Does oblique lumbar interbody fusion promote adjacent degeneration in degenerative disc disease: A finite element analysis

The effect of different fixation systems on oblique lumbar interbody fusion under vibration conditions

Despite the fact that lower back pain caused by degenerative lumbar spine pathologies seriously affects the quality of life, however, there is a paucity of research on the biomechanical properties of different auxiliary fixation systems for its primary treatment (oblique lumbar interbody fusion) under vibratory environments. In order to study the effects of different fixation systems of OLIF surgery on the vibration characteristics of the human lumbar spine under whole-body vibration (WBV), a finite element (FE) model of OLIF surgery with five different fixation systems was established by modifying a previously established model of the normal lumbar spine (L1-S1). In this study, a compressive follower load of 500 N and a sinusoidal axial vertical load of ±40 N at the frequency of 5 Hz with a duration of 0.6 s was applied. The results showed that the bilateral pedicle screw fixation model had the highest resistance to cage subsidence and maintenance of disc height under WBV. In contrast, the lateral plate fixation model exerted very high stresses on important tissues, which would be detrimental to the patient's late recovery and reduction of complications. Therefore, this study suggests that drivers and related practitioners who are often in vibrating environments should have bilateral pedicle screws for OLIF surgery, and side plates are not recommended to be used as a separate immobilization system. Additionally, the lateral plate is not recommended to be used as a separate fixation system.

Biomechanical response of decompression alone in lower grade lumbar degenerative spondylolisthesis--A finite element analysis

BACKGROUND

Previous studies have demonstrated the clinical efficacy of decompression alone in lower-grade spondylolisthesis. A higher rate of surgical revision and a lower rate of back pain relief was also observed. However, there is a lack of relevant biomechanical evidence after decompression alone for lower-grade spondylolisthesis.

PURPOSE

Evaluating the biomechanical characteristics of total laminectomy, hemilaminectomy, and facetectomy for lower-grade spondylolisthesis by analyzing the range of motion (ROM), intradiscal pressure (IDP), annulus fibrosus stress (AFS), facet joints contact force (FJCF), and isthmus stress (IS).

METHODS

Firstly, we utilized finite element tools to develop a normal lumbar model and subsequently constructed a spondylolisthesis model based on the normal model. We then performed total laminectomy, hemilaminectomy, and one-third facetectomy in the normal model and spondylolisthesis model, respectively. Finally, we analyzed parameters, such as ROM, IDP, AFS, FJCF, and IS, for all the models under the same concentrate force and moment.

RESULTS

The intact spondylolisthesis model showed a significant increase in the relative parameters, including ROM, AFS, FJCF, and IS, compared to the intact normal lumbar model. Hemilaminectomy and one-third facetectomy in both spondylolisthesis and normal lumbar models did not result in an obvious change in ROM, IDP, AFS, FJCF, and IS compared to the pre-operative state. Moreover, there was no significant difference in the degree of parameter changes between the spondylolisthesis and normal lumbar models after undergoing the same surgical procedures. However, total laminectomy significantly increased ROM, AFS, and IS and decreased the FJCF in both normal lumbar models and spondylolisthesis models.

CONCLUSION

Hemilaminectomy and one-third facetectomy did not have a significant impact on the segment stability of lower-grade spondylolisthesis; however, patients with LDS undergoing hemilaminectomy and one-third facetectomy may experience higher isthmus stress on the surgical side during rotation. In addition, total laminectomy changes the biomechanics in both normal lumbar models and spondylolisthesis models.

Determining a relative total lumbar range of motion to alleviate adjacent segment degeneration after transforaminal lumbar interbody fusion: a finite element analysis

BACKGROUND

A reduction in total lumbar range of motion (ROM) after lumbar fusion may offset the increase in intradiscal pressure (IDP) and facet joint force (FJF) caused by the abnormally increased ROM at adjacent segments. This study aimed to determine a relative total lumbar ROM rather than an ideal adjacent segment ROM to guide postoperative waist activities and further delay adjacent segment degeneration (ASD).

METHODS

An intact L1-S1 finite element model was constructed and validated. Based on this, a surgical model was created to allow the simulation of L4/5 transforaminal lumbar interbody fusion (TLIF). Under the maximum total L1-S1 ROM, the ROM, IDP, and FJF of each adjacent segment between the intact and TLIF models were compared to explore the biomechanical influence of lumbar fusion on adjacent segments. Subsequently, the functional relationship between total L1-S1 ROM and IDP or total L1-S1 ROM and FJF was fitted in the TLIF model to calculate the relative total L1-S1 ROMs without an increase in IDP and FJF.

RESULTS

Compared with those of the intact model, the ROM, IDP, and FJF of the adjacent segments in the TLIF model increased by 12.6-28.9%, 0.1-6.8%, and 0-134.2%, respectively. As the total L1-S1 ROM increased, the IDP and FJF of each adjacent segment increased by varying degrees. The relative total L1-S1 ROMs in the TLIF model were 11.03°, 12.50°, 12.14°, and 9.82° in flexion, extension, lateral bending, and axial rotation, respectively.

CONCLUSIONS

The relative total L1-S1 ROMs after TLIF were determined, which decreased by 19.6-29.3% compared to the preoperative ones. Guiding the patients to perform postoperative waist activities within these specific ROMs, an increase in the IDP and FJF of adjacent segments may be effectively offset, thereby alleviating ASD.

