3D-Printed Guides, Navigation, and Robotic Assistance in Spinal Instrumentation: A Network Meta-Analysis of Pedicle Screw Accuracy and Clinical Outcomes.

Abstract

Accurate pedicle screw placement is essential to prevent neurovascular injury, revision surgery, and excess healthcare costs. While navigation and robotic systems enhance accuracy over freehand or fluoroscopic techniques, they remain limited by high cost and patient radiation exposure. Three-dimensional printed (3DP) patient-specific guides offer comparable accuracy with potentially reduced intraoperative time and radiation. To compare the accuracy, safety, and operative efficiency of 3DP- guides (3DPG) with navigation (NAV) and robotic-assisted (RA) platforms for pedicle screw placement using network meta-analysis. Systematic review and network meta-analysis of published clinical studies (randomized control studies, prospective and retrospective cohort studies). A total of 133 studies encompassing 15,946 adults (aged 18+) undergoing pedicle screw placement were included. PHYSIOLOGIC OUTCOME MEASURES: pedicle screw breach rates, estimated blood loss, operative time, radiation exposure, and complications. FUNCTIONAL OUTCOME MEASURES: postoperative pain (Visual Analog Scale) and functional outcomes (Oswestry Disability Index). A systematic search of PubMed, MEDLINE, Embase and Cochrane was performed on September 27, 2025, comparing 3D-printed guides, computer navigation systems, and robotic-assisted platforms against conventional techniques (freehand or fluoroscopy-guided). Primary outcomes included pedicle screw breach rates, total operative time, estimated blood loss, overall and neurological complications, and pain and functionality scores. Binary outcomes were pooled as odds ratios (ORs) and continuous outcomes as mean differences (MDs), each with 95% confidence intervals. Radiation exposure, reported using heterogeneous metrics, was synthesized as ratios of means (RoM). Random-effects models were used throughout to account for between-study heterogeneity, with statistical significance set at p < 0.05. Risk of bias was assessed using ROBINS-I and RoB. Compared with conventional techniques, 3DPG achieved the lowest overall breach risk (OR 0.21, 95%CI: 0.16-0.28, p <0.001) and outperformed both RA and NAV. All advanced methods reduced odds of a major breach compared to the conventional method with no differences between them (p > 0.2). 3DPG placement produced the lowest blood loss (mean difference (MD) -79.6 mL, 95%CI: -101.1, -58.1, p < 0.001). Operative time was shortest with 3DPG with RA (+32.4 min, 95%CI: 28.3-36.5, p <0.001) and NAV (+34.8 min, 95%CI: 30.5-39.1, p <0.001) procedures taking significantly longer than 3DPG. Moreover, patient radiation exposure was significantly reduced compared to NAV and RA (ROM 0.21, 95% CI 0.08-0.50, p < 0.01 and ROM 0.35, 95% CI 0.15-0.82, p < 0.05, respectively). No significant differences were observed in postoperative pain (VAS) or neurological complication rates among advanced systems (all p > 0.1). 3DPG demonstrated the lowest breach rates, lowest blood loss, shortest operative time and least radiation exposure compared to the other advanced guidance technologies. However, because this review synthesizes data from studies with variable designs, populations, and reporting methods, direct head-to-head comparisons between newer technologies remain limited. Given their lower per-unit cost, ease of implementation, and lack of reliance on capital-intensive equipment, 3DPG may represent a particularly accessible and cost-effective option, especially for smaller centres . Nevertheless, formal cost-comparison studies among these technologies are warranted.