Effect of surgeon expertise on the accuracy and time required for fluoroscopic, navigated, and robot-assisted thoracolumbar pedicle screw placement

Technological advances in minimally invasive pedicle screw (PS) placement have progressed from 2D fluoroscopy (FL) to 3D navigation (NAV) and robot-assisted navigation (RA). Whether increasing technical support can compensate for limited surgical experience remains unclear. This study investigated the influence of surgeon experience and guidance technology on PS insertion time and accuracy during first-time use. In this experimental study, nine artificial thoracolumbar spine models (T7–S1) were instrumented. Three surgeons with varying levels of experience each placed 72 PS using FL, NAV, and RA. Screw accuracy was assessed using cone-beam CT and classified according to the Gertzbein–Robbins grading system. Median insertion times differed significantly between techniques (p<0.001), with RA being fastest (86 s), followed by NAV (125 s) and FL (163 s). Overall accuracy was 92.1% and varied significantly by technique (p<0.001): 81.9% for FL, 95.8% for NAV, and 98.6% for RA. No significant differences in accuracy were observed between surgeons (p=0.94). With NAV and RA, all surgeons achieved accuracy rates ≥95.8%, whereas FL accuracy ranged from 79.2% to 83.3%. No grade D or E pedicle breaches occurred in the NAV or RA groups. This study shows that the choice of guidance technique has a greater impact on pedicle screw placement performance than differences in surgeon experience during initial use. Under standardized experimental conditions, technology-related workflow characteristics outweighed operator-related factors, suggesting that advanced navigation and robotic systems can help reduce variability between surgeons with different levels of training.