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STUDY DESIGN: Retrospective Cohort Study Objectives: Robot-assisted spine surgery (RASS) is a rapidly evolving technique with potential benefits for improving surgical outcomes. A number of studies on RASS learning curve have focused on early iterations of the Mazor robot. Limited research exists on the learning curve associated with using the Globus Medical ExcelsiusGPS® system. In this retrospective study, we aimed to evaluate the learning curve of RASS using the ExcelsiusGPS® system at a single institution. METHODS: A total of 95 patients (541 screws) who underwent RASS between 2021 and 2022 were included. Variables including operative time, robot registration time, screw placement time, fluoroscopy utilization, and complications were analyzed. Statistical analysis was performed using descriptive statistics and two-sample t-tests. RESULTS: The average operative time significantly decreased after the first 14 cases, indicating a learning curve. However, no significant improvement was observed in robot registration time. Notably, screw placement time significantly improved after approximately 13 cases. When controlling for the number of levels fused, the trends remained consistent. CONCLUSIONS: Our study confirmed the presence of a learning curve in RASS using the ExcelsiusGPS® system and demonstrated rapid proficiency development. Our findings highlight the relatively quick learning curve of 1 RASS system.

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OBJECTIVE: This study aimed to assess the degree of interest in robot-assisted spine surgery (RASS) among residents and to investigate the learning curve for beginners performing robotic surgery. METHODS: We conducted a survey to assess awareness and interest in RASS among young neurosurgery residents. Subsequently, we offered a hands-on training program using a dummy to educate one resident. After completing the program, the trained resident performed spinal fusion surgery with robotic assistance under the supervision of a mentor. The clinical outcomes and learning curve associated with robotic surgery were then analyzed. RESULTS: Neurosurgical residents had limited opportunities to participate in spinal surgery during their training. Despite this, there was a significant interest in the emerging field of robotic surgery. A trained resident performed RASS under the supervision of a senior surgeon. A total of 166 screw insertions were attempted in 28 patients, with 2 screws failing due to skiving. According to the Gertzbein-Robbins classification, 85.54% of the screws were rated as grade A, 11.58% as grade B, 0.6% as grade C, and 1.2% as grade D. The clinical acceptance rate was approximately 96.99%, which is comparable to the results reported by senior experts and time per screw statistically significantly decreased as experience was gained. CONCLUSION: RASS can be performed with high accuracy within a relatively short timeframe, if residents receive adequate training.

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OBJECTIVE: This study aimed to compare the accuracy of robotic spine surgery and conventional pedicle screw fixation in lumbar degenerative disease. We evaluated clinical and radiological outcomes to demonstrate the noninferiority of robotic surgery. METHODS: This study employed propensity score matching and included 3 groups: robot-assisted mini-open posterior lumbar interbody fusion (PLIF) (robotic surgery, RS), c-arm guided minimally invasive surgery transforaminal lumbar interbody fusion (C-arm guidance, CG), and freehand open PLIF (free of guidance, FG) (54 patients each). The mean follow-up period was 2.2 years. The preoperative spine condition was considered. Accuracy was evaluated using the Gertzbein-Robbins scale (GRS score) and Babu classification (Babu score). Radiological outcomes included adjacent segmental disease (ASD) and mechanical failure. Clinical outcomes were assessed based on the visual analogue scale, Oswestry Disability Index, 36-item Short Form health survey, and clinical ASD rate. RESULTS: Accuracy was higher in the RS group (p < 0.01) than in other groups. The GRS score was lower in the CG group, whereas the Babu score was lower in the FG group compared with the RS group. No significant differences were observed in radiological and clinical outcomes among the 3 groups. Regression analysis identified preoperative facet degeneration, GRS and Babu scores as significant variables for radiological and clinical ASD. Mechanical failure was influenced by the GRS score and patients' age. CONCLUSION: This study showed the superior accuracy of robotic spine surgery compared with conventional techniques. When combined with minimally invasive surgery, robotic surgery is advantageous with reduced ligament and muscle damage associated with traditional open procedures.

