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Cadieux C, Brzozowski P, Fernandes RJR, McGregor ME, Zdero R, Bailey CS, McLachlin SD, Rasoulinejad P. Topping-Off a Long Thoracic Stabilization With Semi-Rigid Constructs May Have Favorable Biomechanical Effects to Prevent Proximal Junctional Kyphosis: A Biomechanical Comparison. Global Spine J 2024:21925682241259695. [PMID: 38828634 DOI: 10.1177/21925682241259695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
STUDY DESIGN In-vitro cadaveric biomechanical study. OBJECTIVES Long posterior spinal fusion is a standard treatment for adult spinal deformity. However, these rigid constructs are known to alter motion and stress to the adjacent non-instrumented vertebrae, increasing the risk of proximal junctional kyphosis (PJK). This study aimed to biomechanically compare a standard rigid construct vs constructs "topped off" with a semi-rigid construct. By understanding semi-rigid constructs' effect on motion and overall construct stiffness, surgeons and researchers could better optimize fusion constructs to potentially decrease the risk of PJK and the need for revision surgery. METHODS Nine human cadaveric spines (T1-T12) underwent non-destructive biomechanical range of motion tests in pure bending or torsion and were instrumented with an all-pedicle-screw (APS) construct from T6-T9. The specimens were sequentially instrumented with semi-rigid constructs at T5: (i) APS plus sublaminar bands; (ii) APS plus supralaminar hooks; (iii) APS plus transverse process hooks; and (iv) APS plus short pedicle screws. RESULTS APS plus transverse process hooks had a range of motion (ie, relative angle) for T4-T5 and T5-T6, as well as an overall mechanical stiffness for T1-T12, that was more favourable, as it reduced motion at adjacent levels without a stark increase in stiffness. Moreover, APS plus transverse process hooks had the most linear change for range of motion across the entire T3-T7 range. CONCLUSIONS Present findings suggest that APS plus transverse process hooks has a favourable biomechanical effect that may reduce PJK for long spinal fusions compared to the other constructs examined.
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Affiliation(s)
- Chloe Cadieux
- London Health Science Centre Combined Neurosurgical and Orthopaedic Spine Program, Schulich School of Medicine, Western University, London, ON, Canada
| | - Pawel Brzozowski
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
| | - Renan J R Fernandes
- London Health Science Centre Combined Neurosurgical and Orthopaedic Spine Program, Schulich School of Medicine, Western University, London, ON, Canada
| | - Martine E McGregor
- Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Radovan Zdero
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
| | - Christopher S Bailey
- London Health Science Centre Combined Neurosurgical and Orthopaedic Spine Program, Schulich School of Medicine, Western University, London, ON, Canada
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
| | - Stewart D McLachlin
- Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Parham Rasoulinejad
- London Health Science Centre Combined Neurosurgical and Orthopaedic Spine Program, Schulich School of Medicine, Western University, London, ON, Canada
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
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Lee BJ, Bae SS, Choi HY, Park JH, Hyun SJ, Jo DJ, Cho Y. Proximal Junctional Kyphosis or Failure After Adult Spinal Deformity Surgery - Review of Risk Factors and Its Prevention. Neurospine 2023; 20:863-875. [PMID: 37798982 PMCID: PMC10562224 DOI: 10.14245/ns.2346476.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/06/2023] [Accepted: 06/16/2023] [Indexed: 10/07/2023] Open
Abstract
Proximal junction kyphosis (PJK) is a common imaging finding after long-level fusion, and proximal junctional failure (PJF) is an aggravated form of the progressive disease spectrum of PJK. This includes vertebral fracture of upper instrumented vertebra (UIV) or UIV+1, instability between UIV and UIV+1, neurological deterioration requiring surgery. Many studies have reported on PJK and PJF after long segment instrumentation for adult spinal deformity (ASD). In particular, for spine deformity surgeons, risk factors and prevention strategies of PJK and PJF are very important to minimize reoperation. Therefore, this review aims to help reduce the occurrence of PJK and PJF by updating the latest contents of PJK and PJF by 2023, focusing on the risk factors and prevention strategies of PJK and PJF. We conducted a search on multiple database for articles published until February 2023 using the search keywords "proximal junctional kyphosis," "proximal junctional failure," "proximal junctional disease," and "adult spinal deformity." Finally, 103 papers were included in this study. Numerous factors have been suggested as potential risks for the development of PJK and PJF, including a high body mass index, inadequate postoperative sagittal balance and overcorrection, advanced age, pelvic instrumentation, and osteoporosis. Recently, with the increasing elderly population, sarcopenia has been emphasized. The quality and quantity of muscle in the surgical site have been suggested as new risk factor. Therefore, spine surgeon should understand the pathophysiology of PJK and PJF, as well as individual risk factors, in order to develop appropriate prevention strategies for each patient.