Biomechanical evaluation of Percutaneous endoscopic posterior lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion: a biomechanical analysis

In order to analyze and evaluate the stability of lumbar spine and the risk of cage subsidence after different minimally invasive fusion operations, two finite element models Percutaneous endoscopic posterior lumbar interbody fusion (PE-PLIF) and minimally invasive transforaminal lumbar interbody Fusion (MIS-TLIF) were established. The results showed that compared with MIS-TLIF, PE-PLIF had better segmental stability, lower pedicle screw rod system stress, and lower risk of cage subsidence. The results suggest that the cage with appropriate height should be selected to ensure the segmental stability and avoid the risk of the subsidence caused by the cage with large height.

Biomechanical evaluation of different oblique lumbar interbody fusion constructs: a finite element analysis

BACKGROUND

Finite element analysis (FEA) was performed to investigate the biomechanical differences between different adjunct fixation methods for oblique lumbar interbody fusion (OLIF) and to further analyze its effect on adjacent segmental degeneration.

METHODS

We built a single-segment (Si-segment) finite element model (FEM) for L4-5 and a double-segment (Do-segment) FEM for L3-5. Each complete FEM was supplemented and modified, and both developed two surgical models of OLIF with assisted internal fixation. They were OLIF with posterior bilateral percutaneous pedicle screw (TINA system) fixation (OLIF + BPS) and OLIF with lateral plate system (OLIF + LPS). The range of motion (ROM) and displacement of the vertebral body, cage stress, adjacent segment disc stress, and spinal ligament tension were recorded for the four models during flexion/extension, right/left bending, and right/left rotation by applying follower load.

RESULTS

For the BPS and LPS systems in the six postures of flexion, extension, right/left bending, and right/left rotation, the ROM of L4 in the Si-segment FEM were 0.32°/1.83°, 0.33°/1.34°, 0.23°/0.47°, 0.24°/0.45°, 0.33°/0.79°, and 0.34°/0.62°; the ROM of L4 in the Do-segment FEM were 0.39°/2.00°, 0.37°/1.38°, 0.23°/0.47°, 0.21°/0.44°, 0.33°/0.57°, and 0.31°/0.62°, and the ROM of L3 in the Do-segment FEM were 6.03°/7.31°, 2.52°/3.50°, 4.21°/4.38°, 4.21°/4.42°, 2.09°/2.32°, and 2.07°/2.43°. BPS system had less vertebral displacement, less cage maximum stress, and less spinal ligament tension in Si/Do-segment FEM relative to the LPS system. BPS system had a smaller upper adjacent vertebral ROM, greater intervertebral disc stress in terms of left and right bending as well as left and right rotation compared to the LPS system in the L3-4 of the Do-segment FEM. There was little biomechanical difference between the same fixation system in the Si/Do-segment FEM.

CONCLUSIONS

Our finite element analysis showed that compared to OLIF + LPS, OLIF + BPS (TINA) is more effective in reducing interbody stress and spinal ligament tension, and it better maintains the stability of the target segment and provides a better fusion environment to resist cage subsidence. However, OLIF + BPS (TINA) may be more likely to cause adjacent segment degeneration than OLIF + LPS.

Biomechanical Study of Minimally Invasive Nonfusion Surgery for Treatment of Disc Herniation Associated with Adjacent Segment Disease: A Finite Element Analysis

OBJECTIVE

We explored the biomechanical changes of 2 conventional minimally invasive nonfusion surgical methods for treating disc herniation in adjacent segment disease using 3-dimensional finite element analysis.

METHODS

A model comprising L3 to the sacrum was validated and used to establish an L4-L5 fusion model, and an adjacent segment disease (ASD) model was developed by modifying the material properties of the intervertebral discs. The ASD model was used to simulate 2 conventional minimally invasive nonfusion surgical methods, which resulted in the creation of 2 postoperative models (M1 and M2). The range of motion and the equivalent stress for each model were recorded under 6 different working conditions. The data are descriptive and were analyzed comparatively under a normal load.

RESULTS

Compared with the ASD group, the range of motion of the adjacent segment in the M1 and M2 groups remained unaffected. However, significant Von-Mises stress changes were found in the annulus fibrosus and nucleus pulposus (NP), especially during extension, ipsilateral bending, and rotation. Stress in the NP also shifted toward the surgical incision in the annulus fibrosus during these movements. The maximum Von-Mises stress in the NP of the cephalic segment increased more than did that of the caudal segment.

CONCLUSIONS

Minimal nonfusion surgery for ASD might not affect adjacent segment stability significantly. Nonetheless, it can lead to segmental degeneration deterioration and postoperative recurrence. The cephalic segment is affected more than the caudal segment. Therefore, consideration of disc degeneration and appropriate selection of surgical methods for ASD are crucial.

