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

Table 1 Summary of included studies

Ref.	Country	Study design	Procedure type	Sample size (RA/comparator)	Robotic platform	Comparator type
Wang et al[1], 2023	China	Prospective	MIS-TLIF	61/62	TiRobot	Freehand fluoroscopy
Tong et al[2], 2024	China	Retrospective	OLIF	16/22	Third-gen Mazor X navigation robot	Fluoroscopy
Shafi et al[3], 2022	United States	Retrospective	MIS-TLIF	92/130	ExcelsiusGPS	Intraoperative navigation
Griepp et al[4], 2024	United States	Retrospective	MIS-TLIF	50/133	Mazor X Stealth robot	Fluoroscopy-assisted
Lin et al[5], 2022	Taiwan	Retrospective	MIS-TLIF	75/149	ROSA	Freehand fluoroscopy
Li et al[6], 2025	China	Retrospective	LLIF	31/28	TianJi Robot	Traditional LLIF
Heath et al[7], 2024	Taiwan	Retrospective	MIS-TLIF	42/58	ROSA ONE	O-arm navigation
Chang et al[11], 2022	China	Prospective	MIS-TLIF	26/32	TiRobot	MIS-TLIF
Lai et al[15], 2022	Taiwan	Retrospective	TLIF	29/79	Renaissance	Freehand fluoroscopy
Zhang et al[20], 2019	China	Prospective	TLIF	43/44	TiRobot	FG
Zhang et al[21], 2019	China	Prospective	TLIF	50/50	Robot assisted	FG
Chen et al[22], 2021	China	Retrospective	MIS-TLIF	52/52	TiRobot	Freehand open TLIF
Cui et al[23], 2021	China	Retrospective	MIS-TLIF	23/25	TiRobot	Open TLIF surgery
Feng et al[24], 2020	China	RCT	OLIF	40/40	TiRobot	Open freehand fluoroscopy
Li et al[25], 2024	China	Retrospective	MIS-TLIF	58/56	Tianji Robot	Freehand fluoroscopy
Han et al[26], 2021	China	Retrospective	OLIF vs TLIF	28/33	TiRobot	MIS-TLIF
De Biase et al[27], 2021	United States	Retrospective	MIS-TLIF	52/49	Mazor X	FG
Fayed et al[28], 2020	United States	Retrospective	MIS-TLIF	103/90	ExcelsiusGPS	FG
Yang et al[29], 2019	China	Retrospective	MIS-TLIF	30/30	Robot-assisted surgical system	FG
Schatlo et al[30], 2014	Germany	Retrospective	TLIF	55/40	Mazor	FG
Li et al[31], 2024	China	Retrospective	RA MIS-TLIF (group A) vs RA UBE-T/PLIF (group B) vs traditional MIS-TLIF (group C)	A: 27, B: 30, C: 26	Tianji Robot (3rd Gen)	Traditional MIS-TLIF
Li et al[32], 2022	China	Retrospective	RA MIS-TLIF	33/39	Tianji Robot	Traditional MIS-TLIF

RA: Robot-assisted; MIS-TLIF: Minimally invasive transforaminal lumbar interbody fusion; OLIF: Oblique lumbar interbody fusion; LLIF: Lateral lumbar interbody fusion; RCT: Randomized controlled trial; UBE-T: Unilateral biportal endoscopy-transforaminal; PLIF: Posterior lumbar interbody fusion; FG: Fluoroscopy-guided.