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BACKGROUND: Thoracolumbar (TL) fractures are uncommon in children. While surgical treatment is recommended for unstable TL fractures, there is no consensus on appropriate surgical treatment. We present a case series of pediatric patients with traumatic TL fractures treated with minimally invasive techniques. We discuss our early experience and technical challenges with navigation and robotic-assisted fixation. METHODS: A retrospective review of a prospectively maintained trauma database from February 2018 to February 2023 of all pediatric patients (<18 years old) undergoing percutaneous fixation for unstable TL fractures was performed. Minimally invasive techniques included fluoroscopy and/or navigation-guided or robotic-assisted surgery. Clinical course, radiographic findings, and technical challenges were reviewed. RESULTS: A cohort of 12 patients (age range, 4-17 years) with 6 (50%) Chance fractures, 2 (16%) pars fractures, 2 (16%) pedicle fracture, 1 (8%) burst fracture, and 1 (8%) other fracture were identified. Nine patients had fractures involving the lumbar spine, and the remaining 3 had thoracic fractures. In all cases, percutaneous pedicle screws were placed above and below the fracture with the use of neuronavigation or robotic-assisted navigation (n = 2). Blood loss was <30 mL for single-level fractures and instrumented fusion. Two patients had hardware-related complications. At follow-up (mean 9.67 months after surgery), patients were doing well clinically, and most imaging showed stable alignment. CONCLUSIONS: Our early experience shows that short segment instrumentation through a minimally invasive approach is a safe and effective surgical option for young pediatric patients with good clinical outcomes and favorable radiographic postoperative finding.

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OBJECTIVE: The objective of this study was to evaluate the accuracy of pedicle screw placement in patients undergoing percutaneous pedicle screw fixation with robotic guidance, using a newly developed 3-dimensional quantitative measurement system. The study also aimed to assess the clinical feasibility of the robotic system in the field of spinal surgery. METHODS: A total of 113 patients underwent pedicle screw insertion using the CUVIS-spine pedicle screw guide system (CUREXO Inc.). Intraoperative O-arm images were obtained, and screw insertion pathways were planned accordingly. Image registration was performed using paired-point registration and iterative closest point methods. The accuracy of the robotic-guided pedicle screw insertion was assessed using 3-dimensional offset calculation and the Gertzbein-Robbins system (GRS). RESULTS: A total of 448 screws were inserted in the 113 patients. The image registration success rate was 95.16%. The average error of entry offset was 2.86 mm, target offset was 2.48 mm, depth offset was 1.99 mm, and angular offset was 3.07°. According to the GRS grading system, 88.39% of the screws were classified as grade A, 9.60% as grade B, 1.56% as grade C, 0.22% as grade D, and 0.22% as grade E. Clinically acceptable screws (GRS grade A or B) accounted for 97.54% of the total, with no reported neurologic complications. CONCLUSION: Our study demonstrated that pedicle screw insertion using the novel robot-assisted navigation method is both accurate and safe. Further prospective studies are necessary to explore the potential benefits of this robot-assisted technique in comparison to conventional approaches.

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PURPOSE: Spinal augmentation procedures (SAP) are standard procedures for vertebral compression fractures. Often, SAPs are carried out in a minimally invasive, percutaneous way. Certain anatomic conditions such as small pedicles or kyphotic deformities resulting from a significant collapse of the vertebral body might render the operation more difficult and increase the risk of complications. Thus, robot assistance might be useful to optimize the trajectory and to reduce procedure-associated complications. In this study robot-assisted percutaneous SAPs are compared with conventional fluoroscopy-guided percutaneous SAP. METHODS: A retrospective observational analysis was carried out. Standard demographic parameters were analyzed. Procedural data including radiation dosage records were screened. Biomechanical data were recorded. Cement volumes were analyzed. The precision of the pedicular trajectory was reviewed, and misplaced trajectories were categorized. Procedure-associated complications were analyzed and evaluated for their clinical significance. RESULTS: A total of 130 procedures were reviewed, and 94 patients were finally included. Osteoporotic fractures (OF) were the main indication (60.7%; OF 2-44%, OF 4-33%). Demographic parameters and clinically relevant complications were equally distributed between the two groups. Duration of surgery was significantly longer in robot-assisted procedures (p < 0.001). Intraoperative radiation exposure was equally distributed. Injected cement volume was similar in both groups. There was no significant difference in pedicle trajectory deviation. CONCLUSION: The use of robot assistance in SAP seems not to be superior with regard to accuracy, radiation exposure and the rate of complications when compared to fluoroscopy-guided SAP.

