A Cost-Effectiveness Analysis of the Integration of Robotic Spine Technology in Spine Surgery

  • Menger, Richard Philip (Department of Neurosurgery, Louisiana State University Health Sciences Center) ;
  • Savardekar, Amey R. (Department of Neurosurgery, Louisiana State University Health Sciences Center) ;
  • Farokhi, Frank (Department of Neurosurgery, Louisiana State University Health Sciences Center) ;
  • Sin, Anthony (Department of Neurosurgery, Louisiana State University Health Sciences Center)
  • Received : 2018.03.14
  • Accepted : 2018.07.01
  • Published : 2018.09.30


Objective: We investigate the cost-effectiveness of adding robotic technology in spine surgery to an active neurosurgical practice. Methods: The time of operative procedures, infection rates, revision rates, length of stay, and possible conversion of open to minimally invasive spine surgery (MIS) secondary to robotic image guidance technology were calculated using a combination of institution-specific and national data points. This cost matrix was subsequently applied to 1 year of elective clinical case volume at an academic practice with regard to payor mix, procedural mix, and procedural revenue. Results: A total of 1,985 elective cases were analyzed over a 1-year period; of these, 557 thoracolumbar cases (28%) were analyzed. Fifty-eight (10.4%) were MIS fusions. Independent review determined an additional ~10% cases (50) to be candidates for MIS fusion. Furthermore, 41.4% patients had governmental insurance, while 58.6% had commercial insurance. The weighted average diagnosis-related group reimbursement for thoracolumbar procedures for the hospital system was calculated to be $25,057 for Medicare and $42,096 for commercial insurance. Time savings averaged 3.4 minutes per 1-level MIS procedure with robotic technology, resulting in annual savings of $5,713. Improved pedicle screw accuracy secondary to robotic technology would have resulted in 9.47 revisions being avoided, with cost savings of $314,661. Under appropriate payor mix components, robotic technology would have converted 31 Medicare and 18 commercial patients from open to MIS. This would have resulted in 140 fewer total hospital admission days ($251,860) and avoided 2.3 infections ($36,312). Robotic surgery resulted in immediate conservative savings estimate of $608,546 during a 1-year period at an academic center performing 557 elective thoracolumbar instrumentation cases. Conclusion: Application of robotic spine surgery is cost-effective, resulting in lesser revision surgery, lower infection rates, reduced length of stay, and shorter operative time. Further research is warranted, evaluating the financial impact of robotic spine surgery.



