Journal of Robotic Surgery

https://doi.org/10.1007/s11701-020-01147-7

REVIEW ARTICLE

Robotic‑assisted cortical bone trajectory (CBT) screws using the Mazor

X Stealth Edition (MXSE) system: workflow and technical tips for safe
and efficient use
John A. Buza III1 · Christopher R. Good2 · Ronald A. Lehman Jr.3 · John Pollina4 · Richard V. Chua5 ·
Avery L. Buchholz6 · Jeffrey L. Gum1 

Received: 29 April 2020 / Accepted: 22 September 2020

© Springer-Verlag London Ltd., part of Springer Nature 2020

Abstract
Robotic-assisted spine surgery has a number of potential advantages, including more precise pre-operative planning, a high
degree of accuracy in screw placement, and significantly reduced radiation exposure to the surgical team. While the current
primary goal of these systems is to improve the safety of spine surgery by increasing screw accuracy, there are a number of
technical errors that may increase the risk of screw malposition. Given the learning curve associated with this technology,
it is important for the surgeon to have a thorough understanding of all required steps. In this article, we will demonstrate the
setup and workflow of a combined navigation and robotic spine surgery platform using the Mazor X Stealth Edition (MXSE)
system to place cortical-based trajectory (CBT) screws, including a review of all technical tips and pearls to efficiently
perform this procedure with minimal risk of screw malposition. In this article, we will review surgical planning, operating
room setup, robotic arm mounting, registration, and CBT screw placement using the MXSE system.

Keywords  Robotic surgery · Spine · Workflow · Technique · Mazor X

Introduction [2, 3]. This robot-assist platform was small, spine-mounted

In 2001, Mazor Robotics began work on a small spine-
mounted robot which could assist with pedicle screw instru-
mentation [1]. In 2004, the first generation of this technol-
ogy, called Spine Assist, was FDA-approved for clinical use
John A. Buza III and Jeffrey L. Gum have contributed equally to
this work.
* Jeffrey L. Gum
Jeffrey.Gum@nortonhealthcare.org
1
Department of Spine Surgery, Norton Leatherman Spine
Center, 210 E. Gray St. Suite 900, Louisville, KY 40202,
USA
2
Virginia Spine Institute, Reston, VA, USA
3
Daniel and Jane Och Spine Hospital, New York Presbyterian,
Columbia University Medical Center, New York, NY, USA
4
Department of Neurosurgery, University at Buffalo, Buffalo,
NY, USA
5
Northwest Neurospecialists, Tuscon, AZ, USA
6
Department of Neurosurgery, University of Virginia Health
System, Charlottesville, VA, USA
which had an attached arm with six degrees of freedom,
which provided the trajectory for pedicle screw instrumen-
tation. The surgeon could then perform all instrumentation
through this guided trajectory. Mazor Robotics released the
second generation, termed the Renaissance, in 2011, and
followed with the release of the third generation Mazor X
in 2016 [4, 5]. The most recent version was first utilized in
January of 2019 and it combines navigation and robotics
into a single platform called the Mazor X Stealth Edition
(MXSE) [6]. Mazor robotic systems are the most widely
used spinal robotics in the United States and globally. As
of mid-2018, these robotic systems were in more than 250
centers and 40 countries worldwide [5]. In the last several
years, two competitors have hit the market. The ROSA
robot (Zimmer-Biomet) is a floor mounted robot which has
combined robotic and navigation functions [7]. The Globus
Medical Excelsius GPS Robot was FDA-approved in 2017,
is also floor mounted, and has combined robotic and naviga-
tion functions [8].
Given the widespread use of the Mazor spine robot, most
studies in the literature evaluating the accuracy of robotic-
assisted screw placement have utilized one of the Mazor

