- Alix School of Medicine, Mayo Clinic, Scottsdale,
- Department of Osteopathic Medicine, A. T. Still University, Mesa,
- Department of Neurosurgery, Duke University Medical Center, Durham,
- Department of Neurosurgery, Mayo Clinic, Phoenix,
- Mayo Clinic Neuro-Informatics Laboratory, Rochester, United States.
India C. Rangel, Alix School of Medicine, Mayo Clinic, Scottsdale, United States.
DOI:10.25259/SNI_522_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Rohin Singh1, Kendra Wang2, Muhammad Bilal Qureshi1, India C. Rangel1, Nolan J. Brown1, Shane Shahrestani1, Oren N. Gottfried3, Naresh P. Patel4, Mohamad Bydon5. Robotics in neurosurgery: Current prevalence and future directions. 19-Aug-2022;13:373
How to cite this URL: Rohin Singh1, Kendra Wang2, Muhammad Bilal Qureshi1, India C. Rangel1, Nolan J. Brown1, Shane Shahrestani1, Oren N. Gottfried3, Naresh P. Patel4, Mohamad Bydon5. Robotics in neurosurgery: Current prevalence and future directions. 19-Aug-2022;13:373. Available from: https://surgicalneurologyint.com/surgicalint-articles/11803/
Background: The first instance of a robotic-assisted surgery occurred in neurosurgery; however, it is now more common in other fields such as urology and gynecology. This study aims to characterize the prevalence of robotic surgery among current neurosurgery programs as well as identify trends in clinical trials pertaining to robotic neurosurgery.
Methods: Each institution’s website was analyzed for the mention of a robotic neurosurgery program and procedures. The future potential of robotics in neurosurgery was assessed by searching for current clinical trials pertaining to neurosurgical robotic surgery.
Results: Of the top 100 programs, 30 offer robotic cranial and 40 offer robotic spinal surgery. No significant differences were observed with robotic surgical offerings between geographic regions in the US. Larger programs (faculty size 16 or over) had 20 of the 30 robotic cranial programs (66.6%), whereas 21 of the 40 robotic spinal programs (52.5%) were at larger programs. An initial search of clinical trials revealed 223 studies, of which only 13 pertained to robotic neurosurgery. Spinal fixation was the most common intervention (six studies), followed by Deep Brain Stimulation (DBS, two studies), Cochlear implants (two studies), laser ablation (LITT, one study), and endovascular embolization (one study). Most studies had industry sponsors (9/13 studies), while only five studies had hospital sponsors.
Conclusion: Robotic neurosurgery is still in its infancy with less than half of the top programs offering robotic procedures. Future directions for robotics in neurosurgery appear to be focused on increased automation of stereotactic procedures such as DBS and LITT and robot-assisted spinal surgery.
Keywords: Robotic cranial, Robotic neurosurgery, Robotic spinal, Robotic assisted
The last few decades have marked a rise in minimally invasive surgeries and greater incorporation of robotic assistance in surgical procedures. It is reported that the first application of robotics in surgery took place in the mid-1980s when the PUMA 560 robotic system was used to perform neurosurgical biopsy.[
While the first instance of robotic-assisted surgery occurred in neurosurgery, robotics is now more common in fields with relatively less anatomical space constraints such as urology, gynecology, and orthopedics.[
Recently, there has been increased interest in robotic applications in neurosurgery as the demand for minimally invasive approaches to the brain and spine has grown. As new technologies continue to emerge, it is now possible to predict how neurosurgical robotics will progress in the coming years. This paper seeks to gauge the current prevalence of robotics in neurosurgical programs within the United States and assess future applications of robotics in neurosurgery through a review of ongoing clinical trials. We intend our report to provide key insight regarding current trends and future directions in neurosurgical robotics in a way that assists neurosurgeons in determining how they can optimize incorporation of this technology into their practice.
