Trends in Technology for Pedicle Screw Placement

Abstract

Study Design. Systematic Review Objective. We sought to determine which method of the pedicle screw (PS) placement is most accurate and understand how the development of subsequent generations of robotic systems has changed placement accuracy over time. Summary of Background Data. Previous studies have demonstrated the success of robotic PS placement, but how this accuracy compares to other methods is unclear. Methods. A systematic review following PRISMA Guidelines was performed on articles published between January 2000 and August 2021, comparing PS insertion methods with at least 10 screws per study arm. Single and multiple-arm trials were included. Data were extracted for patient outcomes, including optimal PS placement, misplacement, and accuracy. The logit-event rate of misplacement was calculated for each study. P values were adjusted for multiple comparisons using the Tukey post hoc correction. Results. Our search revealed 127 studies, and 156 comparative arms, with 77,360 pedicle screws placed using five different modalities. Meta-regression of pooled accuracy revealed no significant changes in PS accuracy over time for freehand, 2D fluoroscopic navigation, 3D fluoroscopic navigation, and computed tomography navigation. Robotic navigation had a significant increase in accuracy over time (P=0.036). Pooled misplacement rates were also compared across all modalities. Robotics was found to have the lowest rates of misplacement for PS compared to freehand (P=0.0015) and 2D fluoroscopic navigation (P=0.026). Conclusion. Our analysis is the largest study to date on pedicle screw placement. Pedicle screw placement through robotics was found to be superior due to its low misplacement rates compared with other modalities. Intraoperative 3D fluoroscopic navigation was found to have comparable misplacement rates. In addition, pedicle screw placement accuracy with robotics has continued to improve over time. This speaks to both the stability of the technology and the potential for continued improvement with new and more accurate robotic systems.