Radiation Exposure in Robotic-Assisted Versus Conventional and Navigation-Assisted Spine Surgery: A Systematic Review, Meta-Analysis, and Meta-Regression of 3205 Patients

<b>Objectives</b>: This systematic review and meta-analysis compared freehand and navigation-assisted spine surgery with robot-assisted techniques, focusing on radiation dose, fluoroscopy time, and factors influencing these outcomes. <b>Methods</b>: Following the PRISMA and PROSPERO protocols, we searched major databases for comparative studies on radiation exposure or fluoroscopy duration. Non-comparative, cadaveric, and animal studies were excluded. Bias was assessed with RoB 2 and MINORS. The data were pooled using random-effects models, with subgroup, meta-regression, sensitivity, and publication-bias analyses. <b>Results</b>: Twenty-eight studies (3205 patients) were included. Compared with freehand surgery, robotic assistance did not significantly reduce radiation dose (SMD -0.81; <i>p</i> = 0.07) or fluoroscopy time (SMD -0.56; <i>p</i> = 0.06), with substantial heterogeneity. Subgroup analyses revealed lower exposure with specific robotic systems (e.g., Tianji^®), in degenerative and trauma indications, and at cervical, lumbar, and thoracolumbar levels. No differences were observed between robotic-assisted and navigation-assisted techniques. A meta-regression showed increasing an fluoroscopy time and radiation dose in more recent freehand studies, while trends were stable in robotic cohorts. No publication bias was detected. <b>Conclusions</b>: Robotic-assisted surgery was not associated with statistically significant reductions in overall radiation dose or fluoroscopy time compared with freehand techniques. Effects may vary by robotic platform, indication, and anatomical level; however, substantial heterogeneity limits certainty. Further randomized controlled trails with standardized reporting are warranted.