Comparative Biomechanical Analysis of Unilateral, Bilateral, and Lateral Pedicle Screw Implantation in Oblique Lumbar Interbody Fusion: A Finite Element Study

Oblique lumbar interbody fusion (OLIF) can be combined with different screw instrumentations. The standard screw instrumentation is bilateral pedicle screw fixation (BPSF). However, the operation is time consuming because a lateral recumbent position must be adopted for OLIF during surgery before a prone position is adopted for BPSF. This study aimed to employ a finite element analysis to investigate the biomechanical effects of OLIF combined with BPSF, unilateral pedicle screw fixation (UPSF), or lateral pedicle screw fixation (LPSF). In this study, three lumbar vertebra finite element models for OLIF surgery with three different fixation methods were developed. The finite element models were assigned six loading conditions (flexion, extension, right lateral bending, left lateral bending, right axial rotation, and left axial rotation), and the total deformation and von Mises stress distribution of the finite element models were observed. The study results showed unremarkable differences in total deformation among different groups (the maximum difference range is approximately 0.6248% to 1.3227%), and that flexion has larger total deformation (5.3604 mm to 5.4011 mm). The groups exhibited different endplate stress because of different movements, but these differences were not large (the maximum difference range between each group is approximately 0.455% to 5.0102%). Using UPSF fixation may lead to higher cage stress (411.08 MPa); however, the stress produced on the endplate was comparable to that in the other two groups. Therefore, the length of surgery can be shortened when unilateral back screws are used for UPSF. In addition, the total deformation and endplate stress of UPSF did not differ much from that of BPSF. Hence, combining OLIF with UPSF can save time and enhance stability, which is comparable to a standard BPSF surgery; thus, this method can be considered by spine surgeons.

The effects of topping-off instrumentation on biomechanics of sacroiliac joint after lumbosacral fusion

BACKGROUND

Lumbar/lumbosacral fusion supplemented with topping-off devices has been proposed with the aim of avoiding adjacent segment degeneration proximal to the fusion construct. However, it remains unclear how the biomechanics of the sacroiliac joint (SIJ) are altered after topping-off surgery. The objective of this study was to investigate the biomechanical effects of topping-off instrumentation on SIJ after lumbosacral fusion.

METHODS

The validated finite element model of an intact lumbar spine-pelvis segment was modified to simulate L5-S1 interbody fusion fixed with a pedicle screw system. An interspinous spacer, Device for Intervertebral Assisted Motion (DIAM), was used as a topping-off device and placed between interspinous processes of the L4 and L5 segments. Range of motion (ROM), von-Mises stress distribution, and ligament strain at SIJ were compared between fusion (without DIAM) and topping-off (fusion with DIAM) models under moments of four physiological motions.

RESULTS

ROM at the left and right SIJs in the topping-off model was higher by 26.9% and 27.5% in flexion, 16.8% and 16.1% in extension, 18.8% and 15.8% in lateral bending, and 3.7% and 7.4% in axial rotation, respectively, compared to those in the fusion model. The predicted stress and strain data showed that under all physiological loads, the topping-off model exhibited higher stress and ligament strain at the SIJs than the fusion model.

CONCLUSIONS

Motion, stress, and ligament strain at SIJ increase when supplementing lumbosacral fusion with topping-off devices, suggesting that topping-off surgery may be associated with higher risks of SIJ degeneration and pain than fusion alone.

Elucidation of the Mechanism of Occasional Anterior Longitudinal Ligament Rupture with Posterior Correction Procedure for Adult Spinal Deformity Using LLIF-Finite Element Analysis of the Impact of the Lordotic Angle of Intervertebral LLIF Cage

Background and Objectives: There are several advantages of using lateral lumbar interbody fusion (LLIF) for correction surgeries for adult spinal deformity (ASD); however, we currently have unresolved new issues, including occasional anterior longitudinal ligament (ALL) rupture during the posterior correction procedure. When LLIF was initially introduced, only less lordotic cages were available and ALL rupture was more frequently experienced compared with later periods when more lordotic cages were available. We performed finite element analysis (FEA) regarding the mechanism of ALL rupture during a posterior correction procedure. Methods: A spring (which mimics ALL) was introduced at the location of ALL in the FEA and an LLIF cage with two different lordotic angles, 6 and 12 degrees (6DC/12DC), was employed. To assess the extent of burden on the ALL, the extension length of the spring during the correction procedure was measured and the location of the rotation center was examined. Results: We observed a significantly higher degree of length extension of the spring during the correction procedure in the FEA model with 6DC compared with that of 12DC. We also observed that the location of the rotation center was shifted posteriorly in the FEA model with 6DC compared with that of 12DC. Conclusions: It is considered that the posterior and rostral edge of the less lordotic angle cage became a hinge, and the longer lever arm increased the burden on ALL as the principle of leverage. It is important to use an LLIF cage with a sufficient lordotic angle, that is compatible with the degree of posterior osteotomy in ASD correction.

Does Lumbar Interbody Fusion Modality Affect the Occurrence of Complications in an Osteoporotic Spine Under Whole-Body Vibration? A Finite Element Study

OBJECTIVE

To evaluate the effects of 3 lumbar interbody fusion techniques on the occurrence of complications in an osteoporotic spine under whole-body vibration.

METHODS

A previously developed and validated nonlinear finite element model of L1-S1was modified to develop anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF) models with osteoporosis. In each model, the lower surface of the sacrum was absolutely fixed, a follower load of 400N was applied through the axis of the lumbar spine, and an axial sinusoidal vertical load of ±40N (5 Hz) was imposed on the superior surface of L1, to perform a transient dynamic analysis. The maximal values of intradiscal pressure, shear stress on annulus substance, disc bulge, facet joint stress, and screw and rod stress, along with their dynamic response curves, were collected.

RESULTS

Among these 3 models, the TLIF model generated the greatest screw and rod stress, and the PLIF model generated the greatest cage-bone interface stress. At the L3-L4 level, compared with the other 2 models, the maximal values and dynamic response curves of intradiscal pressure, shear stress of annulus ground substance, and disc bulge were all lower in the ALIF model. However, the facet contact stress at the adjacent segment in the ALIF model was higher than that in the other 2 models.

