ArticleEuropean spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society2026
The accuracy of navigated vs. robot-assisted pedicle screw placement in spine surgery: a retrospective single-centre comparative study.
Article in European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
STUDY
designRetrospective comparative cohort study.
introductionAccurate pedicle screw placement is critical for spinal stability and for preventing neurological or vascular injury. This study compared screw-placement accuracy and safety between robot-assisted and navigation-guided pedicle screw implantation and explored differences between intraoperative 3D-fluoroscopy and preoperative CT-based surface-matching registration.
methodsWe assessed all consecutive patients who underwent robot-assisted or navigation-guided pedicle screw placement at our department between 2018 and 2022. For robot-assisted placement, screw trajectories were planned on preoperative CT, and intraoperative patient registration was performed using two radiographs fused with a preoperative CT. Navigation-guided placement used either intraoperative 3D-fluoroscopy registration in the final prone position or CT-based surface matching using preoperative supine CT images. Screw positions were evaluated on postoperative CT using a standardised ordinal grading scale from 0 to 4, with Grades 3-4 defined as clinically relevant malpositions. We analysed accuracy using generalised estimating equations with patient-level clustering and adjustment for covariates. We also assessed operative time, radiation exposure, complications, and revision rates.
resultsWe analysed 1,718 pedicle screws from 268 patients: 728 were robot-assisted and 990 navigation-guided, including 579 using 3D-fluoroscopy and 411 using CT-based surface matching. Mean screw grades were 0.956 for robot-assisted placement, 0.864 for navigation overall, 0.807 for 3D-fluoroscopy, and 0.944 for surface matching. After accounting for patient clustering and adjustment, screw grade did not differ significantly between navigation-guided and robot-assisted placement (aOR 0.87, 95% CI 0.50-1.53; p = 0.632). Grade 3-4 malpositions occurred in 11.7% of robot-assisted and 9.4% of navigation-guided screws, with no significant difference after adjustment. Radiation exposure and fluoroscopy time differed significantly between groups (p < 0.001), with the lowest median values for robot-assisted placement, followed by surface matching and 3D-fluoroscopy. Registration failure occurred in 12/118 (10.2%) robot-assisted patients compared with 2/150 (1.3%) navigation-guided patients. One new postoperative neurological deficit (foot drop) occurred in the robot-assisted group and none in the navigation group.
conclusionsNo significant overall difference in screw-placement accuracy was demonstrated between the two platforms (Robot vs. navigation) or registration modalities in this heterogeneous real-world cohort; however, they showed different operational profiles, particularly concerning intraoperative radiation exposure, fluoroscopy time, and registration failure.
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