13
Vol.:(0123456789)

platforms. Most recent reports of the Mazor system have
focused on traditional pedicle screw trajectory, with reported
accuracy in the range of 97–99% using the Gertzbein–Rob-
bins grading system [4, 7, 9–19]. Overall, although there
are limitations to the current literature, most studies have
found a fairly high and reproducible accuracy for pedicle
screw placement using robotic-assist systems. Additionally,
with the adoption of any new technology, it is important
to consider the learning curve associated with its use. It
can be very beneficial for new adopters to understand the
learning process and have reasonable expectations to avoid
early abandonment. While there are a limited number of
studies, it appears that the learning curve is in the range of
approximately 15–30 cases [4, 20, 21]. In a study of 102
patients undergoing robotic-assisted pedicle screw place-
ment, Hu et al. found that the rate of successful placement
increased after the first 30 cases [4]. In a matched cohort
comparison of 95 patients undergoing robot-assisted versus
fluoroscopic-guided pedicle screw placement in the lumbar
spine, Schatlo et al. found that the highest rate of conversion
from robot-assisted to manual placement occurred in the
first 5–25 patients [20]. It is likely that for most spine sur-
geons who have experience performing fluoroscopic-assisted
pedicle screw placement, the use of robotic-assisted pedicle
screw insertion can be adopted fairly quickly.
While most studies on robotic-assisted screw placement
have evaluated traditional pedicle screw trajectory, recent
reports have evaluated cortical bone trajectory (CBT) screws
using robotic assistance [22, 23]. CBT screws were first
described in 2009 by Santoni et al. as a minimally invasive
alternative to traditional pedicle trajectory screws during
posterior lumbar interbody fusion procedures [24]. CBT
screws have a number a potential advantages. The corti-
cal trajectory has an inferomedial entry point with a more
superolateral trajectory, which requires a smaller incision to
place instrumentation. In addition, lateral soft-tissue dissec-
tion is limited to the region of the pars interarticularis, with
less retraction required. In addition, CBT screws have been
shown to have higher insertional torque and pullout strength
compared with traditional pedicle screw trajectory [25–27].
Clinical outcome studies in patients with degenerative lum-
bar disorders have demonstrated similar pain, functional,
and disability scores as traditional pedicle screws but with
a lower complication profile [28–30]. While recent reports
have described the use of robotic-assisted surgery to place
CBT screws, the surgical technique of this procedure has not
been well described in the literature [22, 23].
Considering the learning curve associated with robotic-
assisted spine surgery, it is important that surgeons incorpo-
rating this technology into their practice be familiar with the
technical pitfalls that may occur during all stages of robotic-
assisted spine surgery. This article will review the technical
aspects of utilizing the MXSE for cortical bone trajectory
13
Journal of Robotic Surgery
(CBT) screws, including surgical planning, operating room
setup, robotic arm mounting, registration, pedicle cannula-
tion, and CBT screw insertion. Each stage will include tips to
avoid errors which may ultimately lead to screw malposition.
We will include the lessons which we have learned from the
early adoption of this technology at our institution, which has
allowed robotic-assisted spine surgery to be performed in a
safe, efficient, and reproducible manner.
Surgical planning
One of the main purported advantages of robotic-assisted
spine surgery is improved pre-operative planning using soft-
ware for pre-operative planning. The MXSE system is CT
based and requires that the patient undergo a CT scan which
can be done either preoperatively (CT to Fluoro) or intraop-
eratively (Scan and Plan). For the CT to Fluoro workflow,
the CT scan is performed using 1 mm-thick slices and then
loaded to the MXSE and planned prior to incision. This is
our preferred workflow as it avoids intraoperative time for
planning. When utilizing the scan and plan workflow, an
intraoperative CT such as O-arm is utilized and the data
are transferred to the MXSE and then planned, while the
O-arm is being removed. Both modalities allow the surgeon
to plan CBT screw trajectory, diameter, and length. There
are several advantages for CBT while planning. The starting
points may be placed more medially, or in a more divergent
pattern (in the cranial-caudal plane) to reduce the size of
the skin incision and dissection in an effort to be more mini-
mally invasive. This reduction of tissue dissection is con-
sistent with the benefits of CBT. When planning, we align
the tulips in the coronal plane for a straight rod, and in the
sagittal plane, we diverge the screws, so that their insertion
pathway merges on the skin truly minimizing the incision
size (Fig. 1a–b). We have modified our sagittal screw tra-
jectory over time. The UIV or most cranial screws need to
start on the pars just distal to the proximal facet and must
avoid facet violation at all costs to reduce adjacent segment
breakdown. However, the remaining screws can be altered
to start within the facet (trans-facet), since those levels are
being fused (Fig. 2a–c). It is important to prep the surface to
be relatively flat to avoid skive into the joint or off trajectory.
Additionally, since the screw size has already been planned,
the surgical team can already have prepared (improve effi-
ciency) and potentially sterile packed individually to, in
theory, reduce waste.
Operating room setup
The patient may be placed prone or lateral on a radiolu-
cent table. The hands should be placed above the head, so
that the arms will not interfere when acquiring images. It is
Journal of Robotic Surgery