Review of current neurosurgical programs
The US News and World Report’s “Best Hospitals for Neurology and Neurosurgery” list was accessed in January 2022 to compile a list of the top 100 ranked neurosurgical hospitals in the United States. Each institution’s website was analyzed for the mention of a robotic neurosurgery program and the provision of robotic neurosurgical procedures. Programs were, further, classified according to whether robotic spine surgeries and/or robotic cranial surgeries were available. The city and state of each program was collected and each program was classified into the appropriate geographical region (West, Midwest, Northeast, and South). Faculty size information of each program was also collected to determine if size of a program correlated with robotic surgery offerings. Programs were considered small if they had 15 or fewer faculty and large if they had greater than 15 faculties. The previous studies have found 16 faculty members as the median for neurosurgical programs.[
Review of clinical trials
To assess the future potential applications of robotics in neurosurgery, an analysis of recent and ongoing clinical trials pertaining to neurosurgical robotic surgery was conducted. ClinicalTrials.gov,[
Of the resulting studies, those relevant to the application of robotics during neurosurgery-related procedures were retained for analysis. Trials related to postoperative rehabilitation and specialties other than neurosurgery were excluded from further analysis. The following information was collected from each relevant study record: condition(s) or disease(s) being studied, trial status, availability of study results, start date, projected trial duration, projected enrollment, number of sites clinical sites, sponsor type (industry, hospital/university, and NIH), and sponsor name. Each trial was also categorized by relevant clinical intervention based on the provided study description. These categories were as follows: “spinal fixation surgery,” “deep brain stimulation (DBS),” “laser ablation,” “cochlear implantation,” or “endovascular embolization.”
Neurosurgical program analysis
Of the top 100 ranked neurological surgery departments, 40 had robotic spinal programs and 30 had robotic cranial programs. The top 30 ranked programs accounted for 47.5% of the current robotic spinal programs and 60% of the current robotic cranial programs [
Robotic cranial and spinal surgery programs were evenly distributed across all geographic regions. The West had the lowest number of programs for robotic cranial surgery but the highest number of programs for robotic spinal surgery, at five and 11 programs, respectively. The South and Midwest both had nine robotic cranial surgery programs and nearly the same number of robotic spinal surgery programs, at nine and ten programs, respectively. The Northeast had seven robotic cranial surgery programs and 10 robotic spinal surgery programs.
There were 10 robotic cranial surgery programs with 15 or fewer faculty members and 20 programs with >15 faculty members. Nineteen robotic spinal surgery programs had 15 or fewer faculty members and 21 programs had greater than 15. These findings are summarized in
California (three cranial and eight spinal) in the West, Michigan (three cranial and four spinal) in the Midwest, and Florida (four cranial and four spinal) in the South, all accounted for the most programs in both robotic cranial and spinal surgeries. New York (four cranial) in the Northeast had the most programs for robotic cranial surgery whereas Pennsylvania (five spinal) in the Northeast had the most programs for robotic spinal surgery [
Clinical trial analysis
The initial search of clinical trials yielded 223 results, of which 13 were relevant to this study [
Of the nine industry sponsored trials, five were distinct industry sponsors, with Mazor Robotics contributing the most trials sponsored at four. All five of the hospital sponsored trials were conducted at different hospitals. One of the trials was sponsored by both hospital and industry. Having industry sponsors had no correlation with the status of the study [
Of the 13 clinical trial studies, spinal fixation surgeries were the most common intervention. One out of the six spinal fixation surgery studies was hospital sponsored (the “EUROSPIN” study) and four were sponsored by Mazor Robotics. Studies that involved DBS and vertebral body augmentation intervention were all hospital sponsored. The study, “First Clinical Evaluation of HEARO Robotic Cochlear Implantation Surgery in Austria,” was also hospital sponsored by the Medical University of Vienna. The rest of the studies for cochlear implantation, laser ablation, and endovascular embolization interventions were industry sponsored [
The results of this study suggest that robotic usage in neurosurgery could still be in its infancy. Only 40 out of 100 neurosurgical departments have robotic spinal programs and 30 out of 100 departments have robotic cranial programs. While these robotic programs are evenly distributed across the US, they are more often seen in higher ranked institutions – the top 30 ranked neurosurgical programs controlled over 50% of the robotics market share. These findings aligned with the current trends within the literature as neurosurgery to date has not experienced mass adoption of robotics.
Furthermore, examination of future applications for robotics in neurosurgery through the clinical trial database showed a paucity of ongoing studies in this arena – only 13 relevant clinical trials were found to be applicable, none of which have been completed. These studies were also widely spread across a variety of neurological conditions, making it less possible to draw generalized conclusions about the progress of neurosurgical robotics across the field. In addition, industry was responsible for the most sponsors (69.23%) versus hospital sponsored clinical trials (38.46), which raises the potential of biases due to funding sources.
