Scoliosis, defined as abnormal spinal rotation with a coronal curve greater than 10°, can be classified into three subtypes: congenital, neuromuscular, or idiopathic. Approximately 85% of cases are idiopathic, further categorized by age of onset: infantile (≤2 years), juvenile (3–9 years), and adolescent (≥10 years) (1). Adolescent idiopathic scoliosis (AIS) is the most common form, affecting 1%–3% of children aged 10–16 years (2). Approximately 10% of affected individuals progress and require surgical intervention (3). Surgery is indicated in individuals with a primary curve greater than a Cobb's angle of 45° (2). Correction of spinal deformity is crucial for improving a patient's health-related quality of life. Pedicle screw-only construct is safe, effective and reliable in correcting spinal deformities (4–6) and is still considered the widely accepted surgical option. However, screw implantation is particularly challenging if the patient presents with a higher degree of deformity or hypoplasia of the spinal pedicle (7). Spinal robotic technology offers a solution to this problem (8, 9). The Mazor Robotics's SpineAssist™ became the first FDA-approved robot to guide the placement of pedicle screws in 2004 (10). The accuracy of pedicle screw implantation has been well studied (8, 11, 12). However, there is a paucity of information on the radiographic and clinical outcomes, especially in patients with AIS. This study aimed to investigate the radiographic and clinical outcomes of robot-assisted (RO) pedicle screw instrumentation for AIS compared to those of the conventional freehand (FH) method.

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of our institution (No. CE21251B, date of approval: Jul 28, 2021). The requirement for written informed consent was waived by the institutional review board.

The RO technique may outperformed the conventional FH posterior instrumentation surgery for AIS patients in certain aspects. However, the follow-up period was significantly shorter in the RO group, as the Renaissance™ robotic system was not introduced in our institute until 2018. A higher pedicle screw density was attained with RO compared to that with the FH method. The correction rates were similar, at approximately 60%. The operative time per screw and EBL per screw did not differ between the two surgical methods.

Both groups underwent an open approach with a midline incision, with similar LOS in both groups; this correlates with the findings by Schatlo et al. (22) that LOS was not statistically different between RO and conventional FH open-approach techniques (9.8 days vs. 10.3 days), p = 0.390. Hyun et al. (23) compared robot-guided minimally invasive surgery and fluoroscopic-guided open surgery, with LOS reported to be 6.8 days vs. 9.4 days, p = 0.020. It can be concluded that the surgical approach, open or minimally invasive, independently affects LOS, regardless of robotic use (9, 23).

A retrospective multicenter study of postoperative TS in patients with AIS deemed a horizontal deviation greater than 2 cm of the vertical trunk reference line (VTRL) from the center sacral vertical line (CSVL) post-surgically as positive TS. The prevalence of positive TS was found to reduce from 29.3% to 13.6% after surgical intervention (24), similar to the results of our study (from 48.0% to 8.0%). We further conducted the McNemar test to analyze the change in positive TS postoperatively using two different techniques. The TS for the RO group was significantly reduced from 45.1% to 3.2%, p < 0.001, a larger reduction than that for the FH group (52.7%–15.8%), p = 0.065. Patient without trunk shift preoperatively who developed trunk shift after the surgery was considered iatrogenic. In the FH group, two patients (10.5%) exhibited iatrogenic trunk shift, while in the RO group, there were no instances (0%). The RO technique provides more effective correction for TS, and also reduces the risk of iatrogenic trunk shift compared to the FH method.

The existing literature primarily focuses on using RSH as a parameter to predict postoperative shoulder imbalance (PSI). Unbalanced shoulders are defined as having an RSH of 10 mm or more (25). Studies have identified preoperative RSH as an independent predictor of PSI (26). Our data suggest that shoulder imbalance shows significant improvement after RO surgery, in contrast to the FH group, where RSH remains relatively unchanged. We recommend considering RO surgery for patients with preoperative shoulder imbalance to achieve better RSH correction and thereby reduce the risk of PSI.

Due to the financial limitations imposed by our National Health Insurance system, titanium rod remains the sole option for posterior spinal instrumentation in our healthcare setting. Previous literature suggests that cobalt-chromium rods are generally considered better than titanium rods for effectively reducing the rate of rod fractures, correcting spinal deformities, and ensuring postoperative stability (27, 28). Limited to using titanium rods, we need to increase pedicle screw density to effectively and safely perform the reduction by derotation technique with the rods. Through preoperative planning and the assistance of a robot during surgery, surgeons are able to implant a greater number of pedicle screws, achieving a higher screw density.