Table 2 Combined accuracy and perioperative outcomes of included studies

Ref.	Classification	RA accuracy (grade A)	Comparator accuracy (grade A)	Statistical significance	Clinically acceptable screws (A + B)	Statistical significance	Operative time (RA vs comparator)	EBL (mL) (RA vs comparator)	Radiation exposure (RA vs comparator)	Notes
Wang et al[1], 2023	Gertzbein-Robbins	85.4%	69.5%	P < 0.001	97.1% vs 95.0%	NS	160.25 ± 12.13 vs 154.35 ± 15.00 (P = 0.018)	78.85 ± 33.52 vs 82.90 ± 20.91 (NS)	Surgeon: 13.28 ± 3.09 vs 94.87 ± 6.02 (P < 0.001) patient: NSD (NS)	Less disc height loss at adjacent segments (P < 0.001)
Tong et al[2], 2024	Gertzbein-Robbins	95.4%	85.5%	P < 0.05	98.4% vs 95.5%	P = 0.04	158.8 minutes vs 129.9 minutes (P < 0.05)	89.8 vs 117.3 (P < 0.05)	13.3 vs 48.5 fluoroscopy counts (P < 0.05)	Longer operative time in RA but reduced blood loss and radiation exposure. Higher screw accuracy (98.4% vs 95.5%)
Shafi et al[3], 2022	Gertzbein-Robbins	88.5%	88.4%	NS	97.4% vs 95.3%	NS	Not reported	Not reported	Surgeon: Significantly lower with RN (P < 0.001)	Fewer high-grade breaches (0% RN vs 1.2% ION, P = 0.05)
Griepp et al[4], 2024	Gertzbein-Robbins	Not directly reported; lower revision rate (0%) in RA suggests higher accuracy	Not reported; higher revision rate (2.4%) in FA group	P = 0.03 (lower revision rate in RA group)	Not reported	Not reported	33.3 ± 8.57 minutes/screw vs 30.7 ± 6.87 minutes/screw, P = 0.125)	161.4 ± 365.7 vs 155.1 ± 194.7 (NS)	4.9 ± 7.6 vs 20.3 ± 14.0 mGy/screw (P < 0.001)	RA had longer anesthesia time (49.1 minutes/screw vs 43.6 minutes/screw, P = 0.009)
Lin et al[5], 2022	Gertzbein-Robbins	99.7%	98.2%	P = 0.04	99.7% vs 98.2%	P = 0.04	280.7 vs 251.4 minutes (NS)	313.7 vs 431.6 mL (P = 0.019)	Not reported	RA reduced blood loss significantly. Shorter operative time for 4-level surgeries with RA. No difference in complications or pain outcomes
Li et al[6], 2025	Gertzbein-Robbins	96.8%	92.9%	NS	99.2% vs 98.2%	NS	147 minutes vs 165 minutes (P = 0.04)	124.4 vs 138.9 (NS)	54.6 seconds vs 87.8 seconds (P < 0.01)	Shorter fluoroscopy and operative time in RA, no significant difference in blood loss
Heath et al[7], 2024	Gertzbein-Robbins	98.0%	80.0%	P < 0.001	100% vs 92.1%	P = 0.003	263.5 minutes vs 243.4 minutes (P = 0.28)	340.6 vs 256.6 (NS)	Not quantified (O-arm used in both groups)	Longer operative time for RA in 2-level fusions (324.7 vs 266.4 min, P = 0.03). No medial breaches or revisions in either group
Chang et al[11], 2022	Gertzbein-Robbins	99.1%	93.7%	P < 0.05	100% vs 98.4%	P = 0.001	208 ± 15.2 minutes vs 161 ± 7.9 minutes (P = 0.02)	25 ± 10 vs 100 ± 20 (P = 0.01)	Reduced (implied, not quantified)	RA-TLIF had shorter incisions (1.4 cm vs 2.5 cm, P = 0.01). Lower screw misplacement rate (0.9% vs 6.3%, P < 0.05). Steep learning curve noted
Lai et al[15], 2022	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	259.0 minutes vs 225.0 minutes (NS)	400.0 vs 366.7 mL (NS)	Not reported	Lower screw loosening rate with RA (4.3% vs 10.2%, P = 0.049). Similar complication rates (24.1% both groups). RA screws placed closer to upper endplate (P < 0.001)
Zhang et al[20], 2019	Gertzbein-Robbins	93.2%	85.8%	P = 0.02	98.3% vs 93.6%	P = 0.02	165.3 ± 58.9 minutes vs 154.7 ± 46.0 minutes (P = 0.349)	187.2 ± 95.2 mL vs 373.2 ± 320.3 mL (P = 0.001)	Dose: 25.9 ± 14.2 μSv vs 70.5 ± 27.3 μSv (P < 0.001) time: 93.5 ± 37.9 seconds vs 70.5 ± 28.3 seconds (P = 0.002)	Fewer facet violations: 5 vs 24 screws (P = 0.001). Lower revisions: 0 (RA) vs 2 (FG). Learning curve noted for RA (longer setup time)
Zhang et al[21], 2019	Gertzbein-Robbins	85.0%	71.0%	P = 0.017	98.0% vs 94.0%	NS	184.7 minutes vs 117.8 minutes (P < 0.001)	171.6 vs 362.0 mL (P = 0.001)	30.3 vs 65.3 μSv (P < 0.001)	Longer op time but less radiation in RA
