Best of Both Worlds: Use of Robotic Principles for Placing Navigated Cervical and Difficult Upper Thoracic Pedicle...

Navigated pedicle screw placement can be particularly challenging for cervical and upper thoracic levels in obese patients. This technical challenge can be compounded by smaller-diameter tools, which can be flexible and therefore confound navigation. It is imperative to avoid excessive manipulation of surrounding tissues to maintain navigation accuracy in the mobile cervical spine.¹ Robotic-assisted spinal approaches use firm guides to aid drilling and screw placement but are hindered by high costs with equipment acquisition.^2,3 Here, we propose a technical nuance that combines robotic surgical principles with tools that are more readily available in many surgical departments (Video 1). We present the case of a 64-year-old woman with a chief complaint of neck pain, irradiating to the left worse than right arm and prior history of C5-7 anterior cervical diskectomy and fusion. Imaging showed multilevel degenerative disease and a solid prior C5-7 anterior cervical diskectomy and fusion with grade I anterolisthesis at C7-T1 due to severe facet degeneration with severe left-sided foraminal stenosis. Given failure of conservative management, the patient was brought to the operating room for left C7-T1 foraminotomy and C7-T1 posterior instrumented fusion. Here, we show the use of a tubular retractor fixed to the surgical bed for solid and reproducible trajectory for all tools to minimize the risk of surrounding tissue manipulation and its effect on navigation accuracy.