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Background: Robotic-assisted surgery has emerged as an innovative approach widely adopted in the field of orthopedics. However, its application specifically for managing atlantoaxial dislocation with a high-riding vertebral artery (AAD-HVA) remains underreported in the existing literature. Objective: To compare the perioperative outcomes of robotic-assisted (RA) and fluoroscopic-guided free-hand (FH) techniques for atlantoaxial dislocation in combination with a high-riding vertebral artery (AAD-HVA). Study design: This was a retrospective study. Setting: This research was performed at a single department of spine surgery. Methods: Data from patients who underwent atlantoaxial internal fixation between July 2018 and January 2022 at our hospital were retrospectively analyzed. Among the cases, 14 were performed using free-hand (FH) techniques and 11 utilized robotic-assisted (RA) techniques. Data collected included case notes, imaging records, and follow-up data. The reliability of screw placement was evaluated based on the Gertzbein and Robbins scores, while treatment outcomes were assessed using the Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS), neck disability index (NDI), and postoperative complication rate. Results: Baseline patient characteristics were comparable between the FH and RA groups. The mean blood loss was markedly lower in the RA group (157.3 ± 49.7 ml) compared to the FH group (290.0 ± 110.3 ml) (p = 0.03). Although the average operative time was slightly higher in FH group than in RA group, this disparity did not achieve statistical significance (p = 0.7588). Moreover, the radiation exposure dose was remarkably higher in FH group (32.7 ± 4.4 mGy) than in RA group (23.0 ± 3.2 mGy) (p < 0.0001). The percentage of clinically acceptable screw placement was slightly lower in FH group (87.5%) than in RA group (97.8%), but the observed variance was not statistically meaningful (p = 0.3669). Furthermore, the differences in JOA, VAS, and NDI scores between the FH and RA groups were not statistically significant. Additionally, no obvious differences were found in clinical outcomes or complications related to screw implantation between the two groups. Limitations: This study has inherent limitations as it was retrospective in nature and conducted at a single center. Conclusion: Robotic-assisted surgery for AAD-HVA patients offers a minimally invasive approach, reduced bleeding and lower radiation exposure compared with traditional free-hand surgery. [ABSTRACT FROM AUTHOR]