Chen et al[22], 2021	Gertzbein-Robbins	92.3%	77.4%	P < 0.001	98.6% vs 96.6%	NS	169.67 minutes vs 135.48 minutes (P < 0.001)	92 vs 261 mL (P < 0.001)	1.26 minutes vs 0.54 minutes (P < 0.001)	Longer op time but less blood loss in RA
Cui et al[23], 2021	Gertzbein-Robbins	94.6%	85.0%	P = 0.025	100% vs 100%	NS	RA MIS-TLIF: 135.1 ± 11.2 minutes. Open TLIF: 102.2 ± 7.1 minutes (P = 0.002)	RA MIS-TLIF: 173.6 ± 17.9 mL open TLIF: 332.1 ± 23.5 mL (P = 0.005)	Not reported	RA MIS-TLIF showed longer operative time (learning curve) but significantly reduced blood loss and postoperative drainage (97.5 mL vs 261.3 mL, P < 0.001). Faster recovery: Shorter hospitalization (7.3 days vs 10.0 days) and time to ambulation (1.5 days vs 2.9 days, P < 0.05). Less muscle atrophy: Paraspinal muscle cross-sectional area decreased by 3.9% (vs 14.5% in open TLIF, P = 0.016)
Feng et al[24], 2020	Gertzbein-Robbins	98.2%	93.1%	P = 0.039	100% vs 99.4%	NS	196.25 minutes vs 230.63 minutes (P < 0.05)	165 mL vs 237.5 mL (P < 0.05)	Not reported	Efficiency benefit with RA
Li et al[25], 2024	Gertzbein-Robbins	87.5%	70.1%	P < 0.001	98.3% vs 96.9%	NS	158.5 minutes vs 146.4 minutes (P < 0.001)	58.5 vs 52.8 (NS)	Surgeon: 13.8 vs 74.7 fluoroscopy counts (P < 0.001)	Longer operative time in RA but reduced surgeon radiation exposure. Lower adjacent segment degeneration (0.63 mm vs 0.92 mm height loss, P = 0.001)
Han et al[26], 2021	Gertzbein-Robbins	92.9%	90.9%	NS	97.3% vs 96.2%	NS	OLIF: 164.9 ± 56.0 minutes MIS-TLIF: 121.5 ± 48.2 minutes (P < 0.01)	OLIF: 142.4 ± 89.4 mL MIS-TLIF: 291.5 ± 72.3 mL (P < 0.01)	Not reported	OLIF had significantly longer operative time but less blood loss. OLIF required position change (lateral to prone), contributing to longer time
De Biase et al[27], 2021	Gertzbein-Robbins	97.4%	93.9%	NS	99.8% vs 99.3%	NS	241 minutes vs 246 minutes (NS)	73.8 mL vs 73.9 mL (NS)	31.5 vs 59.5 mGy (P = 0.035)	RA reduced radiation
Fayed et al[28], 2020	Gertzbein-Robbins	94.2%	96.7%	NS	98.1% vs 100%	NS	Not reported	Not reported	Not reported	RA-PPS: 5.8% breach rate (6/103 screws), with 1.9% significant breaches (> 2 mm). FG-PPS: 3.3% breach rate (3/90 screws), with 1.1% significant breaches. Learning curve: 5 breaches in first 48 screws (10 cases) vs 1 breach in next 55 screws (10 cases). Lateral breaches (4/6) linked to facet hypertrophy/skiving
Yang et al[29], 2019	Gertzbein-Robbins	93.8%	73.8%	P = 0.012	98.5% vs 96.9%	NS	Not reported	Not reported	Not reported	The study focused on accuracy (pedicle screw placement) and facet joint violation, not perioperative efficiency metrics. RA group had significantly lower pedicle wall penetration (6.2% vs 26.2%) and facet joint violation (5.1% vs 15.6%) compared to FG group. No severe deviations (Neo grade III) in RA group
Schatlo et al[30], 2014	Gertzbein-Robbins	83.6%	79.8%	NS	91.4% vs 87.1%	NS	205 minutes vs 189 minutes (NS)	375 mL vs 713 mL (P < 0.01)	Not reported	Lower blood loss in RA
Li et al[31], 2024	Gertzbein-Robbins	96.3%	95.0%	P < 0.05	A: 99%, B: 98%, C: 91%	P < 0.05	A: 146.9 ± 10.8, B: 172.5 ± 13.2, C: 169.0 ± 13.6 (A < B/C, P < 0.05)	A: 89.3 ± 11.3, B: 74.4 ± 14.6, C: 111.6 ± 20.9 (B < A < C, P < 0.05)	Significantly lower in A/B vs C (P < 0.05)	Group A had shortest operation time. Group B had least blood loss. Group C had highest radiation exposure
Li et al[32], 2022	Gertzbein-Robbins	99.24%	91.03%	P = 0.002	Not specifically reported in A + B form, but grade A alone was 99.24% in RA	Not explicitly reported for A + B, only for grade A	154.75 ± 7.32 vs 172.22 ± 14.82 (P = 0.001)	89.49 ± 18.63 vs 121.48 ± 20.55 (P = 0.001)	Fluoroscopy: 59.54 ± 6.56 vs 70.67 ± 9.70 (P = 0.001)	Robot group had shorter hospital stays (3.86 ± 1.17 days vs 5.03 ± 0.73 days)

