Robot-Assisted versus non-robotic frame-based deep brain stimulation: a systematic review and meta-analysis of targeting accuracy and clinical outcomes

Clinical Snapshot

Key Findings

• P Value: Target point error: P = 0.04; Targeting outliers: P = 0.002; Vector error: P = 0.05 (marginal, not conventionally significant)

• Effect Size: Target point error: MD = -0.31 mm; Targeting outliers: OR = 0.15; Vector error: MD = -0.70 mm (marginal); Radial error, operative times, complications, UPDRS-III: no significant difference

• Primary Outcome: Target point error significantly reduced with RA-DBS versus NRA-DBS; clinically significant targeting outliers significantly less frequent with RA-DBS

• Nnt Or Sensitivity: OR = 0.15 for clinically significant targeting outliers (85% relative odds reduction); absolute risk reduction and NNT not calculable from abstract data alone. No sensitivity/specificity or hazard ratio applicable to this intervention comparison.

• Confidence Interval: Target point error: 95% CI -0.61 to -0.01; Targeting outliers: 95% CI 0.04 to 0.51; Vector error CI not reported in abstract

Clinical Application

Robotic DBS platforms (e.g., ROSA, Neuromate, Mazor) are available in high-volume neurosurgical centres globally but represent significant capital investment. Feasibility is centre-dependent, requiring specialised training, equipment maintenance, and institutional infrastructure. The absence of operative time advantage reduces the efficiency argument for adoption. In Australia, DBS is funded through the Medicare Benefits Schedule (MBS) for approved indications including Parkinson's disease, essential tremor, and dystonia. Robotic-assisted neurosurgery platforms are available at select tertiary neurosurgical centres (e.g., major metropolitan hospitals in Sydney, Melbourne, Brisbane). The TGA has approved several robotic surgical systems for neurosurgical use. However, robotic DBS is not specifically incentivised or mandated under current RACGP or Neurosurgical Society of Australasia guidelines. Given the absence of demonstrated clinical superiority in UPDRS-III outcomes and comparable complication rates, Australian health technology assessment bodies (e.g., MSAC) would likely require stronger evidence — including cost-effectiveness data and quality-of-life outcomes — before recommending preferential funding of RA-DBS over conventional frame-based approaches. PBS listing of DBS hardware is not directly affected by surgical technique. Adult patients with movement disorders (Parkinson's disease, essential tremor, dystonia) being considered for DBS lead implantation at centres with access to robotic stereotactic platforms

Abstract

Deep brain stimulation (DBS) outcomes depend on accurate lead placement. Robot-assisted DBS (RA-DBS) has been increasingly adopted, yet its advantages over conventional non-robotic frame-based DBS (NRA-DBS) regarding targeting accuracy, operative efficiency, and clinical outcomes remain debated.To compare RA-DBS versus NRA-DBS for targeting accuracy and clinical outcomes in patients undergoing DBS for movement disorders.This meta-analysis and systematic review was registered in PROSPERO (CRD420261336001) and adhered to PRISMA. Patients with mobility disorders treated with RA-DBS versus frame-based NRA-DBS were included in comparative studies (RCTs and prospective/retrospective cohorts). Targeting accuracy measures (such as target point error, vector error, and radial error) and extreme targeting outliers were the main results. Operative time measurements, perioperative problems (such as cerebral bleeding), and motor improvement (UPDRS-III) were secondary outcomes. Fixed-effects or random-effects models based on heterogeneity were used to compute pooled odds ratios (OR) and weighted mean differences (MD) with 95% confidence intervals (CI). Nine high-quality comparative studies encompassing 495 patients (227 RA-DBS vs. 268 NRA-DBS) were synthesized. RA-DBS significantly minimized target point error (MD = -0.31 mm, 95% CI: -0.61 to -0.01; P = 0.04) and significantly reduced the incidence of clinically significant targeting outliers (OR = 0.15, 95% CI: 0.04 to 0.51; P = 0.002). Comprehensive three-dimensional vector error was marginally lower in the RA-DBS cohort (MD = -0.70 mm; P = 0.05), whereas two-dimensional radial error and total operating room time, surgical duration, anesthesia time, perioperative complications, and 12-month UPDRS-III motor improvements were statistically equivalent between groups. Subgroup analyses revealed that the spatial precision advantage of RA-DBS was geographically robust across East Asian and Western cohorts, whereas chronological efficiency was heavily dependent on the specific robotic platform used.Compared with conventional frame-based stereotaxy, robot-assisted DBS significantly enhances target point precision and reduces electrode deviations. However, these technical accuracy advantages do not translate into overall clinical superiority, as both approaches yield comparable operative efficiency, perioperative safety, and mid-term motor symptom relief.

References

1. 1.Liu, J., Sun, Y., Liu, M., Huo, J., Guo, J., & Wei, C. (2026). Robot-Assisted versus non-robotic frame-based deep brain stimulation: a systematic review and meta-analysis of targeting accuracy and clinical outcomes. Journal of Robotic Surgery. https://doi.org/10.1136/jnnp-2023-331282