  1. Joseph JR, Smith BW, Liu X, et al. Current applications of robotics in spine surgery: a systematic review of the literature. Neurosurg Focus 2017;42:E2.
  2. Goz V, Rane A, Abtahi AM, et al. Geographic variations in the cost of spine surgery. Spine (Phila Pa 1976) 2015;40:1380-9.
  3. Kaplan RS, Witkowski M, Abbott M, et al. Using time-driven activity-based costing to identify value improvement opportunities in healthcare. J Healthc Manag 2014;59:399-412.
  4. Lee R, Ng CK, Shariat SF, et al. The economics of robotic cystectomy: cost comparison of open versus robotic cystectomy. BJU Int 2011;108:1886-92.
  5. Yu HY, Hevelone ND, Lipsitz SR, et al. Use, costs and comparative effectiveness of robotic assisted, laparoscopic and open urological surgery. J Urol 2012;187:1392-8.
  6. Menger RP, Thakur JD, Jain G, et al. Impact of insurance precertification on neurosurgery practice and health care delivery. J Neurosurg 2017;127:332-7.
  7. National Comparisons of Commercial and Medicare Fee-For-Service Payments to Hospitals [Internet]. Washington DC: America's Health Insurance Plans; 2016 [cited 2016 Feb 17]. Available from:
  8. U.S. Government Publishing Office [Internet]. Washington DC: U.S. Government Publishing Office; 2015 [cited 2015 Aug 17]. Available from:
  9. Macario A. What does one minute of operating room time cost? J Clin nesth 2010;22:233-6.
  10. Vaccaro AR, Harris J, Crawford N, et al. In vitro analysis of accuracy, dosage, and surgical time required for pedicle screw placement using convention percutaneous screw and robotic-assisted screw techniques. In: NASS 32nd Annual Meeting; 2017 Oct 25-28; Orlando (FL), USA. 2017.
  11. Schroder ML, Staartjes VE. Revisions for screw malposition and clinical outcomes after robot-guided lumbar fusion for spondylolisthesis. Neurosurg Focus 2017;42:E12.
  12. Watkins RG, Gupta A, Watkins RG. Cost-effectiveness of image-guided spine surgery. Open Orthop J 2010;4:228-33.
  13. Menger R, Haydel J, Sin A, et al. Retrospective analysis of durotomy and surgical site infection rates in minimally invasive transforaminal lumbar interbody fusion. In: 2014 Annual Meeting of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves; 2014 May 5-8; Orlando (FL), USA. 2014.
  14. Yeramaneni S, Robinson C, Hostin R. Impact of spine surgery complications on costs associated with management of adult spinal deformity. Curr Rev Musculoskelet Med 2016;9:327-32.
  15. McGirt MJ, Parker SL, Lerner J, et al. Comparative analysis of perioperative surgical site infection after minimally invasive versus open posterior/transforaminal lumbar interbody fusion: analysis of hospital billing and discharge data from 5170 patients. J Neurosurg Spine 2011;14:771-8.
  16. Goldstein CL, Macwan K, Sundararajan K, et al. Perioperative outcomes and adverse events of minimally invasive versus open posterior lumbar fusion: meta-analysis and systematic review. J Neurosurg Spine 2016;24:416-27.
  17. Ellison A. Average cost per inpatient day across 50 states [Internet]. Chicago (IL): Becker's Healthcare; [cited 2016 Jan 13]. Available from:
  18. Medicare hospital prospective payment system - How DRG rates are calculated and updated [Internet]. Washington DC: Office of Inspector General; 2001 Aug [cited 2001 Aug 1]. Available from:
  19. Schousboe JT, Paudel ML, Taylor BC, et al. Estimation of standardized hospital costs from Medicare claims that reflect resource requirements for care: impact for cohort studies linked to Medicare claims. Health Serv Res 2014;49:929-49.
  20. Kaplan RS, Porter ME. The big idea: how to solve the cost crisis in health care [Internet]. Boston (MA): Harvard Business Review; 2011 [cited 2011 Sep 1]. Available from:
  21. Maeso S, Reza M, Mayol JA, et al. Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis. Ann Surg 2010;252:254-62.
  22. Gkegkes ID, Mamais IA, Iavazzo C. Robotics in general surgery: a systematic cost assessment. J Minim Access Surg 2017;13:243-55.
  23. Overley SC, Cho SK, Mehta AI, et al. Navigation and robotics in spinal surgery: where are we now? Neurosurgery 2017;80:S86-99.
  24. Roser F, Tatagiba M, Maier G. Spinal robotics: current applications and future perspectives. Neurosurgery 2013;72 Suppl 1:12-8.
  25. Kantelhardt SR, Martinez R, Baerwinkel S, et al. Perioperative course and accuracy of screw positioning in conventional, open robotic-guided and percutaneous robotic-guided, pedicle screw placement. Eur Spine J 2011;20:860-8.
  26. Schizas C, Thein E, Kwiatkowski B, et al. Pedicle screw insertion: robotic assistance versus conventional C-arm fluoroscopy. Acta Orthop Belg 2012;78:240-5.
  27. Ringel F, Stuer C, Reinke A, et al. Accuracy of robot-assisted placement of lumbar and sacral pedicle screws: a prospective randomized comparison to conventional freehand screw implantation. Spine (Phila Pa 1976) 2012;37:E496-501.
  28. Lonjon N, Chan-Seng E, Costalat V, et al. Robot-assisted spine surgery: feasibility study through a prospective, casematched analysis. Eur Spine J 2016;25:947-55.
  29. Phillips FM, Cheng I, Rampersaud YR, et al. Breaking through the "glass ceiling" of minimally invasive spine surgery. Spine (Phila Pa 1976) 2016;41 Suppl 8:S39-43.
  30. Lu VM, Kerezoudis P, Gilder HE, et al. Minimally invasive surgery versus open surgery spinal fusion for spondylolisthesis: a systematic review and meta-analysis. Spine (Phila Pa 1976) 2017;42:E177-85.
  31. Mummaneni PV, Bisson EF, Kerezoudis P, et al. Minimally invasive versus open fusion for grade I degenerative lumbar spondylolisthesis: analysis of the Quality Outcomes Database. Neurosurg Focus 2017;43:E11.
  32. Parker SL, Mendenhall SK, Shau DN, et al. Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis: comparative effectiveness and cost-utility analysis. World Neurosurg 2014;82:230-8.
  33. Sensakovic WF, O'Dell MC, Agha A, et al. CT radiation dose reduction in robot-assisted pediatric spinal surgery. Spine (Phila Pa 1976) 2017;42:E417-24.
  34. Verma R, Krishan S, Haendlmayer K, et al. Functional outcome of computer-assisted spinal pedicle screw placement: a systematic review and meta-analysis of 23 studies including 5,992 pedicle screws. Eur Spine J 2010;19:370-5.
  35. Gelalis ID, Paschos NK, Pakos EE, et al. Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques. Eur Spine J 2012;21:247-55.
  36. Shin BJ, James AR, Njoku IU, et al. Pedicle screw navigation: a systematic review and meta-analysis of perforation risk for computer-navigated versus freehand insertion. J Neurosurg Spine 2012;17:113-22.
  37. Molliqaj G, Schatlo B, Alaid A, et al. Accuracy of robot-guided versus freehand fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery. Neurosurg Focus 2017; 42:E14.
  38. Gertzbein SD, Robbins SE. Accuracy of pedicular screw placement in vivo. Spine (Phila Pa 1976) 1990;15:11-4.
  39. Kim HJ, Jung WI, Chang BS, et al. A prospective, randomized, controlled trial of robot-assisted vs freehand pedicle screw fixation in spine surgery. Int J Med Robot 2017 Sep; 13(3).
  40. Hyun SJ, Kim KJ, Jahng TA, et al. Minimally invasive robotic versus open fluoroscopic-guided spinal instrumented fusions: a randomized controlled trial. Spine (Phila Pa 1976) 2017;42:353-8.
  41. Keric N, Doenitz C, Haj A, et al. Evaluation of robot-guided minimally invasive implantation of 2067 pedicle screws. Neurosurg Focus 2017;42:E11.
  42. Devito DP, Kaplan L, Dietl R, et al. Clinical acceptance and accuracy assessment of spinal implants guided with Spine-Assist surgical robot: retrospective study. Spine (Phila Pa 1976) 2010;35:2109-15.