Abstract:[Objective] To compare the clinical efficacy of robot-assisted percutaneous pedicle screw fixation (PPSF) versus conventional freehand PPSF in the treatment of thoracolumbar fractures. [Methods] A retrospective research was conducted on 72 patients who received PPSF combined with vertebral body bone grafting for thoracolumbar fractures in our hospital from January 2022 to November 2023. According to the communication between doctors and patients, 35 patients were treated with robot-assisted PPSF, while other 37 patients were with conventional manual PPSF. The perioperative, follow-up, and imaging data of the two groups were compared. [Results] All patients in both groups had corresponding surgeries performed successfully without severe complications. There were no statistically significant differences in operation time, incision length, and hospital stay between the two groups (P＞0.05), but the robot-assisted group had significantly fewer intraoperative fluoroscopy [times, (13.1±1.0) vs (35.8±4.4), P＜0.001], less intraoperative blood loss [mL, (64.7±37.4) vs (101.1±81.5), P＜0.001], and better incision healing grades [cases, A/B/C, (35/0/0) vs (33/4/0), P＜0.001] than the conventional group. All patients were followed up for more than one year, and the robot-assisted group regained ambulation [d, (1.9±0.8) vs (2.7±0.9), P＜0.001] and full weight-bearing activity [d, (31.4±3.5) vs (44.8±3.0), P＜0.001] significantly earlier than the conventional group. The VAS and ODI scores significantly decreased over time in both groups (P＜0.05), which in the robot-assisted group were significantly better than the conventional group 3 days postoperatively (P＜0.05), and became not statistically different between the two groups 3 months postoperatively and at the last followup (P＞0.05). Regarding imaging, the robot-assisted group proved significantly superior to the conventional group in terms of Badu grade [0/1/2/3, (149/5/2/0) vs (150/12/4/4), P=0.016], GRS grade for screw placement [A/B/C/D/E, (199/9/2/0/0) vs (190/29/ 1/2/0), P=0.002], vertebral vacuum signs [cases, yes/no, (4/31) vs (13/24), P=0.018], and bone graft scale [cases, 0/1/2/3/4, (0/0/5/11/19) vs (0/3/12/14/8), P＜0.001]. In addition, the robot-assisted group was also significantly better than the conventional group in terms of local kyphotic angles [°, (6.1±0.8) vs (7.3±0.9), P＜0.001] and anterior vertebral height [mm, (25.7±1.0) vs (24.6±2.3), P=0.011] at the last followup. [Conclusion] The robot-assisted percutaneous pedicle screw fixation and bone grafting does improve screw placement accuracy, effectively correct local kyphotic deformity, restore vertebral height, and achieve satisfactory clinical outcomes for thoracolumbar fractures.