Li et al[32] includes three groups: Robot-assisted minimally invasive-transforaminal lumbar interbody fusion (group A), robot-assisted unilateral biportal endoscopy-transforaminal/posterior lumbar interbody fusion (group B), and traditional minimally invasive-transforaminal lumbar interbody fusion (group C). RA: Robot-assisted; EBL: Estimated blood loss; NS: Not significant; MIS: Minimally invasive surgery; TLIF: Transforaminal lumbar interbody fusion; OLIF: Oblique lumbar interbody fusion; RN: Robot navigation; NSD: Not statistically different; ION: Intraoperative navigation; PPS: Percutaneous pedicle screw; FG: Fluoroscopy-guided.

Table 3 Radiographic outcomes

Ref.	Procedure	Sagittal alignment changes	Facet joint violation (RA vs comparator)	Notes
Wang et al[1], 2023	MIS-TLIF (RA vs FA)	Not reported	FJV grades: RA: 89.8% grade 0 (no violation) FA: 62.1% grade 0 (P < 0.001) - mean FJV grade lower in RA (0.24 vs 0.50; P < 0.001)	Adjacent segment: Less disc height loss at proximal adjacent segment in RA (0.69 mm vs 0.93 mm; P < 0.001). Fusion rates: No difference (BSF-3: 88.5% RA vs 85.5% FA; P = 0.616)
Tong et al[2], 2024	RA-OLIF vs FG OLIF	Sagittal alignment parameters (LL, SL, PI-LL) not explicitly reported	RA-OLIF: 4.7% FJV rate (61 grade 0, 2 grade 1, 1 grade 2)	RA-OLIF had higher screw accuracy (98.4% grade A/B vs 95.5% in fluoroscopy; P = 0.015)
		Focus on screw accuracy and FJV rates	Fluoroscopy: 19.3% FJV rate (71 grade 0, 11 grade 1, 5 grade 2, 1 grade 3)	Shorter-term benefits: Lower VAS-back at 3 days post-op (P = 0.003)
			(P = 0.009)
Shafi et al[3], 2022	MIS-TLIF (RN vs ION)	Not reported	FJV rates: RN: 5.0% ION: 1.3% (P = 0.0017)	Screw dimensions: RN allowed larger screw diameters (7.25 mm vs 6.72 mm; P < 0.001) and longer screws (48.4 mm vs 45.6 mm; P < 0.001)
				Accuracy: Similar “ideal” (grade A) screw rates (88.5% RN vs 88.4% ION; P = 0.969), but RN eliminated high-grade breaches (0% grade E vs 1.2% in ION; P = 0.051)
				Endplate breaches: Higher in RN (6.9% vs 1.3%; P = 0.001), but most were clinically insignificant
Griepp et al[4], 2024	MIS-TLIF (RA vs O-arm navigation)	Not reported	Lateral breaches: RA: 4/210 (1.9%, all grade B)- ON: 24/304 (7.89%, grades C-D) medial breaches: 0 in both groups	No revisions for malposition in either group
Lin et al[5], 2022	MIS-TLIF (robot-guided vs freehand)	Not reported	Not reported	Pedicle screw breach rates: Robot-guided (0.27%) vs freehand (1.75%), P = 0.04
				Lateral breaches more common in freehand group (9/12 breaches). No medial breaches with robotics
Li et al[6], 2025	RA-SP-LLIF vs traditional LLIF	Significant postoperative improvements in LL (45.2°-51.5°), SL (24.0°-29.3°), and PI-LL (13.0°-7.8°) (P < 0.01). Gains in LL/SL/PI-LL were not sustained at final follow-up (P > 0.05 vs baseline). No difference in PT/SS changes	Not explicitly reported, but the high screw accuracy (99.2% RA vs 98.2% traditional) suggests low risk	Comparable fusion rates (Bridwell grade) and complications between groups
Heath et al[7], 2024	RA-MIS-TLIF vs ON-MIS-TLIF	Sagittal alignment parameters (LL, SL, PI-LL) not explicitly reported	RA-MIS-TLIF: 0% breach rate (100% grades A/B)	No reoperations for screw malposition in either group
		Focus on screw accuracy and breach rates	ON-MIS-TLIF: 7.89% breach rate (92.1% grades A/B; P < 0.001)
			No medial breaches in either group
Chang et al[11], 2022	PE RA-TLIF vs MIS-TLIF	Not reported	Not reported	Screw accuracy: Robot 0.9% vs fluoroscopy 6.3% (P < 0.05)
				Fusion rates: 87.3% (robot) vs 91.8% (fluoroscopy, P = 0.53)
				Smaller incisions, less blood loss with robotics
