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Objective: Spinal metastases can significantly affect quality of life in patients with cancer and present complex neurosurgical challenges for surgeons. Surgery with instrumentation is often indicated to alleviate pain, preserve neurological function, and ensure mechanical stability. However, distortions in the bony anatomy due to oncological disease can decrease the accuracy of pedicle screw placement. Robotic-assisted surgery may offer an opportunity to increase screw accuracy and improve navigation of spinal lesions compared to conventional techniques. Therefore, we presented our institutional experience evaluating robotic-assisted surgical fixation for spinal metastases., Methods: Patients undergoing robotic-assisted surgery at a large tertiary care center between January 2019 - January 2023 for the treatment of spinal metastases were identified. Patient characteristics, including demographics, tumor pathology, surgical complications, and post-operative outcomes were extracted. The Gertzbein Robbins classification system (GRS) was used to assess pedicle screw placement accuracy in patients with post-operative computed tomography., Results: Twenty patients were identified, including 7 females (35 %), with an overall median age of 66 years (range: 39-80 years) and median BMI of 25 kg/m 2 (range: 17-34 kg/m 2 ). An average of four spinal levels were instrumented, with metastases located primarily in the thoracic (n=17, 85 %) spine. Common primary tumor types included prostate (n=4), lung (n=2), and plasma cell (n=2) cancers. Most pedicle screws (92 %) were classified as GRS A in patients with postoperative imaging. Post-operative complications were unrelated to the use of the robot, and included pulmonary embolism (n=1), deep vein thrombosis (n=2), and gastric symptoms (n=3). Three patients were readmitted at 30 days, with one reoperation due to tumor recurrence. Four patients were deceased within 6 months of surgery., Conclusions: Despite the inherent high-risk nature of these surgeries, this study underscores the safety and efficacy of robotic-assisted surgery in the management of spinal metastases. Robots can be helpful in ensuring accuracy of pedicle screw placement in patients with metastatic disease., Competing Interests: Conflict of Interest Nicholas Theodore has received royalties from, holds stock ownership in, has consulted for, and has served on the scientific advisory board/other office for Globus Medical. Dr. Lubelski reported serving as a consultant for Icotec, Carbofix, and Mindset Medical. Dr. Lubelski receives research support from Dilon Technologies. The other authors have no conflicts of interest to disclose. No generative artificial intelligence (AI) or AI-assisted technologies were utilized in the writing of this manuscript., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Applications and workflows around spinal robotics have evolved since these systems were first introduced in 2004. Initially approved for lumbar pedicle screw placement, the scope of robotics has expanded to instrumentation across different regions. Additionally, precise navigation can aid in tumor resection or spinal lesion ablation. Robot-assisted surgery can improve accuracy while decreasing radiation exposure, length of hospital stay, complication, and revision rates. Disadvantages include increased operative time, dependence on preoperative imaging among others. The future of robotic spine surgery includes automated surgery, telerobotic surgery, and the inclusion of machine learning or artificial intelligence in preoperative planning., Competing Interests: Disclosures Nicholas Theodore receives royalties from and owns stock in Globus Medical. He is a consultant for Globus Medical and has served on the scientific advisory board/other office for Globus Medical. The remaining authors have no conflicts of interest to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)