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BACKGROUND: The aim of this study was to compare the intraoperative and postoperative outcomes between a robot-assisted versus a navigated transpedicular fusion technique. METHODS: This retrospective analysis included patients who underwent transpedicular posterior fusion of the spine due to trauma, pyogenic spondylodiscitis and osteoporosis. Surgery was done either with a robot-assisted or a percutaneous navigated transpedicular fusion technique. The outcome analysis included the duration of surgery, the radiation exposure, the postoperative screw position and complications. RESULTS: A total of 60 patients were operated and 491 screws were analysed. No statistical difference was seen in the applied cumulative effective radiation dose per patient. The radiological assessment revealed a more accurate screw placement with robot assistance. A learning curve could be observed in robot-assisted fusion. CONCLUSION: Robot-assisted and navigated transpedicular fusion techniques are both effective and safe. Robot-assisted transpedicular spine fusion goes along with higher placement accuracy but its implementation needs an adequate learning curve.

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STUDY DESIGN: Prospective single-cohort analysis. OBJECTIVES: To compare the outcomes/complications of 2 robotic systems for spine surgery. METHODS: Adult patients (≥18-years-old) who underwent robot-assisted spine surgery from 2016-2019 were assessed. A propensity score matching (PSM) algorithm was used to match Mazor X to Renaissance cases. Preoperative CT scan for planning and an intraoperative O-arm for screw evaluation were preformed. Outcomes included screw accuracy, robot time/screw, robot abandonment, and radiation. Screw accuracy was measured using Vitrea Core software by 2 orthopedic surgeons. Screw breach was measured according to the Gertzbein/Robbins classification. RESULTS: After PSA, a total of 65 patients (Renaissance: 22 vs. X: 43) were included. Patient/operative factors were similar between robot systems (P > .05). The pedicle screw accuracy was similar between robots (Renaissance: 1.1%% vs. X: 1.3%, P = .786); however, the S2AI screw breach rate was significantly lower for the X (Renaissance: 9.5% vs. X: 1.2%, P = .025). Robot time per screw was not statistically different (Renaissance: 4.6 minutes vs. X: 3.9 minutes, P = .246). The X was more reliable with an abandonment rate of 2.3% vs. Renaissance:22.7%, P = .007. Radiation exposure were not different between robot systems. Non-robot related complications including dural tear, loss of motor/sensory function, and blood transfusion were similar between robot systems. CONCLUSION: This is the first comparative analyses of screw accuracy, robot time/screw, robot abandonment, and radiation exposure between the Mazor X and Renaissance systems. There are substantial improvements in the X robot, particularly in the perioperative planning processes, which likely contribute to the X's superiority in S2AI screw accuracy by nearly 8-fold and robot reliability by nearly 10-fold.

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STUDY DESIGN: Cross-Sectional Analysis. OBJECTIVES: To summarize medical device reports (MDRs) between August 1, 2017 and November 30, 2021 relating to robot-assisted spine systems within the Manufacturer and User Facility Device Experience (MAUDE) database maintained by The Food and Drug Administration (FDA). METHODS: The MAUDE database was abstract for all MDRs relating to each FDA-approved robot-assisted spine system. Event descriptions were reviewed and characterized into specific event types. Outcome measures include specific robot-assisted spine systems and reported events as detailed by the MDRs. All data is de-identified and in compliance with the Health Insurance Portability and Accountability Act (HIPAA). RESULTS: There were 263 MDRs consisting of 265 reported events. Misplaced screws represented 61.5% (n = 163) of reported events. Of the 163 reported events, 57.1% (n = 93) described greater than 1 misplaced screw, 15.3% (n = 25) required return to the operating room, 8.6% (n = 14) resulted in neurologic injury, 4.3% (n = 7) resulted in dural tear, and 1.2% (n = 2) resulted in hemorrhage or bleeding. Reported events other than misplaced screws included system imprecision detected prior to screw placement (58/265, 21.9%), mechanical failure (23/265, 8.7%), and software failure (18/265, 6.8%). CONCLUSIONS: As more robot-assisted spine systems gain FDA approval and the adoption of these systems continues to grow, documenting and understanding the range of reported events associated with each "tool" is imperative to balancing patient safety with surgical innovation. This study of the MAUDE database provides a unique summary of reported events associated with robot-assisted spine systems that is not directly linked to a research setting.

