Robotic-Assisted Surgery for Spinal Tumors Shows Low Complication Rate

Commentary by Isador H. Lieberman, MD and Bawarjan Schatlo, MD

Robotics ImageNo perioperative or postoperative complications were found among 9 consecutive patients who underwent robotic-assisted surgery for treatment of metastatic and primary spine tumors, according to study in the International Journal of Spine Surgery. Given that historical complication rates with traditional surgical approaches for such cases range from 5% to 19%, robotic-assisted surgery may improve the complication rate, the study authors noted.

“Use of robotics allowed for less invasive surgery, and this in turn allows for quicker recovery and potentially earlier start of chemotherapeutics or radiation treatment,” said senior author Isador H. Lieberman, MD, Director of the Scoliosis & Spine Tumor Center, Texas Back Institute, Texas Health Presbyterian Hospital Plano, Plano, Texas. “Robotic-assisted surgery is useful for any cases in which the surgeon needs to implant screws into the spine,” Dr. Lieberman said.

How the Robotic System Works
The robotic system consists of a computerized workstation on which a patient’s computed tomography scan is uploaded and the surgical procedure is planned, and a cylindrical device with robotic arms that facilitate placement of spinal instrumentation.

Dr. Lieberman and colleagues reviewed their experiences with 9 consecutive patients with spinal tumors who underwent spine surgeries using robotic-assisted pedicle screw placement and/or vertebral augmentation between December 2010 and December 2013. The patients were between the ages of 47 and 69 (mean age, 60 years) and presented with thoracic or lumbar vertebral collapse and/or myelopathy.

Robotic System Successfully Facilitated Pedicle Screw Placement
All the patients underwent successful robotic-assisted placement of pedicle screws, and the system was used to assist vertebral augmentation in 4 of the patients. The average number of levels instrumented was 5.

The average surgery time was approximately 4.5 hours (range 1.5-6.5 hours) and the mean blood loss was 319 mL (range, 75-1,000 mL). No complications were found during the surgery or through the last follow-up (range, 1 month to 12 months). In addition, improvements in back and/or leg pain were found in 7 of the 9 patients (follow-up data was not available in the 2 remaining patients).

“The robot is not doing the surgery, it facilitates the surgery,” Dr. Lieberman pointed out. “A robot is not going to make a bad surgeon good, it makes a good surgeon more efficient and more precise,” he said.

The authors noted that the robotic system also may be beneficial for non­-pedicle–screw procedures such as biopsies and vertebral augmentations (vertebroplasty and kyphoplasty).


Bawarjan Schatlo, MD
Consultant, Department of Neurosurgery
University Hospital Göttingen/Georg-August University
Göttingen, Germany

Drs. Hu, Scharschmidt, Ohnmeiss, and Lieberman are to be commended for sharing their early pioneering experience on robot-assisted surgery for spine tumors. They operated on 9 patients with the aid of the Mazor spine surgery system (Mazor Robotics, Inc., Orlando, FL) in this first article on robotic surgery for oncological spinal disease. Robot-guided vertebral body augmentation or pedicle screw instrumentation was performed between the upper thoracic spine (T4) and the lower lumbar spine (L5). All 7 patients available for follow-up between 2 weeks and 1 year after surgery showed an improvement in their visual analogue scale for pain after surgery.

As masters of robotic spine surgery, the authors now showed that instrumenting the upper thoracic spine with the help of a robotic system yields reasonable clinical results. This is an important article since most metastases are located in the thoracic spine and the importance of instrumentation increases given the life-expectancy of these patients. Some additional outcome data not presented in the study such as screw accuracy and the frequency of registration errors may have been of interest.

In our and the authors’ experience at least 25 to 30 surgeries are necessary to reach the plateau of the learning curve.1,2  It would be interesting to know if switching from lumbar to thoracic spine surgery demanded a renewed effort.

Overall, our clinical impression from dozens of tumor cases operated with robotic assistance mirrors the authors´ point of view that performing robot-assisted dorsal instrumentation for tumor-induced instability is safe and feasible and generally reliable despite an occasionally more cumbersome registration process in the upper thoracic spine. Earlier works on robotic spine surgery naturally focused on degenerative spinal diseases of the lumbar spine.3-5 After an early dip in performance in the first published prospective trial,6 the following prospective study7 demonstrated that robotic pedicle screw placement yields constant results comparable to the accuracy of experienced surgeons. More light will be shed on the utility of robot-assisted surgery for spine tumors in future clinical trials, some of which are under way (

Updated on: 08/18/16
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