CONCLUSIONS

In an osteoporotic spine under whole-body vibration, TLIF has the highest risk of screw and rod breakage, PLIF has the highest risk of cage subsidence, and ALIF has the lowest risk of upper adjacent disc degeneration, but the highest risk of adjacent facet joint degeneration.

Biomechanical effects of screws of different materials on vertebra-pediculoplasty: a finite element study

Background: The effects of cannulated screws made of polyetheretherketone (PEEK) on the biomechanical properties of the vertebral body during vertebra-pediculoplasty remain unclear. This study aimed to investigate whether PEEK screws have the potential to replace titanium alloy screws. Methods: The surgical model of two different materials of screws was constructed using the finite element method. The biomechanical effects of the two models on the vertebral body under different working conditions were compared. Results: ① The peak von Mises stress of PEEK screws was significantly lower than that of titanium screws, with a reduction ranging from 52% to 80%. ② The von Mises stress values for the injured T12 spine were similar for both materials. Additionally, the segmental range of motion and intervertebral disc pressure showed no significant difference between the two materials. Conclusion: PEEK screws demonstrated advantages over titanium screws and may serve as a viable alternative for screw materials in vertebra-pediculoplasty.

Biomechanical Evaluation of Rigid Interspinous Process Fixation Combined With Lumbar Interbody Fusion Using Hybrid Testing Protocol

Rigid interspinous process fixation (RIPF) has been recently discussed as an alternative to pedicle screw fixation (PSF) for reducing trauma in lumbar interbody fusion (LIF) surgery. This study aimed to investigate biomechanics of the lumbar spine with RIPF, and also to compare biomechanical differences between two postoperative stages (before and after bony fusion). Based on an intact finite-element model of lumbosacral spine, the models of single-level LIF with RIPF or conventional PSF were developed and were computed for biomechanical responses to the moments of four physiological motions using hybrid testing protocol. It was found that compared with PSF, range of motion (ROM), intradiscal pressure (IDP), and facet joint forces (FJF) at adjacent segments of the surgical level for RIPF were decreased by up to 8.4%, 2.3%, and 16.8%, respectively, but ROM and endplate stress at the surgical segment were increased by up to 285.3% and 174.3%, respectively. The results of comparison between lumbar spine with RIPF before and after bony fusion showed that ROM and endplate stress at the surgical segment were decreased by up to 62.6% and 40.4%, respectively, when achieved to bony fusion. These findings suggest that lumbar spine with RIPF as compared to PSF has potential to decrease the risk of adjacent segment degeneration but might have lower stability of surgical segment and an increased risk of cage subsidence; When achieved bony fusion, it might be helpful for the lumbar spine with RIPF in increasing stability of surgical segment and reducing failure of bone contact with cage.

Comparison of the biomechanical effects of lumbar disc degeneration on normal patients and osteoporotic patients: A finite element analysis

BACKGROUND

Some older patients who suffered from both conditions (disc degeneration and osteoporosis) have higher surgical risks and longer postoperative recovery times. Understanding the relation between disc degeneration and osteoporosis is fundamental to know the mechanisms of orthopedic disorders and improve clinical treatment. However, there is a lack of finite element (FE) studies to predict the combined effects of disc degeneration and osteoporosis. So the aim of the present study is to explore the differences of biomechanical effects of lumbar disc degeneration on normal patients and osteoporotic patients.

METHODS

A normal lumbar spine finite element model (FEM) was developed based on the geometric information of a healthy male subject (age 35 years; height 178 cm; weight 65 kg). This normal lumbar spine FEM was modified to build three lumbar spine degeneration models simulating mild, moderate and severe grades of disc degeneration at the L4-L5 segment. Then the degenerative lumbar spine models for osteoporotic patients were constructed on the basis of the above-mentioned degeneration models. Firstly, the normal model (flexion: 8 Nm; extension: 6 Nm; lateral bending: 6 Nm; torsion: 4 Nm) and degenerative models (10 Nm) were calibrated under pure moment load, respectively. Secondly, under a 400 N follower load, the 7.5 Nm moments of different directions were applied on all models to simulate different motion postures. Finally, under the above loading conditions, we calculated and analyzed the range of motion (ROM), Mises stress in cortical (MSC1), Mises stress in endplate (MSE), Mises stress in cancellous (MSC2), and Mises stress in post (MSP).

RESULTS

Compared with disc degeneration patients without osteoporosis, the ROM, MSC1, and MSE of osteoporosis patients with various disc degeneration decreased in all postures, while the MSC2 and MSP increased. With increase in the degree of disc degeneration, the reduction proportions of ROM and MSE in osteoporotic patients gradually increased, while the reduction percentages in MSC1 of osteoporotic patients gradually decreased. The increase percentages of MSC2 in osteoporotic patients gradually increased. Given the progressive changes of disc degeneration, the changes in MSP in osteoporosis patients were uneven.

CONCLUSION

In summary, the effect of disc degeneration on flexibility in the two kinds of patients (osteoporosis and non-osteoporosis patients) was nearly same. By comparing the remaining biomechanical parameters (MSC1, MSE, MSC2, and MSP), we found that degenerated intervertebral discs caused changes in loading patterns of osteoporosis patients. Disc degeneration reduced the Mises stress in the cortical and endplate, which increased the Mises stress in the cancellous and post. That is to say, in order to cope with the changes in bone stresses caused by disc degeneration and osteoporosis, clinicians should be more careful in choosing the surgical option for osteoporotic patients with disc degeneration.

