Robotic-Assisted Decompression, Decortication, and Instrumentation for Minimally Invasive Transforaminal Lumbar Interbody Fusion
Authors: Altorfer Franziska C.S. , Avrumova Fedan , Lebl Darren R. 
Published: December 2024

Background:
Robotic-assisted spine surgery has been reported to improve the accuracy and safety of pedicle screw placement and to reduce blood loss, hospital length of stay, and early postoperative pain
1
. Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is a procedure that is well suited to be improved by recent innovations in robotic-assisted spine surgery. Heretofore, the capability of robotic navigation and software in spine surgery has been limited to assistance with pedicle screw insertion. Surgical decompression and decortication of osseous anatomy in preparation for biological fusion had historically been outside the scope of robotic-assisted spine surgery. In 2009, early attempts to perform surgical decompressions in a porcine model utilizing the da Vinci Surgical Robot for laminotomy and laminectomy were limited by the available technology
2
. Recent advances in software and instrumentation allow registration, surgical planning, and robotic-assisted surgery on the posterior elements of the spine. A human cadaveric study assessed the accuracy of robotic-assisted bone laminectomy, revealing precision in the cutting plane
3
. Robotic-assisted facet decortication, decompression, interbody cage implantation, and pedicle screw fixation add automation and accuracy to MI-TLIF.

Description:
A surgical robotic system comprises an operating room table-mounted surgical arm with 6 degrees of freedom that is physically connected to the patient’s osseous anatomy with either a percutaneous Steinmann pin to the pelvis or a spinous process clamp. The Mazor X Stealth Edition Spine Robotic System (Version 5.1; Medtronic) is utilized, and a preoperative plan is created with use of software for screw placement, facet decortication, and decompression. The workstation is equipped with interface software designed to streamline the surgical process according to preoperative planning, intraoperative image acquisition, registration, and real-time control over robotic motion. The combination of these parameters enables the precise execution of preplanned facet joint decortication, osseous decompression, and screw trajectories. Consequently, this technique grants the surgeon guidance for the drilling and insertion of screws, as well as guidance for robotic resection of bone with a bone-removal drill.

Alternatives:
The exploration of robotically guided facet joint decortication and decompression in MI-TLIF presents an innovative alternative to the existing surgical approaches, which involve manual bone removal and can be less precise. Other robotic systems commonly utilized in spine surgery include the ROSA (Zimmer Biomet), the ExcelsiusGPS (Globus Medical), and the Cirq (Brainlab)
4
.

Rationale:
The present video article provides a comprehensive guide for executing robotic-assisted MI-TLIF, including robotic facet decortication and osseous decompression. The introduction of advanced robotic technology capable of both decompressing bone and providing implant guidance represents a considerable advancement in robotic-assisted spine surgery. Software planning for robotic-assisted decortication of fused surfaces, surgical decompression, interbody cage placement, and pedicle screw placement allows for a less invasive and more precise MI-TLIF.

Expected Outcomes:
Anticipated outcomes include reduction in low back and leg pain, improved functional status, and successful spinal fusion. Radiographic outcomes are expected to show restored foraminal height and solid bony fusion. Further, enhanced surgical precision, reduced approach-related morbidity by expanded robotic capabilities in spinal fusion surgery, and a shift from manual bone removal to precise mechanized techniques can be expected. The introduction of robotic-assisted facet joint decortication and decompression represents a notable milestone in spine surgery, enhancing patient care and technological advancement.

Important Tips:

Although robotic systems were initially predominantly employed for thoracic or lumbar pedicle screw insertion, recent advancements in robotic technology and software have allowed registration of the posterior elements. This advancement has expanded the utility of robotic systems to the initiation of spinal decompression and the decortication of facet joint surfaces, enhancing fusion procedures.Maintaining anatomical precision and preventing the need for re-registration are critical considerations in this surgical procedure. It is recommended to follow a consistent surgical workflow: facet decortication, decompression, modular screw placement, discectomy, insertion of an interbody cage, placement of reduction tabs, rod insertion, and set screw locking.The incorporation of robotic assistance in MI-TLIF is not exempt from a set of challenges. These encompass issues that pertain to dependability of the setup process, occurrences of registration failures, logistical complexities, time constraints, and the unique learning curve associated with the novel capability of robotic decompression of bone and facet joints.

Acronyms and Abbreviations:

MI-TLIF= minimally invasive transforaminal lumbar interbody fusionOR = operating roomPSIS= posterior superior iliac spineCT = computed tomographyAP = anteroposterior