A comparison of key performance metrics of major robotic platforms in spine surgery: a network meta-analysis of 14,462 screws.

Purpose: This meta-analysis compares prominent robotic platforms for spinal surgery, using conventional (freehand or fluoroscopy) and non-robotic navigation as common controls.

Methods: Literature searches were conducted using MEDLINE and EMBASE databases. Studies comparing screw placement of robot-assisted surgery with freehand/fluoroscopic or non-robotic navigation were included. Standard pairwise and network meta-analysis techniques with a random effects model (REM) were used with significance set at P < 0.05. Primary objective was to compare screw placement accuracy and breach incidence across robot platforms. Secondary objective was to compare neurologic complication (NC) rate and blood loss (BL) among platforms.

Results: A total of 27 studies totaling 3404 patients were included. The robotic group demonstrated significantly fewer breaches compared to the conventional group (OR 0.54, P = 0.0004). The TiRobot (TINAVI) and Renaissance (Mazor) demonstrated the best overall accuracy. The robotic group demonstrated significantly lower NC (OR 0.3, P = 0.02) and lower BL (MD: - 112.74 mL, P = 0.002) compared to the conventional approach (freehand or fluoroscopy). Potential conflicts of interest and source bias were found in 60% of TiRobot and 30% of SpineAssist studies. Robotic surgery had significantly lower major breach rates compared to non-robotic navigation (OR 0.39, P = 0.04). The Mazor X model was superior between all robotic platforms, with an OR of 0.15 (95% CrI 0.01 to 0.69, P < 0.00001, I = 0%) for major breaches compared to non-robotic navigation.

Conclusion: Robot-assisted navigation platforms show significant reduction in breach rates compared to conventional and non-robotic navigation approaches in adult spinal instrumentation surgery. MazorX (Mazor), TiRobot (TINAVI) and Renaissance (Mazor) emerge as leaders in robotic spine surgery, each contributing to the increase efficacy. To obtain a more reliable evidence base guiding clinical practice and decision-making on the safety, efficacy, and superiority of specific robot-assisted navigation platforms in spinal surgery, further unbiased RCTs with international collaborations are needed.