SURGICAL ROBOTICS IN NEUROSURGERY SERIES

Robotic Applications in Cranial Neurosurgery:

Current and Future
Tyler Ball, MD‡∗
Jorge González-Martínez,
MD, PhD§∗
Ajmal Zemmar, MD, PhD‡ ¶∗
Ahmad Sweid, MD ||∗
Sarat Chandra, MCh#∗
David VanSickle, MD,
PhD∗∗∗
Joseph S. Neimat, MD‡
Pascal Jabbour, MD ||
Chengyuan Wu, MD,
MSBmE||
‡
Department of Neurosurgery, University
of Louisville, Louisville, Kentucky, USA;
§
Department of Neurosurgery, Univer-
sity of Pittsburgh, Pittsburgh, Pennsyl-
vania, USA; ¶ Department of Neuro-
surgery, People’s Hospital of Zhengzhou
University, Henan Provincial People’s
Hospital, Henan University People’s
Hospital, Henan University School of
Medicine, Zhengzhou, China; || Depart-
ment of Neurosurgery, Thomas Jefferson
University, Philadelphia, Pennsylvania,
USA; # Department of Neurosurgery,
All India Institute of Medical Science,
New Delhi, India; ∗∗ Neurosurgery One,
Littleton, Colorado, USA
Robotics applied to cranial surgery is a fast-moving and fascinating field, which is trans-
forming the practice of neurosurgery. With exponential increases in computing power,
improvements in connectivity, artificial intelligence, and enhanced precision of accessing
target structures, robots are likely to be incorporated into more areas of neurosurgery
in the future—making procedures safer and more efficient. Overall, improved efficiency
can offset upfront costs and potentially prove cost-effective. In this narrative review, we
aim to translate a broad clinical experience into practical information for the incorpo-
ration of robotics into neurosurgical practice. We begin with procedures where robotics
take the role of a stereotactic frame and guide instruments along a linear trajectory.
Next, we discuss robotics in endoscopic surgery, where the robot functions similar to
a surgical assistant by holding the endoscope and providing retraction, supplemental
lighting, and correlation of the surgical field with navigation. Then, we look at early
experience with endovascular robots, where robots carry out tasks of the primary surgeon
while the surgeon directs these movements remotely. We briefly discuss a novel micro-
surgical robot that can perform many of the critical operative steps (with potential for
fine motor augmentation) remotely. Finally, we highlight 2 innovative technologies that
allow instruments to take nonlinear, predetermined paths to an intracranial destination
and allow magnetic control of instruments for real-time adjustment of trajectories. We
believe that robots will play an increasingly important role in the future of neurosurgery
and aim to cover some of the aspects that this field holds for neurosurgical innovation.
KEY WORDS: Robotics, Stereotaxy, Deep brain stimulation, Epilepsy, Endovascular, Endoscopic
Operative Neurosurgery 21:371–379, 2021 https://doi.org/10.1093/ons/opab217

