Robot-Assisted Pedicle Screw Insertion in Pediatric Spine Surgery: An Institutional Experience and Meta-Analysis

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BACKGROUND AND OBJECTIVES: Robotic-assisted spine surgery (RASS) has demonstrated significant advantages in adult spinal surgery, including improved screw placement accuracy, reduced radiation exposure, and decreased perioperative morbidity. However, its adoption in pediatric spinal surgery remains limited, with unclear evidence regarding its safety, efficacy, and clinical outcomes. This study evaluates institutional outcomes of RASS in pediatric patients and systematically reviews the literature to assess its utilization trends, perioperative outcomes, and complication rates. METHODS: A retrospective review was conducted on pediatric patients (<21 years of age) who underwent RASS at the Johns Hopkins Hospital between 2019 and 2023. Demographic, clinical, radiological, and surgical data were collected. A systematic review and meta-analysis up to March 2025 was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled estimates were generated using random-effects models, and meta-regression assessed temporal trends in utilization and outcomes. RESULTS: Seven pediatric patients underwent RASS at our institution, with a mean age of 18.4 ± 3.2 years. Across the literature, 900 pediatric patients (mean age: 15.1 ± 0.9 years) were identified. The most common indication was adolescent idiopathic scoliosis (59.6%). Among 11 434 pedicle screws analyzed, the overall accuracy was 97.2% ± 3.64%, with a malposition rate of 2.67% ± 3.61% and a revision rate of 0.79% ± 0.51%. The institutional screw accuracy was 91.7%, with 1 intraoperative revision (2.4%). The pooled mean operative time was 324.1 ± 62 minutes, and the estimated blood loss was 577.4 ± 346.6 mL. Institutional patients had lower mean estimated blood loss (145.71 ± 185.08 mL) and 2 postoperative complications. Meta-regression showed improving screw accuracy and decreasing durotomy rates over time. CONCLUSION: RASS in pediatric patients demonstrates high screw accuracy and low complication rates. Further studies are needed to optimize outcomes and guide standardized pediatric implementation.

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