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Background: Although a growing amount of literature that suggests robots are safe and can achieve comparable outcomes to conventional techniques, much of this literature is limited by small sample sizes and single-surgeon or single center series. Furthermore, it is unclear what the impact of robotic technology has made on operative and clinical outcomes over time. This is the first and largest multicenter study to examine the trends in outcomes and complications after robot-assisted spine surgery over a 5-year period. Methods: Adult (≥18 years old) patients who underwent spine surgery with robot-assistance between 2015 and 2019 at four unique spine centers. The robotic systems used included the Mazor Renaissance, Mazor X, and Mazor Stealth Edition. Patients with incomplete data were excluded from this study. The minimum follow-up was 90 days. Results: A total of 722 adult patients were included (117 Renaissance, 477 X, 128 Stealth). Most patient and operative factors (e.g., sex, tobacco status, total instrumented levels, and pelvic fixation,) were similar across the years. Mean ± standard deviation Charlson comorbidity index (CCI) was 1.5±1.5. The most commonly reported diagnoses included high grade spondylolisthesis (40.6%), degenerative disc disease (18.4%), and degenerative scoliosis (17.6%). Mean (standard deviation) number of instrumented levels was 3.8±3.4. From 2015 to 2019, average robot time per screw improved from 7.2 to 5.5 minutes (P=0.004, R2=0.649). Average fluoroscopy time per screw improved from 15.2 to 9.4 seconds (P=0.002). Rates of both intraoperative screw exchange for misplaced screw (2015-2016: 2.7%, 2019: 0.8%, P=0.0115, R2=0.1316) and robot abandonment (2015-2016: 7.1%, 2019: 1.1%, P=0.011, R2=0.215) improved significantly over time. The incidence of other intraoperative complications (e.g., dural tear, loss of motor/sensory function, blood transfusion) remained consistently low, but similar throughout the years. The length of stay (LOS) decreased by nearly 1 day from 2015 to 2019 (P=0.007, R2=0.779). 90-day reoperation rates did not change significantly. Conclusions: At four institutions among seven surgeons, we demonstrate robot screw accuracy, reliability, operative efficiency, and radiation exposure improved significantly from 2015 to 2019. 90-day complication rates remained low and LOS decreased significantly with time. These findings further validate continued usage of robot-assisted spine surgery and the path toward improved value-based care.

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BACKGROUND: In robot-assisted (RA) spine surgery, the relationship between the surgical outcome and the learning curve remains to be evaluated. AIM: To analyze the learning curve of RA pedicle screw fixation (PSF) through fitting the operation time curve based on the cumulative summation method. METHODS: RA PSFs that were initially completed by two surgeons at the Beijing Jishuitan Hospital from July 2016 to March 2019 were analyzed retrospectively. Based on the cumulative sum of the operation time, the learning curves of the two surgeons were drawn and fit to polynomial curves. The learning curve was divided into the early and late stages according to the shape of the fitted curve. The operation time and screw accuracy were compared between the stages. RESULTS: The turning point of the learning curves from Surgeons A and B appeared in the 18th and 17th cases, respectively. The operation time [150 (128, 188) min vs 120 (105, 150) min, P = 0.002] and the screw accuracy (87.50% vs 96.30%, P = 0.026) of RA surgeries performed by Surgeon A were significantly improved after he completed 18 cases. In the case of Surgeon B, the operation time (177.35 ± 28.18 min vs 150.00 ± 34.64 min, P = 0.024) was significantly reduced, and the screw accuracy (91.18% vs 96.15%, P = 0.475) was slightly improved after the surgeon completed 17 RA surgeries. CONCLUSION: After completing 17 to 18 cases of RA PSFs, surgeons can pass the learning phase of RA technology. The operation time is reduced afterward, and the screw accuracy shows a trend of improvement.