∗
Tyler Ball, Jorge González-Martínez,
Ajmal Zemmar, Ahmad Sweid, Sarat

Chandra, and David VanSickle
contributed equally to this work.
Some of this work was presented during
a premeeting workshop at the Congress
of Neurological Surgeons Annual
Scientific Meeting on October 7, 2018, in
Houston, Texas.
Correspondence:
Chengyuan Wu, MD, MSBmE,
Department of Neurosurgery,
Thomas Jefferson University,
909 Walnut St, Third Floor,
Philadelphia, PA 19107, USA.
Email: Chengyuan.Wu@jefferson.edu
Twitter: @ChenWuMD
Received, November 19, 2020.
Accepted, May 16, 2021.
Published Online, June 30, 2021.
C Congress of Neurological Surgeons
2021. All rights reserved. For permissions,
please e-mail:
journals.permissions@oup.com
T
he exponential increase in computing
power has enabled the production of
increasingly advanced surgical robots,
which have been supplemented by advances in
surgical instruments, navigation technology, and
digital imaging modalities that have facilitated
the incorporation of robotics into intracranial
surgery. In this narrative review, we intend to
provide insight into commonly used robotic
technologies in cranial neurosurgery based
on expert opinion of high-volume users. In
addition, we hope to introduce some promising
ABBREVIATIONS: CT, computed tomography; DBS,
deep brain stimulation; FDA, food and drug admin-
istration; LITT, laser interstitial thermal therapy;
MER, microelectrode recording; MNS, magnetic
navigation systems; OR, operating room; RNS,
responsive neurostimulation; SEEG, stereoelec-
troencephalography
potential robotic implementations. See Table
for an overview of cranial robotic technologies
discussed.
Given the broad definition of “robotics,” it
is outside the scope of the paper to discuss
every current and potential future application of
robotics in the field. We have included devices
that either augment a surgeon’s movements or
simplify a multistep process, but not those
that execute a simple translational or rotational
movement under direct surgeon control. In
addition, although certainly important, we do
not intend to provide detailed economic or
ethical analyses of the incorporation of robotics
into neurosurgical practice.
ROBOTICS FOR STEREOTAXIS
Deep Brain Stimulation
Deep brain stimulation (DBS) has tradi-
tionally been performed awake guided by

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BALL ET AL

TABLE. Cranial Robotic Technologies Discussed

Device Status Description Role

Neuromate Commercially available
(Renishaw)
ROSA Commercially available
(Zimmer Biomet)
Mazor Renaissance No longer commercially
available
Stealth Autoguide Commercially available
(Medtronic) (Medtronic)
SurgiScope Commercially available (ISIS
Robotics)
CorPath GRX Robotic Commercially available
System (Corindus)
NeuroArm Prototype built and
successfully used clinically,
but not commercially
available
Follow the leader Research stage
curved needles
Magnetic navigation Research stage
systems
DaVinci surgical Widespread use in urologic,
system gynecologic, and general
surgery, but currently
limited to cadaveric studies
for cranial surgery
Floor-mounted robotic arm to align and
maintain linear trajectory
Floor-mounted robotic arm to align and
maintain linear trajectory
Skull-mounted robotic arm to align and
maintain linear trajectory
Mayfield clamp- mounted robotic arm
to align and maintain linear trajectory
Ceiling-mounted surgical microscope
capable of frameless robotic stereotaxis
Translational and rotational
endovascular catheter movements
Open surgical maneuvers (scalable in
amplitude and speed)
Guide therapeutic device to target via a
“predetermined” but nonlinear path
driven via a MRI-compatible robotic
actuator
Guide therapeutic device to target via
dynamic changes in a magnetic field
Floor-mounted robot translates
surgeon’s hand movements from a
remote console
Frameless stereotaxis with
semiautomated targeting
For endoscopy, can function as a
surgical assistant (retraction, lighting,
correlation of location with navigation)
Frameless stereotaxis with
semiautomated targeting
For endoscopy, can function as a
surgical assistant (retraction, lighting,
correlation of location with navigation)
Frameless stereotaxis with
semiautomated targeting
Frameless stereotaxis with
semiautomated targeting
Can be used for frameless stereotaxis
with semiautomated targeting (not its
primary purpose)
Telesurgery
Can execute catheter manipulation on
behalf of the primary surgeon
Telesurgery
Can execute microsurgical movements
on behalf of the primary surgeon,
potentially with fine motor
augmentation (scalable movements,
tremor filter)
Nonlinear frameless stereotaxis along
complex paths
Robotic actuation can execute
movements on behalf of the primary
surgeon
Potentially telesurgery
Stereotactic guidance with degrees of
freedom not possible with tactile
methods
Potentially radiosurgery
Telesurgery
Can execute microsurgical movements
on behalf of the primary surgeon, with
scalable movements, tremor filter,
wristed instruments, and 3-dimensional
visualization

