Abstract
BACKGROUND: Minimally invasive lumbar interbody fusion (LIF) procedures have evolved rapidly in recent years, with robot-assisted (RA) techniques increasingly integrated into clinical practice. However, questions remain regarding the relative advantages of RA over traditional fluoroscopy-guided and navigation-assisted methods in terms of perioperative, radiographic, and clinical outcomes. This systematic review synthesizes current evidence on these comparisons, focusing on the accuracy of screw placement, perioperative efficiency, radiographic and clinical outcomes, and complications. AIM: To investigate the comparative effectiveness of RA vs conventional LIF techniques. METHODS: A systematic review and meta-analysis was conducted in accordance with PRISMA 2020 and Cochrane guidelines. Databases searched included PubMed, EMBASE, Web of Science, Scopus, and the Cochrane Library (through May 2025). Eligible studies were randomized controlled trials and observational studies comparing RA with fluoroscopy - or navigation-guided LIF (transforaminal lumbar interbody fusion, lateral lumbar interbody fusion, oblique lumbar interbody fusion) in adults. Two reviewers independently extracted data and assessed risk of bias. The Grading of Recommendations Assessment, Development and Evaluation framework was used to evaluate certainty of evidence. Meta-analyses were performed where data were sufficiently homogeneous. RESULTS: Twenty-two studies were included, encompassing a total of 2313 patients - 1046 who underwent RA-guided procedures and 1267 who received comparator techniques. Meta-analyses showed that RA significantly improved perfect pedicle screw placement [pooled odds ratio = 2.93; 95% confidence interval (CI): 1.40-6.14; I (2) = 78.2%] and reduced intraoperative blood loss (pooled standardized mean difference = -0.28; 95%CI: -0.47 to -0.08; I (2) = 0%). Operative time did not significantly differ between groups (pooled standardized mean difference = 0.01; 95%CI: -0.30 to 0.31; I (2) = 66%). Radiation dose could not be synthesized quantitatively due to heterogeneous definitions and measurement units. Narratively, RA demonstrated consistent advantages in reducing surgical exposure and adjacent segment degeneration. Clinical and radiographic outcomes, fusion success, and complication rates were generally comparable across groups. CONCLUSION: RA LIF improves pedicle screw placement accuracy and reduces blood loss and surgeon radiation exposure while maintaining similar clinical outcomes and safety profiles to conventional techniques. These findings support the integration of RA into spine surgery but highlight the need for high-quality multicenter randomized controlled trials and cost-effectiveness studies to guide broader implementation.