Lai et al[15], 2022	MIS-TLIF (robot vs fluoroscopy)	Not reported	Not reported	Screw loosening: Robot 4.3% vs fluoroscopy 10.2% (P = 0.049)
				Robot screws placed closer to upper endplate (ratio 0.35 vs 0.39, P < 0.001). Loosening linked to age, multilevel fusion, and endplate distance ratio
Zhang et al[20], 2019	TLIF with pedicle screws	Not reported for LL/SL/PI-LL	RA: 5/176 screws (2.8%) violated facets FG: 24/204 screws (11.8%) (P=0.001)	RA achieved higher perfect screw placement (grade A: 93.2% vs 85.8%, P = 0.020)
				No severe breaches (grade E) in RA vs 2 in FG
Zhang et al[21], 2019	TLIF with percutaneous pedicle screws	Not reported for LL/SL/PI-LL	RA: 4/100 screws (4%) violated facets (grades 1-2) FG: 26/100 screws (26%) (grades 1-3) (P < 0.001)	RA eliminated severe FJV (grade 3 0% vs 3% in FG)
				Larger screw-to-facet distance (4.16 mm vs 1.92 mm, P < 0.001)
Chen et al[22], 2021	RA MIS-TLIF vs open TLIF	Not reported	Not reported	RA advantages: Higher screw accuracy (92.3% grade A vs 77.4%), faster early pain relief (VAS/ODI at 1 month)
				Both groups: Similar 1-year fusion rates (94.2% vs 92.3%)
Cui et al[23], 2021	RA-MIS-TLIF vs open TLIF	Alignment restored in both groups (no quantitative LL/SL data)	RA: 0% (no revisions) vs open: 5% (5 screws revised)	RA: Reduced paraspinal muscle atrophy (P = 0.016) at 2-year follow-up
Feng et al[24], 2020	RA-OLIF vs freehand OLIF	Alignment restored via indirect decompression (no quantitative LL/SL data)	RA: 1.8% (3/170 screws breached) vs freehand: 6.9% (12/174 screws breached)	RA: Reduced blood loss (P = 0.022) and eliminated postoperative drainage
Li et al[25], 2024	RA-MIS-TLIF vs fluoroscopy-MIS-TLIF	Sagittal alignment parameters (LL, SL, PI-LL) not explicitly reported	RA-MIS-TLIF: 0.13 ± 0.43 FJV grade (90.1% grade 0)	Reduced adjacent segment disc height loss (0.63 ± 0.38 mm vs 0.92 ± 0.35 mm; P = 0.001)
		Focus on screw accuracy, FJV, and adjacent segment degeneration	Fluoroscopy: 0.43 ± 0.68 FJV grade (66.1% grade 0) (P < 0.001)	Comparable fusion rates (BSF grades; P = 0.522)
Han et al[26], 2021	OLIF vs MIS-TLIF	Not reported	Not reported	OLIF advantages: Higher disc height (12.4 vs 11.2 mm) and fusion rate (96% vs 87%)
				Both groups: Similar screw accuracy (97.3% vs 96.2%)
De Biase et al[27], 2021	RA vs FG MI-TLIF	Not reported	Not reported	RA advantages: 50% lower radiation dose (31.5 vs 59.5 mGy)
				Both groups: 0% screw breaches, similar revision rates (1 vs 2 cases)
Fayed et al[28], 2020	RA-PPS (ExcelsiusGPS) vs FG-PPS	Not explicitly measured; alignment inferred from screw accuracy	RA: 5.8% breaches (4 lateral, 2 grade E) vs FG: 3.3% breaches (1 medial)	RA breaches linked to facet hypertrophy; no revisions needed. Short learning curve (1.9% significant breaches after initial cases)
Yang et al[29], 2019	MIS-TLIF with percutaneous pedicle screws	Screw insertion angle: RA: 23.8° ± 6.1° vs fluoroscopy: 18.4° ± 7.2° (P = 0.017)	RA: 5.1% (grades I-II) fluoroscopy: 15.6% (grades I-III), including 2.1% severe (grade III)	RA reduced severe deviations (Neo grade III: 0% vs 3.1%) and improved pedicle screw accuracy (93.8% grade 0 vs 73.8%)
Schatlo et al[30], 2014	Lumbar fusion (open/percutaneous)	Not reported for LL/SL/PI-LL	RA: 8.6% poor trajectory (grades C-E/R)	Lateral misplacement most frequent (RA: 47% of deviations; FG: 39%)
			FG: 12.9% (grades C-E) (P = 0.09)	No difference in clinically acceptable screws (A/B: 91.4% RA vs 87.1% FG, P = 0.19)
Li et al[31], 2024	RA MIS-TLIF/UBE-T/PLIF	Not reported	Not reported	Screw accuracy significantly better in groups A/B vs C (P < 0.05)
Li et al[32], 2022	RA MIS-TLIF	Not reported	Not reported	Higher screw accuracy in robot group (P = 0.002)