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Affiliation(s)
- Byung-Jou Lee
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Sung Soo Bae
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Ho Young Choi
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dae Jean Jo
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Yongjae Cho
- Department of Neurosurgery, Ewha Womans University School of Medicine, Seoul, Korea
| | - Korean Spinal Deformity Society (KSDS)
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Neurosurgery, Ewha Womans University School of Medicine, Seoul, Korea
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Colantonio DF, Le AH, Pisano AJ, Chung JM, Wagner SC, Fredericks DR, Roach WB, Schlaff C, Dill A, Mauntel TC, Hendershot BD, Helgeson MD. Hooks Versus Pedicle Screws at the Upper Instrumented Level: An In Vitro Biomechanical Comparison. Spine (Phila Pa 1976) 2023; 48:E94-E100. [PMID: 36745404 DOI: 10.1097/brs.0000000000004547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/12/2022] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Controlled laboratory study. OBJECTIVE The aim was to compare motions at the upper instrumented vertebra (UIV) and supra-adjacent level (UIV+1) between two fixation techniques in thoracic posterior spinal fusion constructs. We hypothesized there would be greater motion at UIV+1 after cyclic loading across all constructs and bilateral pedicle screws (BPSs) with posterior ligamentous compromise would demonstrate the greatest UIV+1 range of motion. SUMMARY OF BACKGROUND DATA Proximal junctional kyphosis is a well-recognized complication following long thoracolumbar posterior spinal fusion, however, its mechanism is poorly understood. MATERIALS AND METHODS Twenty-seven thoracic functional spine units were randomly divided into three UIV fixation groups (n=9): (1) BPS, (2) bilateral transverse process hooks (TPHs), and (3) BPS with compromise of the posterior elements between UIV and UIV+1 (BPS-C). Specimens were tested on a servohydraulic materials testing system in native state, following instrumentation, and after cyclic loading. functional spine units were loaded in flexion-extension (FE), lateral bending, and axial rotation. RESULTS After cyclic testing, the TPH group had a mean 29.4% increase in FE range of motion at UIV+1 versus 76.6% in the BPS group ( P <0.05). The BPS-C group showed an increased FE of 49.9% and 62.19% with sectioning of the facet joints and interspinous ligament respectively prior to cyclic testing. CONCLUSION BPSs at the UIV led to greater motion at UIV+1 compared to bilateral TPH after cyclic loading. This is likely due to the increased rigidity of BPS compared to TPH leading to a "softer" transition between the TPH construct and native anatomy at the supra-adjacent level. Facet capsule compromise led to a 49.9% increase in UIV+1 motion, underscoring the importance of preserving the posterior ligamentous complex. Clinical studies that account for fusion rates are warranted to determine if constructs with a "soft transition" result in less proximal junctional kyphosis in vivo .
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Affiliation(s)
- Donald F Colantonio
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Anthony H Le
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
| | - Alfred J Pisano
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Joon M Chung
- School of Medicine, Georgetown University, Washington, DC
| | - Scott C Wagner
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Donald R Fredericks
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - William B Roach
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Cody Schlaff
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Andrew Dill
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Timothy C Mauntel
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Womack Army Medical Center, Fort Bragg, NC
| | - Brad D Hendershot
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Science, Bethesda, MD
| | - Melvin D Helgeson
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
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The Sagittal Plane in Spinal Fusion for Adolescent Idiopathic Scoliosis. J Am Acad Orthop Surg 2022; 30:e957-e967. [PMID: 35797683 DOI: 10.5435/jaaos-d-21-01060] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 04/24/2022] [Indexed: 02/01/2023] Open
Abstract
Sagittal balance is widely recognized as the primary determinant of optimal outcomes in adult spinal deformity. In adolescent idiopathic scoliosis (AIS), coronal correction risks being obtained at the expense of sagittal malalignment after posterior spinal fusion. Apical lordosis, often underestimated on two-dimensional imaging, is the primary deforming factor in AIS. Failure to restore thoracic kyphosis and lumbar lordosis during posterior spinal fusion contributes to problematic early surgical complications, including proximal or distal junctional kyphosis and failure. Although adolescent patients often compensate for sagittal imbalance in the short-term and mid-term, late sequelae of iatrogenic sagittal imbalance include flatback syndrome, disk degeneration, cervical kyphosis, and late decompensation. Objective criteria using spinopelvic parameters and preoperative three-dimensional planning can guide sagittal plane correction during PSF for AIS. Technical caveats can help avoid sagittal plane complications, including instrumentation level selection, anchor type, and anatomic protection of adjacent levels. Other surgical techniques to optimize restoration of thoracic kyphosis include higher implant density, stiffer rod material, Ponte osteotomies, and deformity correction technique.
