Robotic systems in cranial surgery: a systematic review of accuracy, clinical outcomes, and adverse events

Robotic-assisted surgery is becoming more prevalent in neurosurgery. Many studies have classified the advantages and disadvantages, particularly in spinal robotic surgeries. However, the use of robotics in cranial procedures has been limited to individual studies without large-scale review of the different modalities. This study is a comprehensive systematic review of the major robotics utilized in cranial neurosurgical procedures and their respective outcomes. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was conducted over PubMed, Cochrane, and Embase for articles published between January 2000 to February 2025. EndNote and Rayyan were utilized to organize the 1,409 identified studies and conduct a blinded multiphase process for including and excluding studies. Originally, studies were intended to be run as a meta-analysis to compare robotic modalities, but the existing data was too heterogeneous to statistically contrast outcomes. Overall, 51 studies were included, with six robots being discussed in more than one study. The use of robotics in cranial neurosurgery stretches mostly across functional neurosurgery, with different applications in brain tumor biopsies and resection, hemorrhage drainage, and endoscopic surgeries. Cranial neurosurgical procedures primarily apply robotics in the world of functional neurosurgery. Outside of this subspecialty, robotic-assisted cranial surgery remains sparse in the literature. As technology evolves, more use cases may be realized.