Aug. 18, 2026
Computer-guided navigation methods have transformed the landscape of pediatric spine surgery over the decades. These 3D-image-guided systems help address unique challenges associated with pediatric scoliosis surgery, including the need for greater surgical precision due to small bone structures.
For children and adolescents with scoliosis, these image-guided approaches continue to contribute to improved outcomes after life-changing procedures. Early research from Mayo Clinic showed that navigated procedures resulted in a lower incidence of revision surgery. These findings were later supported by a large national registry study published in Spine Deformity. Mayo Clinic surgeons have been integrating these methods and the latest technologies for correcting adolescent idiopathic scoliosis (AIS) for decades.
Early adopters of navigated pediatric spine surgery have helped define how to adapt these technologies to smaller anatomies and more complex deformities. Innovation at Mayo Clinic Children's has improved both the safety and efficacy of these techniques. That experience is now helping inform how to evaluate and integrate robot-assisted technologies into pediatric scoliosis surgery.
"Navigation has evolved from under 10% adoption to mainstream use in about 50% of cases, and robotics may follow a similar trajectory," says A. Noelle Larson, M.D., a pediatric orthopedic surgeon, professor of Orthopedic Surgery and chair of Mayo Clinic Children's in Rochester, Minnesota. "Although robotic assistance in pediatric spine fusion surgery is still an emerging technology, it may represent the future of improved safety in pediatric spine surgery."
Why precision matters in pediatric scoliosis surgery
Corrective surgery for AIS addresses severe curvature of the spine, ranging from 40 to 100 or more degrees. Larger curves can progress in adulthood and cause pain, discomfort and breathing problems.
Corrective options include vertebral body tethering (VBT), where surgeons correct the spine with a flexible plastic cord to preserve motion and growth. This is available for flexible curves of up to 65 degrees and typically recommended for children who are still growing.
The mainstay of pediatric spinal surgery is spinal fusion. Surgeons place one or two screws in each vertebra affected by the curve, typically involving 10 to 13 of the 17 vertebrae in the back. Screw diameter and trajectory are critical to anchoring metal rods that correct, stabilize and align the spine until a permanent fusion forms. Historically, malpositioned screws were a common cause of return to surgery and occasionally resulted in other complications. Accurate placement of screws can ensure patient safety and improve surgical outcomes.
Younger patients with significant curvature carry higher risks of blood loss or neurologic complications due to the smaller size of the pedicles and their proximity to major blood vessels, the spinal cord and nerves. Early practices involving freehand techniques for inserting screws relied on a surgeon's mental model of the spine and experience, typically supported by a portable fluoroscopy or X-ray. However, reliance on surface landmarks along the spine to guide decisions increases the risk of malpositioned screws or breaches that can injure surrounding structures.
Image-guided navigation using computerized tomography (CT) offers surgeons access to a 3D road map of the patient's anatomy. Anatomical models generated at different time points primarily drive the navigation:
- Preoperative CT (pCT) builds a high-resolution 3D map from a scan obtained before surgery. Surgeons convert the scan into a virtual model of the spine that allows them to plan screw trajectories and guide their instruments during the procedure.
- Intraoperative CT (iCT) updates the map in real time by acquiring 3D scans of the patient's spine in its current position. This accounts for changes in orientation due to any movement or manipulation and validates pedicle screw placement.
CT-based navigation systems rely on linking coordinates from the CT scans with a patient's physical position. This "registration" creates a single map shared between the surgical instruments and the spine. The map's accuracy requires frequent registration events during a procedure to link pCT scans with a patient's orientation.
Navigation can provide an additional tool for safe pedicle screw placement, resulting in increased accuracy of screw placement and fewer reoperations. Studies led by Dr. Larson and Todd A. Milbrandt, M.D., recent past president of the Pediatric Orthopaedic Society of North America (POSNA), also helped minimize radiation exposure for patients and staff. By optimizing low-dose pCT and iCT protocols, the researchers reduced patient radiation exposure by up to 90%.
Dr. Larson says that perspectives are still evolving among clinicians regarding the need for navigation methods based largely on their impact on surgical workflows and operative time. However, experience gradually tempered that point of view.
"After using the technology, there seemed to be a collective realization of what it offered in terms of increased precision," Dr. Larson says. "The 3D navigation offers a far more precise and patient-specific view of the anatomy and reveals the unique curvature and structural variations of each individual."
