Learning curve for robot-assisted percutaneous pedicle screw placement in thoracolumbar surgery

Abstract

Study Design: Retrospective review of an initial cohort of consecutive patients undergoing robot-assisted pedicle screw placement. Purpose: We aimed to evaluate the learning curve, if any, of this new technology over the course of our experience. OverView of Literature: Percutaneous pedicle screws have specific advantages over open freehand screws. However, they require intraoperative imaging for their placement (e.g., fluoroscopy and navigation) and require increased surgeon training and skill with the learning curve estimated at approximately 20-30 cases. To our knowledge, this is the first study that measures the learning curve of robot-guided purely percutaneous pedicle screw placement with comprehensive objective postoperative computed tomography (CT) scoring, time per screw placement, and fluoroscopy time. Methods: We included the first 80 consecutive patients undergoing robot-assisted spinal surgery at Melbourne Private Hospital. Data were collected for pedicle screw placement accuracy, placement time, fluoroscopy time, and revision rate. Patient demographic and relevant perioperative and procedural data were also collected. The patients were divided equally into four sub-groups as per their chronological date of surgery to evaluate how the learning curve affected screw placement outcomes. Results: Total 80 patients were included; 73 (91%) had complete data and postoperative CT imaging that could help assess that placement of 352 thoracolumbar pedicle screws. The rate of clinically acceptable screw placement was high (96.6%, 95.4%, 95.6%, and 90.7%, in groups 1 to 4, respectively, p=0.314) over time. The median time per screw was 7.0 minutes (6.5, 7.0, 6.0, and 6.0 minutes in groups 1 to 4, respectively,p=0.605). Intraoperative revision occurred in only 1 of the 352 screws (0.3%). Conclusions: We found that robot-assisted screw placement had high accuracy, low placement time, low fluoroscopy time, and a low complication rate. However, there were no significant differences in these parameters at the initial experience and the practiced, experience placement (after approximately 1 year), indicating that robot-assisted pedicle screw placement has a very short (almost no) learning curve.