Biomechanical Performances of an Oblique Lateral Interbody Fusion Cage in Models with Different Bone Densities: A Finite Element Analysis

Study Design

Finite element models of the L3-S1 vertebrae were reconstructed using computed tomography scans.

Objective

We compared the biomechanical performances of an oblique lateral interbody fusion (OLIF) cage in different bone density mode.

Summary of Background Data

Low bone density is an els.key factor limiting the use of stand-alone OLIF cage.

Methods

Four models-intact (M0), normal bone density with OLIF (M1), bone mass loss with OLIF (M2), and osteoporotic with OLIF (M3)-were created based on 3-dimensional scans. Flexion, extension, and lateral bending movements (each lasting 10 N·m) were performed on the superior surface of the L3 vertebra with a compressive preload of 500 N. Range of motion (ROM), peak stresses in the L4-5 cortical endplates, cage stress, and adjacent intervertebral disk stress were evaluated.

Results

ROMs during different physiological movements were similar to those reported by previous researchers. Compared with that in M0, L4-5 ROMs of all movements decreased in M1, M2 and M3, most evidently in M3. Stress distribution in the cortical endplates rose to 7.8% in M1 and M2, even 16.2% in M3. Cage stress increased by less than 8.1% in M1 and M2, but by 25.3% in M3, especially in the movements of extension and right rotation. Compared with that in M0, L3-4 and L5-S1 intervertebral disk stress increased with bone density in all the other models, by up to 69.8% and 98.3%, respectively. As osteoporosis worsened, stress in the adjacent intervertebral disk also increased.

Conclusion

Stand-alone OLIF in M3 is not recommended because of the risk of cage subsidence. OLIF in M1 and M2 achieved similar results in various lumbar spine movements. In M1 and M2 model (T >  - 2.5), the L4-L5 showed reduced mobility in all directions, increased rigidity, limited cage displacement, lessened deformation, and better stability.

Biomechanical analysis of lumbar nonfusion dynamic stabilization using a pedicle screw-based dynamic stabilizer or an interspinous process spacer

This study aimed to investigate and compare the effects of two widely used nonfusion posterior dynamic stabilization (NPDS) devices, pedicle screw-based dynamic stabilizer (PSDS) and interspinous process spacer (IPS), on biomechanics of the implanted lumbar spine under static and vibration loadings. The finite element model of healthy human lumbosacral segment was modified to incorporate NPDS device insertion at L4-L5 segment. Bioflex and DIAM were used as PSDS-based and IPS-based NPDS devices, respectively. As a comparison, lumbar interbody fusion with rigid stabilization was also simulated at L4-L5. For static loading, segmental range of motion (ROM) of the models under moments of four physiological motions was computed using hybrid testing protocol. For vibration loading, resonant modes and dynamic stress of the models under vertical excitation were extracted through random response analysis. The results showed that compared with the rigid fusion model, ROM of the nonfusion models was higher at L4-L5 level but lower at adjacent levels (L1- L2, L2-L3, L3-L4, L5-S1). Compared with the Bioflex model, the DIAM model produced higher ROM at L4-L5 level but lower ROM at adjacent levels, especially under lateral bending and axial rotation; resonant frequency of the DIAM model was slightly lower; dynamic response of nucleus stress at L4-L5 level was slightly higher for the DIAM model, and the dynamic stress at adjacent levels was no obvious difference between the nonfusion models. This study reveals biomechanical differences between the Bioflex and DIAM systems, which may provide references for selecting surgical approaches in clinical practice.

Impact of cage position on biomechanical performance of stand-alone lateral lumbar interbody fusion: a finite element analysis

Background

This study aimed to compare the biomechanical performance of various cage positions in stand-alone lateral lumbar interbody fusion(SA LLIF).

Methods

An intact finite element model of the L3-L5 was reconstructed. The model was verified and analyzed. Through changing the position of the cage, SA LLIF was established in four directions: anterior placement(AP), middle placement(MP), posterior placement(PP), oblique placement(OP). A 400 N vertical axial pre-load was imposed on the superior surface of L3 and a 10 N/m moment was applied on the L3 superior surface along the radial direction to simulate movements of flexion, extension, lateral bending, and axial rotation. Various biomechanical parameters were evaluated for intact and implanted models in all loading conditions, including the range of motion (ROM) and maximum stress.

Results

In the SA LLIF models, the ROM of L4-5 was reduced by 84.21–89.03% in flexion, 72.64–82.26% in extension, 92.5-95.85% in right and left lateral bending, and 87.22–92.77% in right and left axial rotation, respectively. Meanwhile, ROM of L3-4 was mildly increased by an average of 9.6% in all motion directions. Almost all stress peaks were increased after SA LLIF, including adjacent disc, facet joints, and endplates. MP had lower stress peaks of cage and endplates in most motion modes. In terms of the stress on facet joints and disc of the cephalad segment, MP had the smallest increment.

Conclusion

In our study, SA LLIF risked accelerating the adjacent segment degeneration. The cage position had an influence on the distribution of endplate stress and the magnitude of facet joint stress. Compared with other positions, MP had the slightest effect on the stress in the adjacent facet joints. Meanwhile, MP seems to play an important role in reducing the risk of cage subsidence.