Having a larger program size, in terms of the number of faculty, also seemed to play some role in the adoption of robotic cranial surgery programs – most of these programs (67%) had more than 15 faculty members. This did not seem to apply to robotic spinal surgery programs; however, where the number of programs did not differ based on program size. Although further investigation is required to understand the reason for this disparity, it is possible that funding opportunities are simply more readily available for robotic spinal surgery programs, especially given the apparent industry enthusiasm for the incorporation of this technology. For example, of the six spinal fixation studies, five were industry sponsored, while studies involving deep brain fixation were solely hospital sponsored.
As evidenced by the results of this study, neurosurgery has not seen wide adoption in the usage of robotics despite the rich history of neurosurgical innovation in stereotaxy and brain localization, the highly technical nature of the field, and the continued demand for minimally invasive procedures.[
The findings of this study must be seen in the light of some limitations. The novel SARS-CoV-2 (COVID-19) pandemic has impacted the practice of medicine, and neurosurgical programs may have outdated websites due to the unforeseen challenges of the COVID-19 pandemic. Therefore, assessing whether a neurosurgery program utilizes robotics using the information provided by its website, without official confirmation from the department chair, may provide incorrect data. In addition, regardless of the of COVID-19 pandemic, it is possible that some programs simply may not list the most up-to-date description of their robotic surgical services or may report offering certain services that are not currently available. Furthermore, using the clinical trials, database may leave out current trials outside of the United States that is not receiving funding from the National Institutes of Health. Future studies should incorporate searches using international clinical trial databases to present the current prevalence of robotics in neurosurgery across the world, or survey program faculty directly regarding the current status of robotic services at their institution.
Future studies could also survey current neurosurgical residents to assess how impactful the educational experience would become if neurosurgical robotics were incorporated within their curriculum. If strong desire exists, it may be the needed catalyst to drive the change required to move neurosurgery forward. Likewise, it may encourage leaders within the neurosurgical community to establish a fellowship program that gives programs without robotics an opportunity for residents to learn the symbiotic relationship between humans and machines.
Barriers and challenges still exist within the broad adoption of robotic assistance; however, if we ask the right questions, neurosurgery will continue to innovate as we enter the fourth industrial revolution.
Patient’s consent not required as there are no patients in this study.
There are no conflicts of interest.
1. Ahmed SI, Javed G, Mubeen B, Bareeqa SB, Rasheed H, Rehman A. Robotics in neurosurgery: A literature review. J Pak Med Assoc. 2018. 68: 258-63
2. . Available from: https://clinicaltrials.gov [Last accessed on 2022 Jun 06].
3. D’Souza M, Gendreau J, Feng A, Kim LH, Ho AL, Veeravagu A. Robotic-assisted spine surgery: History, efficacy, cost, and future trends. Robot Surg. 2019. 6: 9-23
4. Denning NL, Kallis MP, Prince JM. Pediatric robotic surgery. Surg Clin North Am. 2020. 100: 431-43
5. Doulgeris JJ, Gonzalez-Blohm SA, Filis AK, Shea TM, Aghayev K, Vrionis FD. Robotics in neurosurgery: Evolution, current challenges, and compromises. Cancer Control. 2015. 22: 352-9
6. Elsabeh R, Singh S, Shasho J, Saltzman Y, Abrahams JM. Cranial neurosurgical robotics. Br J Neurosurg. 2021. 35: 532-40