microelectrode recording (MER), but asleep surgery is
becoming increasingly common.1-4 Regardless of technique,
the goal is to place the lead as accurately as possible for the
best clinical outcome.5,6 Robotic assistance can be used in
conjunction with either technique to provide high accuracy and
precision for electrode implantation while offering increased
efficiency.
While no longer commercially available, we have used
the Mazor Renaissance (Medtronic, Dublin, Ireland) since
2014 for asleep DBS followed by intraoperative computed
tomography (CT) to verify lead location (Figure 1).
The skull-mounted design allows it to fit into the CT, and if
the lead is deemed unacceptable, it can be repositioned using
the offset afforded by the “Ben-gun” electrode guidance array.
Using our workflow for 241 implanted leads, we achieved an
initial radial error of 1.06 ± 0.60 mm and a final deviation of
0.85 ± 0.38 mm when considering lead repositioning.7 Mean
operating time was 115.4 ± 42.1 min for 97 unilateral and
193.3 ± 34.7 min for 11 bilateral cases making this efficient and
possibly contributing to a low infection rate of 0.41%.8 Using
the same robot, Ho et al9 showed a significant decrease in mean
operative times (P < .02) and a decrease in the average number

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FIGURE 1. A skull-mounted robot (Mazor Renaissance, Medtronic) is one option for robotic DBS A and can be used in conjunction with intra-
operative CT (CereTom) for purposes of image-based intraoperative verification of electrode position B.
of MER passes (1.05 vs 1.45, P < .001) with a mean radial error
of 1.4 ± 0.11 mm.
Other robots used in DBS include the ROSA (Zimmer
Biomet, Westminster, Colorado) and Neuromate (Renishaw,
West Dundee, Illinois). Unlike the Mazor, these robots are floor-
mounted and attach to the Mayfield clamp. Both systems consist
of an articulating arm with several degrees of freedom that holds
a working platform in the planned trajectory. Both systems have
demonstrated submillimetre accuracy in DBS.10,11 Additionally,
a recent meta-analysis has shown that robotic-assisted stereo-
taxis provides additional target error reduction.12 Kramer et al13
showed that human calculation errors were among the most
common sources of error in DBS surgery. It therefore stands to
reason that a robot that eliminates some sources of human error
will increase the safety and efficiency of DBS.
Another robot for intracranial stereotaxis is the Stealth
Autoguide (Medtronic, Dublin, Ireland), a much more compact
device. Whereas the ROSA and Renishaw have a large footprint,
the articulating arm of the Autoguide mounts directly to the
Mayfield clamp. While the articulating arm is not as robust
as those of the ROSA or Renishaw, drill-guides with teeth
can be used to engage the skull prior to drilling in order to
achieve another semirigid point of fixation and reduce skiving.
Additionally, the system is compatible with the Midas-style high-
speed drill (Medtronic, Dublin, Ireland) capable of up to 75 000
rpm, which can also reduce skiving risk compared to orthopedic-
style drills. While clinical experience with the Autoguide remains
limited, early preclinical and clinical experience is promising.
Brandman et al14 found no significant difference in target
error between the Leksell (Elekta) frame (2.5 ± 1.1 mm) and
Stealth Autoguide (2.6 ± 1.3 mm) for placement of stereo-
electroencephalography (SEEG) electrodes in cadaveric brains.
Additionally, they showed a 50% reduction in time to target
acquisition compared with the Medtronic Navigus system with
no significant difference in accuracy in a phantom gelatin model
(1.2 ± 0.9 mm for the Autoguide vs 1.5 ± 1.4 mm for the
Navigus). Minchev et al15 found an error of 0.6 mm (range of
OPERATIVE NEUROSURGERY
CRANIAL ROBOTICS
0.1-0.9 mm) for preclinical phantom trials (air medium intracra-
nially) when measured with digital calipers and a median “radial”
target error of 0.9 mm (range of 0-3.1 mm) in a series of
25 patients. Notably, given the procedures performed in this series
(biopsy, shunt placement, or cyst drainage), the methodology of
accuracy determination may not be comparable to those for DBS.
Epilepsy
SEEG provides precise recordings from intraparenchymal
locations in multiple noncontiguous lobes, avoiding the need
for large craniotomies.16-30 With its long-reported success, we
speculate the technical complexity of SEEG implantation using
conventional techniques likely contributed to limited and delayed
clinical application outside France and Italy, and modern robots
were potentially an important driving force in adoption in North
America. Like DBS, SEEG is a procedure well-suited for robots.
The multiplicity and nonstereotypical location of SEEG targets
increase the efficiency advantage, and multiple publications have
shown the utility of both SEEG and robot-assisted placement of
SEEG electrodes.28-42
In a recent report, we analyzed 100 patients with drug-resistant
focal epilepsy who underwent robot-assisted SEEG (101 proce-
dures).43 There were no cancellations due to technical malfunc-
tions. Average planning time was 30 min (15-60 min) and
average operative time was 130 min (45-160 min). Analyses
of SEEG recordings resulted in hypothetical epileptogenic zone
localization in 97 patients (97%) and 68 underwent surgical
resection (70.1%).
In 500 consecutive trajectories, mean entry error was
1.38 ± 0.8 mm and mean target error was 2.31 ± 0.9 mm. There
were 4 patients (4%) with complications related to intracranial
bleeding (2 subdural and 2 intraparenchymal hematomas), of
which 3 were asymptomatic with small volume hemorrhages
(<2 cm3 ) in noneloquent cortical areas. No surgical interven-
tions or changes in length of hospitalization were necessary. The
major complication rate was 1%, comparable to other publica-
tions with morbidity rates ranging from 0% to 5.6%, and the
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FIGURE 2. Robotic RNS method applied to a patient with medical refractory Rolandic epilepsy. A, Planning of electrode trajectories using the robotic’s native stereotactic
software. B, Patient’s positioning, scalp fiducial registration, and intraoperative recordings. C and D, Postoperative X-ray depicting the final implantation aspect of the
implanted RNS device.

