName":"","lastName":"Rossini","suffix":""}],"badges":[],"createdAt":"2025-04-22 07:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6501351/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6501351/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82795802,"identity":"e8554d51-7d20-4f1a-9bcc-63aa86a80ff3","added_by":"auto","created_at":"2025-05-15 10:37:08","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":119598,"visible":true,"origin":"","legend":"\u003cp\u003eA. The RoboticScope features a 6-axis robotic arm with ±0.03 mm movement precision. At its end, two cameras capture and transmit stereoscopic 3D extended Full HD/HDR+ video from the surgical field to the HMD. B. The HMD tracks head movements, enabling simultaneous visualization of both the display and the surgical field. C. The display overlays information onto the surgical field, including the cursor (blue dot) and various icons representing different functions: Orbit view, allowing perspective changes in lateral and anteroposterior directions around a fixed target; Zoom, with 8 levels (2.7–30.1x); Free view mode; Focus and orientation adjustment, with up to 120° rotation around a fixed target.; Lighting control; Image mode, allowing selection between right-eye, left-eye, or 3D view, as well as Picture-in-Picture (PiP) display; Working distance adjustment (300, 450, 600 mm); HMD lift function; Save and return to the operating position; MediaTool, for capturing images or recording videos.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6501351/v1/d6ca08625ef472dbb1992411.jpg"},{"id":82794238,"identity":"86ea65a8-081b-49d8-b37e-f53ba6cfc6c6","added_by":"auto","created_at":"2025-05-15 10:29:08","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":170902,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative setting during screw placement. A. The surgeons are alternatively focused on trajectory checking for the screws. Thanks to the PiP function, they can simultaneously look at navigation screen through the HMD and at the target in macroscopic vision, without turning the head to the screen of the navigator. B. At the end of screw placement, the RS is placed over the surgical field. Simultaneous pictures representing the surgical field and the navigation screen can be visualized, choosing the size of the two videos according to the surgeon’s preference.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6501351/v1/d6f6c00b8fdca901bdefc502.jpg"},{"id":82794236,"identity":"b3570125-c793-4111-89cd-4137c96e8c84","added_by":"auto","created_at":"2025-05-15 10:29:08","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":259279,"visible":true,"origin":"","legend":"\u003cp\u003eLumbar spine decompression and interbody fusion. A. Hemilaminectomy and artrectomy. B. Flavectomy. C. Foraminotomy. D. Microdiscectomy. E. Vertebral plates shaving. F. Interbody cage placement. In severe spinal canal stenoses, bilateral decompression is preferred.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6501351/v1/516d72296f130a30bfc8ccc6.jpg"},{"id":84637174,"identity":"3b03ccc4-330e-4d71-a0fe-724ad3721da0","added_by":"auto","created_at":"2025-06-15 13:01:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1136661,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6501351/v1/92891f28-3180-4aca-bd9d-971f32e69854.pdf"},{"id":82794223,"identity":"a52c9c7c-16a0-4f58-89ae-9ea465168fe7","added_by":"auto","created_at":"2025-05-15 10:29:08","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16523,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6501351/v1/276fb6e516ed98ba846bba38.docx"},{"id":82795803,"identity":"978d46ec-77de-4c93-a256-b90b921efc1a","added_by":"auto","created_at":"2025-05-15 10:37:08","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14675,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6501351/v1/e7a71529ec7c7893d74e0408.docx"},{"id":82797482,"identity":"79880c55-a396-474f-bf33-591ea589a762","added_by":"auto","created_at":"2025-05-15 10:45:08","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":14481,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-6501351/v1/40f0edac90a7e854f621b294.docx"},{"id":82794225,"identity":"408254be-1eb8-4088-b54f-27e1bcde5714","added_by":"auto","created_at":"2025-05-15 10:29:08","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":16496,"visible":true,"origin":"","legend":"","description":"","filename":"Table4.docx","url":"https://assets-eu.researchsquare.com/files/rs-6501351/v1/c096e52be6558b800c93b47a.docx"}],"financialInterests":"Competing interest reported. Z.R. reports a Consulting relationship with BHS Technologies a nonfinancial (personal) relationship with BHS Technologies.