***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Even though robotic technology holds great potential for performing spinal surgery and advancing neurosurgical techniques , it is of utmost importance to establish its practicality and to demonstrate better clinical outcomes compared with traditional techniques , especially in the current cost-effective era . Several systems have proved to be safe and reliable in the execution of tasks on a routine basis , are commercially available , and are used for specific indications in spine surgery . However , workflow , usability , interdisciplinary setups , efficacy , and cost-effectiveness have to be proven prospect ively . This article includes a short description of robotic structures and workflow , followed by preliminary results of a r and omized prospect i ve study comparing conventional free-h and techniques with routine spine navigation and robotic-assisted procedures . Additionally , we present cases performed with a spinal robotic device , assessing not only the accuracy of the robotic-assisted procedure but also other factors ( eg , minimal invasiveness , radiation dosage , and learning curves ) . Currently , the use of robotics in spinal surgery greatly enhances the application of minimally invasive procedures by increasing accuracy and reducing radiation exposure for patients and surgeons compared with st and ard procedures . Second-generation hardware and software up grade s of existing devices will enhance workflow and intraoperative setup . As more studies are published in this field , robot-assisted therapies will gain wider acceptance in the near future Study Design . A retrospective chart review was performed for 112 consecutive minimally invasive spinal surgery patients who underwent pedicular screw fixation in a community hospital setting . Objective . To assess the clinical accuracy and deviation in screw positions in robot-assisted pedicle screw placement . Summary of Background Data . Accuracy of pedicle screw placement in in vivo studies varies widely , especially when minimally invasive techniques are used . Robotic guidance was recently introduced to increase screw placement accuracy but still reported accuracies vary . Methods . Reproducibility of the surgeon 's plan using robotic guidance was assessed by fusing individual vertebras from the preoperative computed tomography ( CT ) containing the planning with a postoperative CT .  Deviation in entry point and difference in angle of insertion was measured on axial and sagittal planes . Grading of pedicle screw placement was performed on postoperative CTs using the Gertzbein-Robbins classification . Results . CT-to-CT fusion succeeded for 178 screws , but these appeared to be r and om , with no apparent selection bias . Mean deviation in entry point was 2.0 ± 1.2 mm . Mean difference in angle of insertion was 2.2 ° ± 1.7 ° on the axial plane and 2.9 ° ± 2.4 ° on the sagittal plane . Assessment of pedicle screw accuracy showed that 477 of 487 screws ( 97.9 % ) were safely placed ( < 2 mm , category A+B ) , 8 screws in category C and 1 in category D. None of the screws necessitated resurgery for revised placement . Conclusion . Preoperative planning of robotic guidance is reproduced intraoperatively within acceptable deviations . We conclude that robotic guidance allows for highly accurate execution of the preoperative plan , leading to accurate screw placement . Level of Evidence : Study Design : This is a prospect i ve r and omized comparison study between the fluoroscopy-guided and navigation coupled with O-arm – guided pedicle screw placement in the thoracic and lumbosacral spines . Objective : The objective of the study was to evaluate the accuracy and clinical benefits of a navigation coupled with O-arm – guided method in the thoracic and lumbar spines by comparing with a C-arm fluoroscopy-guided method . Methods : Under fluoroscopy guidance , 138 pedicle screws were inserted from T9 to S1 in 20 patients , and 124 pedicle screws were inserted from T9 to S1 in 20 patients using the navigation .  