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Page 390 Sadagopan et al. Art Int Surg 2024;4:387-400 https://dx.doi.org/10.20517/ais.2024.34

Table 1. Stages of surgical automation proposed by Yang et al. [17]
Stage Description
0 No autonomy
1 Robot assistance
2 Task autonomy
3 Conditional autonomy
4 High autonomy
5 Full autonomy

Stage 3 - conditional autonomy
Conditional autonomy represents a partnership between surgeons and robotic systems, where both entities
contribute to surgical tasks. Surgeons choose the surgical plan, but then the robot implements the plan with
predefined constraints under the surgeon’s oversight. This stage fosters synergy between human expertise
and machine capabilities.

Stage 4 - high autonomy
In stage 4, robotic systems assume greater responsibility for executing surgical tasks and can make decisions
while under the surveillance of a human operator. Surgeons would oversee the procedure and intervene
when necessary, ensuring patient safety and procedural integrity. Robotic systems leverage AI algorithms to
adapt to dynamic surgical environments and make operative decisions, enhancing adaptability and
responsiveness.

Stage 5 - full autonomy
Full autonomy represents the pinnacle of surgical automation, where robotic systems perform entire
surgical procedures independently without direct human intervention. Currently, there are no devices
approved for operative use with stage 5 autonomy.

This stratification of surgical autonomy has been utilized extensively to analyze the levels of automation of
[19]
robotic devices in both pre-clinical and clinical phases of FDA approval . However, this framework has
not been utilized to thoroughly analyze autonomous systems employed in spine surgery. This review aims
to examine the current trends, practices, and advancements in surgical automation and serves as an
overview of the stages of automation of devices currently employed within spine surgery.

METHODS
A comprehensive literature review was conducted using PubMed, Web of Science, and Google Scholar,
focusing on autonomous robotic systems in spine surgery. The inclusion criteria encompassed research
articles on robotic automation in spine surgery. Data were extracted regarding robot names, manufacturers,
purposes, FDA status, automation stages, methods, results, and significance.

RESULTS OF THE LITERATURE REVIEW
Emerging autonomous technologies
The following technologies are currently not FDA-approved but are at the cutting edge of autonomous
spine surgery [Table 2]. In some cases, companies have developed the discussed robotic platforms for
explicitly surgical use; in other cases, research groups have adapted existing robotic platforms and integrated
them with other components - such as sophisticated imaging modalities, augmented reality systems, and
more - to achieve new degrees of autonomy and efficiency.