\nThe other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.","formattedTitle":"Circumferential lumbar arthrodesis and decompression for degenerative disorders: robot- assisted exoscope with head-mounted display versus traditional microscope","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWithin the aging society, the prevalence of spinal disorders is continuously raising [1], [2], [3]. Lumbar spinal stenosis, degenerative disc disease and spondylolisthesis are a part of a broader spectrum of degenerative disorders of the lumbar spine, characterized by a constellation of clinical symptoms, from low back pain to radiculopathy to neurogenic claudicatio. Chronic low back pain (LBP) imposes huge costs to society, either directly by health-care consumption or indirectly by lost productivity because of work absenteeism and early retirement[4], [5]. There is a wide range of available treatments for these patients, including both conservative and operative approaches: when conservative measures prove ineffective, surgical intervention is often warranted [6], [7], [8], [9], [10]. Circumferential arthrodesis and decompression represent an option, according to patient’s symptoms assessment and related tailored treatment. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cbr\u003eIn recent years, exoscope-assisted spinal surgery has emerged as a promising advancement, facilitating precise visualization that is essential for successful surgical outcomes[11], [12], [13]. Although traditional surgical microscopes have historically been the predominant tool, they limit optimal visualization in deep fields and ergonomics. In contrast, exoscopes seem to offer enhanced visualization, superior magnification, and adjustable camera angles. Furthermore, exoscopes confer significant ergonomic advantages and may offer substantial educational benefits[14]. Nonetheless, there are notable limitations associated with their use, including the absence of stereoscopy, challenges related to light overexposure that result in reduced illumination in deeper fields, and the lack of a mouthpiece, which disrupts the conventional workflow. While many neurosurgeons are integrating these advanced visualization tools into their practice, the possibility of replacing conventional operating microscopes (OM) for various standardized procedures remains a topic of investigation[15], [16].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe present and evaluate our institutional experience in transitioning from the standard OM to a robotic binocular digital visualization system featuring a head-mounted display controller for circumferential lumbar arthrodesis and decompression procedures for lumbar degenerative diseases\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003ePatient Cohort and Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this retrospective study (October 2023–November 2024), we analysed 32 patients undergoing circumferential lumbar arthrodesis and decompression for single-level degenerative diseases (lumbar stenosis with instability, degenerative spondylolisthesis, or discopathy). Patients were divided into Group A (robot-assisted exoscope with head-mounted display—RoboticScope®) and Group B (standard navigation with an operative microscope—Zeiss Kinevo® 900 S).\u003c/p\u003e\n\u003cp\u003eRecorded data included age, gender, neurological status, NRS pain scores (back/leg), and medication intake (opioids, steroids, NSAIDs) in the four weeks before presentation. NRS \u0026gt;4 was classified as moderate-to-severe. Clinical assessments and Oswestry Disability Index (ODI) were evaluated at the last follow-up (≥3 months). Pre-operative imaging (MRI, CT, morpho-dynamic X-ray) was reviewed, along with degenerative disease type, affected level, Meyerding grade, surgical duration (distinguishing screws' placement from decompression/interbody fusion), and adverse events (SAVES v-2 grading)[17].\u0026nbsp;The RULA ergonomic assessment was performed for both groups. Surgeons rated illumination, magnification, manoeuvrability, focus, and 3D perception on a scale of 0–10.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe RoboticScope\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe RoboticScope® (RS) is a fully digital 3D microscope providing stereoscopic visualization, comprising three meticulously coordinated main components: Head-Mounted Display (HMD), robotic arm, and microscopic camera. The robotic arm, with six axes, enables precise 3D movements of the robotic camera above the operational field. By pushing a footplate, the HMD detects the surgeon's head gestures, thereby controlling the robotic camera in response. Notably, all crucial functions and movements of the RS can be hands-free activated. With the HMD, the surgeon is equipped with two digital micro displays directly in front of their eyes, providing a real-time 3D image of the operational field. Sensors within the HMD interpret the head movements of the surgeon, and the robotic arm and camera head execute corresponding movements with high precision. (Figure 1).\u0026nbsp;\u003cbr\u003eAs previously reported, a 30 minutes training on cadaverlike models is recommended before surgery[19].