Fig. 1  Planning views from

an L3-S1 CBT construct after
having an ALIF at L5-S1. a
Coronal view showing the tulips
lining up to keep the rod as
straight as possible in this plane.
b Sagittal view showing that the
trajectory should be modified to
align and intersect on the skin to
minimize the incision size

Fig. 2  Comparison of CBT constructs. a A classic CBT construct straight in as a trans-facet orientation. c The axial view of the plan-
with both UIV and LIV screws starting on the pars with an up/out ning process of the modified LIV screws
direction. b A modified CBT construct with the LIV screws more

important to secure the patient to the operating room table
prior to beginning the procedure. If the table does not have
a frame, a bed frame must be attached to the operating room
table before transferring the patient onto the operating room
table. The robotic base should be placed at the foot of the
operating room table, as this will allow room for the robotic
arm mount and room for fluoroscopy. C-arm fluoroscopy
may approach the patient from either side, but should be
on the side opposite the sterile field. The MXSE Robotics
image adaptor must be attached to the C-arm image intensi-
fier prior to surgery (Fig. 3).
Robotic arm mounting
After the patient is placed on the operating room table
and prior to skin preparation, the next step is to mount the
MXSE system onto the bed frame. Given the weight of the
robotic arm, there is an on-board automated lifting mecha-
nism stored within the MXSE workstation which allows
for mounting onto the bed frame. We prefer to mount the
robotic arm at the foot of the bed on the patient’s right
side (when prone), although it can be placed on either side

