Robot-assisted vs conventional lumbar interbody fusion: A systematic review and meta-analysis of perioperative, radiographic, and clinical outcomes

Table 3 Radiographic outcomes

Ref.	Procedure	Sagittal alignment changes	Facet joint violation (RA vs comparator)	Notes
Wang et al[1], 2023	MIS-TLIF (RA vs FA)	Not reported	FJV grades: RA: 89.8% grade 0 (no violation) FA: 62.1% grade 0 (P < 0.001) - mean FJV grade lower in RA (0.24 vs 0.50; P < 0.001)	Adjacent segment: Less disc height loss at proximal adjacent segment in RA (0.69 mm vs 0.93 mm; P < 0.001). Fusion rates: No difference (BSF-3: 88.5% RA vs 85.5% FA; P = 0.616)
Tong et al[2], 2024	RA-OLIF vs FG OLIF	Sagittal alignment parameters (LL, SL, PI-LL) not explicitly reported	RA-OLIF: 4.7% FJV rate (61 grade 0, 2 grade 1, 1 grade 2)	RA-OLIF had higher screw accuracy (98.4% grade A/B vs 95.5% in fluoroscopy; P = 0.015)
		Focus on screw accuracy and FJV rates	Fluoroscopy: 19.3% FJV rate (71 grade 0, 11 grade 1, 5 grade 2, 1 grade 3)	Shorter-term benefits: Lower VAS-back at 3 days post-op (P = 0.003)
			(P = 0.009)
Shafi et al[3], 2022	MIS-TLIF (RN vs ION)	Not reported	FJV rates: RN: 5.0% ION: 1.3% (P = 0.0017)	Screw dimensions: RN allowed larger screw diameters (7.25 mm vs 6.72 mm; P < 0.001) and longer screws (48.4 mm vs 45.6 mm; P < 0.001)
				Accuracy: Similar “ideal” (grade A) screw rates (88.5% RN vs 88.4% ION; P = 0.969), but RN eliminated high-grade breaches (0% grade E vs 1.2% in ION; P = 0.051)
				Endplate breaches: Higher in RN (6.9% vs 1.3%; P = 0.001), but most were clinically insignificant
Griepp et al[4], 2024	MIS-TLIF (RA vs O-arm navigation)	Not reported	Lateral breaches: RA: 4/210 (1.9%, all grade B)- ON: 24/304 (7.89%, grades C-D) medial breaches: 0 in both groups	No revisions for malposition in either group
Lin et al[5], 2022	MIS-TLIF (robot-guided vs freehand)	Not reported	Not reported	Pedicle screw breach rates: Robot-guided (0.27%) vs freehand (1.75%), P = 0.04
				Lateral breaches more common in freehand group (9/12 breaches). No medial breaches with robotics
Li et al[6], 2025	RA-SP-LLIF vs traditional LLIF	Significant postoperative improvements in LL (45.2°-51.5°), SL (24.0°-29.3°), and PI-LL (13.0°-7.8°) (P < 0.01). Gains in LL/SL/PI-LL were not sustained at final follow-up (P > 0.05 vs baseline). No difference in PT/SS changes	Not explicitly reported, but the high screw accuracy (99.2% RA vs 98.2% traditional) suggests low risk	Comparable fusion rates (Bridwell grade) and complications between groups
Heath et al[7], 2024	RA-MIS-TLIF vs ON-MIS-TLIF	Sagittal alignment parameters (LL, SL, PI-LL) not explicitly reported	RA-MIS-TLIF: 0% breach rate (100% grades A/B)	No reoperations for screw malposition in either group
		Focus on screw accuracy and breach rates	ON-MIS-TLIF: 7.89% breach rate (92.1% grades A/B; P < 0.001)
			No medial breaches in either group
Chang et al[11], 2022	PE RA-TLIF vs MIS-TLIF	Not reported	Not reported	Screw accuracy: Robot 0.9% vs fluoroscopy 6.3% (P < 0.05)
				Fusion rates: 87.3% (robot) vs 91.8% (fluoroscopy, P = 0.53)
				Smaller incisions, less blood loss with robotics
Lai et al[15], 2022	MIS-TLIF (robot vs fluoroscopy)	Not reported	Not reported	Screw loosening: Robot 4.3% vs fluoroscopy 10.2% (P = 0.049)
				Robot screws placed closer to upper endplate (ratio 0.35 vs 0.39, P < 0.001). Loosening linked to age, multilevel fusion, and endplate distance ratio
Zhang et al[20], 2019	TLIF with pedicle screws	Not reported for LL/SL/PI-LL	RA: 5/176 screws (2.8%) violated facets FG: 24/204 screws (11.8%) (P=0.001)	RA achieved higher perfect screw placement (grade A: 93.2% vs 85.8%, P = 0.020)
				No severe breaches (grade E) in RA vs 2 in FG
Zhang et al[21], 2019	TLIF with percutaneous pedicle screws	Not reported for LL/SL/PI-LL	RA: 4/100 screws (4%) violated facets (grades 1-2) FG: 26/100 screws (26%) (grades 1-3) (P < 0.001)	RA eliminated severe FJV (grade 3 0% vs 3% in FG)