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperative Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures were performed by the same surgical team (Z.R., C.B., M.D.R., A.B., E.S., M.P.T., M.F.) to reduce bias. Patients were prone on a Wilson frame, and the midline incision was planned with fluoroscopic landmarks. After skeletal dissection, a passive frame was placed on the cranial spinous process, followed by a 3D-CT scan (O-arm, Medtronic) interfaced with a neuro-navigation system (StealthStation S8, Medtronic).\u003c/p\u003e\n\u003cp\u003eFor Group A, surgeons wore the HMD, enabling screen transfer for navigation while maintaining a neutral head position. Pedicle screws were placed with intraoperative navigation and verified via a second 3D-CT scan. Contoured rods were inserted bilaterally, followed by distraction and, if necessary, vertebral reduction. Technical details have been already described by our group[19]. (Figure 2)\u003c/p\u003e\n\u003cp\u003eDecompression was performed using the RS (Group A) or operative microscope (Group B). Surgeons stood opposite each other, with the RS camera 20–37 cm above the field. Laminotomy, arthrectomy, and foraminotomy were conducted to achieve neural decompression and enhance lordosis. For grade ≥2 spondylolisthesis with severe radicular compression, posterior element release preceded reduction to minimize nerve injury.\u003c/p\u003e\n\u003cp\u003eDiscectomy and endplate decortication facilitated interbody fusion. Bone chips from excised laminae were packed into the intervertebral space, and a hydroxyapatite pre-filled lordotic cage was inserted. The camera was positioned 60 cm above the field for precision. Compression maneuvers and final fixation were confirmed via intraoperative 2D scans. Posterolateral bone fusion was enhanced with autologous bone (Figure 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCategorical data were expressed as numbers/percentages, continuous variables as means (SD). Variations in surgical time, NRS, and ODI scores were described with mean, SD, and 95% CI. Follow-up time was reported as median and range. Group differences were analyzed using the Chi-square test (categorical variables) or Mann-Whitney/Student t-tests (continuous variables), with significance set at p\u0026lt;0.05. Analyses were conducted using Stata v18.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective technical assessment of a certified product was conducted per the Declaration of Helsinki and approved by the local ethics committee (CET Lombardia 5, study n. 17/25). Informed consent was obtained from all patients. Identifiable individuals consented to image publication. The case series follows the PROCESS guideline. Clinical trial number: not applicable.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 36 patients were enrolled in the study, with 16 patients in group A and 16 patients in group B. Males comprised 8 (50%) of the participants in both groups. The mean age of group A was 65.38 years (SD ± 9.01), while the mean age of group B was 65 years (SD ± 9.84). The L4-L5 intervertebral level was the most commonly affected in both groups. In group A, 3 patients (18.75%) presented with L5-S1 as the affected level, while the remaining 15 patients (93.75%) had L4-L5 involvement.\u0026nbsp; In the Group B, L4-L5 represented 78.13%, L5-S1 18.75% and L3-L4 3.13% level involved, respectively.\u003cbr\u003e\u0026nbsp;Six patients in group A (35.29%) and 3 patients (18.75%) in group B reported neurogenic claudication, whereas 11 patients (68.75%) in group A and all patients in group B experienced radicular pain. All patients in both groups reported chronic back pain (\u0026gt; 6 months).\u0026nbsp;\u003cbr\u003e\u0026nbsp;12 (75%) patients of group A and 14 of group B (87.5%) presented with spondylolisthesis on pre-operative imaging. Within group A, 4 (25%) patients exhibited Meyerding grade II spondylolisthesis, while in group B, 1 (6.25%) patient had grade II and 1 (6.25%) patient had grade III spondylolisthesis. The remaining cases in both groups were classified as grade I. At baseline, the mean Numeric Rating Scale (NRS) back pain scores were 6.25 (SD ± 1.73) for group A and 7.13 (SD ± 1.59) for group B (p=\u0026nbsp;0.147), while the mean NRS leg pain scores were 6.88 (SD ± 2.75) for group A and 7.25 (SD ± 1.24) for group B (p=0,623). Most patients in both groups with moderate-to-severe pain were prescribed opioid medications and steroids, particularly in cases of radicular pain. At discharge, the mean NRS back pain scores were 3.5 (SD ± 1.03) for group A and 3.94 (SD ± 1.24) for group B (p=0,286), while the mean NRS leg pain scores were 2.63 (SD ± 1.20) for group A and 2.5 (SD ± 1.46) for group B (p=0,896).