Li et al[32] includes three groups: Robot-assisted minimally invasive transforaminal lumbar interbody fusion (group A), robot-assisted unilateral biportal endoscopy-transforaminal/posterior lumbar interbody fusion (group B), and traditional minimally invasive transforaminal lumbar interbody fusion (group C). RA: Robot-assisted; FA: Freehand approach; FJV: Facet joint violation; OLIF: Oblique lumbar interbody fusion; LL: Lumbar lordosis; SL: Segmental lordosis; PI: Pelvic incidence; ON: O-arm navigation; SP-LLIF: Single-position lateral lumbar interbody fusion; PT: Pelvic tilt; VAS: Visual Analog Scale; ODI: Oswestry disability index; GPS: Globus ExcelsiusGPS robotic navigation platform; BSF-3: Bridwell spine fusion grade 3; LLIF: Lateral lumbar interbody fusion; MIS-TLIF: Minimally invasive transforaminal lumbar interbody fusion; UBE-T: Unilateral biportal endoscopy-transforaminal; PLIF: Posterior lumbar interbody fusion; FG: Fluoroscopy-guided.

Table 4 Clinical and patient-reported outcomes

Ref.	VAS/ODI improvement	Revision rate (RA vs comparator)	Fusion success	Notes
Wang et al[1], 2023	VAS back: Pre-op 6.92 → 0.90 (RA), 6.78 → 0.71 (FA) at 2 years (P > 0.05)	RA: 1 lateral wall violation (adjusted intraoperatively)	RA: 88.5% (BSF-3)	RA showed fewer facet violations (P < 0.001)
	VAS leg: Pre-op 7.70 → 0.54 (RA), 7.56 → 0.44 (FA) (P > 0.05)	FA: 1 anterior vertebral perforation (abdominal pain), 1 nerve root irritation (required revision)	FA: 85.5% (BSF-3) (P > 0.05)	Less disc height loss at adjacent segments in RA (P < 0.001)
	ODI: Pre-op 70.90 → 15.23 (RA), 71.00 → 14.89 (FA) (P > 0.05)
Tong et al[2], 2024	VAS-back: Significantly lower in robot group at 3 days post-op (2.19 vs 3.18, P < 0.05); no difference at 3/6 months	1 case vs 1 case	Not reported	No complications like infection or dural tear reported in either group
	VAS-leg: No significant difference at any time point
	ODI: No significant difference at any time point
Shafi et al[3], 2022	Not reported	RA: No high-grade breaches (grade E)	Not reported	Higher facet violations in RN (5.0% vs 1.3%, P < 0.001), but no clinically significant breaches
		ION: 1.2% high-grade breaches (17 screws, P = 0.05)
Griepp et al[4], 2024	ODI: Significant improvement in both groups at 6mo (Δ18.6 robot vs Δ18.2 fluoroscopy) and 12mo (Δ20.7 vs Δ22.4), with similar MCID achievement rates (P > 0.05). NRS back pain: Significant improvement in both groups at 6 months (Δ2.8 vs Δ2.3) and 12 months (Δ2.6 vs Δ2.8), with no inter group differences (P > 0.05)	RA: 1 revision (infection-related hardware removal). Fluoroscopy group: 3 revisions (2 infections, 1 foraminotomy)	High	Low rates in both groups (4.9% overall), with no neurological injuries
		Screw malposition: 0 revisions in both groups
Lin et al[5], 2022	Similar (P > 0.05)	RA: 1.3% intraop (K-wire malposition), 4.0% postop (CSF leak, wound infection) FG: 1.3% intraop (durotomy), 4.0% postop (screw malposition, wound infection) (P = 0.99 for postop surgery-related complications)	Not reported	RA reduced pedicle breaches (0.27% vs 1.75%, P = 0.04) and blood loss (P = 0.019)
Li et al[6], 2025	VAS-back: 6.3 → 1.8 (RA) vs 6.1 → 1.7 (traditional)	0% (RA) vs 0.9% (traditional)	90.3% vs 85.7% grade I	RA: 4 paresthesias; traditional: 2 paresthesias
	ODI: Comparable at 2 years
Heath et al[7], 2024	VAS/ODI: Not explicitly reported in the study. Clinical safety was confirmed by maintained neurological status postoperatively	RA: 0 revisions for screw malposition. Navigation group: 0 revisions for screw malposition	High (no difference)	No medial breaches or neurological complications in either group
Chang et al[11], 2022	VAS for back pain: Better in PE RA-TLIF (1.3 ± 0.4) vs MIS-TLIF (2.1 ± 0.1), P < 0.05.ODI: No significant difference (17 ± 5 vs 21 ± 8, P = 0.09)	No revisions reported. Misplacement rate: 0.9% (PE RA-TLIF) vs 6.3% (MIS-TLIF), P < 0.05	Fusion rate: 87.3% (PE RA-TLIF) vs 91.8% (MIS-TLIF), P = 0.53	PE RA-TLIF showed reduced surgical trauma and faster recovery
Lai et al[15], 2022	VAS-leg/back and ODI (preop to 12-month): VAS-leg: Preop 8.0 → 0.0 (Ro) vs 0.0 (FG) VAS-Back: Pre-op 8.0 → 2.0 (Ro) vs 3.0 (FG) ODI: Pre-op 57.78 → 26.67 (Ro) vs 28.89 (FG) (all P < 0.05 for improvement; no intergroup differences)	Complications: RA TLIF: 24.1% (7/29): 3 screw loosening, 3 cage subsidence, 2 infections. FG TLIF: 24.1% (19/79): 14 screw loosening, 2 cage subsidence, 3 infections	Not reported	Less screw loosening in RA (P = 0.049)