				Larger screw-to-facet distance (4.16 mm vs 1.92 mm, P < 0.001)
Chen et al[22], 2021	RA MIS-TLIF vs open TLIF	Not reported	Not reported	RA advantages: Higher screw accuracy (92.3% grade A vs 77.4%), faster early pain relief (VAS/ODI at 1 month)
				Both groups: Similar 1-year fusion rates (94.2% vs 92.3%)
Cui et al[23], 2021	RA-MIS-TLIF vs open TLIF	Alignment restored in both groups (no quantitative LL/SL data)	RA: 0% (no revisions) vs open: 5% (5 screws revised)	RA: Reduced paraspinal muscle atrophy (P = 0.016) at 2-year follow-up
Feng et al[24], 2020	RA-OLIF vs freehand OLIF	Alignment restored via indirect decompression (no quantitative LL/SL data)	RA: 1.8% (3/170 screws breached) vs freehand: 6.9% (12/174 screws breached)	RA: Reduced blood loss (P = 0.022) and eliminated postoperative drainage
Li et al[25], 2024	RA-MIS-TLIF vs fluoroscopy-MIS-TLIF	Sagittal alignment parameters (LL, SL, PI-LL) not explicitly reported	RA-MIS-TLIF: 0.13 ± 0.43 FJV grade (90.1% grade 0)	Reduced adjacent segment disc height loss (0.63 ± 0.38 mm vs 0.92 ± 0.35 mm; P = 0.001)
		Focus on screw accuracy, FJV, and adjacent segment degeneration	Fluoroscopy: 0.43 ± 0.68 FJV grade (66.1% grade 0) (P < 0.001)	Comparable fusion rates (BSF grades; P = 0.522)
Han et al[26], 2021	OLIF vs MIS-TLIF	Not reported	Not reported	OLIF advantages: Higher disc height (12.4 vs 11.2 mm) and fusion rate (96% vs 87%)
				Both groups: Similar screw accuracy (97.3% vs 96.2%)
De Biase et al[27], 2021	RA vs FG MI-TLIF	Not reported	Not reported	RA advantages: 50% lower radiation dose (31.5 vs 59.5 mGy)
				Both groups: 0% screw breaches, similar revision rates (1 vs 2 cases)
Fayed et al[28], 2020	RA-PPS (ExcelsiusGPS) vs FG-PPS	Not explicitly measured; alignment inferred from screw accuracy	RA: 5.8% breaches (4 lateral, 2 grade E) vs FG: 3.3% breaches (1 medial)	RA breaches linked to facet hypertrophy; no revisions needed. Short learning curve (1.9% significant breaches after initial cases)
Yang et al[29], 2019	MIS-TLIF with percutaneous pedicle screws	Screw insertion angle: RA: 23.8° ± 6.1° vs fluoroscopy: 18.4° ± 7.2° (P = 0.017)	RA: 5.1% (grades I-II) fluoroscopy: 15.6% (grades I-III), including 2.1% severe (grade III)	RA reduced severe deviations (Neo grade III: 0% vs 3.1%) and improved pedicle screw accuracy (93.8% grade 0 vs 73.8%)
Schatlo et al[30], 2014	Lumbar fusion (open/percutaneous)	Not reported for LL/SL/PI-LL	RA: 8.6% poor trajectory (grades C-E/R)	Lateral misplacement most frequent (RA: 47% of deviations; FG: 39%)
			FG: 12.9% (grades C-E) (P = 0.09)	No difference in clinically acceptable screws (A/B: 91.4% RA vs 87.1% FG, P = 0.19)
Li et al[31], 2024	RA MIS-TLIF/UBE-T/PLIF	Not reported	Not reported	Screw accuracy significantly better in groups A/B vs C (P < 0.05)
Li et al[32], 2022	RA MIS-TLIF	Not reported	Not reported	Higher screw accuracy in robot group (P = 0.002)

Li et al[32] includes three groups: Robot-assisted minimally invasive transforaminal lumbar interbody fusion (group A), robot-assisted unilateral biportal endoscopy-transforaminal/posterior lumbar interbody fusion (group B), and traditional minimally invasive transforaminal lumbar interbody fusion (group C). RA: Robot-assisted; FA: Freehand approach; FJV: Facet joint violation; OLIF: Oblique lumbar interbody fusion; LL: Lumbar lordosis; SL: Segmental lordosis; PI: Pelvic incidence; ON: O-arm navigation; SP-LLIF: Single-position lateral lumbar interbody fusion; PT: Pelvic tilt; VAS: Visual Analog Scale; ODI: Oswestry disability index; GPS: Globus ExcelsiusGPS robotic navigation platform; BSF-3: Bridwell spine fusion grade 3; LLIF: Lateral lumbar interbody fusion; MIS-TLIF: Minimally invasive transforaminal lumbar interbody fusion; UBE-T: Unilateral biportal endoscopy-transforaminal; PLIF: Posterior lumbar interbody fusion; FG: Fluoroscopy-guided.