13

Fig. 3  The Mazor Robotics image adaptor attached to the C-arm
image intensifier
per surgeon preference (Fig. 4). After the robotic system
is mounted to the bed, it can be draped. It is important
to drape the arm after the patient has been placed on the
operating room table.
Incision and exposure
After mounting the robotic arm, prior to draping the arm
or the patient we place a spinal needle at the approxi-
mate center of the incision and obtain a lateral radiograph
(Fig. 5a). After adjusting as necessary, this minimizes our
incision. We then perform our surgical approach exposing
to the lateral edge of the facets with another intraoperative
lateral radiograph to confirm level(s). For a one-level fusion,
we typically make a 3 cm incision centered over the level
to be fused (Fig. 5b). We prefer to use a McCulloch retrac-
tor for 1–2-level fusions, utilizing the wide blades with the
retractor rack placed on the side opposite (cranially) the
robotic arm. It is important to perform a meticulous sub-
periosteal dissection to remove all muscle and soft tissue
off of the lamina and projected screw starting points, with
preservation of the superior facet capsule. This will remove
13
Journal of Robotic Surgery
Fig. 4  The Mazor robotic arm mounted to the operating room table
all soft tissues from the planned trajectory and allow the
surgeon to visualize the cannula dock directly onto the bone
surface. This direct visualization is very advantageous when
early in adoption as it allows the surgeon to trust the system.
Additionally, we prep any obvious uneven surfaces such as
an overgrown facet to minimize the skive potential by having
the flattest surface possible. All of this should be done prior
to mounting to, as well, minimize shift between the patient
and the system once registered.
Mounting the patient to the robotic arm
For additional stability, the MXSE system requires that the
patient is directly mounted to the robotic arm. There are
multiple different options available for affixing a coupler
to the patient’s bony anatomy, including a spinous pro-
cess clamp, dual spinous process clamp, link bridge to the
spinous process, MIST (MIS Thoracic) bridge to the spinous
process, and a Schanz screw/pin into the pelvis. The Schanz
pin is intended for open procedures from L4 to S2, or mini-
mally invasive procedures from L1 to S2. The Schanz pin
is our most commonly performed and preferred technique
for bone mounting in CBT cases. To place the Schanz pin,
Journal of Robotic Surgery
Fig. 5  a Spinal needle place-
ment used for localization of
incision. b Typical 3–4 cm
incision length for a one or two
level spinal fusion
a stab incision is made directly over the posterior superior
iliac spine (PSIS). The Schanz pin is then advanced directly
into the PSIS (Fig. 6a). For patients that have an easily pal-
pable PSIS, we tend to use the 80 mm Schanz pin. For larger
patients with increased soft tissue over the PSIS, we tend to
use the 120 mm Schanz pin. The Schanz pin is advanced into
the PSIS until it is stable. We prefer to toggle the Schanz
pin periodically after advancement; when the entire patient
moves in coordination with the Schanz pin, it is deemed sta-
ble (Fig. 6b). This step is critical to minimize shift between
the patient and MXSE system. If the Schanz pin is noted to
be loose, or toggles independently of the patient, it is rec-
ommended be repositioned until stable fixation is achieved.
After placement of the Schanz pin, the Schanz screw ball
adaptor is connected to the Schanz pin (Fig. 6c). This is then
attached to the bone mount bridge (Fig. 6d). If preferred, one
may connect directly the Schanz pin with the appropriate
connection (either a Schanz arm or Dynamic Schanz con-
nector), but we prefer use the Schanz screw ball adaptor. We
then toggle the system again to confer that the patient, bed,
and MXSE system all move as a single unit. At this point,
the robotic arm is linked to the patient’s anatomy and the
surgeon may begin the process of registration.
Registration
The MXSE system has two available workflows as described
in surgical planning. We prefer the most common workflow
(CT to fluoro), which is described hereafter. After initiating
the robot using the MXSE computer screen, the Mazor X eye
camera should be moved into a position where it recognizes
the reference marker, and will perform a 3D scan to define
the working volume for the surgeon. This is referred to as the
“no fly zone scan” (Fig. 7). It is important to make sure that
before initiating this scan, that the sterile sleeve slack is held
tight against the surgical arm, so that it does not obstruct the
camera, and to place blue towels over the surgical wound
with lights removed. We then perform a “snapshot” that tells
the navigation system where the robotic arm is and merges
the two together.
Following this scan, the surgeon defines the region of
interest using the navigation probe at the cranial and cau-
dal boundaries which is typically the top and bottom of the
surgical wound for short segment fusions. The next step
includes obtaining AP and oblique fluoroscopy images for
registration (Fig. 8). These images must be obtained with
the surgical arm in the respective (AP or oblique) position,
as this allows the system to calibrate the position of the arm
in space. For the AP image, the 3D marker is attached to
the target extender, which is directly after obtaining the AP
image, the surgeon must ensure that all levels to be operated
on are included in the image, and that the entire 3D marker
pattern is visible in the image. The 3D marker should ideally
be located in the center of the AP fluoro shot. Once an AP
image is obtained that meets these criteria, the AP image is
acquired by the software and the same steps may be repeated
for the oblique image. After registration, the surgeon must
perform the verification process before activating the robotic
arm. Visual fluoroscopic registration is performed for all
registered vertebrae as shown.
Cortical cannulation and screw placement
The surgeon activates the surgical arm by selecting the
planned trajectory at the desired level to be executed. The
surgical arm will move into position during this time and
13
 Journal of Robotic Surgery