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BACKGROUND: Current literature on robot-assisted S2 alar-iliac (S2AI) screw placement shows favorable outcomes and screw accuracy; however, the data is limited by a few retrospective, single-surgeon studies. To the author's knowledge, this is the first multicenter study which evaluates the accuracy of robot-assisted S2AI screws. METHODS: Adult (≥18 years old) patients who underwent robot-assisted S2AI screw placement from 2017-2019 were reviewed. All surgeries used the same proprietary robotic guidance system, Mazor X (Mazor Robotics Ltd). RESULTS: A total of 65 screws were assessed in 31 patients. The mean follow-up ± standard deviation was 362±190 days (minimum was 90 days). The mean age was 61.1±11 years old, and 54.8% (n=17) of patients were female. Nearly half of the patients had a primary diagnosis of degenerative scoliosis (48.4%, n=15). Other diagnosis included pseudarthrosis (22.6%, n=7), degenerative disc disease (16.1%, n=5), and high-grade spondylolisthesis (12.9%, n=4). The mean length and diameter of screws were 84.6±6.1 mm and 8.4±0.7, respectively. The mean axial and sagittal angles were 50.0±6.3 and 24.0±10.5, respectively. The overall screw accuracy was 93.8% (n=61). There were four iliac cortex breaches (anterior =3, inferior 1) with a mean breach distance of 3.5±3.2. No statistically significant differences in screw length, diameter, axial angle, and sagittal angle were observed between screws with and without a breach. No intraoperative neurologic, vascular, or visceral complications from the S2AI screw were observed. No post-discharge wound complications, screw prominence issues, or revision of S2AI screws were observed during the study's follow-up period. CONCLUSIONS: Robot-assisted S2AI screw placement was found to be safe and accurate in this multicenter study. This is largely attributed to the versatility of the robotic guidance software that allows for detailed and precise preoperative and intraoperative planning.

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BACKGROUND CONTEXT: Robot-assisted spine surgery continues to rapidly develop as evidenced by the growing literature in recent years. In addition to demonstrating excellent pedicle screw accuracy, early studies have explored the impact of robot-assisted spine surgery on reducing radiation time, length of hospital stay, operative time, and perioperative complications in comparison to conventional freehand technique. Recently, the Mazor X Stealth Edition was introduced in 2018. This robotic system integrates Medtronic's Stealth navigation technology into the Mazor X platform, which was introduced in 2016. It is unclear what the impact of these advancements have made on clinical outcomes. PURPOSE: To compare the outcomes and complications between the most recent iterations of the Mazor Robot systems: Mazor X and Mazor X Stealth Edition. STUDY DESIGN: Multicenter cohort PATIENT SAMPLE: Among four different institutions, we included adult (≥18 years old) patients who underwent robot-assisted spine surgery with either the Mazor X (non-navigated robot) or Stealth (navigated robot) platforms. OUTCOME MEASURES: Primary outcomes included robot time per screw, fluoroscopic radiation time, screw accuracy, robot abandonment, and clinical outcomes with a minimum 90 day follow up. METHODS: A one-to-one propensity-score matching algorithm based on perioperative factors (e.g. demographics, comorbidities, primary diagnosis, open vs. percutaneous instrumentation, prior spine surgery, instrumented levels, pelvic fixation, interbody fusion, number of planned robot screws) was employed to control for the potential selection bias between the two robotic systems. Chi-square/fisher exact test and t-test/ANOVA were used for categorical and continuous variables, respectively. RESULTS: From a total of 646 patients, a total of 372 adult patients were included in this study (X: 186, Stealth: 186) after propensity score matching. The mean number of instrumented levels was 4.3. The mean number of planned robot screws was 7.8. Similar total operative time and robot time per screw occurred between cohorts (p>0.05). However, Stealth achieved significantly shorter fluoroscopic radiation time per screw (Stealth: 7.2 seconds vs. X: 10.4 seconds, p<.001) than X. The screw accuracy for both robots was excellent (Stealth: 99.6% vs. X: 99.1%, p=0.120). In addition, Stealth achieved a significantly lower robot abandonment rate (Stealth: 0% vs. X: 2.2%, p=0.044). Furthermore, a lower blood transfusion rate was observed for Stealth than X (Stealth: 4.3% vs. X: 10.8%, p=0.018). Non-robot related complications such as dura tear, motor/sensory deficits, return to the operating room during same admission, and length of stay was similar between robots (p>0.05). The 90-day complication rates were low and similar between robot cohorts (Stealth: 5.4% vs. X: 3.8%, p=0.456). CONCLUSION: In this multicenter study, both robot systems achieved excellent screw accuracy and low robot time per screw. However, using Stealth led to significantly less fluoroscopic radiation time, lower robot abandonment rates, and reduced blood transfusion rates than Mazor X. Other factors including length of stay, and 90-day complications were similar.

