Robotic Cervical Spine Pedicle Screw Placement: A Step-by-Step Guide

Introduction

Robotic assistance in cervical spine surgery enhances precision, reduces surgical time, and minimizes complications. This guide outlines the steps for placing cervical pedicle screws using robotic assistance.

Step 1: Surgical Exposure and Preparation

Perform a conventional midline exposure to the lateral border of the lateral mass.
Flatten entry points to manage osteophytes, and use bone wax to plug any raw bleeding.
Pack the surgical field with gauze to control bleeding.
Remove retractors before conducting the O-arm scan.

Step 2: Robot Setup and Imaging

Secure the robot on the table and ensure the arm can reach the vertex (past occiput)
Perform the scan to establish the work volume and verify instruments in the meantime.
Navigation registration is done by the snapshot tracker.

Step 3: Star Marker Positioning

Use a blunt passive planar probe to mark the region of interest.
Lower the star marker without touching patient anatomy; remove tubes and wires from the surgical field during the O-arm scan for clear images.
Transfer the O-arm scans to the robot console for further processing.

Step 4: Planning and Alignment

Identify anatomical regions.
Align segments parallel to the end plates and label using C1 or C2 as reference for numbering.
Carefully inspect the planned trajectory, keeping the drill line centered in the pedicle.
Avoid too lateral or medial entry, and keep in mind the course of the vertebral artery.

Step 5: Screw Placement Strategy

We prefer placing C3-C4 screws through a single incision and C5-C7 through another incision.
Use "Skin Level" feature to place multiple screws through a single incision.

Special Considerations

Note that screws and taps for cervical spines are not navigable with the robotic guide.
We have adapted this workflow using available instruments and robotic assistance.
We use a mix of MIS lumbar system dilator sleeves with the robotic system to facilitate safe cervical pedicle screw placement.

Step 6: Screw Insertion

Send the robotic arm to the planned trajectory.
Make a separate incision for dilator and outer sleeve.
Use a Feather touch drill to create the pilot hole.
Insert a guide wire and serial dilators until the last sleeve fits snuggly with the robotic guide.
Remove inner sleeve and manually tap the trajectory, followed by removal of another 2 sleeves to insert the screw, and tighten slowly until resistance is felt.

Step 7: Post-Procedural Verification

Verify screw positions post-procedure by comparing them to the pre-planned positioning.

Conclusion

Robotic-assisted cervical spine pedicle screw placement offers precision and consistency. By following this guide, the surgeons can effectively implement robotic technologies in posterior cervical pedicle screw placement, although it lacks specific instruments currently.