\u003cbr\u003eThe mean surgical operative time was 148.19 min (SD ± 30.16 min) for group A and 143.25 min (SD ± 31.55 min) for group B (p=0,654); the mean screws’ placement interval time was 32.31 min (SD ± 7.26) for group A and 31.75 min (SD ± 7.97) for group B (p=0,836), while the mean decompression/interbody fusion time interval was 87.19 min (SD ± 22.07) for group A and 82.38 min (SD ± 20.42) for group B (p=0,526) . RULA score was 2 for group A and 6 for group B. \u003cstrong\u003eTable 1\u003c/strong\u003e reports the mean scores, ranging from 0 to 10, assigned by each surgeon for each item related to the utilization of the RS. (Table 3)\u003c/p\u003e\n\u003cp\u003eThe length of hospital stay was 3 days for all patients. No intraoperative adverse events were reported. Postoperatively, group A experienced one case of urinary tract infection and one of mild residual radiculopathy, both graded as 1 according to the SAVES-v2 classification. Group B reported a superficial wound infection (grade 2). All cases were managed conservatively. \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;The median follow-up time was 8.5 months (range, 3-12) for both groups. At the last follow-up, all patients demonstrated favorable outcomes, with a mean Oswestry Disability Index (ODI) score of 17 (SD ± 7.75) for group A and 20.06 (SD ± 11.1) for group B (p=0,372). The mean NRS back pain scores were 2.13 (SD ± 0.96) for group A and 3 (SD ± 1.55) for group B (p=0,064), while the mean NRS leg pain scores were 1.81 (SD ± 2.01) for group A and 1.19 (SD ± 1.52) for group B (p=0,328). (Table 2)\u003c/p\u003e\n\u003cp\u003eThe mean scores regarding illumination, magnification, maneuverability, focus, and 3D perception, measured with a Visual Analogue Scale (VAS) ranging from 0 to 10, have been reported in Table 3. \u0026nbsp;Finally, the participants estimated as minimum procedures number to reach a proficient user level 13±5 cases.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study represents the first comparative analysis between patients undergoing surgery for spondylolisthesis utilizing the RoboticScope® versus a conventional operating microscope (OM). In Table 4, a technical comparison between RS and OM has been resumed. (Table 4)\u003c/p\u003e\n\u003cp\u003eIn literature, some authors have already investigated the effects of exosope in spinal procedures.[20] According to Ferreira T et al., the main benefits of exoscopes in spine surgery is enhanced visualisation, improved ergonomics, improved surgical precision, reduced operation times and postoperative infection rates. The authors advocate the integration of robotics in exoscope-assisted spine surgery to enable autofocus function, ensuring the integrity of the sterile field, providing superior image quality, resolution and three-dimensional perception[13]. Similar benefits have been reported by Abunimer AL et al., who however recognize as a limit the lack of stereopsis and advocate the implementation with 3D modules[21]. Reporting their experience with 40 cases of spinal canal decompression using VITOM 3D (KARL STORZ SE \u0026amp; Co. KG), Siller S et al. rated intraoperative process flow and surgical situs to be superior to the OM. However, they reported inferior visualization/illumination quality compared with the OM[22], [23].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrom a technical perspective, the RS seems to provide the same advantages but also to overcome the limitations of the exoscopes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrom an ergonomic perspective, the RoboticScope® provides a significant advantage over traditional OM. The head-mounted display (HMD) allows the surgeon to maintain a comfortable and neutral posture, reducing physical strain and fatigue. The ability to control the robotic camera using head movements further enhances ergonomic benefits by minimizing the need for repetitive manual adjustments[19], [24]. Moreover, the stereopsis provided by two 4K cameras enhance the 3D perception and visualization quality. In addition, thanks to the double illumination system coming both from the camerahead and from the HMD, the lighthness can be tailored according to surgeon preference, allowing to increase the visual perception of deep structures[19], [25], [26], [27].\u003c/p\u003e\n\u003cp\u003eOne of the key advantages of the RoboticScope® lies in its integration of a picture-in-picture (PIP) system, which enables the visualization of multiple intraoperative elements on a single screen. This feature allows for better control of the surgical field and auxiliary tools within the operating room, enhancing workflow efficiency and situational awareness for the surgical team[19], [25]. In instrumented spine surgery, when using different tools, like Neuronavigation interfaced with the OArm, we found that the PiP function guarantees an efficacious integration of different information provided to the surgeon, who continues to maintain his vision focused to the surgical field.\u003c/p\u003e\n\u003cp\u003eOur findings indicate that clinical outcomes and surgical duration are comparable between the two groups, demonstrating that the RoboticScope® is a safe and effective tool for spinal procedures.