**5. Current limitations of robotic spine surgery**

Over the past decade, robot-assisted surgery has played a significant role in the advancement of MISS, but there are limitations preventing its widespread adoption. These hurdles range from technical issues, cost, and operating room efficiency, to the learning curve associated with safely incorporating the robot into the operating room. Initial iterations of spine robots were met with concerns regarding instrument skiving and tool deflection, registration failures, and a lack of real-time navigation. Newer software iterations, as well as advancements in the robotic arm and its associated end-effectors have partly addressed these concerns. With regards to cost, there is no denying the significant capital expenditure required to obtain a spine robot; however, there may be a cost savings stemming from decreased postoperative complications secondary to improved instrumentation accuracy [46]. Further cost-effectiveness studies are needed, however, particularly with regards to MISS [62]. Lastly, there is a learning curve associated with performing safe robotic spinal surgery, but that learning curve may not be as high as previously conceived. One study demonstrated that 30 screws would need to be placed before a noticeable improvement in efficiency was observed [63], and two other studies demonstrated that between 13 and 20 cases may be needed to obtain proficiency in robotic screw placement [64, 65].

### **6. Future of robotic spine surgery**

The safe implementation of robotic-assisted spine surgery in MISS continues to make progress and newer generations of spinal robots with improved software and real-time navigation will allow for the robot to be utilized for more than just pedicle screw instrumentation. Spine robots with real-time navigation currently allow for surgeons to plan tubular retractor trajectories, interbody placement, and navigated disc preparation. As the software continues to improve, magnetic resonance imaging (MRI)-based registration and navigation may allow for robot-assisted disc and ligamentum flavum resection as well as soft tissue tumor resection. Additionally, as burrs become compatible with the spinal robot, pre-operative planning and precise intra-operative execution of bony decompressions may become possible. Even in the domain of instrumentation, there is room for further advancement. While current spine robots only allow for assisted pedicle screw placement, future iterations may allow for fully automated pedicle screw placement. Yet another possibility is the syncing of intra-operative data from multiple robotic systems, which may one day enable machine learning and artificial intelligence algorithms to make real-time, intra-operative suggestions to surgeons based on previous surgeries. These future directions for robot-assisted MISS will likely continue to promote an increased integration and utilization of robotics into MISS.

*Robotic Guided Minimally Invasive Spine Surgery DOI: http://dx.doi.org/10.5772/intechopen.97599*
