Radiation Exposure and Dose Estimates of Robot-Guided Versus Fluoroscopy-Guided Spinal Fusion: A Meta-Analysis of Randomized Controlled Trials.

STUDY DESIGN: Systematic review and meta-analysis. SUMMARY OF BACKGROUND DATA: Robot-guided (RG) pedicle screw placement offers several advantages over fluoroscopy-guided (FG) surgery to patients undergoing spinal fusion. Radiation exposure and detrimental risks associated with RG surgery are poorly described in the literature. OBJECTIVES: We perform a systematic review and meta-analysis of randomized controlled trials comparing RG to FG spinal fusion to assess radiation exposure to patients and clinicians. METHODS: MEDLINE, Embase, Web of Science, and Cochrane Central were systematically queried. Inclusion was restricted to RCTs in adults. Version 2 of the Cochrane risk-of-bias tool for RCTs (RoB 2) was used to evaluate risk of bias and quality was appraised using the GRADE assessment tool. Continuous data were pooled across trials with inverse variance weighting to mean difference (MD) and dichotomous data were pooled with Mantel-Haenszel weighting to odds ratio (OR) with corresponding 95% CI. RESULTS: A total of 1042 patients (RG: 651; FG: 391) from 8 RCTs were included. Radiation time was reduced in the RG group by 39.6% (MD: -25.65 seconds, 95% CI: -51.07 to -0.22) with an estimated anteroposterior and lateral dose-area product in the RG group measuring 123.85±73.12 and 241.08±142.33 cGycm2, respectively. Estimated cancer risk and detrimental hereditary disorder risk were reduced by 40.2% in the RG group (3.60×10-5±2.12×10-5 and 1.31×10-6±7.72×10-7, respectively). Intraoperative bleeding volume was reduced in the RG group (MD: -61.52 mL, 95% CI: -100.16 to -22.87, P=0.002, I2=48%). However, surgical duration was significantly higher in the RG group (MD: 12.01 min, 95% CI: 1.63-22.39). Pedicle screw accuracy and length of hospital stay differences were not significant. CONCLUSIONS: Radiation exposure to patients undergoing spinal fusion is lower in RG surgery compared with FG surgery. These findings can be supported with long-term studies that better characterize radiation dosages associated with these procedures. LEVEL OF EVIDENCE: Level I.