		Revisions: 1 broken rod (FG TLIF)
Zhang et al[20], 2019	Not reported	RA: 0% (0/176 screws)	Not reported	FJV: RA-PPS: 5 screws vs FG-PPS: 24 screws (P = 0.001)
		Comparator: 1.0% (2/204 screws)		Blood loss: Reduced in RA group (187.2 mL vs 373.2 mL, P = 0.001
Zhang et al[21], 2019	Not reported	RA: 0% (0/100 screws); FG: 1% (1/100 screws)	Not reported	FJV: RA: 4% (4/100) vs FG: 26% (26/100) (P = 0.0001)
				Severe FJV (grade 3): Only in FG group (3 screws)
				Intra-pedicle accuracy (grade A): RA: 85% vs FG: 71% (P = 0.017)
				Blood loss: RA: 171.6 mL vs FG: 362.0 mL (P = 0.001)
Chen et al[22], 2021	Similar (P > 0.05)	None	94.2% vs 92.3% (NS)	RA showed shorter hospital stay
Cui et al[23], 2021	VAS: 6.9 → 2.1 (RA) vs 6.5 → 3.7 (open) (P = 0.004); ODI: Comparable at 2 years	0% (RA) vs 5% (open)	Comparable	RA: 1 transient numbness; open: 1 screw loosening
Feng et al[24], 2020	VAS back pain: Immediate post-op: 2.15 (RA) vs 3.35 (comparator) (P < 0.05) ODI: No significant difference between groups at any time point	RA: 0.01% (1/170 screws) comparator: 3.4% (6/174 screws)	Not reported	RA group had shorter operative time, less blood loss, and no postoperative drainage
				Complications: RA (1 hip flexor weakness); comparator (1 infection, 1 hip flexor weakness, 1 delayed wound healing)
Li et al[25], 2024	VAS-back/Leg: No significant difference between groups pre-op, post-op 3 days, or final follow-up (P > 0.05). ODI: No significant difference at any time point (P > 0.05)	RA: 1 screw revision (penetrated outer pedicle wall, adjusted intraoperatively). Freehand group: 2 screws revised (penetrated anterior cortex, causing transient abdominal pain; 1 screw irritated nerve root, requiring immediate revision)	No significant difference in fusion status (BSF grading) between groups (P > 0.05)	Lower FJV in robot group (0.13 grades vs 0.43 grades, P < 0.001). Less adjacent segment disc height loss in robot group (0.63 mm vs 0.92 mm, P = 0.001)
Han et al[26], 2021	VAS back pain: Lower in OLIF at 1 week (2.8 vs 3.5, P < 0.05) and 3 months (1.6 vs 2.1, P < 0.05). ODI: Lower in OLIF at 3 months (22.3 vs 26.1, P < 0.05) - no differences in leg pain VAS	No revisions reported.Complications: OLIF (7/28) vs MIS-TLIF (5/33), all resolved conservatively	Fusion rate: Higher in OLIF (96% vs 87%, P < 0.01). Disc height: Greater in OLIF (12.4 mm vs 11.2 mm, P < 0.01	Higher fusion in OLIF with RA OLIF had less blood loss (142.4 vs 291.5 mL, P < 0.01) and shorter hospital stays (3.2 vs 4.2 days, P < 0.01)
De Biase et al[27], 2021	Not reported	Revisions: 1/52 (RA, pseudoarthrosis) vs 2/49 (FG, no surgery required)	Fusion status: No significant differences (pseudoarthrosis rates: 2% RA vs 4% FG, P = 0.523).	Lower radiation in RA group. Operative time, blood loss, hospital stay, and complication rates were similar
Fayed et al[28], 2020	Not reported	RA: 0% (0/103 screws); comparator: 1.1% (1/90 screws)	Not reported	Complications: No revisions required in RA-PPS group; 1 revision in FG-PPS group (medial breach)
Yang et al[29], 2019	Not reported	RA: 0% (0/130 screws); comparator: 3.1% (4/130 screws)	Not reported	FJV: RA-PPS: 5.1% (5/98 screws); FG-PPS: 15.6% (15/96 screws) (P = 0.021)
				Complications: No severe facet violations (Babu grade III) in RA-PPS group; 2 cases in FG-PPS group
Schatlo et al[30], 2014	Not reported	Robot-assisted: 2.5% (6/244 screws revised intraoperatively); FG: 1 revision surgery (for radiculopathy due to screw malposition)	Not reported	Neurological injury occurred in 1 FG case (resolved after revision)
				No significant difference in infection rates (robot: 1.8%, fluoroscopy: 2.5%)
				Blood loss was significantly lower in the robot-assisted group
Li et al[31], 2024	Significant improvement at 6 months (P < 0.05), no difference between groups (P > 0.05)	A: 0, B: 0, C: 0	Not reported	Macnab excellent/good rates: A: 96%, B: 93%, C: 92% (P > 0.05). No difference in complications (P > 0.05)
Li et al[32], 2022	No significant difference between groups (P > 0.05)	0/33 vs 2/39 (screw reinsertion)	Not reported	Macnab excellent rate: 91% (RA) vs 87% (conventional group), P = 0.900. Complications: 9% vs 20%

