Pedicle Screw Revision in Robot-Guided, Navigated, and Freehand Thoracolumbar Instrumentation: A Systematic Review and Meta-Analysis

OBJECTIVE: Various computer-based guidance systems have been devised to reduce costly screw-related complications, yet their clinical effectiveness has never been comparatively assessed in a meta-analysis. We aimed to evaluate the incidence of clinically relevant pedicle screw revisions among robot-guided, navigated, and freehand spinal instrumentation. METHODS: Controlled trials comparing robot-guided, navigated, or freehand spinal instrumentation for any indication and that specifically reported the proportion of patients who experienced pedicle screw revisions were included. Estimates were pooled using random-effects meta-analyses. Sensitivity analyses including zero-event trials and assessing per screw incidences were carried out. RESULTS: Among 37 studies (7095 patients), intraoperative revisions in robot-guided (odds ratio [OR], 3.6; 95% confidence interval [CI], 0.7-19.4; P [0.14) and navigated (OR, 1.5; 95% CI, 0.3-7.2; P [0.64) procedures were comparable to freehand. Although postoperative revisions were reduced in robot-guided (OR, 0.3; 95% CI, 0.1-0.9; P [0.04) and navigated (OR, 0.3; 95% CI, 0.2-0.5; P < 0.001) procedures, statistical significance was lost in sensitivity analyses for robotic guidance, but not for navigation. The pooled incidence of malpositioned screws requiring postoperative revision was 2.1%. CONCLUSIONS: Based on the available data in the peer-reviewed literature, computer assistance in the form of robotic guidance or navigation has the potential to reduce the incidence of costly and clinically relevant postoperative revisions for screw malposition. It is essential to further investigate on a higher level of evidence if the clinical benefits of computer assistance warrant the high acquisition and maintenance costs inherent to these systems.