\u003c/p\u003e\n\u003cp\u003eOur clinical results, assessed through NRS and ODI scores, showed significant improvement in both groups, with no statistically significant differences in pain reduction and disability scores at discharge and follow-up. Likewise, the mean surgical duration did not significantly differ between the two groups, confirming that the integration of the RoboticScope® does not prolong operative time. This supports the hypothesis that the RoboticScope® is a viable alternative to traditional OM, providing similar clinical efficacy and safety.\u003c/p\u003e\n\u003cp\u003eAnother important finding concerns the potential for improved surgical times with increasing experience using the RoboticScope®. As demonstrated in our previous study, surgeons with greater familiarity with the system required less time for intraoperative camera repositioning, as the hands-free control via head gestures eliminated the need for manual adjustments[19]. This suggests that the RoboticScope® may further optimize surgical efficiency over time as surgeons become more proficient with its functionalities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimits\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite its advantages, the RoboticScope® still has certain limitations that should be acknowledged. First, the system requires an additional screen to ensure proper visualization for all members of the surgical team, which may add logistical complexity. Second, intraoperative radiological checks necessitate disconnecting and reconnecting the HMD, leading to minor workflow interruptions. A direct cable input on the HMD would be a more efficient solution. Third, the RoboticScope® requires predefined positioning before surgery, which, while not problematic in our specific procedure, may limit flexibility in other spinal surgeries.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, our study highlights that the RoboticScope® is a safe and effective alternative to traditional OM for decompression and arthrodesis in spondylolisthesis surgery. Its comparable clinical outcomes, potential for improved efficiency with experience, and superior ergonomic benefits make it a valuable tool for spinal surgeons. However, some technical limitations remain, and further refinements in system design could enhance its usability and flexibility in different surgical contexts. Future studies with larger cohorts and longer follow-up periods will be necessary to further validate these findings and explore additional applications of this technology in spinal surgery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eRS (RoboticScope); OM (Operative Microscope); ODI (Oswestry Disability Index); RULA (Rapid Upper Limb Assessment); SAVES v-2 (Spinal Adverse Events Severity System, version 2)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eSubmission statement\u003c/strong\u003e: This manuscript is original and has not been submitted elsewhere in part or in whole\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrevious Presentations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo previous presentation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMario De Robertis:\u003c/strong\u003e Conceptualization, Methodology, Writing Original Draft\u003cstrong\u003e. Emanuele Stucchi\u003c/strong\u003e: Data curation, Writing- Original draft, Writing – Review and Editing.\u003cstrong\u003eAli Baram\u003c/strong\u003e : Visualization, Data Curation. \u003cstrong\u003eAndrea Franzini\u003c/strong\u003e\u003cem\u003e:\u003c/em\u003e Supervision, Data Curation, Investigation. \u003cstrong\u003eMaria Pia Tropeano\u003c/strong\u003e: Data Curation, Investigation, Validation.: \u003cstrong\u003eBeatrice Bono:\u003c/strong\u003e Data Curation, Investigation, Validation. \u003cstrong\u003eCarlo Brembilla\u003c/strong\u003e: Supervision, Visualization, Data Curation. \u003cstrong\u003eMaurizio Fornari:\u0026nbsp;\u003c/strong\u003eSupervision, Visualization.\u0026nbsp;\u003cstrong\u003eFederico Pessina\u003c/strong\u003e: Supervision, Visualization. \u003cstrong\u003eZefferino Rossini\u003c/strong\u003e, Conceptualization, Writing – Review and Editing, Supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any funding or financial support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZ.R. reports a Consulting relationship with BHS Technologies a nonfinancial (personal) relationship with BHS Technologies.\u003c/p\u003e\n\u003cp\u003eThe other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFerreira ML et al (2023) \u0026lsquo;Global, regional, and national burden of low back pain, 1990\u0026ndash;2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021\u0026rsquo;, \u003cem\u003eLancet Rheumatol\u003c/em\u003e, vol. 5, no. 6, pp. e316\u0026ndash;e329, Jun. