Objective To compare the effectiveness of spinal robot-assisted pedicle screw placement through different surgical approaches and to guide the clinical selection of appropriate robot-assisted surgical approaches. MethodsThe clinical data of 14 patients with thoracolumbar vertebral diseases who met the selection criteria between January 2023 and August 2023 were retrospectively analyzed, and all of them underwent pedicle screw placement under assistant of the Mazor X spinal surgery robot through different surgical approaches. The patients were divided into posterior median approach (PMA) group (n=6) and intermuscular approach (IMA) group (n=8) according to the surgical approaches, and there was no significant difference in age, gender, body mass index, disease type, and fixed segment between the two groups (P>0.05). The operation time, intraoperative blood loss, screw-related complications, and reoperation rate were recorded and compared between the two groups; the inclination angle of the screw, the distance between the screw and the midline, and the caudal inclination angle of the screw were measured based on X-ray films at immediate after operation. Results There was no significant difference in operation time and intraoperative blood loss between the two groups (P>0.05). There was no screw-related complication such as nerve injury in both groups, and no patients underwent secondary surgery. At immediate after operation, the inclination angle of the screw, the distance between the screw and the midline, and the caudal inclination angle of the screw in the IMA group were significantly greater than those in the PMA group (P<0.05). ConclusionThere are differences in the position and inclination angle of screws placed with robot-assisted surgery through different surgical approaches, which may be due to the obstruction of the screw path by soft tissues such as skin and muscles. When using spinal robot-assisted surgery, selecting the appropriate surgical approach for different diseases can make the treatment more reasonable and effective.