Exoscope versus microscope in spine surgery: a meta-analysis based on procedure-specific subgroup analysis

Exoscope versus microscope in spine surgery: a meta-analysis based on procedure-specific subgroup analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Exoscope versus microscope in spine surgery: a meta-analysis based on procedure-specific subgroup analysis Alberto Benato, Donato Creatura, Davide Palombi, Cédric Yves Barrey This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9327951/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Three-dimensional (3D) exoscopes have recently emerged as an alternative to the operating microscope (OM) in spine surgery, offering potential ergonomic and educational advantages. However, comparative evidence on surgical outcomes remains fragmented across different spinal pathologies and procedures,. With this work, we aim at comparing surgical and clinical outcomes of exoscopic versus microscopic spine surgery for degenerative conditions through a global meta-analysis, with procedure-specific subgroup analyses. Methods A systematic review and meta-analysis were conducted according to PRISMA guidelines. Comparative studies evaluating 3D exoscope versus microscope in spine surgery for degenerative conditions were included. Continuous outcomes (operative time, blood loss, length of stay, visual analogue scale [VAS] scores) were pooled using a random-effects inverse-variance model and expressed as mean differences (MD). Dichotomous outcomes (complications) were analyzed using Mantel–Haenszel odds ratios (OR). Heterogeneity was quantified with I² and τ² statistics. Subgroup analyses were performed by procedure (ACDF, MIS-TLIF, lumbar microdecompression/microdiscectomy), along with sensitivity analyses and meta-regressions when indicated. Results A total of 785 patients across 7 studies were included. No significant differences were found in operative time (MD − 5.9 min; 95% CI − 16.4 to + 4.7), complications (OR 0.83; 95% CI 0.53–1.30), length of stay (MD − 0.15 days; 95% CI − 0.84 to + 0.53), or postoperative VAS scores. Blood loss was slightly reduced with the exoscope (MD − 5.9 mL; 95% CI − 11.1 to − 0.6), although the clinical relevance appears negligible. Subgroup analyses showed consistent findings across ACDF, MIS-TLIF, and lumbar microdecompression. Conclusions Despite significant limitations, current literature supports the non-inferiority of exoscope to OM in spine surgery, with comparable surgical and clinical outcomes across procedures. Exoscopes may offer ergonomic and didactic advantages without increasing operative time, complications, or hospital stay. However, standardized quantification of performance in the former non-clinical domains is missing. Further high-quality randomized studies are needed to confirm these findings and define procedure-specific benefits. Neurosurgery Orthopedic Surgery Spine surgery Exoscope Meta-analysis 3D Cervical spine surgery Lumbar spine surgery Full Text Additional Declarations The authors declare no competing interests. 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-9327951","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":617857798,"identity":"199c7e95-667a-4267-bff6-981295eb6b31","order_by":0,"name":"Alberto Benato","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYBACAxiDTwJM2QAxY+MBglpAKtgkwIw0kJYGkrQcZoAJ4ATm7L0HP3+oYJBnk24+BmSct1vbfhhoS41NNC4tlj3nkiUOnGEwbJM5ljzjwJnbydvOJAK1HEvLbcDlsBs5BhIH2xgY2yRyjBkOtt1ONjsA1MLYcBi3lvtvjH8Atdi3SeR/Bmo5l2x2/iEBLTd4zEC2JAJtYQZqOWBndoOALZY9OWYWZ85IJAP9Ysxw5kxygtkNoC0JePxizn7G+EZFhY1tv3TzY4aKCjt7s/PpDx98qLHBqQUKJOCsRLDKBPzKUYE9KYpHwSgYBaNgZAAAOO9k25lmhf0AAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-2150-1213","institution":"Department of Spine and Spinal Cord Surgery, Hospices Civils de Lyon, Lyon,, France","correspondingAuthor":true,"prefix":"","firstName":"Alberto","middleName":"","lastName":"Benato","suffix":""},{"id":617857799,"identity":"bae97462-e2b1-4f98-804b-7d1acf0c6b9a","order_by":1,"name":"Donato Creatura","email":"","orcid":"","institution":"Department of Neurosurgery, Humanitas Research Hospital, Milan, Italy","correspondingAuthor":false,"prefix":"","firstName":"Donato","middleName":"","lastName":"Creatura","suffix":""},{"id":617857800,"identity":"a845d813-e533-418c-aa2a-bb4a00131ba5","order_by":2,"name":"Davide Palombi","email":"","orcid":"","institution":"Department of Pediatric Neurosurgery, Fondazione Policlinico “A. 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However, comparative evidence on surgical outcomes remains fragmented across different spinal pathologies and procedures,. With this work, we aim at comparing surgical and clinical outcomes of exoscopic versus microscopic spine surgery for degenerative conditions through a global meta-analysis, with procedure-specific subgroup analyses.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A systematic review and meta-analysis were conducted according to PRISMA guidelines. Comparative studies evaluating 3D exoscope versus microscope in spine surgery for degenerative conditions were included. Continuous outcomes (operative time, blood loss, length of stay, visual analogue scale [VAS] scores) were pooled using a random-effects inverse-variance model and expressed as mean differences (MD). Dichotomous outcomes (complications) were analyzed using Mantel\u0026ndash;Haenszel odds ratios (OR). Heterogeneity was quantified with I\u0026sup2; and τ\u0026sup2; statistics. Subgroup analyses were performed by procedure (ACDF, MIS-TLIF, lumbar microdecompression/microdiscectomy), along with sensitivity analyses and meta-regressions when indicated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 785 patients across 7 studies were included. No significant differences were found in operative time (MD \u0026minus;\u0026thinsp;5.9 min; 95% CI \u0026minus;\u0026thinsp;16.4 to +\u0026thinsp;4.7), complications (OR 0.83; 95% CI 0.53\u0026ndash;1.30), length of stay (MD \u0026minus;\u0026thinsp;0.15 days; 95% CI \u0026minus;\u0026thinsp;0.84 to +\u0026thinsp;0.53), or postoperative VAS scores. Blood loss was slightly reduced with the exoscope (MD \u0026minus;\u0026thinsp;5.9 mL; 95% CI \u0026minus;\u0026thinsp;11.1 to \u0026minus;\u0026thinsp;0.6), although the clinical relevance appears negligible. Subgroup analyses showed consistent findings across ACDF, MIS-TLIF, and lumbar microdecompression.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDespite significant limitations, current literature supports the non-inferiority of exoscope to OM in spine surgery, with comparable surgical and clinical outcomes across procedures. Exoscopes may offer ergonomic and didactic advantages without increasing operative time, complications, or hospital stay. However, standardized quantification of performance in the former non-clinical domains is missing. Further high-quality randomized studies are needed to confirm these findings and define procedure-specific benefits.\u003c/p\u003e","manuscriptTitle":"Exoscope versus microscope in spine surgery: a meta-analysis based on procedure-specific subgroup analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-07 15:31:55","doi":"10.21203/rs.3.rs-9327951/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":"7ea06781-f493-4549-8f28-1c2a8682f29b","owner":[],"postedDate":"April 7th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":65752503,"name":"Neurosurgery"},{"id":65752504,"name":"Orthopedic Surgery"}],"tags":[],"updatedAt":"2026-04-07T15:31:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-07 15:31:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9327951","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9327951","identity":"rs-9327951","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}