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Evolution of Proximal Junctional Kyphosis and Proximal Junctional Failure Rates Over 10 Years of Enrollment in a Prospective Multicenter Adult Spinal Deformity Database. Spine (Phila Pa 1976) 2022; 47:922-930. [PMID: 35472089 DOI: 10.1097/brs.0000000000004364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/18/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to investigate the evolution of proximal junctional kyphosis (PJK) rate over 10-year enrollment period within a prospective database. SUMMARY OF BACKGROUND DATA PJK is a common complication following adult spinal deformity (ASD) surgery and has been intensively studied over the last decade. METHODS Patients with instrumentation extended to the pelvis and minimum 2-year follow-up were included. To investigate evolution of PJK/proximal junctional failure (PJF) rate, a moving average of 321 patients was calculated across the enrollment period. Logistic regression was used to investigate the association between the date of surgery (DOS) and PJK and/or PJF. Comparison of PJK/PJF rates, demographics, and surgical strategies was performed between the first and second half of the cohort. RESULTS A total of 641 patients met inclusion criteria (age: 64±10 years, 78.2% female, body mass index: 28.3±5.7). The overall rate of radiographic PJK at 2 years was 47.9%; 12.9% of the patients developed PJF, with 31.3% being revised within 2-year follow-up. Stratification by DOS produced two halves. Between these two periods, rate of PJK and PJF demonstrated nonsignificant decrease (50.3%-45.5%, P =0.22) and (15.0%-10.9%, P =0.12), respectively. Linear interpolation suggested a decrease of 1.2% PJK per year and 1.0% for PJF. Patients enrolled later in the study were older and more likely to be classified as pure sagittal deformity ( P <0.001). There was a significant reduction in the use of three-column osteotomies ( P <0.001), an increase in anterior longitudinal ligament release ( P <0.001), and an increase in the use of PJK prophylaxis (31.3% vs 55.1%). Logistical regression demonstrated no significant association between DOS and radiographic PJK ( P =0.19) or PJF ( P =0.39). CONCLUSION Despite extensive research examining risk factors for PJK/PJF and increasing utilization of intraoperative PJK prophylaxis techniques, the rate of radiographic PJK and/or PJF did not significantly decrease across the 10-year enrollment period of this ASD database.
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Liebsch C, Wilke HJ. How Does the Rib Cage Affect the Biomechanical Properties of the Thoracic Spine? A Systematic Literature Review. Front Bioeng Biotechnol 2022; 10:904539. [PMID: 35782518 PMCID: PMC9240654 DOI: 10.3389/fbioe.2022.904539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/06/2022] [Indexed: 11/29/2022] Open
Abstract
The vast majority of previous experimental studies on the thoracic spine were performed without the entire rib cage, while significant contributive aspects regarding stability and motion behavior were shown in several other studies. The aim of this literature review was to pool and increase evidence on the effect of the rib cage on human thoracic spinal biomechanical characteristics by collating and interrelating previous experimental findings in order to support interpretations of in vitro and in silico studies disregarding the rib cage to create comparability and reproducibility for all studies including the rib cage and provide combined comparative data for future biomechanical studies on the thoracic spine. After a systematic literature search corresponding to PRISMA guidelines, eleven studies were included and quantitatively evaluated in this review. The combined data exhibited that the rib cage increases the thoracic spinal stability in all motion planes, primarily in axial rotation and predominantly in the upper thorax half, reducing thoracic spinal range of motion, neutral zone, and intradiscal pressure, while increasing thoracic spinal neutral and elastic zone stiffness, compression resistance, and, in a neutral position, the intradiscal pressure. In particular, the costosternal connection was found to be the primary stabilizer and an essential determinant for the kinematics of the overall thoracic spine, while the costotransverse and costovertebral joints predominantly reinforce the stability of the single thoracic spinal segments but do not alter thoracic spinal kinematics. Neutral zone and neutral zone stiffness were more affected by rib cage removal than the range of motion and elastic zone stiffness, thus also representing the essential parameters for destabilization of the thoracic spine. As a result, the rib cage and thoracic spine form a biomechanical entity that should not be separated. Therefore, usage of entire human non-degenerated thoracic spine and rib cage specimens together with pure moment application and sagittal curvature determination is recommended for future in vitro testing in order to ensure comparability, reproducibility, and quasi-physiological validity.
