Article Reviewed Diaz-Aguilar LD, Brown NJ, Bui N, et al. The use of robot-assisted surgery for the unstable traumatic spine: A retrospective cohort study. North American Spine Society Journal (NASSJ). 2023;15:100234. doi:10.1016/j.xnsj.2023.100234 Commentary This commentary reviews the retrospective cohort study by Diaz-Aguilar et al that demonstrated the safe application of robotic-assisted spine surgery to the management of traumatic injuries ranging from thoracic to lumbosacral in a series of consecutive cases at an academic medical center. While the use of robotic-assisted surgery has previously been established in the literature for degenerative issues, this assesses its expanded application to a trauma population.

A cohort of consecutive patients who were treated surgically at a single tertiary care center were identified. Patients were evaluated using the Thoracolumbar Injury Classification and Severity Score (TLICS) and those with scores greater than 4 were included in the study. All patients underwent robotic-assisted surgery performed by 1 of 3 surgeons using the Globus ExcelsiusGPS robotic navigation platform. This retrospective study did not include a control arm for comparison.

Patient data collected included demographic information such as age, sex, body mass index (BMI) as well as medical comorbidities and injury morphology. Operative details like instrumented levels, estimated blood loss (EBL), and fluoroscopy time were noted. Additionally, perioperative complications were recorded such as durotomy, pseudoarthrosis, wound infection, readmission, and surgical revision.

Following a retrospective chart review, a total of 42 patients were included in this study and further stratified by instrumented level. Patients were stratified by operative levels, 2 (n=10), 3-4 (n=11), 5-6 (n=13), or >6 (n=8). Of the 42 procedures, no pedicle screw breaches were reported and therefore no screw replacement or revision surgeries were performed. Additionally, there were no instances of perioperative complications in surgeries involving 5 levels or less. For surgeries with greater than 5 levels, there were complications in 6 out of 21 cases for a complication rate of 29%. However, none of these complications involved wound or surgical site infection. In the cohort, there was only 1 case of durotomy resulting in a cerebrospinal fluid (CSF) leak, and no severe complications or death were reported.

Overall, the reviewed study reports the safe application of robotic-assisted surgery in a traumatic patient population. The authors found that the traumatic nature of the injuries did not impair the robotic platform registration. The assertion was that robotic-assisted surgery can be used in the treatment of traumatic injuries despite the possibility of altered anatomy and instability. While this is not an unexpected finding, it is helpful to consider the specific application of evolving technologies such as robot-assisted surgery.

There remains the question regarding the benefit of robotic-assisted surgery in comparison to more traditional free hand, fluoroscopic, or navigation surgery for injuries such as those included in the currently reviewed study. Further, many studies describe the learning curved associated with implementing new technologies and that should not be overlooked if considering applying such technology in the described fashion.

In conclusion, Diaz-Aguilar et al evaluate a cohort of traumatic spinal injury patients treated with robotic-assisted surgery. The study demonstrates that this technology can be safely applied to the spine trauma patient population and lays the foundation for comparison to other instrumentation approaches and the use of robotics to novel areas.