Fig. 6  a The Schanz pin is

advanced directly into the poste-
rior iliac spine. b Schanz pin is
toggled to ensure that adequate
fixation has been achieved. c
The Schanz screw ball adaptor
is connected to the Schanz
screw. d The Schanz screw ball
adaptor is directly mounted to
the bone mount bridge

will make an audible noise until the arm comes to a com-
plete stop. The trajectory of the planned pedicle screw
should be assessed at each stage. If there is any suspicion
for inaccuracy, the surgeon should verify system accuracy by
either placing a navigated instrument on known anatomy and
confirming or placing the stylus probe into the arm guide. If
there is any doubt, we recommend to redo the snapshot step
and potentially re-register. Once the robotic arm is in posi-
tion, the surgeon may insert the appropriate length working
cannula. Once the cannula is in position, the drill guide can
be gently inserted into the cannula by allowing it to fall into
place with its own momentum (Fig. 9a). Once the drill guide
is in place, it should be lightly malleted into place to allow
the teeth to engage without forcefully pushing the arm off
trajectory. The teeth are very sharp and one should utilize
this to help minimize skive. Then, follow the light taps with
a few more aggressive taps. The surgeon can confirm that the
drill guide is securely positioned by applying gentle torque
to the head to the drill guide to ensure that it does not easily
rotate. To detect skive throughout these steps, we encourage
surgeons to watch the black end-effector (EE) very close. If
it deviates even a small amount, it has a high potential to
skive and go off-axis. Additionally, there should be no soft-
tissue pressure on the system.
Following successful docking of the drill guide, the
appropriate drill tip (short or long) can be attached to the

13
Journal of Robotic Surgery

Fig. 7  3D scan to define the

working volume for the surgeon,
otherwise known as the “no fly
zone” scan

Fig. 8  For the AP image, the 3D marker is attached to the target
extender, which is directly attached to the robotic arm
drill, and placed into the drill guide (Fig. 9b). The drill bit
should pass smoothly within the drill guide. It is critically
important not to apply any excessive force when using any
of the tools, as this can cause skive of the trajectory. Once
the drill bit is confirmed to pass smoothly through the drill
guide, the surgeon’s non-dominant hand should be used to
stabilize the drill guide, and the drill should be advanced
into the bone. The drill bit has a stop which prevents from
excessive drilling at a depth of 30 mm. Once the pilot
hole is drilled, the surgeon may choose to tap or place the
screw. To tap, the drill cannula (inner cannula) is removed,
leaving only the outer cannula in place. The tap can then
be inserted through the outer cannula (Fig. 9c), followed
by the appropriately sized pedicle screw (Fig. 9d). It is
again important to remember that at each of these stages,
the surgeon should avoid excessive force on the system or
surgical accessories to prevent translation or skive. Also,
as an internal check when disengaging the driver from
the screw and pulling back, if there is translation or skive
of the EE and it takes a lot of force to remove, the screw
likely skived or was off trajectory.
Once all screws trajectories have been drilled, the
robotic arm may be removed from the surgical field once
their placement has been confirmed. The bone mount
bridge may be removed from the bone mount platform, and
the surgical arm may be removed from the operation area.
The Schanz pin drilled into the PSIS may be removed. We
prefer to close this small incision with a buried 2–0 vicryl
and dermabond.

