The Impact of Image-Guided Screw Placement on Unexpected Return to the Operating Room: A Systematic Review and Meta-Analysis of 91,285 Patients

Why clinicians should know about it

• Picked for Spine Surgery (paper of the day, 29 September 2026): Meta‑analysis of image‑guided vs freehand screw placement

Abstract

Study designSystematic Review and Meta-Analysis.ObjectivesNavigation-guided screw placement improves screw accuracy and may reduce hardware-related revision, yet its effect on overall unexpected return to the operating room (URTO) remains uncertain. This study compares image-guided (navigation and robotics) with freehand screw placement for hardware-related revision, non-hardware reoperation, and URTO following spinal fixation.MethodsA PRISMA-guided systematic review identified comparative studies evaluating image-guided versus freehand screw fixation. Two reviewers performed screening, data extraction, and risk-of-bias assessment. Odds ratios (ORs) were pooled using a random-effects Mantel-Haenszel meta-analysis. Subgroup analyses compared navigated, robotic, and freehand techniques.ResultsTwenty-one studies were included, comprising 91,285 patients (8,743 image-guided; 82,442 freehand). Compared with freehand, image guidance was associated with lower odds of hardware-related revision (OR 0.55, 95% CI 0.40-0.75) and lower odds of URTO (OR 0.69, 95% CI 0.50-0.94), with no difference in non-hardware reoperation (OR 1.03, 95% CI 0.67-1.57). Navigation was associated with lower odds of hardware-related revision (OR 0.51, 95% CI 0.35-0.77) and URTO (OR 0.63, 95% CI 0.51-0.77) versus freehand, whereas robotics showed no significant differences across outcomes. Indirect comparison between navigation and robotics was not statistically significant. Risk of bias was overall high because of retrospective study design, confounding, and inconsistent outcome reporting.ConclusionsNavigation was associated with lower odds of hardware-related revision and lower odds of URTO, without a difference in non-hardware reoperation. Robotics showed no statistically significant advantage over freehand fixation, but its underrepresentation and differing case mix limit comparative conclusions.

Abstract as published, via PubMed.