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Page 392 Sadagopan et al. Art Int Surg 2024;4:387-400 https://dx.doi.org/10.20517/ais.2024.34

Shenzen Futuretec and introduced in 2022, represents an experimental stage 4 automation in robotic
[22]
vertebroplasty , as it is capable of making intraoperative decisions based on preoperative planning. This
system is designed for autonomous vertebral puncture and bone cement injection, specifically targeting
procedures for spinal stabilization. The base robotic platform is the Orthobot XGK‐6508A. It integrates
preoperative planning with real-time intraoperative guidance using fused CT and C-arm fluoroscopic
images. The system operates with a robotic arm capable of 6 DOF, ensuring precise movements and
positioning. Key components include a bone drill and an injection propulsion unit, both equipped with
force sensors for real-time pressure feedback, which enhance safety and real-time adjustment control during
the procedure. The AOSRV demonstrated superior performance in comparative studies using a pig spine
model, significantly reducing operation time, puncture adjustments, and intraoperative fluoroscopies while
achieving high accuracy and lower bone cement leakage rates.

There is a notable absence of mature systems for robot-assisted laminectomy. A Chinese group at Peking
University in 2023 proposed a novel integrative system for automated laminectomy based on a 6-DOF
AUBO-i5 robotic arm which relies on preoperative CT to operate fully autonomously, a stage 4
[23]
innovation . The arm is further equipped with a force sensor and an ultrasonic osteotome, providing real-
time feedback and precise control. The study involved 40 vertebrae from four cadavers. Robotic
performance, as evaluated by mean deviation from the cutting path, was 0.67 mm at the superior point and
0.73 mm at the inferior point, with 83% of the laminectomy planes rated as grade A for accuracy and 81%
considered safe. The system demonstrated high accuracy and efficiency, with no significant differences in
deviation between thoracic and lumbar procedures.

Assistive robots for visualization
The KUKA LBR iiwa 7 R800 is a robotic arm introduced in 2022 that has been adapted for use in
autonomous spinal sonography . Manual ultrasound acquisitions are costly and time-consuming as they
[24]
require operation by trained sonographers. Groups have built the LBR iiwa 7 into a broader system to
implement a “dual agent” framework (real-time reinforcement and DL) to autonomously guide an
ultrasound probe in such a way that mimics the decision making of an expert sonographer by using view-
[24]
specific acoustic shadowing as a robotic guidance marker . With the integration of DL software into the
robotic arm, this system may have stage 3 autonomous capabilities as it would function autonomously
within a set of parameters set by the surgeon. The validated system demonstrated high navigational
accuracy, a promising finding for future autonomous surgical systems that will need to adjust in real time
for micromovements and other intraoperative positional changes.

Further innovation in autonomous imaging includes autonomous neuro-registration. The Robotic
neuronavigation (RONNA) system, developed by the University of Zagreb, was introduced in 2018 for
frameless stereotactic neurosurgery for spinal applications . This stage 2 automation robot focuses on
[25]
providing precise navigation for spinal surgeries without the need for invasive frames. The system is
designed to be mounted on any robotic arm (the researchers used a KUKA robotic arm) and relies on
several fiducial markers. RONNA has shown substantial accuracy in its applications; evaluations using
different localization strategies revealed application errors in the sub-millimeter range, indicating a high
level of precision in navigational tasks. RONNA’s ability to perform stereotactic procedures with minimal
error could significantly improve the efficiency and safety of applicable procedures, making it a reliable
alternative to traditional methods.

Exoscopes provide neurosurgeons with enhanced visualization and ergonomics compared to traditional
surgical microscopes by projecting the surgical field onto a 2D or 3D monitor, thus offering a closer view