13
 Journal of Robotic Surgery

Fig. 9  a Drill guide is gently

inserted into the cannula using
its own momentum. b The drill
tip is inserted into the drill
guide, and advanced into bone.
c After removing the inner
sleeve, the tap is inserted and
advanced into bone an appropri-
ate distance. d The proper sized
pedicle screw is inserted under
power

Shift and skive translational force if the surgeon is not meticulous about

There are two primary errors that occur during CBT screw
placement. The first error is generally referred to as ‘shift’
and is a change in position of the MXSE system relative to
the patient. This may occur at many phases and can be from
leaning on the patient, bumping the system with fluoroscopy,
but is mitigated most by a robust connection between patient
and system. The second primary error that may occur dur-
ing pedicle screw placement is referred to as ‘skive.’ This
generally occurs when a downward force applied to the can-
nula, drill, tap, or guide causes the instrument to change
position relative to its bony landmark. This can occur when
the surgeon introduces a translational force to the cannula
or instruments such as soft tissue. The hand drill and asso-
ciated instruments are heavy, and may act to introduce a
maintaining a constant in-line trajectory with the guide and
cannula. While many translational errors can be detected
by watching the navigation screen (pedicle screw not trave-
ling in line with planned trajectory) and/or movement of
the EE, subtle shift may occur that is difficult to recognize.
Anatomically, this is most common on the steep slope of the
lateral edge of the facet which is a common starting point
in traditional pedicle screws but not CBT. If the surgeon
applies a downward force on the instrument, the cannula
or guide may slide down the edge of the facet to an inap-
propriate position. This frequently introduces both a trans-
lational and angular error (skive). Again, while this may be
detected with on-screen navigation, a subtle degree of skive
may not be identified. For this reason, it is important not to
introduce any unnecessary force to the drill or instruments

13
Journal of Robotic Surgery
during use. In addition, similar to the traditional freehand
pedicle screw placement, the surgeon should palpate all
bony pedicle screw pilot holes with a ball-tipped feeler to
ensure safe and accurate placement. Finally, intraoperative
radiographs should be used to evaluate satisfactory screw
placement and ensure that the goals of surgery have been
achieved (Fig. 10).
Review and discussion
While the technique described above pertains to robotic-
assisted CBT screw placement, various forms of advanced
imaging technology (including fluoroscopy and naviga-
tion) have previously been described for the purpose of
CBT screw placement. It is important for the surgeon to
weigh the pros and cons for each of these technologies
when considering safe placement of CBT screws. The
major advantage of navigation or robotic technology over
simple C-arm fluoroscopy is obtaining true images in the
axial plane, which can only be estimated by the surgeon
when they are limited to orthogonal images. This may
be especially important for CBT screw placement, as the
cortical tract is narrower and more difficult to cannulate
compared to a traditional pedicle screw. The use of naviga-
tion-based CBT screw placement has been described in the
literature and does offer the advantage of imaging in the
axial plane. This technique has been shown to be safe and
reproducible. The major advantages of robotic-assisted
screw placement over navigation-based screw placement
include increased accuracy and safety in screw insertion,
Fig. 10  Grade 2 Spondylolisthe-
sis treated with robotic midline
lumbar interbody fusion with
partial reduction of spondylolis-
thesis and restoration of disc
height and foramen
improved precision in screw size selection and planned
screw position, ease of registration and reduction of oper-
ating room time, reduced radiation to the operating room
staff, and an enhancement of the surgeon’s ergonomics and
dexterity for repetitive tasks in pedicle screw placement
[4, 12, 14, 18, 20, 21, 31–34].
Finally, it is important for the surgeon to consider the
different types of robotic-assisted technology that are
available, which include the Mazor X Stealth Edition
robotic system (Medtronic), the ROSA robot (Zimmer-
Biomet), and the Globus Medical Excelsius GPS Robot
[5, 7]. [8] Given the widespread use of the Mazor spine
robot, most studies in the literature evaluating the accuracy
of robotic-assisted screw placement have utilized one of
the Mazor platforms. Most recent reports of the Mazor
system have focused on the traditional pedicle screw tra-
jectory, with reported accuracy in the range of 97–99%
using the Gertzbein–Robbins grading system [4, 7, 9–19].
While there are fewer studies to date on the Globus Medi-
cal Excelsius GPS Robot, accuracy of traditional pedi-
cle screw placement appears to be in the same range of
97–98% [34–38]. The ROSA robot system has been evalu-
ated in feasibility and cadaveric studies, but has only been
evaluated in clinical accuracy studies in a small number of
patients, making comparison to other robotic technologies
difficult [7, 39–41]. Further clinical studies are required
before a direct comparison of pedicle screw placement
accuracy can be made between these different robotic
systems. Although these robotic systems have different
workflows, the principles of robotic-guided pedicle screw
placement are similar irrespective of the system used.
13

