Where Are All the Neurosurgery Robots?

Introduction: While robotic technology has advanced in neurosurgery, fully autonomous systems are not yet standard practice, and robotic pedicle screw insertion receives mixed support from spine surgeons. Despite the potential of robotics to enhance operative precision, multiple barriers including economic, regulatory, and liability limit their integration. Our study investigates the factors hindering widespread adoption of robotic approaches in neurosurgery, emphasizing the need for evaluation beyond technical precision.

Methods: We conducted a narrative review, analyzing economic, legal, and cultural influences on neurosurgical robotics, alongside specific outcomes in robot-assisted pedicle screw insertion (PSI). This review also addresses governance models aligned with the United Nations Sustainable Development Goals (SDGs) to assess how surgical robotics could better serve global health.

Results: Out of 13 approved robotic devices for neurosurgical or spine surgery, 8 are approved for pedicle screw placement. Robotic PSI systems have been shown to improve accuracy significantly (OR = 2.83, 95% CI = 2.20–3.64), yet no notable reductions in complication rates or intraoperative time were found compared to traditional methods, with some studies arguing that robotic PSI significantly increases intraoperative time by up to 35.6% (P < 0.0001). Liability remains a concern, with pedicle screw litigation payouts averaging $1.2 million. While these devices could theoretically bridge surgical disparities, only a handful of AI-enabled systems have reached conditional autonomy (Yang Level 4) without further FDA clearance for higher autonomy levels.

Conclusion : Marginal gains in surgical precision may not sufficiently outweigh the high fixed and variable costs associated with these systems. Lower PSI revision rates should be a prime selling point for robotic systems; but without compelling data, it may be challenging to justify the costs of purchasing a new robot. To accelerate adoption, surgical robotics require comprehensive evaluation metrics, including cost-benefit analyses, liability considerations, and patient outcomes. Establishing robust governance frameworks and addressing financial barriers are essential for achieving equitable access and safety in autonomous neurosurgical procedures.