RA: Robot-assisted; VAS: Visual Analog Scale; ODI: Oswestry disability index; FG: Fluoroscopy-guided; OLIF: Oblique lumbar interbody fusion; TLIF: Transforaminal lumbar interbody fusion; MIS: Minimally invasive surgery; PE: Percutaneous endoscopic; BSF: Bridwell spine fusion; NRS: Numeric rating scale; MCID: Minimal clinically important difference; FJV: Facet joint violation; PPS: Percutaneous pedicle screw; ION: Intraoperative navigation; CSF: Cerebrospinal fluid; Pre-op: Preoperative; Ro: Range of motion; FA: Freehand approach; RN: Robot navigation.

Table 5 Risk of bias assessment for randomized controlled trial (Cochrane Risk of Bias Tool 2.0)

Ref.	Randomization process	Deviations from intended interventions	Missing outcome data	Measurement of the outcome	Selection of reported result	Overall risk of bias
Feng et al[24], 2020	Low	Low	Low	Low	Low	Low

Table 6 Risk of bias assessment for observational studies (risk of bias in non-randomized studies of interventions)

Ref.	Confounding	Selection bias	Classification of interventions	Deviations from intended interventions	Missing data	Measurement of outcomes	Selection of reported result	Overall risk of bias
Wang et al[1], 2023	Low	Low	Low	Low	Low	Low	Low	Low
Tong et al[2], 2024	Moderate	Moderate	Low	Low	Low	Low	Low	Moderate
Shafi et al[3], 2022	Moderate	Moderate	Low	Low	Low	Low	Low	Moderate
Griepp et al[4], 2024	Moderate	High	Low	Low	Low	Low	Low	Moderate
Lin et al[5], 2022	Moderate	Moderate	Low	Low	Low	Low	Moderate	Moderate
Li et al[6], 2025	Moderate	Low	Low	Low	Low	Low	Low	Moderate
Heath et al[7], 2024	Moderate	Moderate	Low	Low	Low	Low	Low	Moderate
Chang et al[11], 2022	Moderate	Low	Low	Low	Low	Low	Low	Moderate
Lai et al[15], 2022	High	Moderate	Low	Low	Low	Low	Moderate	Moderate
Zhang et al[20], 2019	High	High	Low	Low	Low	Moderate	Moderate	High
Zhang et al[21], 2019	Moderate	Moderate	Low	Low	Low	Low	Low	Moderate
Chen et al[22], 2021	Moderate	Moderate	Low	Low	Low	Low	Moderate	Moderate
Cui et al[23], 2021	Moderate	Low	Low	Low	Low	Moderate	Low	Moderate
Li et al[25], 2024	Moderate	Moderate	Low	Low	Low	Low	Low	Moderate
Han et al[26], 2021	High	Moderate	Low	Low	Low	Moderate	Moderate	High
De Biase et al[27], 2021	High	Moderate	Low	Low	Moderate	Moderate	Moderate	High
Fayed et al[28], 2020	Moderate	Moderate	Low	Low	Low	Low	Low	Moderate
Yang et al[29], 2019	Moderate	Moderate	Low	Low	Low	Low	Low	Moderate
Schatlo et al[30], 2014	High	Moderate	Low	Low	Low	Low	Low	Moderate
Li et al[31], 2024	Moderate	Low	Low	Low	Low	Low	Low	Moderate
Li et al[32], 2022	Moderate	Low	Low	Low	Low	Low	Low	Moderate

Table 7 Summary of findings and Grading of Recommendations Assessment, Development and Evaluation evidence quality assessment

Outcome	Number of studies	Study design(s)	Risk of bias	Inconsistency	Indirectness	Imprecision	Publication bias	Overall quality (GRADE)	Comments/explanation
Screw accuracy (grade A)	1 RCT, 21 observationals	RCT, observational	Moderate	Not serious	Not serious	Not serious	Undetected	Moderate	Consistent large effect across multiple studies despite observational nature
Operative time	1 RCT, 17 observationals	RCT, observational	Moderate	Serious	Not serious	Serious	Undetected	Low	Risk of confounding and moderate heterogeneity across studies (I2 = 66%)
Blood loss	1 RCT, 17 observationals	RCT, observational	Low	Not serious	Not serious	Not serious	Undetected	Low	Multiple studies had critical ROBINS-I domains; small-to-moderate effect size
FJV	1 RCT, 12 observationals	RCT, observational	Moderate	Not serious	Not serious	Not serious	Undetected	Moderate	RA reduced FJV rates by 50%-75%
Sagittal alignment	0 RCT, 7 observationals	Observational	Moderate	Serious	Not serious	Serious	Undetected	Low	Limited data; heterogeneous measurements
Patient-reported outcomes	1 RCT, 14 observationals	RCT, observational	Moderate	Not serious	Not serious	Not serious	Undetected	Moderate	No long-term differences between RA and comparators

Certainty of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation approach. “Moderate” certainty was retained only when effect sizes were consistent and robust despite observational design. Downgrades were applied based on risk of bias in non-randomized studies of interventions assessments (e.g., selection bias, confounding, missing data), statistical heterogeneity, and inconsistency where applicable. Radiation dose was excluded from formal grading due to incompatible outcome units (e.g., mGy, μSv, exposure time, image count). GRADE: Grading of Recommendations Assessment, Development and Evaluation; RCT: Randomized controlled trial; ROBINS-I: Risk of bias in non-randomized studies of interventions; RA: Robot-assisted; FJV: Facet joint violation.