A critical revelation from our research is the remarkable surge in the adoption of robotic technology, a fivefold increase within a few short years, with a discernible and enduring impact. This escalating trend underscores the urgency and importance of delving deeper into the comparative efficacy of robotic versus non-robotic lumbar fusion surgeries.

Addressing the central question of whether robotic surgery surpasses non-robotic alternatives, our study provides multifaceted insights that unravel the complexities of this evolving landscape. Notably, we observe a substantial discrepancy in total charges between the two approaches, with robotic surgeries incurring an average cost nearly $30,000 higher. Our findings on cost diverge significantly from earlier published studies, as a considerable number of them predates the last decade. Subsequent to these studies, both inflationary trends and policy advancements have transpired, influencing the current landscape of medical expenditures [11]. This economic divergence, while considerable, can be rationalized by the substantial upfront investment required for robotic systems, typically priced around $1 million [9, 12]. The economic considerations raise pivotal questions about the cost-effectiveness of robotic surgery, prompting a nuanced evaluation of its benefits against the financial investment [12, 13].

Spinal fusion is a surgical procedure known for its significant perioperative blood loss, ranging from 0.5 to 2 L [14]. Our study reveals higher blood loss among patients undergoing robotic in comparison to non-robotic surgery group. Although a small case highlighted the opposite [15], according to large retrospective analysis of 4185 elective robotic surgeries revealed correspond with our result and revealed higher postoperative anemia [16]. Robotic surgeries have been associated with extended operative durations [17, 18], prompting us to postulate that the heightened incidence of blood loss in robotic procedures is most likely attributed to the prolonged operation time.

Our analysis of current research aligns with prevailing evidence regarding complication rates in robotic versus non-robotic single-level lumbar fusion surgery. Propensity-matched studies [19, 20] found no significant difference in complication rates, including surgical site infections, at various follow-up periods (30, 90 days, and 1 year) between the two groups [19, 20]. This finding is further supported by multicenter analyses like Mazor Robotic-Guided Versus Fluoroscopic-Guided Spinal Fusions: The MIS ReFRESH Prospective Comparative Study by Amundsen et al. [21], which reported no association between robotic-assisted surgery and 1-year reoperation rates [21]. However, they did observe a potential increase in blood loss requiring transfusion in the robotic surgery group [21].

While some studies suggest potential benefits of robotic surgery like improved visualization and potentially more precise screw placement [1, 22], these may be offset by the observed increase in blood loss in our study and potentially longer operative times reported elsewhere [20, 21]. Understanding the long-term impact of robotic surgery on complication rates, fusion rates, and patient functionality remains an area for future research.

Our findings indicate no significant variance in patient mortality between the two groups. However, a subtle difference in the duration of hospital stay comes to light. Notably, patients undergoing robotic surgery experienced only a marginally shorter hospital stay, suggesting that this small-time difference may not hold substantial clinical importance. While this efficiency over time could potentially alleviate the economic burden associated with robotic procedures, it does not negate the higher overall costs linked to robotic lumbar fusion surgeries. Therefore, a thorough consideration of benefits versus economic implications is essential [12].

Further exploration into postoperative complications paints a nuanced picture. Complications such as stroke, pulmonary embolism, pneumonia, and surgical site infection exhibit no significant disparity between patients undergoing robotic and non-robotic lumbar fusion surgeries. While there is a paucity of research on robotic-spine surgeries in the existing literature, our findings align with previously published studies conducted in the realm of non-robotic surgical interventions [23]. This suggests that, at least in our dataset, the selection between these surgical approaches does not substantially impact the incidence of these complications.

The core objective of employing robotic assistance in lumbar fusion surgery is to enhance precision, particularly in pedicle screw placement [24,25,26]. In this pursuit, our study highlights a significant advantage associated with the use of robotic systems—a notably reduced incidence of traumatic spinal injuries. While the absolute numbers are low, less than 0.26% of cases without robotic assistance experienced traumatic spinal injuries, this difference is statistically significant and holds paramount clinical significance. Traumatic spinal injuries can lead to severe long-term neurological deficits [27], making the observed reduction a noteworthy advantage of robotic-assisted procedures.

However, a nuanced consideration is warranted as our study also reveals certain drawbacks associated with robotic surgeries. Patients undergoing robotic lumbar fusion surgeries exhibited a higher incidence of acute kidney injuries and increased blood loss necessitating transfusions. While the exact cause is challenging to ascertain from our extensive dataset, a plausible explanation may lie in the potential prolongation of surgeries associated with robotic assistance, leading to increased blood loss and subsequent renal implications. This prompts a critical reevaluation of the purported benefits of robotic systems, especially when confronted with adverse outcomes such as heightened postoperative complications [2].

Synthesizing these findings with existing research on the topic, a complex narrative emerges. Some studies indicate no substantial performance improvement with robotic assistance, while others suggest enhanced outcomes. This diversity in findings further complicates the decision-making process for clinicians and underscores the need for more nuanced research methodologies [3,4,5,6,7,8,9,10,11].

In addition to the variability in study outcomes, our investigation reveals that robotic-assisted lumbar fusion surgeries remain a relatively novel method, utilized in less than 2% of the cases in our dataset. This highlights the need for cautious interpretation of the results, considering the evolving nature of this technology and the learning curve associated with its implementation [2].

Looking ahead, future studies should explore the efficacy of robotic assistance in multilevel lumbar fusion surgeries, a scenario not extensively addressed in our current investigation focused on single-level procedures. Understanding the applicability and potential advantages of robotic systems in more complex spinal surgeries will be crucial for informing clinical decisions and advancing patient care.

Acknowledging the limitations of our methodology, characterized by the use of extensive ICD codes from a large dataset, our study provides a macro-level perspective. While lacking granularity at the individual patient level, the sheer volume of cases lends statistical power to our findings. It is essential to recognize the inherent trade-off between detailed patient-level insights and the strength derived from a comprehensive analysis involving more than 400,000 one level lumbar fusions.

In conclusion, our expansive investigation sheds light on the escalating trend of robotic-assisted lumbar fusion surgeries and their comparative outcomes. The economic implications, nuanced clinical advantages, and potential drawbacks uncovered in our study present a comprehensive foundation for future research, policy considerations, and clinical decision-making in the ever-evolving landscape of spinal surgeries.