# Robotic Systems and Navigation Techniques in Orthopedics: A Historical Review
## 2 Robotic Systems (RSs)
### Hands-On RS
#### 2.2.12 Mazor  
Spine Assist (Mazor Robotics, Caesarean, Israel) is the first robotic system used in spine surgery and was approved by the FDA (Mazor SpineAssist FDA 2004 file (accessed on 28 June 2023): [[https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K033413](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K033413)]([https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K033413](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K033413))) in 2004 [57]. The Spine Assist system evolved into the Renaissance system, which was approved by the FDA (Mazor Renaissance FDA 2011 file (accessed on 28 June 2023): [[https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K110911](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K110911)]([https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K110911](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K110911))) in 2011, and then Mazor X, which was approved by the FDA (Mazor X FDA 2017 file (accessed on 28 June 2023): [[https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K163221](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K163221)]([https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K163221](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K163221))) in 2017, and then Mazor X Stealth (Medtronic, Dublin, Ireland) which was approved by the FDA (Mazor X Stealth FDA 2018 file (accessed on 28 June 2023): [[https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K182077](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K182077)]([https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K182077](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K182077))) in 2018. The example products of Mazor systems are shown in Figure 10. Note that Mazor Robotics (Mazor Spine Robotics website (accessed on 28 June 2023): [[https://www.medtronic.com/ca-en/healthcare-professionals/therapies-procedures/spinal-orthopaedic/spine-robotics.html](https://www.medtronic.com/ca-en/healthcare-professionals/therapies-procedures/spinal-orthopaedic/spine-robotics.html)]([https://www.medtronic.com/ca-en/healthcare-professionals/therapies-procedures/spinal-orthopaedic/spine-robotics.html](https://www.medtronic.com/ca-en/healthcare-professionals/therapies-procedures/spinal-orthopaedic/spine-robotics.html))) was acquired by Medtronic in 2018. A detailed comparison between these four versions of the Mazor systems can be found in [57]. Nowadays, the robotic system is just called Mazor. A systematic review on robotics in spine surgery can be found in [60,61]. The Spine Assist robotic system can be used for pedicle screw placement in spine surgery, but the accuracy of the screw placement is relatively low [55,57]. The updated version, the Renaissance system, preserves a similar operational workflow but with significant software changes [57]. Finally, the latest version of the Mazor system, Mazor X Stealth, has an accuracy of around 99-100% for the screw placement. Both Spine Assist and Renaissance require preoperative CT scans, based on which preoperative planning (e.g., optimal implant size and trajectory) is conducted. Nowadays, the Mazor system can be used in conjunction with the imaging system O-arm for 3D images, besides the use of a CT scan (Scan and Plan workflow). Before the spine surgery, the robot is mounted to the patient's spine. During the surgery, intraoperative fluoroscopic images of the anatomy are acquired and matched with the preoperative CT scans in real time, and this procedure is called the CT-to-Fluoro workflow. Alternatively, the Scan and Plan workflow can be used. In both workflows, the robotic arm provides guidance according to the preplanned trajectory [57].