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2665-9913(23)00098-X\u003c/span\u003e\u003cspan address=\"10.1016/S2665-9913(23)00098-X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParenteau CS, Lau EC, Campbell IC, Courtney A (Mar. 2021) Prevalence of spine degeneration diagnosis by type, age, gender, and obesity using Medicare data. 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J Robot Surg 18(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11701-023-01777-7\u003c/span\u003e\u003cspan address=\"10.1007/s11701-023-01777-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRossini Z et al (2023) \u0026lsquo;Minimally invasive microsurgical decompression of the lumbar spine using a novel robotised digital microscope: A preliminary experience\u0026rsquo;, \u003cem\u003eThe International Journal of Medical Robotics and Computer Assisted Surgery\u003c/em\u003e, vol. 19, no. 2, Apr. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/rcs.2498\u003c/span\u003e\u003cspan address=\"10.1002/rcs.2498\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmetspahic A et al (2023) \u0026lsquo;RoboticScope-Assisted Microanastomosis in a Chicken Leg Model\u0026rsquo;, \u003cem\u003eAsian J Neurosurg\u003c/em\u003e, vol. 18, no. 04, pp. 782\u0026ndash;789, Dec. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0043-1776794\u003c/span\u003e\u003cspan address=\"10.1055/s-0043-1776794\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePiloni M, Bailo M, Gagliardi F, Mortini P (2021) \u0026lsquo;Resection of Intracranial Tumors with a Robotic-Assisted Digital Microscope: A Preliminary Experience with Robotic Scope\u0026rsquo;, \u003cem\u003eWorld Neurosurg\u003c/em\u003e, vol. 152, pp. e205\u0026ndash;e211, Aug. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wneu.2021.05.075\u003c/span\u003e\u003cspan address=\"10.1016/j.wneu.2021.05.075\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\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":"robotic assisted surgery, spinal canal decompression, lumbar spine fusion, spine arthrodesis, new technologies in spine surgery","lastPublishedDoi":"10.21203/rs.3.rs-6501351/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6501351/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLumbar degenerative diseases, including lumbar spinal stenosis, spondylolisthesis, and degenerative disc disease, are a growing concern in aging populations. Circumferential lumbar arthrodesis and decompression are effective surgical treatments when conservative options fail. Recently, robotic-assisted exoscopes have emerged as an alternative to traditional operating microscopes (OMs), offering enhanced visualization, improved ergonomics, and better surgical maneuverability. This study evaluates our institutional experience using a robotic binocular digital visualization system with a head-mounted display (BHS RoboticScope®) in circumferential lumbar arthrodesis and decompression procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective analysis was conducted on 32 patients undergoing single-level circumferential lumbar arthrodesis and decompression between October 2023 and November 2024. Patients were divided into two groups: Group A (RoboticScope®) and Group B (OM). Data collected included demographics, surgical time, intraoperative complications, and postoperative outcomes, assessed through the Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI). Ergonomic assessment was performed using the Rapid Upper Limb Assessment (RULA) score, while surgeons rated visualization quality and usability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth groups showed significant postoperative improvement in NRS and ODI scores. The RoboticScope® group demonstrated comparable surgical outcomes with no significant increase in operative time (p=0,654). Surgeons reported improved ergonomics (lower RULA scores) and enhanced visualization with the RoboticScope, though challenges included an initial learning curve.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRoboticScope represents a promising alternative to traditional OMs in spinal surgery, offering improved ergonomics and comparable clinical outcomes. While limitations exist, continued technological advancements may further optimize their application in complex spinal procedures.\u003c/p\u003e","manuscriptTitle":"Circumferential lumbar arthrodesis and decompression for degenerative disorders: robot- assisted exoscope with head-mounted display versus traditional microscope","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-15 10:29:03","doi":"10.21203/rs.3.rs-6501351/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":"476d3357-0621-4f19-b97c-8a21184bc7d0","owner":[],"postedDate":"May 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-15T12:53:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-15 10:29:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6501351","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6501351","identity":"rs-6501351","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}