Conclusion
Given the widespread interest and rapid growth, robotic
technology will likely play an increasing role in the oper-
ating room over the coming decades. There are a number
of advantages that this technology will offer both surgeons
and patients, including increased accuracy, efficiency, and
decreased radiation exposure. However, along with the
advantages, there is a learning curve associated with the
adoption of any new technology that must be considered.
Although robotic technology has been shown to increase
pedicle screw placement accuracy, there are a number of
technical errors during the procedure that may lead to mis-
placed pedicle screws. We have summarized the steps which
we follow during CBT screw placement to ensure a safe and
reproducible outcome. Additionally, we feel that CBT screw
placement is a great starting point for surgeons when intro-
ducing robotic-assisted technology. It offers a direct visuali-
zation of cannula-bone interface to double check accuracy,
the planning allows you to truly minimize skin incision, and
finally, non-robotic assisted CBT requires either navigation
or fluoro (not freehand), so the utilization of the robotic sys-
tem is substitutive and not additive to improve workflow (not
just add steps).
Acknowledgements None.
Author contributions  Dr. JB and Dr. JG were involved in the creation,
writing, and final editing of this publication. Drs. CG, RL, JP, AB, and
RC were involved in the creation of the review, revised it critically for
intellectual content, and approved the final version to be published. All
authors involved agree to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any part
of the work are appropriately investigated and resolved. All authors
of this manuscript certify that it is (1) is a unique submission, (2) has
not been submitted and is not being considered for publication by any
other source in any medium, and (3) has not been published, in part or
in full, in any form.
Funding  No funding was received for this article.
Compliance with ethical standards  robot-assisted vs. freehand pedicle screw fixation in spine surgery.
Conflicts of interest John Buza has no conflicts of interest. Jeffrey
Gum has the following disclosures: Acuity: IP royalties, Paid consult-
ant;; Cingulate Therapeutics, Stock or stock Options; DePuy, A John-
son & Johnson Company, Paid presenter or speaker; K2M, Paid con-
sultant; MAZOR Surgical Technologies, Paid consultant; Medtronic,
Paid consultant; Nuvasive, IP royalties, Paid consultant; Stryker, Paid
presenter or speaker; Spine Deformity Journal—Reviewer, Editorial or
governing board; The Spine Journal—Reviewer, Editorial or govern-
ing board. Ronald Lehman has the following disclosures: Medtronic:
Consulting fees and royalties; Stryker: Royalty fees. Richard Chua has
the following disclosures: Indirect interest as a consultant/speaker’s
bureau related to surgeon education. Avery Buchholz has the following
disclosures: Medtronic: Consulting fees. John Pollina has the follow-
ing disclosures: Atec Spine: Consulting fees and royalties; Medtronic:
Surgeon Education, Christopher Good has the following disclosures:
13
Journal of Robotic Surgery
Mazor Robotics: Stock options, consulting fees; Medtronic: Consult-
ing, advisory board; Stryker/K2M: Consulting, Royalties, Advisory
Board; Augmedics: Advisory Board, Stock Options; National Spine
Health Foundation: Board Member.
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