Robot-assisted vs conventional lumbar interbody fusion: A systematic review and meta-analysis of perioperative, radiographic, and clinical outcomes

Abstract

BACKGROUND

Minimally invasive lumbar interbody fusion (LIF) procedures have evolved rapidly in recent years, with robot-assisted (RA) techniques increasingly integrated into clinical practice. However, questions remain regarding the relative advantages of RA over traditional fluoroscopy-guided and navigation-assisted methods in terms of perioperative, radiographic, and clinical outcomes. This systematic review synthesizes current evidence on these comparisons, focusing on the accuracy of screw placement, perioperative efficiency, radiographic and clinical outcomes, and complications.

AIM

To investigate the comparative effectiveness of RA vs conventional LIF techniques.

METHODS

A systematic review and meta-analysis was conducted in accordance with PRISMA 2020 and Cochrane guidelines. Databases searched included PubMed, EMBASE, Web of Science, Scopus, and the Cochrane Library (through May 2025). Eligible studies were randomized controlled trials and observational studies comparing RA with fluoroscopy - or navigation-guided LIF (transforaminal lumbar interbody fusion, lateral lumbar interbody fusion, oblique lumbar interbody fusion) in adults. Two reviewers independently extracted data and assessed risk of bias. The Grading of Recommendations Assessment, Development and Evaluation framework was used to evaluate certainty of evidence. Meta-analyses were performed where data were sufficiently homogeneous.

RESULTS

Twenty-two studies were included, encompassing a total of 2313 patients - 1046 who underwent RA-guided procedures and 1267 who received comparator techniques. Meta-analyses showed that RA significantly improved perfect pedicle screw placement [pooled odds ratio = 2.93; 95% confidence interval (CI): 1.40-6.14; I² = 78.2%] and reduced intraoperative blood loss (pooled standardized mean difference = -0.28; 95%CI: -0.47 to -0.08; I² = 0%). Operative time did not significantly differ between groups (pooled standardized mean difference = 0.01; 95%CI: -0.30 to 0.31; I² = 66%). Radiation dose could not be synthesized quantitatively due to heterogeneous definitions and measurement units. Narratively, RA demonstrated consistent advantages in reducing surgical exposure and adjacent segment degeneration. Clinical and radiographic outcomes, fusion success, and complication rates were generally comparable across groups.

CONCLUSION

RA LIF improves pedicle screw placement accuracy and reduces blood loss and surgeon radiation exposure while maintaining similar clinical outcomes and safety profiles to conventional techniques. These findings support the integration of RA into spine surgery but highlight the need for high-quality multicenter randomized controlled trials and cost-effectiveness studies to guide broader implementation.

Keywords: Arthrodesis; Minimally invasive surgical procedures; Robotics; Fluoroscopy; Neuronavigation

Core Tip: This article confirms that robot-assisted lumbar interbody fusion significantly improves pedicle screw placement accuracy and reduces intraoperative blood loss, with no significant difference in operative time. Additionally, robot-assisted techniques offer clear advantages in reducing surgeon radiation exposure and adjacent segment degeneration. Despite these benefits, long-term clinical and fusion outcomes were comparable to those of conventional methods. These findings support the clinical precision and perioperative efficiency of robotic systems while highlighting the need for high-quality multicenter trials and cost-effectiveness analyses to inform broader implementation in spine surgery.