Robotic navigation assistance for spinal fixation in Marfan syndrome: a case report addressing anatomical challenges

Patients with Marfan syndrome (MFS) can experience spinal deformity characterized by thoracolumbar kyphoscoliosis, severe spondylolisthesis, dural ectasia, vertebral body scalloping, and hypoplastic pedicles. These unique anatomical features complicate conventional spinal instrumentation techniques, rendering robotic navigation assistance (RNA) a viable option in such cases.

A 41-year-old woman diagnosed with MFS presented with progressive mid-thoracic and low back pain spanning over two decades. Imaging revealed characteristic findings of MFS, including severe leftward thoracolumbar kyphotic scoliosis, dural ectasia, hypoplastic pedicles (1 mm), and vertebral body scalloping. Due to debilitating pain and impaired function, a two-stage thoracolumbar fusion was planned. The 1^st stage involved posterior fusion from T10 to S1, along with a planned L2 pedicle subtraction osteotomy (PSO), guided by RNA. RNA enabled accurate placement of juxtapedicular, cortical-bone-trajectory (CBT), and bilateral S2 alar-iliac (S2AI) screws, accommodating the patient's severely hypoplastic pedicles while ensuring adequate fixation. The 2^nd stage occurred one month postoperatively and involved a L3-L5 lateral lumbar interbody fusion (LLIF) and a L5-S1 anterior lumbar interbody fusion (ALIF), also guided by RNA.

At the six-month and three-year follow-ups, the patient reported significant improvements in back pain and functionality, with imaging demonstrating progressive fusion without loosening of the implants. RNA effectively addressed the unique anatomical challenges of hypoplastic pedicles and sacral body scalloping in a patient with MFS-associated spinal deformity. This technology enabled an individualized surgical approach through preoperative planning of instrumentation at each spinal level, allowing for precise placement of juxtapedicular and S2AI screws to achieve stable fixation in anatomically constrained regions.