per-electrode major hemorrhagic complication rate was 0.08%
for 1245 implanted electrodes.26,29,31,43
Regarding seizure outcome, the mean follow-up after robotic
SEEG-guided resection was 18 mo (6-30 mo). Of patients who
underwent resections, 45 (66.2%) had class I seizure-free outcome
and 11 (16.2%) had rare disabling seizures (class II). Similar
results from others demonstrate that robotic-assisted stereotactic
procedures are safe, accurate, efficient, and comparable to frame-
based techniques.16,28,35,43
In summary, robotic-assisted stereotaxis can reduce time-
consuming and error-prone frame coordinate adjustments,
which can translate into improved consistency, reduced errors,
shorter operations, and reductions in perioperative complica-
tions.12,29-31,42 Besides SEEG, stereotactic robots are being used
for other epilepsy therapies including laser interstitial thermal
therapy (LITT) and responsive neurostimulation (RNS) depth
electrodes (Figure 2). The patient in Figure 2 gave informed
consented for image publication.
Another benefit of robots is the ability to reach locations and
achieve trajectories unobtainable with stereotactic frames, which
have limitations in the posterior fossa and inferior middle fossa
and when the target is more cranial than the entry.
As with any new technology, there are tradeoffs when
comparing robots to the existing standard of care. Perhaps the

