Pedicle screw fixation is central to modern spinal stabilization, but the optimal technique for accurate and safe placement remains debated. We systematically compared robotic-assisted (RA), navigation-guided (NV), and conventional freehand (FH) techniques for pedicle screw placement across radiographic accuracy, perioperative metrics, complications, radiation exposure, and cost considerations. A PRISMA- informed search of major electronic sources identified comparative studies up to August 2024 evaluating at least two of the three techniques. Risk of bias was assessed using design-appropriate tools, and random- effects models were used to pool dichotomous and continuous outcomes where feasible. Across pooled analyses, RA showed the highest probability of achieving “perfect” screw placement (Gertzbein– Robbins Grade A), with significantly greater odds than NV and FH. When accuracy was defined as “clinically acceptable” (Grade A+B), technology- assisted approaches (RA/NV) remained superior to FH. Safety signals favored technology assistance: RA/ NV demonstrated markedly lower rates of facet joint violation and a lower risk of major complications compared with FH, while neurological injury rates were low across techniques and did not consistently differ. The principal trade-off was operative efficiency: RA was associated with longer operative time than FH, likely reflecting setup and workflow factors. Radiation exposure metrics generally favored RA/ NV, particularly for the surgical team. Economic implications were context-dependent; substantial capital and per-case costs may be offset by avoided revisions, reduced length of stay, and improved throughput in high-volume centers, whereas low- volume settings may not reach break-even thresholds. Overall, RA provides the highest radiographic accuracy and may reduce select complications, but adoption should be individualized based on case complexity, institutional volume, and value considerations.