Oblique lateral interbody fusion stand-alone vs. combined with percutaneous pedicle screw fixation in the treatment of discogenic low back pain

Objective

Oblique lateral interbody fusion (OLIF) has unique advantages in the treatment of discogenic low back pain (DBP). However, there are few studies in this area, and no established standard for additional posterior internal fixation. The purpose of this study was to investigate the efficacy of OLIF stand-alone vs. combined with percutaneous pedicle screw fixation (PPSF) in the treatment of DBP.

Methods

This retrospective case-control study included forty patients. All patients were diagnosed with DBP by discography and discoblock. Perioperative parameters (surgery duration, blood loss, and muscle damage), complications, Visual analog scale (VAS), and Oswestry Disability Index (ODI) were assessed. Imaging data including cage subsidence, cage retropulsion, fusion rate, and adjacent spondylosis degeneration (ASD) were analyzed.

Results

There were 23 patients in the OLIF stand-alone group and 17 patients in the OLIF + PPSF group. The mean surgery duration, blood loss, and muscle damage in the OLIF stand-alone group were significantly better than those in the OLIF + PPSF group (P < 0.05). However, there was no significant difference in the average hospitalization time between the two groups (P > 0.05). There was no significant difference in the VAS and ODI scores between the two groups before surgery (P > 0.05), and VAS and ODI scores significantly improved after surgery (P < 0.05). The VAS and ODI scores in the OLIF stand-alone group were significantly better than those in the OLIF + PPSF group at 1 month (P < 0.05), While there was no significant difference between the two groups at 12 months and last follow up (P > 0.05). At the last follow-up, there was no significant difference in cage subsidence, fusion rate, ASD and complication rate between the two groups (P > 0.05).

Conclusion

OLIF stand-alone and OLIF + PPSF are both safe and effective in the treatment of DBP, and there is no significant difference in the long-term clinical and radiological outcomes. OLIF stand-alone has the advantages of surgery duration, blood loss, muscle damage, and early clinical effect. More clinical data are needed to confirm the effect of OLIF stand-alone on cage subsidence and ASD. This study provides a basis for the clinical application of standard DBP treatment with OLIF.

Development of a Computational Model of the Mechanical Behavior of the L4-L5 Lumbar Spine: Application to Disc Degeneration

Degenerative changes in the lumbar spine significantly reduce the quality of life of people. In order to fully understand the biomechanics of the affected spine, it is crucial to consider the biomechanical alterations caused by degeneration of the intervertebral disc (IVD). Therefore, this study is aimed at the development of a discrete element model of the mechanical behavior of the L4-L5 spinal motion segment, which covers all the degeneration grades from healthy IVD to its severe degeneration, and numerical study of the influence of the IVD degeneration on stress state and biomechanics of the spine. In order to analyze the effects of IVD degeneration on spine biomechanics, we simulated physiological loading conditions using compressive forces. The results of modeling showed that at the initial stages of degenerative changes, an increase in the amplitude and area of maximum compressive stresses in the disc is observed. At the late stages of disc degradation, a decrease in the value of intradiscal pressure and a shift in the maximum compressive stresses in the dorsal direction is observed. Such an influence of the degradation of the geometric and mechanical parameters of the tissues of the disc leads to the effect of bulging, which in turn leads to the formation of an intervertebral hernia.

Effects of osteoporosis on the biomechanics of various supplemental fixations co-applied with oblique lumbar interbody fusion (OLIF): a finite element analysis

Background

Oblique lumbar interbody fusion (OLIF) is an important surgical modality for the treatment of degenerative lumbar spine disease. Various supplemental fixations can be co-applied with OLIF, increasing OLIF stability and reducing complications. However, it is unclear whether osteoporosis affects the success of supplemental fixations; therefore, this study analyzed the effects of osteoporosis on various supplemental fixations co-applied with OLIF.

Methods

We developed and validated an L3-S1 finite element (FE) model; we assigned different material properties to each component and established models of the osteoporotic and normal bone lumbar spine. We explored the outcomes of OLIF combined with each of five supplemental fixations: standalone OLIF; OLIF with lateral plate fixation (OLIF + LPF); OLIF with translaminar facet joint fixation and unilateral pedicle screw fixation (OLIF + TFJF + UPSF); OLIF with unilateral pedicle screw fixation (OLIF + UPSF); and OLIF with bilateral pedicle screw fixation (OLIF + BPSF). Under the various working conditions, we calculated the ranges of motion (ROMs) of the normal bone and osteoporosis models, the maximum Mises stresses of the fixation instruments (MMSFIs), and the average Mises stresses on cancellous bone (AMSCBs).

Results

Compared with the normal bone OLIF model, no demonstrable change in any segmental ROM was apparent. The MMSFIs increased in all five osteoporotic OLIF models. In the OLIF + TFJF + UPSF model, the MMSFIs increased sharply in forward flexion and extension. The stress changes of the OLIF + UPSF, OLIF + BPSF, and OLIF + TFJF + UPSF models were similar; all stresses trended upward. The AMSCBs decreased in all five osteoporotic OLIF models during flexion, extension, lateral bending, and axial rotation. The average stress change of cancellous bone was most obvious under extension. The AMSCBs of the five OLIF models decreased by 14%, 23.44%, 21.97%, 40.56%, and 22.44% respectively.