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greatest barriers to widespread adoption are high upfront and
maintenance costs, but the need for additional staff training
is another consideration.44 Also, the floor-mounted ROSA and
Renishaw preclude intraprocedural operating room (OR) table
adjustments given the rigid attachment to the Mayfield clamp.
Additionally, their large size can be an impediment in smaller
ORs. Conversely, a disadvantage of the smaller Autoguide system
is the required manual repositioning for trajectories outside the 4
× 4 cm working zone.
Though repositioning of Robotic arms is generally efficient,
there is 1 system that can arguably be even more efficient.
The STarFixTM stereotactic platform (FHC, Bowdoin, Maine)
is three-dimensional (3D) printed with all SEEG trajectories
incorporated into 1 platform, eliminating the step of moving
an arm between trajectories.45 Its downside is a separate outpa-
tient procedure to implant skull fiducials to which the platform
attach. Also, the STarFixTM platform does not allow creation of
new trajectories or SEEG trajectory modification in the OR (for
DBS, some adjustments are possible via entry and target offsets).
However, given the frames typically range from $3000 to 5000,
the upstart cost is significantly less than for a robot and there are
no associated maintenance costs.
ROBOTIC USE IN ENDOSCOPIC
NEUROSURGERY
Another robotic application is assisting endoscopic-guided
hemispherotomy, a well-described surgical option for children
with drug-resistant epilepsy arising from hemispheric pathologies.
A robotic-assisted endoscopic approach, developed by Chandra
et al to minimize morbidity,46-49 has been furthered by other
groups.50,51 An endoscope is attached to a robotic arm (ROSA,
Zimmer Biomet, Westminster, Colorado) and hemispheric
disconnection is performed using an interhemispheric approach
via a small (3 × 4 cm) precoronal craniotomy (Figure 3A-3F).
A craniotomy anterior to the coronal suture helps avoid bridging
veins, while the endoscope reduces the surgical footprint. This
approach provides visualization and lighting while avoiding inter-
ference with other instruments. The advantages of the robotic
arm include (1) providing stability of the endoscope with haptic
feedback allowing for rapid manipulation and micromovements
to optimize visualization; (2) allowing surgery to be performed
comfortably in critical areas; and (3) serving as a neuronaviga-
tional device. Despite these advantages, there remains the possi-
bility of leaving residual temporal stem in the deepest area of the
surgical field.52
Of 52 patients undergoing robotic-assisted endoscopic
hemispherotomy, 45 (90%) had class I outcome (follow up of
34 ± 9 mo). Of these, 4 required a second surgery (for residual
temporal stem) to achieve class I outcome.
A similar robotic application has been used for complete corpus
callosotomy with commissurotomy (anterior, hippocampal, and
posterior) with good results (100% control of drop attacks with
56% reduction in intensity and frequency of other seizures).46,48
OPERATIVE NEUROSURGERY
CRANIAL ROBOTICS
Other similar applications include endoscopic endonasal
procedures, resection of intraventricular tumors, and endoscopic
third ventriculostomies.53-55 The drawbacks of “robotic-assisted”
endoscopic surgery (not endoscopic-surgery in general) are
similar to those previously mentioned (start-up costs, additional
training).
NEUROENDOVASCULAR ROBOTICS
While robotic use in neurosurgery naturally started with
relatively simple tasks of aligning and maintaining linear trajec-
tories, technological progress enabled robots that can apply trans-
lational and rotational movements to intravascular catheters and
execute some movements of the primary surgeon. The CorPath
GRX Robotic System (Corindus Inc, Waltham, Massachusetts)
is one such system56-58 (Figure 4). The Food and Drug Admin-
istration (FDA) approved the system for percutaneous coronary
intervention in 2012 and peripheral vascular intervention in
2018.59 The first model was designed to manipulate large-
caliber devices. The current model has been refined with
neuroendovascular-specific engineering and software modifica-
tions to allow manipulation of microcatheters and microwires.
The current model was tested in animal models for simulated
neurovascular pathology with optimal outcomes.60,61 A total
of 3 different institutions reported the feasibility and efficacy
of robotic-assisted neuroendovascular procedures.56-58 There
was a technical success rate of 81.2% without complications
across 7 cases of carotid artery stenting, 7 cases of digital
subtraction angiography (DSA), and o1 case of stent-assisted
coiling. Technical failure occurred in 3 DSA procedures due to
a Bovine aortic arch.57
Besides allowing precise, controlled movements unaffected by
fatigue or stress, software optimization and artificial intelligence
algorithms could help robots provide consistent results among
different operators though preset movements. Additionally,
robots reduce occupational hazards to the operator and staff by
eliminating cumulative radiation. Also, the ability to perform
procedures sitting without heavy radiation shields improves
ergonomics. Lastly, one of the most transformational innovations
with robotic assistance is the ability to perform remote inter-
ventions. Such an advantage is exceptionally beneficial to handle
the surge in stroke interventions and the shortage of physicians
trained in thrombectomy, especially in remote areas.
A significant limitation of the current model is the absence
of tactile feedback, which is important to avoid vessel injury.
Therefore, operators rely on visual cues and subtle changes in the
shape and motion of catheters to adjust their manipulation. Also,
the current model is not FDA-approved for intracranial use with
essential neurointerventional devices.
OTHER CRANIAL ROBOTIC SYSTEMS
There are several other robotic systems that, while not as widely
utilized for cranial neurosurgery and not personally used by the
authors, deserve mention given their significance to the topic.
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FIGURE 3. A, The position of the robot attached to the endoscope while performing endoscopic hemispherotomy. As may be seen here, the endoscope should be long
enough to allow comfortable insertion of instruments. In addition, the line of vision with the monitor should also be unhindered. It is also important for the surgeon
to be seated comfortably while performing this technique with comfortable elbow support. B and C, The location and the size of the craniotomy for endoscopic
hemispherotomy. Having an anterior trajectory reduces the foot print of the hemispheric disconnection D as compared to vertical microscopic technique E. F, A
schematic diagram of the technique of endoscopic hemispherotomy. Following interhemispheric approach, a corpus callosotomy is first performed. Following this, a
transventricular anterior disconnection is performed that extends from the genu medially to the sphenoid ridge laterally (arrow 1). Next, the middle disconnection
is performed (arrow 2), which is the largest disconnection and passes along the parasagittal plane separating the insula laterally (arrow 5) and the basal ganglia
medially. The middle disconnection joins the lateral ventricle to the temporal horn. It is also essential to excise the ventral amygdala, head of hippocampus and the
temporal stem (arrow 3). Finally, the posterior disconnection is performed (arrow 4), which disconnects the tail of hippocampus and the fornix.

