Robot-assisted pedicle screw placement in spinal surgery: an updated systematic umbrella review and meta-meta-analysis of comparisons against freehand and navigation-guided techniques

Background: The efficacy and safety of robot-assisted pedicle screw placement versus freehand and computer-assisted navigation techniques remain debatable. This umbrella review synthesizes meta-analytic evidence on the associated accuracy, safety, and clinical outcomes. Methods: A comprehensive search was performed in PubMed, Embase, Scopus, Web of Science, Ovid, and Cochrane databases, from inception to October 2025, with no language restrictions. Researchers independently assessed meta-analyses that compared robot-assisted with freehand and computer-assisted navigation techniques. Methodological quality was assessed using the AMSTAR-2 tool, and evidence was graded using the GRADE framework. The primary outcomes included accuracy metrics (acceptable and perfect screw placement) and safety indicators (intraoperative blood loss, radiation exposure, and hospital stay). The protocol was registered with PROSPERO (registration number: CRD42024556304). Results: A total of 38 meta-analyses comprising 414 primary studies were included. Convincing evidence (class I) supported robotic superiority for acceptable placement versus freehand (eOR = 2.74; 95% CI: 2.33-3.22) and versus navigation (eOR = 2.36; 95% CI: 1.73-3.22), and for perfect placement versus navigation (eOR = 2.47; 95% CI: 1.84-3.32). Highly suggestive evidence (class II) supported superior perfect placement (vs freehand) and shorter hospital stays. Suggestive evidence (class III) indicated reductions in intraoperative blood loss and radiation exposure. Conclusion: Robot-assisted pedicle screw placement demonstrates superior accuracy versus freehand and navigation-guided methods, supported by convincing (class I) evidence. Highly suggestive (class II) evidence also supports its superiority in perfect placement and shortening hospital stays, while suggestive (class III) evidence indicates reduced blood loss and radiation. These findings, supported by a robust evidence base, underscore the need for standardized clinical guidelines to maximize impact on patient outcomes.