Conclusions

For some supplemental fixations, the AMSCBs were all reduced and the MMSFIs were all increased in the osteoporotic model, compared with the OLIF model of normal bone. Therefore, the biomechanical performance of an osteoporotic model may be inferior to the biomechanical performance of a normal model for the same fixation method; in some instances, it may increase the risks of fracture and internal fixation failure.

Biomechanical effects of interbody cage height on adjacent segments in patients with lumbar degeneration: a 3D finite element study

Objective

To investigate the biomechanical effects of interbody cage height on adjacent segments in patients with lumbar degeneration undergoing transforaminal lumbar interbody fusion (TLIF) surgery, so as to provide references for selection of interbody cage.

Methods

The finite element model of normal lower lumbar spine (L3–S1) was built and validated, then constructed three different degenerative segments in L3–L4, and the cages with different height (8, 10, 12, 14 mm) were implanted into L4–L5 disc. All the twelve models were loaded with pure moment of 7.5 N m to produce flexion, extension, lateral bending and axial rotation motions on lumbar spine, and the effects of cage height on range of motion (RoM) and intervertebral pressure in lumbar spine were investigated.

Results

The RoM of adjacent segments and the maximum stress of intervertebral discs increased with the increase in cage height, but this trend was not obvious in mild and moderate degeneration groups. After implantation of four different height cages (8, 10, 12, 14 mm), the RoM of L3/L4 segment reached the maximum during extension. The RoM of mild degeneration group was 2.07°, 2.45°, 2.48°, 2.54°, that of moderate degeneration group was 1.79°, 1.97°, 2.05°, 2.05°, and that of severe degeneration group was 1.43°, 1.66°, 1.74°, 1.74°. The stress of L3–L4 intervertebral disc reached the maximum during flexion. The maximum stress of L3–L4 intervertebral disc was 20.16 MPa, 20.28 MPa, 20.31 MPa and 20.33 MPa in the mild group, 20.58 MPa, 20.66 MPa, 20.71 MPa and 20.75 MPa in the moderate group, and 21.27 MPa, 21.40 MPa, 21.50 MPa and 21.60 MPa in the severe group.

Conclusion

For patients with mild-to-moderate lumbar degenerative disease who need to undergo TLIF surgery, it is recommended that the height of fusion cage should not exceed the original intervertebral space height by 2 mm, while for patients with severe degeneration, a fusion cage close to the original intervertebral height should be selected as far as possible, and the intervertebral space should not be overstretched.

Novel force-displacement control passive finite element models of the spine to simulate intact and pathological conditions; comparisons with traditional passive and detailed musculoskeletal models

Passive finite element (FE) models of the spine are commonly used to simulate intact and various pre- and postoperative pathological conditions. Being devoid of muscles, these traditional models are driven by simplistic loading scenarios, e.g., a constant moment and compressive follower load (FL) that do not properly mimic the complex in vivo loading condition under muscle exertions. We aim to develop novel passive FE models that are driven by more realistic yet simple loading scenarios, i.e., in vivo vertebral rotations and pathological-condition dependent FLs (estimated based on detailed musculoskeletal finite element (MS-FE) models). In these novel force-displacement control FE models, unlike the traditional passive FE models, FLs vary not only at different spine segments (T12-S1) but between intact, pre- and postoperative conditions. Intact, preoperative degenerated, and postoperative fused conditions at the L4-L5 segment for five static in vivo activities in upright and flexed postures were simulated by the traditional passive FE, novel force-displacement control FE, and gold-standard detailed MS-FE spine models. Our findings indicate that, when compared to the MS-FE models, the force-displacement control passive FE models could accurately predict the magnitude of disc compression force, intradiscal pressure, annulus maximal von Mises stress, and vector sum of all ligament forces at adjacent segments (L3-L4 and L5-S1) but failed to predict disc shear and facet joint forces. In this regard, the force-displacement control passive FE models were much more accurate than the traditional passive FE models. Clinical recommendations made based on traditional passive FE models should, therefore, be interpreted with caution.

Biomechanical study of oblique lumbar interbody fusion (OLIF) augmented with different types of instrumentation: a finite element analysis

Background

To explore the biomechanical differences in oblique lumbar interbody fusion (OLIF) augmented by different types of instrumentation.

Methods

A three-dimensional nonlinear finite element (FE) model of an intact L3-S1 lumbar spine was built and validated. The intact model was modified to develop five OLIF surgery models (Stand-alone OLIF; OLIF with lateral plate fixation [OLIF + LPF]; OLIF with unilateral pedicle screws fixation [OLIF + UPSF]; OLIF with bilateral pedicle screws fixation [OLIF + BPSF]; OLIF with translaminar facet joint fixation + unilateral pedicle screws fixation [OLIF + TFJF + UPSF]) in which the surgical segment was L4–L5. Under a follower load of 500 N, a 7.5-Nm moment was applied to all lumbar spine models to calculate the range of motion (ROM), equivalent stress peak of fixation instruments (ESPFI), equivalent stress peak of cage (ESPC), equivalent stress peak of cortical endplate (ESPCE), and equivalent stress average value of cancellous bone (ESAVCB).

Results

Compared with the intact model, the ROM of the L4–L5 segment in each OLIF surgery model decreased by > 80%. The ROM values of adjacent segments were not significantly different. The ESPFI, ESPC, and ESPCE values of the OLIF + BPSF model were smaller than those of the other OLIF surgery models. The ESAVCB value of the normal lumbar model was less than the ESAVCB values of all OLIF surgical models. In most postures, the ESPFI, ESPCE, and ESAVCB values of the OLIF + LPF model were the largest. The ESPC was higher in the Stand-alone OLIF model than in the other OLIF models. The stresses of several important components of the OLIF + UPSF and OLIF + TFJF + UPSF models were between those of the OLIF + LPF and OLIF + BPSF models.