In 2013, Sutherland et al62 introduced a magnetic resonance
(MR)-compatible image-guided telerobot, the neuroArm, with
2 arms capable of manipulating microsurgical instruments. A
surgical assistant is physically present in the OR, and the primary
surgeon operates via interacting with a human-machine interface
that provides stereoscopic vision and haptic feedback. It also
allows setting of no-go zones, implementation of tremor filters,
and scaling of both the magnitude and speed of movements.
The obvious promise in this technology may eventually allow
operating on a scale that is not possible without robotic
augmentation, as pointed out by Sutherland. Unfortunately,
this advanced system has not seen widespread clinical implemen-
tation and as such, the pros and cons of the system for neurosur-
geons at-large remain unknown. In the meantime, we can only
rely on Sutherland’s publications on the technology.31,62-66
376 | VOLUME 21 | NUMBER 6 | DECEMBER 2021
Another device capable of robotic-assisted stereotaxis is
the SurgiScope (ISIS Robotics, Saint-Martin-d’Hères, France),
a robotic microscope typically used for open craniotomies.
While not its primary purpose, it can be adapted for stereo-
taxis. One limitation is that it is ceiling mounted and not
portable.37,67
The da Vinci Surgical System (Intuitive Surgical, Sunnycale,
California) has gained widespread use in urologic, gynecologic,
and general surgery, but to our knowledge has not been used in
intracranial surgery outside of cadaveric studies.68,69
For a systematic review of robotic stereotaxy in cranial
neurosurgery, see the review by Fomenko and Serletis37
that includes earlier robotic systems. For a broader intro-
duction to the human-robotic interaction, see the review by
Sheridan.70
www.operativeneurosurgery-online.com