Whereas screw placement previously depended on expert judgment guided by general anatomical knowledge, navigation introduced a higher level of precision and confidence. The result was more accurate and tailored screw trajectories that translated into fewer revision surgeries.
How robotic assistance builds upon CT-guided navigation
Doctors at Mayo Clinic Children's are weaving robotic assistance into surgical settings as an extension of existing navigation workflows. Robotics builds upon image‑guided navigation and offers the potential to enhance the highly precise, repeatable movements involved in pedicle screw placement. Specifically, the robot functions as a guidance and execution tool manipulated by a surgeon, who retains full control over decision-making.
With current robotic systems in spine surgery, surgeons remain in complete control of every instrument and manual tool. However, the field is evolving rapidly, mirroring the trajectory of robotic adoption in hip and knee arthroplasty. Dr. Larson notes that early robotic systems could slow or stop surgical instruments from moving when they deviated from a "safe zone" as determined by the registered CT scan.
Participation in studies designed to build consensus among surgeons using robot-assisted spine surgery is a critical part of this evolution. The goal is to help refine adoption of the technology by highlighting best practices, as well as describing potential pitfalls.
"Even with ongoing advances in robotic technology, the operating room looks nothing like a modern automotive assembly line," Dr. Larson says. "That level of automation is still a long way off, and underlying patient variability makes patient-specific treatment essential in the medical field."
Dr. Larson has evaluated these systems since the first platforms approved by the Food and Drug Administration became available for adult and pediatric applications. Access to the resources and expertise at Mayo Clinic and close collaborations with the adult spine practice enabled their early adoption and use in pediatric surgical cases. This also allows their teams to generate real-world data to drive the field forward.
"I see the transition from navigation to robotics as a continuum," Dr. Larson explains. She adds that navigation has been the standard of care for pediatric scoliosis patients at Mayo Clinic, including all spine fusion and VBT cases, for nearly a decade. That level of experience uniquely positions Dr. Larson and her colleagues to evaluate the best ways to integrate robot-assisted methods.
"Navigation remains central to our practice, because we've demonstrated that it improves the accuracy of implant placement," Dr. Larson says. "That depth of experience enables us to introduce new technology thoughtfully and ethically in a real-world clinical setting and rigorously report the outcomes."
How data are driving the future of robot-assisted pediatric scoliosis surgery
Similarities in the workflows, from registration to navigated guidance, have made the integration of robotics at Mayo Clinic Children's relatively seamless. Mayo Clinic Children's remains one of the few centers in the nation using the technology, especially in a pediatric setting. This makes meaningful comparisons of conventional methods against robot-assisted techniques difficult, with current data limited to the use of first-generation robotic devices.
To address this, Mayo Clinic Children's surgeons participate in multiple research consortia, including the Setting Scoliosis Straight Foundation, the POSNA Surgeon Quality Improvement Database and the Pediatric Spine Foundation. They also partner with research scientists, regulatory stakeholders and patient advocacy groups to advance care.
These collaborations also promote participation in patient registries that:
- Accelerate discovery by providing access to larger populations representing a wider variety of backgrounds.
- Generate real-world evidence about robotic spine surgery's effectiveness and safety.
- Streamline analysis by collecting hundreds of data points and images, enabling sophisticated comparisons of robotics versus conventional methods.
- Support research of a rare procedure in a small population by pooling cases from multiple sites.
- Track innovation by monitoring the evolution of robotic technology and the effect of surgeon experience on outcomes.
"Participation in registries allows surgeons to learn from one another and benchmark their surgical outcomes," Dr. Milbrandt explains. "Collectively sharing and analyzing scoliosis surgery results accelerates progress and supports the safe introduction of new approaches."
Dr. Milbrandt also emphasizes that Mayo Clinic Children's involvement in evaluating innovative techniques continues to provide patients with safe, well-informed access to the latest technologies.
"Our experience has proven that navigation provides an additional layer of safety in these procedures beyond surgeons' anatomical knowledge, years of training or what they feel with their hands," Dr. Larson says. "I believe that robotics holds the potential to add yet another layer of safety, and my goal is to help study it."
For more information
Baky FJ, et al. Intraoperative computed tomography-guided navigation for pediatric spine patients reduced return to operating room for screw malposition compared with freehand/fluoroscopic techniques. Spine Deformity. 2019;7:577.
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