Postoperative plain radiographs demonstrated significantly reduced LL values for patients in the FH group, whereas RO surgery maintained the LL. Iatrogenic loss of LL is a disabling complication after corrective scoliosis surgery, resulting in the inability to stand upright and back pain (29). Chun et al. (30) also reported a strong relationship between low back pain (LBP) and lumbar lordotic angle. Given this evidence, we concluded that the RO technique could provide sustained postoperative LL, resulting in less LBP than the conventional FH method. This corresponded with our finding of significantly improved back pain three months postoperatively (ΔVAS_3m) with the use of a robot. We suggest that special attention should be paid while operating on patients with especially small LL using the traditional FH method.

We observed that SVA was significantly increased, moving anteriorly, after conventional FH surgery, but remained unchanged in the RO group. The postoperative SVAs for both groups were within the physiological range of the child (−31.6–22.4 mm). Notably, postoperative SVA in the FH group was beyond the normal range (9.5 mm) of the adult Schwab Adult Spinal Deformity Classification (31). The RO technique may be better for sustaining patient SVA.

As for the accuracy of RO pedicle screw instrumentation, previous studies have already verified its accuracy, ranging from 90% to 100% (32). In our study, the rate of satisfactory screw position was 90.5%; we believe that this is related to the pedicle hypoplasia commonly present in AIS patients. Additionally, we aimed to achieve a higher screw density when performing surgery. Provided that the screw could reach the vertebral body during preoperative planning, we could specially design an “in-out-in” trajectory for some patients with pedicle hypoplasia. To avoid medial wall violation, it is feasible to increase the total number of pedicle screws in a safe way (only lateral breech), and further achieve better corrective force. Conversely, such a trajectory could not be designed preoperatively if using the conventional FH method, and we would rather not insert screws at the vertebrae of patients with pedicle hypoplasia.

Our data demonstrates that the RO group had a significantly lower breach rate compared to the FH group (9.5% vs. 32.3%, p < 0.001). This reduced breach rate allows for the successful placement of a larger number of pedicle screws, significantly increasing screw density. Hwang et al. have reported that high-density pedicle screw constructs lead to better deformity correction in AIS patients (33). The RO technique, by achieving higher screw density, provides stronger spinal fixation, enabling surgeons to safely perform more effective deformity corrections.

The changes in the ODI and QALYs after surgery were not significantly different between the two groups, except for ΔODI_3m. However, all patients reported better function and quality of life 12 months postoperatively compared with that observed preoperatively. The VAS for back pain was the main clinical parameter that verified the superiority of the RO surgery. The RO technique outperformed conventional FH surgery at alleviating LBP from the third postoperative month (ΔVAS_3m). This correlated with the radiographic finding that RO surgery could maintain postoperative LL, resulting in reduced LBP compared with that with the conventional FH method.

Costa et al. (34) performed a biomechanical study and found that a misplaced screw in the craniocaudal direction was associated with significantly less primary stability than screws in the centered sagittal position. Açikbaş et al. (35) also found that significant spinal motion on flexion-extension radiographs was observed in patients with screw misplacement, and this significant motion was correlated with more intense back pain. Robotic technology has demonstrated significantly superior accuracy with fewer misplaced pedicle screws compared to that with conventional techniques (8, 11, 12), providing stability to the spinal structures and further alleviating back pain.

To our knowledge, this study is the first to highlight the radiographic and clinical outcomes of RO pedicle screw instrumentation in patients with AIS; this is clinically important in assisting surgeons with adopting RO techniques.

First, the sample size was small, which could be owing to the inclusion of only all-pedicle-screw construct and exclusion of hybrid implants. Second, there is chronological bias. Before the robotic system was first introduced in our institute in 2018, patients could only choose conventional FH surgery, which caused a significant difference in follow-up time between the two groups. Finally, data from only one institute were included.

Overall, RO pedicle screw instrumentation achieves a significantly reduced breech rate and provides satisfactory radiographic and clinical outcomes in AIS patients. TS and RSH were significantly corrected with preserved LL, resulting in an improved VAS score for back pain.