FIGURE 4. The robotic arm connected to the catheter A and the surgeon operating the console remotely B.
EMERGING TECHNOLOGIES
Curved Trajectory Devices
Minimally invasive MR-guided LITT is changing the way
we approach epilepsy surgery, but a major limitation of current
technology is being constrained to a linear trajectory. Current
technologies to compensate for this include directional lasers
that ablate tissue eccentric to the planned trajectory, but thermal
spread limits the efficacy to a finite region surrounding the laser.
Newer technologies are being developed to allow nonlinear trajec-
tories. Steerable needles and magnetic navigation systems (MNSs)
are promising avenues to allow improved safety and efficacy by
bypassing important structures along the trajectory and allowing
a more complete ablation of curved anatomic structures. While
these are not solely robotic, they employ elements of robotic
technology and have the potential to advance the field beyond
what current robots allow.
A strategy for achieving a nonlinear trajectory to an intracranial
target has been described at Vanderbilt University, which uses
flexible curved nitinol needles to advance along a nonlinear
path. This is made possible by the “super-elastic” and “shape
memory” properties of nitinol, which Hoh et al71 have described.
Upon exit from a rigid guide tube, the nitinol needle returns
to its helical configuration. This system can achieve “follow
the leader deployment” such that the curved catheters advance
with minimal collateral damage to surrounding tissue, a strategy
particularly well suited for amygdalohippocampal ablation given
the curved anatomy.72 Anatomic modeling in 20 magnetic
resonance imaging (MRI) scans demonstrated the feasibility of
using curvilinear trajectories to ablate the hippocampus via the
foramen ovale, which could enable percutaneous hippocampal
ablation.73 This modeling study showed that curved nitinol tubes
could be advanced along the medial axis of the hippocampus
with mean deviations from the curved axis of only 1.14 mm.
Additionally, they demonstrated curved trajectories could reach
areas of the hippocampus not possible with a linear trajectory.
This is clinically relevant given the evidence that increased
OPERATIVE NEUROSURGERY
CRANIAL ROBOTICS
extent of hippocampal resection in open surgery correlated
with increased rates of seizure freedom.74 The group has also
designed a mechanism to advance needles incrementally via a
pneumatic-actuation robot, thereby making the entire system
MRI-compatible. In the future, algorithms could help plan the
optimal trajectory to be maintained by robots.
An alternate strategy for achieving nonlinear trajectories is
through MNSs. These were developed in the 1980s to steer
cardiac catheters and for neurosurgical applications.75-77 These
systems were initially difficult to integrate clinically given the
large size and moving components, but newer MNSs operate
with static magnets, are lighter, and are mobile, permitting
seamless integration into clinical workflow.78,79 Paired with
flexible catheters with independent stiffness control, MNSs allow
a yet unidentified degree of freedom for probe navigation.
Additionally, this system enables remote surgery, which protects
healthcare workers from radiation and mitigates pathogen spread.
Proof-of-concept studies have been completed,78,79 and studies
evaluating clinical feasibility of MNS in animal and cadaveric
studies are underway.
There is enthusiasm that one or both strategies may provide
options not afforded by linear trajectories, though much work is
needed prior to clinical implementation.
Another factor that could revolutionize stereotactic neuro-
surgery is the potential for big data in the form of multi-
center databases to correlate planned trajectories with implan-
tation accuracy and patient outcomes. The ease with which these
factors could be exported from a robotic system would facilitate
date acquisition.
Limitations and Other Considerations
The complexity of robots far exceeds stereotactic frames,
so both routine maintenance and troubleshooting of technical
failures require advanced training with manufacturer support.
Another consideration is the loss of basic skills such as
visuospatial reasoning and fine motor skills. Contrarily, robotics
can provide resources to trainees not available via traditional
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BALL ET AL
means. Additionally, the potential security issues of increasing
automatization cannot be understated, and this must always be
considered when incorporating new technologies. However, these
concerns must be balanced with the fact that many patients could
derive real benefits from telerobots that they may not have access
to otherwise. Finally, COVID-19 has highlighted areas where
robots could help address workforce issues and reduce exposures
to transmissible disease.80
CONCLUSION
Technological capabilities of robots will continue to advance
with increased computational power and enable safer, more
efficient surgery. While there are currently well-defined roles for
robotics in frameless stereotaxis, SEEG, and endoscopy, the role
of robotics in other portions of intracranial surgery is less defined.
However, available technology shows promise in being able to
augment other areas of neurosurgery.
Funding
This study did not receive any funding or financial support.
Disclosures
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
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Acknowledgments
The authors would like to thank Dr Mahendra Singh Chouhan for providing
the schematic diagram, Figure 3F.
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