Robot-assisted cervical pedicle screw placement using a novel hybrid dilator technique: A clinical series of 565 screws

Cervical pedicle screws provide superior biomechanical fixation with pullout strength four times greater than lateral mass screws, but placement is technically demanding with traditional malposition rates of 6.7%-31.6%. Robotic-assisted spine surgery has demonstrated success in thoracolumbar applications, but cervical translation has been hindered by the lack of cervical-specific instrumentation requiring expensive custom instruments. We developed a hybrid technique combining robotic guidance with standard cervical instrumentation using minimally invasive surgery dilators as an interface. Sixty-five consecutive patients underwent robot-assisted cervical pedicle screw placement with 565 screws across C2-C7 levels using MazorX Stealth robotic system with O-arm navigation. Accuracy was assessed using Gertzbein-Robbins and Neo classification systems with 3-6-month follow-up for complications. The technique achieved 98.76% clinically acceptable accuracy (Gertzbein-Robbins Grade A + B) with 1.24% breach rate. Perfect placement (Grade A) occurred in 95.22% of screws. Vertebral artery protection was excellent with 99.65% showing no foramen breach. Major complications occurred in 1.5% of patients (single vertebral artery injury), with 7.7% experiencing transient C5 weakness that resolved completely. No patients required revision surgery. This hybrid technique addresses instrument compatibility barriers in robotic cervical spine surgery by eliminating dependence on custom instruments while maintaining robotic accuracy. The technique demonstrates superior outcomes compared to traditional approaches and facilitates broader robotic cervical surgery adoption. Multi-center validation studies are needed to establish the generalizability.