Robotic and navigated pedicle screws are safer and more accurate than fluoroscopic freehand screws: a systematic review and meta-analysis

Navigated and robotic pedicle screw placement systems have been developed to improve the accuracy of screw placement. However, the literature comparing the safety and accuracy of robotic and navigated screw placement with fluoroscopic freehand screw placement in thoracolumbar spine surgery has been limited.To perform a systematic review and meta-analysis of randomized control trials that compared the accuracy and safety profiles of robotic and navigated pedicle screws with fluoroscopic freehand pedicle screws.Systematic review and meta-analysis PATIENT SAMPLE: Only randomized controlled trials comparing robotic-assisted or navigated pedicle screws placement with freehand pedicle screw placement in the thoracolumbar spine were included.Odds ratio (OR) estimates for screw accuracy according to the Gertzbein-Robbins scale and relative risk (RR) for various surgical complications.We systematically searched PubMed and EMBASE for English-language studies from inception through April 7, 2022, including references of eligible articles. The search was conducted according to PRISMA guidelines. Two reviewers conducted a full abstraction of all data, and one reviewer verified accuracy. Information was extracted on study design, quality, bias, participants, and risk estimates. Data and estimates were pooled using the Mantel-Haenszel method for random-effects meta-analysis.A total of 14 papers encompassing 12 randomized controlled trials were identified (n=892 patients, 4,046 screws). The pooled analysis demonstrated that robotic and navigated pedicle screw placement techniques were associated with higher odds of screw accuracy (OR 2.66, 95% CI 1.24-5.72, p=.01). Robotic and navigated screw placement was associated with a lower risk of facet joint violations (RR 0.09, 95% CI 0.02-0.38, p<.01) and major complications (RR 0.31, 95% CI 0.11-0.84, p=.02). There were no observed differences between groups in nerve root injury (RR 0.50, 95% CI 0.11-2.30, p=.37), or return to operating room for screw revision (RR 0.28, 95% CI 0.07-1.13, p=.07).These estimates suggest that robotic and navigated screw placement techniques are associated with higher odds of screw accuracy and superior safety profile compared with fluoroscopic freehand techniques. Additional randomized controlled trials will be needed to further validate these findings.