Are the Clinical Outcomes and Cost-Effectiveness of Robot-Assisted Pedicle Screw Placement in Lumbar Fusion Surgery Superior to CT-Navigated and Freehand Fluoroscopy-Guided Techniques? A Systematic Review and Network Meta-Analysis.

Spinal fusion surgery is known to be an expensive intervention. Although innovative technologies in the field aim at improving operative efficiency and outcomes, total costs must be considered. The authors hope to elucidate any differences between robot-assisted (RA) and CT-navigated (CT-nav) or freehand fluoroscopy-guided (FFG) pedicle screw placement in relation to patient outcomes and cost-effectiveness in lumbar fusion surgery (LFS). Following the PRISMA guidelines, the authors performed a systematic review to identify studies comparing clinical outcomes between CT-nav or RA versus FFG in LFS patients. All included studies utilized bilateral pedicle screws. Statistical analysis was performed using R. Of the 1162 identified studies, five were included in the analysis. Direct evidence showed that RA decreased hospital length of stay (LOS) when compared to FFG (MD: -2.67 days; 95% CI: -4.25 to -1.08; p<0.01). Indirect evidence showed that RA decreased operative time when compared to CT-nav (MD: -65.57 mins; 95% CI: -127.7 to -3.44 ; p<0.05). For estimated blood loss (EBL), direct evidence showed that RA was superior to FFG (MD: -120.62 mL; 95% CI: -206.39 to -34.86; p<0.01). However, no significant difference was found between RA and CT-nav for EBL (MD: 14.88 mL; 95% CI: -105.54 to 135.3; p>0.05). There were no other significant differences in ODI, VAS, or complication or re-operation rates between RA and FFG or CT-nav. This study shows that RA pedicle screw placement in LFS provides similar patient outcomes to CT-nav and FFG. Robot-assisted operations were found to give rise to cost savings via decreased LOS when compared to both CT-nav and FFG techniques. Cost-savings of $4,086-$4,865/patient and $7,317-$9,654/patient could be achieved when utilizing RA over CT-nav and FFG, respectively. However, extra upfront and maintenance costs may impact full adoption of RA in LFS.

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