Conclusions

Our biomechanical FE analysis indicated the greater ability of OLIF + BPSF to retain lumbar stability, resist cage subsidence, and maintain disc height. Therefore, in the augmentation of OLIF, bilateral pedicle screws fixation may be the best approach.

Biomechanical changes at the adjacent segments induced by a lordotic porous interbody fusion cage

Biomechanical changes at the adjacent segments after interbody fusion are common instigators of adjacent segment degeneration (ASD). This study aims to investigate how the presence of a lordotic porous cage affects the biomechanical performance of the adjacent segments. A finite element model (FEM) of a lumbar spine implanted with a lordotic cage at L3-L4 was validated by in-vitro testing. The stress distribution on the cage and range of motion (ROM) of L3-L4 were used to assess the stability of the implant. Three angles of cage (0° = non-restoration, 7° = normal restoration and 11° = over-restoration) were modelled with different porosities (0%, 30% and 60%) and evaluated in the motions of flexion, extension, lateral bending and rotation. The ROM, intervertebral disc pressure (IDP) and facet joint force (FJF) were used to evaluate biomechanical changes at the adjacent segments in each model. The results indicated that porous cages produced more uniform stress distribution, but cage porosity did not influence the ROM, IDP and FJF at L2-L3 and L4-L5. Increasing the cage lordotic angle acted to decrease the ROM and IDP, and increase the FJF of L4-L5, but did not alter the ROM of L2-L3. In conclusion, changes in ROM, IDP and FJF at the adjacent segments were mainly influenced by the lordotic angle of the cage and not by the porosity. A larger angle of lordotic cage was shown to reduce the ROM and IDP, and increase the FJF of the lower segment (L4-L5), but had little effect on the ROM of the upper segment (L2-L3).

Biomechanical Evaluation of an Oblique Lateral Locking Plate System for Oblique Lumbar Interbody Fusion: A Finite Element Analysis

OBJECTIVE

The oblique lateral locking plate system (OLLPS) is a novel internal fixation with a locking and reverse pedicle track screw configuration designed for oblique lumbar interbody fusion (OLIF). The OLLPS is placed in a single position through the oblique lateral surgical corridor to reduce operative time and complications associated with prolonged anesthesia and prone positioning. The purpose of this study was to verify the biomechanical effect of the OLLPS.

METHODS

An intact finite element model of L1-S1 (intact) was established based on computed tomography images of a healthy male volunteer. The L4-L5 intervertebral space was selected as the surgical segment. The surgical models were established separately based on OLIF surgical procedures and different internal fixations: 1) stand-alone OLIF (SA); 2) OLIF with a 2-screw lateral plate; 3) OLIF with a 4-screw lateral plate; 4) OLIF with OLLPS; and 5) OLIF with bilateral pedicle screw fixation (BPS). After validation of the intact model, physiologic loads were applied to the superior surface of L1 to simulate motions such as flexion, extension, left bending, right bending, left rotation, and right rotation. The evaluation indices included the L4/5 range of motion, the L4 maximum displacement, and the maximum stresses of the superior and inferior end plates, the cage, and the supplemental fixation.

RESULTS

During OLIF surgery, the OLLPS provided multiplanar stability similar to that provided by BPS. Compared with 2-screw lateral plate and 4-screw lateral plate, OLLPS had better biomechanical properties in terms of enhancing the instant stability of the surgical segment, reducing the stress on the superior and inferior end plates of the surgical segment, and decreasing the risk of cage subsidence.

CONCLUSIONS

With a minimally invasive background, the OLLPS can be used as an alternative to BPS in OLIF and it has better prospects for clinical promotions and applications.

Biomechanical comparison of four types of instrumentation constructs for revision surgery in lumbar adjacent segment disease: A finite element study

BACKGROUND

Different constructs are applied in revision surgery (RS) for adjacent segment disease (ASD) aiming to further decompress and fixate the affected segment(s) in two ways: replacing or preserving the primary implants. This study aimed to compare the biomechanical properties of four constructs with different configurations.

METHODS

An T12-L5 finite element (FE) model was constructed and validated. Primary surgery was performed at L4-L5 and instrumented from L3 to L5. Thereafter, RS was undertook by decompressing L2-L3 and fixated with implant-replacing construct A, or implant-preserving construct B, C or D. Range of motion (ROM) and intervertebral disc pressure (IDP) were compared. Maximum von Mises stress on the rods between Construct A and B was evaluated.

RESULTS

An obvious reduction of ROM was observed when the FE model was instrumented with four constructs respectively. The overall changing characteristics of ROM were approximately identical among four constructs. The changing characteristic of IDP among four constructs was similar. The degree of IDP reduction of Construct B was comparable to Construct A, while that of Construct C was comparable to Construct D. Maximum von Mises stress on the rods between Construct A and B indicated that no stress concentration was recorded at the locking part of the connector rod.

CONCLUSIONS

The biomechanics of implant-preserving constructs were comparable to the traditional implant-replacing construct. The location of side-by-side connector could not affect the stability of Construct C and D. Construct B might be an optimal choice in RS for less dissection, less complication and more convenience in manipulation.