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BACKGROUND: Robot-assisted platforms in spine surgery have rapidly developed into an attractive technology for both the surgeon and patient. Although current literature is promising, more clinical data is needed. The purpose of this paper is to determine the effect of robot-related complications on clinical outcomes METHODS: This multicenter study included adult (≥18 years old) patients who underwent robot-assisted lumbar fusion surgery from 2012-2019. The minimum follow-up was 1 year after surgery. Both bivariate and multivariate analyses were performed to determine if robot-related factors were associated with reoperation within 1 year after primary surgery. RESULTS: A total of 320 patients were included in this study. The mean (standard deviation) Charlson Comorbidity Index was 1.2 (1.2) and 52.5% of patients were female. Intraoperative robot complications occurred in 3.4% of patients and included intraoperative exchange of screw (0.9%), robot abandonment (2.5%), and return to the operating room for screw exchange (1.3%). The 1-year reoperation rate was 4.4%. Robot factors, including robot time per screw, open vs. percutaneous, and robot system, were not statistically different between those who required revision surgery and those who did not (P>0.05). Patients with robot complications were more likely to have prolonged length of hospital stay and blood transfusion, but were not at higher risk for 1-year reoperations. The most common reasons for reoperation were wound complications (2.2%) and persistent symptoms due to inadequate decompression (1.5%). In the multivariate analysis, robot related factors and complications were not independent risk factors for 1-year reoperations. CONCLUSION: This is the largest multicenter study to focus on robot-assisted lumbar fusion outcomes. Our findings demonstrate that 1-year reoperation rates are low and do not appear to be influenced by robot-related factors and complications; however, robot-related complications may increase the risk for greater blood loss requiring a blood transfusion and longer length of stay.

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Recently, spine surgery has gradually evolved from conventional open surgery to minimally invasive surgery, and endoscopic spine surgery (ESS) has become an important procedure in minimally invasive spine surgery. With improvements in the optics, spine endoscope, endoscopic burr, and irrigation pump, the indications of ESS are gradually widening from lumbar to cervical and thoracic spine. ESS was not only used previously for disc herniations that were contained without migration but is also used currently for highly migrated disc herniations and spinal stenosis; thus, the indications of ESS will be further expanded. Although ESS has certain advantages such as less soft tissue dissection and muscle trauma, reduced blood loss, less damage to the epidural blood supply and consequent less epidural fibrosis and scarring, reduced hospital stay, early functional recovery, and improvement of quality of life as well as better cosmesis, several obstacles remain for ESS to be widespread because it has a steep learning curve and surgical outcome is strongly dependent on the surgeon's skillfulness. A solid surgical technique requires reproducibility and ensured safety in addition to surgical outcomes. In this review article, how to improve ESS was investigated by grafting novel technologies such as navigation, robotics, and 3-dimensional and ultraresolution visualization.

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OBJECTIVES: To describe the learning curve of pedicle screw placement using robot-assisted spine surgery of an experienced neurosurgeon and 2 supervised neurosurgical fellows. METHODS: The first 120 cases of robot-assisted spine surgery at our institution were assessed. Patient variables included age, body mass index, and indication for surgery. Intraoperative variables included the vertebral level of screw placement, number of screws placed by each operator, intraoperative blood loss, and operative time. Postoperative variables included length of stay, discharge disposition, 30-day readmissions, wound complications, and hardware revisions. Screw accuracy was determined with image overlay analysis comparing planned screw trajectory on the navigation software with the intraoperative computed tomography scan with final screw placement. Two-dimensional accuracy was determined for the tip of the screw, tail of the screw, and angle at the screw was placed. The supervising physician and first fellow began utilizing the robot concurrently upon its arrival, and the second fellow began using the robot after the system had been in place for 7 months. RESULTS: Both experienced surgeon and first fellow displayed a learning curve and achieved statistically significant improvement of accuracy after 30 screws. The second fellow had significantly better accuracy than the experienced surgeon in his first 30 screws. There were no complications from hardware placement in either group. There were no returns to the operating room for hardware issues. CONCLUSIONS: Robot-assisted spine surgery is a safe, accurate method of pedicle screw instrumentation. Our data show similar learning adaptation rates for the first fellow and the experienced surgeon. Techniques learned by the attending surgeon were immediately transferable to a new learner, who was able to achieve a faster learning curve than both the first fellow and the experienced surgeon.

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