The position of the screws within the pedicle was assessed from grade 0 ( no violation cortex ) to grade 3 ( > 4 mm violation ) , and the location of the violated cortex was determined . Preparation time of each equipment setting , time for screwing , and the number of x-ray shots were evaluated . Results : The number of screws observed as grade 0 was 121 ( 87.7 % ) in the fluoroscopy-guided group and 114 ( 91.9 % ) in the navigation-guided group . The lateral cortex was most commonly involved in the fluoroscopy-guided group ( 6 cases , 35.3 % ) , and the medial cortex was most common in the navigation-guided group ( 4 cases , 40 % ) . The mean time required for preparation for screw placement was 3.7 minutes in the fluoroscopy-guided group and 14.2 minutes in the navigation-guided group . Average screwing time was 3.6 minutes in the fluoroscopy-guided group and 4.3 minutes in the navigation-guided group . The mean number of x-ray shots for each screw placement in the fluoroscopy-guided group was 6.5 . Postoperatively , 2 patients with misplacement of a screw under fluoroscopy guidance presented ipsilateral leg paresthesia , possibly related to the screw position . Conclusions : The present prospect i ve study reveals that the pedicle screw placement guided by the navigation coupled with O-arm system was more accurate and safer than that under fluoroscopy guidance Abstract This purpose of this retrospective study is validation of an intraoperative robotic grading classification system for assessing the accuracy of Kirschner-wire ( K-wire ) placements with the postoperative computed tomography (CT)-base classification system for assessing the accuracy of pedicle screw placements . We conducted a retrospective review of prospect ively collected data from 35 consecutive patients who underwent 176 robotic assisted pedicle screws instrumentation at Kaohsiung Medical University Hospital from September 2014 to November 2015 . During the operation , we used a robotic grading classification system for verifying the intraoperative accuracy of  K-wire placements .  Three months after surgery , we used the common CT-base classification system to assess the postoperative accuracy of pedicle screw placements . The distributions of accuracy between the intraoperative robot-assisted and various postoperative CT-based classification systems were compared using kappa statistics of agreement . The intraoperative accuracies of K-wire placements before and after repositioning were classified as excellent ( 131/176 , 74.4 % and 133/176 , 75.6 % , respectively ) , satisfactory ( 36/176 , 20.5 % and 41/176 , 23.3 % , respectively ) , and malpositioned ( 9/176 , 5.1 % and 2/176 , 1.1 % , respectively)In postoperative CT-base classification systems were evaluated . No screw placements were evaluated as unacceptable under any of these systems . Kappa statistics revealed no significant differences between the proposed system and the aforementioned classification systems ( P < 0.001).Our results revealed no significant differences between the intraoperative robotic grading system and various postoperative CT-based grading systems . The robotic grading classification system is a feasible method for evaluating the accuracy of K-wire placements . Using the intraoperative robot grading system to classify the accuracy of K-wire placements enables predicting the postoperative accuracy of pedicle screw placements OBJECT Minimally invasive transforaminal lumbar interbody fusion ( TLIF )  is an increasingly popular procedure . The technique involves use of fluoroscopy to assist with pedicle screw ( PS ) placement . The potential exists for both the surgeon and the patient to become exposed to significant amounts of radiation . The authors undertook this study to quantify the radiation dose to the surgeon and patient during minimally invasive TLIF . METHODS The authors undertook a prospect i ve study of 24 consecutive patients who underwent minimally invasive TLIF .  All surgeries were performed by the senior author ( R.K.B. ) , who used techniques previously described . The surgeon wore a radiation monitor under an apron-style lead shield at waist level , at an unshielded collar location , and as a sterile ring badge containing a thermoluminescent dosimeter on the dominant ( right ) h and ring finger . Dosimeter readings were obtained for each case . A total of 33 spinal levels were treated in 24 patients . All treated levels were between L3 - 4 and L5-S1 . In all cases of 1-level disease , 4 PSs were placed , and in all cases of 2-level disease , 6 screws were placed . RESULTS Mean fluoroscopy time was 1.69 minutes per case ( range 3.73 - 0.82 minutes ) . Mean exposure per case to the surgeon on his dominant h and was 76 mRem , at the waist under a lead apron was 27 mRem , and at an unprotected thyroid level was 32 mRem . Mean exposure to the patient 's skin was 59.5 mGy ( range 8.3 - 252 mGy ) in the posteroanterior plane and 78.8 mGy ( range 6.3 - 269.5 mGy ) in the lateral plane . CONCLUSIONS To the authors ' knowledge , this is the first study of radiation exposure to the surgeon or patient in minimally invasive TLIF .  