7. Elswick CM, Strong MJ, Joseph JR, Saadeh Y, Oppenlander M, Park P. Robotic-assisted spinal surgery: Current generation instrumentation and new applications. Neurosurg Clin N Am. 2020. 31: 103-10
8. Fan M, Liu Y, He D, Han X, Zhao J, Duan F. Improved accuracy of cervical spinal surgery with robot-assisted screw insertion: A prospective, randomized, controlled study. Spine (Phila Pa 1976). 2020. 45: 285-91
9. Fan Y, Du JP, Liu JJ, Zhang JN, Qiao HH, Liu SC. Accuracy of pedicle screw placement comparing robot-assisted technology and the free-hand with fluoroscopy-guided method in spine surgery: An updated meta-analysis. Medicine (Baltimore). 2018. 97: e10970
10. Fomenko A, Serletis D. Robotic stereotaxy in cranial neurosurgery: A qualitative systematic review. Neurosurgery. 2018. 83: 642-50
11. Gao S, Wei J, Li W, Zhang L, Cao C, Zhai J. Accuracy of robot-assisted percutaneous pedicle screw placement under regional anesthesia: A retrospective cohort study. Pain Res Manag. 2021. 2021: 6894001
12. Ghezzi TL, Corleta OC. 30 years of robotic surgery. World J Surg. 2016. 40: 2550-7
13. Lane T. A short history of robotic surgery. Ann R Coll Surg Engl. 2018. 100: 5-7
14. Laratta JL, Shillingford JN, Lombardi JM, Alrabaa RG, Benkli B, Fischer C. Accuracy of S2 alar-iliac screw placement under robotic guidance. Spine Deform. 2018. 6: 130-6
15. Lee NJ, Khan A, Lombardi JM, Boddapati V, Park PJ, Mathew J. The accuracy of robot-assisted S2 alar-iliac screw placement at two different healthcare centers. J Spine Surg. 2021. 7: 326-34
16. Li HM, Zhang RJ, Shen CL. Accuracy of pedicle screw placement and clinical outcomes of robot-assisted technique versus conventional freehand technique in spine surgery from nine randomized controlled trials: A meta-analysis. Spine (Phila Pa 1976). 2020. 45: E111-9
17. Linden GS, Birch CM, Hresko MT, Cook D, Hedequist DJ. Intraoperative use of robotics with navigation for pedicle screw placement in treatment of pediatric high-grade spondylolisthesis: A preliminary report. J Pediatr Orthop. 2021. 41: 591-6
18. Mattei TA, Rodriguez AH, Sambhara D, Mendel E. Current state-of-the-art and future perspectives of robotic technology in neurosurgery. Neurosurg Rev. 2014. 37: 357-66
19. Mikhail D, Sarcona J, Mekhail M, Richstone L. Urologic robotic surgery. Surg Clin North Am. 2020. 100: 361-78
20. Moon AS, Garofalo J, Koirala P, Vu MT, Chuang L. Robotic surgery in gynecology. Surg Clin North Am. 2020. 100: 445-60
21. Panesar SS, Kliot M, Parrish R, Fernandez-Miranda J, Cagle Y, Britz GW. Promises and perils of artificial intelligence in neurosurgery. Neurosurgery. 2020. 87: 33-44
22. Peng YN, Tsai LC, Hsu HC, Kao CH. Accuracy of robot-assisted versus conventional freehand pedicle screw placement in spine surgery: A systematic review and meta-analysis of in neurosurgery randomized controlled trials. Ann Transl Med. 2020. 8: 824
23. Peters BS, Armijo PR, Krause C, Choudhury SA, Oleynikov D. Review of emerging surgical robotic technology. Surg Endosc. 2018. 32: 1636-55
24. Singh R, De La Peña NM, Azuma AF, Smaga BW, Pollock JR, Patel NP.editors. Letter to the editor: Analysis of neurosurgery residency websites by educational and recruitment information in 2020. World Neurosurg. 2021. 151: 307-8
25. Tamaki A, Rocco JW, Ozer E. The future of robotic surgery in otolaryngology head and neck surgery. Oral Oncol. 2020. 101: 104510
26. Trybula SJ, Oyon DE, Wolinsky JP. Robotic tissue manipulation and resection in spine surgery. Neurosurg Clin N Am. 2020. 31: 121-9
27. Vardiman AB, Wallace DJ, Crawford NR, Riggleman JR, Ahrendtsen LA, Ledonio CG. Pedicle screw accuracy in clinical utilization of minimally invasive navigated robot-assisted spine surgery. J Robot Surg. 2020. 14: 409-13
28. Wagner CR, Phillips T, Roux S, Corrigan JP. Future directions in robotic neurosurgery. Oper Neurosurg (Hagerstown). 2021. 21: 173-80
29. Wang MY, Goto T, Tessitore E, Veeravagu A. Introduction. Robotics in neurosurgery. Neurosurg Focus. 2017. 42: E1