Patient exposures were low and compare favorably with exposures involving other common interventional fluoroscopically guided procedures . Surgeon exposures are limited but require careful monitoring . Annual dose limits could be exceeded if a large number of these and other fluoroscopically guided procedures were performed Study Design . A prospect i ve r and omized clinical trial . Objective . To compare the impact of robotic guidance in a minimally invasive spine surgery ( MIS ) to a fluoroscopy-guided open approach in lumbar fusions . Summary of Background Data . MIS requires a protracted learning curve and excessively exposes the patient and surgical team to harmful radiation . Robotic-guidance has been shown to improve accuracy and radiation in most studies , but there is conflicting prospect i ve data . Methods . Patients indicated to undergo a 1 or 2 level spinal fusion were r and omized between robotic-guided MIS ( RO ) and fluoroscopic-guided open surgery ( FA ) . Patient demographics and outcomes were recorded . Results . Thirty patients were recruited to each arm . Average age was 66.7 years , 71.5 % were females , and average body mass index was 25.2 . Thirty-five levels were instrumented with 130 pedicle screws in RO versus 40 levels with 140 screws in FA , or 4.3 and 4.7 screws per surgery , respectively . Use of fluoroscopy was 3.5 versus 13.3 seconds in the RO and FA respectively ( P < 0.001 ) . C-arm output in mSv was 0.13 versus 0.27 in the RO and FA respectively ( P = 0.015 ) . By thermoluminescent dosimeters , the average per-screw radiation in the RO arm was 37.5 % of that in the FA arm , demonstrating a mean reduction of 62.5 % in use of radiation . There was no difference in the improvement in Visual Analog Scale scores for back and leg or the Oswestry Disability Index . All screws were accurate in RO whereas two screws breached ( > 2 mm and > 4 mm ) in FA ( P = 0.500 ) . One proximal facet violation occurred in the study , it was in FA ( P = 1.000 ) . The average distance from the proximal facets was 5.8 versus 4.6 mm in the RO and FA respectively ( P < 0.001 ) . The average length of stay was 6.8 versus 9.4 days in RO compared with FA ( P = 0.020 ) . Conclusion . MIS using robotic-guidance significantly reduced radiation exposure and length of stay . Patient outcomes were not affected by the surgical technique . Level of Evidence : Bone-mounted robotic guidance for pedicle screw placement has been recently introduced , aim ing at increasing accuracy . The aim of this prospect i ve study was to compare this novel approach with the conventional fluoroscopy assisted freeh and technique ( not the two- or three-dimensional fluoroscopy-based navigation ) . Two groups were compared : 11 patients , constituting the robotical group , were instrumented with  64 pedicle screws ; 23 other patients , constituting the fluoroscopic group , were also  instrumented  with 64 pedicle screws .  Screw position was assessed by two independent observers on postoperative CT-scans using the Rampersaud A to D classification . No neurological complications were noted . Grade A ( totally within pedicle margins ) accounted for 79 % of the screws in the robotically assisted and for 83 % of the screws in the fluoroscopic group respectively ( p = 0.8 ) . Grade C and D screws , considered as misplacements , accounted for 4.7 % of all robotically inserted screws and 7.8 % of the fluoroscopically inserted screws ( p = 0.71 ) . The current study did not allow to state that robotically assisted screw placement supersedes the conventional fluoroscopy assisted technique , although the literature is more optimistic about the former Study Design . Single-center prospect i ve r and omized controlled study . Objective . To evaluate the accuracy of  robot-assisted ( RO ) implantation of lumbar/sacral pedicle screws  in comparison with the freeh and ( FH ) conventional technique . Summary of Background Data . SpineAssist is a miniature robot for the implantation of thoracic , lumbar , and sacral pedicle screws . The system , studied in cadaver and cohort studies , revealed a high accuracy , so far . A direct comparison of the robot assistance with the FH technique is missing . Methods . Patients requiring mono- or bisegmental lumbar or lumbosacral 
    Output:
    
CONCLUSIONS Robotics in spine surgery is an emerging technology that holds promise for future applications .
Surgical accuracy in instrumentation implanted using robotics appears to be high .
However , the impact of robotics on radiation exposure is not clear and seems to be dependent on technique and robot type