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Boroda N, Pradhan S, Forsthoefel CW, Mardjetko SM, Bou Monsef J, Amirouche F. Motion capture evaluation of sagittal spino-pelvic biomechanics after lumbar spinal fusion. Spine Deform 2022; 10:473-478. [PMID: 34981456 DOI: 10.1007/s43390-021-00448-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/20/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE The spine and pelvis coexist as a dynamic linked system in which spinal and pelvic parameters are correlated. Investigation of this system can inform the understanding and treatment of spinal deformity. Here, we demonstrate the use of motion capture technology to measure spine biomechanical parameters using a novel testing apparatus. METHODS Three complete cadaveric spines with skull and pelvis were mounted into a biomechanical testing apparatus. Each lumbar vertebra was monitored by motion capture cameras as the spines underwent maximal anterior and posterior pelvic tilts about two sagittal axes at a controlled speed and applied force. These axes were defined as the sacral axis which passes transversely through the ilium and S1, and the acetabular axis which passes transversely through both acetabula. The experiments were repeated after L4-L5 fusion, and then, after both L4-L5 and T12-S1 fusion with pedicle screw instrumentation. Data were collected for total range of motion and for coupled translation at each functional spinal unit (FSU). RESULTS Total range of motion and coupled translation within functional spinal units (FSUs) was decreased after spinal fusion. The displacement of each individual FSU was captured and summarized along with the observed patterns under each experimental condition. CONCLUSION Lumbar fusion decreases spinal motion in the sagittal plane in both overall ROM and individual coupled translations of lumbar vertebrae. This was demonstrated using motion capture technology which is useful for quantifying the translations of individual FSUs in a multisegmental spinal model.
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Affiliation(s)
- Nickolas Boroda
- Department of Orthopaedics, University of Illinois at Chicago, 835 S. Wolcott Ave, Room E270, Chicago, IL, 60612, USA
| | - Sonia Pradhan
- Department of Orthopaedics, University of Illinois at Chicago, 835 S. Wolcott Ave, Room E270, Chicago, IL, 60612, USA
| | - Craig William Forsthoefel
- Department of Orthopaedics, University of Illinois at Chicago, 835 S. Wolcott Ave, Room E270, Chicago, IL, 60612, USA
| | - Steven M Mardjetko
- Department of Orthopaedics, University of Illinois at Chicago, 835 S. Wolcott Ave, Room E270, Chicago, IL, 60612, USA
| | - Jad Bou Monsef
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Farid Amirouche
- Department of Orthopaedics, University of Illinois at Chicago, 835 S. Wolcott Ave, Room E270, Chicago, IL, 60612, USA.
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Zhao G, Wang X, Liu D, Wu K, Zhao J, Fei W. A biomechanical study of ligament tethers strengthening for the prevention of proximal junctional kyphosis after posterior long-segment spinal fusion. Clin Biomech (Bristol, Avon) 2022; 94:105621. [PMID: 35299117 DOI: 10.1016/j.clinbiomech.2022.105621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Proximal junctional kyphosis is a known complication of posterior long-segment thoracolumbar fusion. Here, the biomechanical effectiveness of ligament tethers strengthening and vertebral body augmentation, in proximal junctional kyphosis prevention was explored using the finite element analysis. METHODS Based on a validated model of T1-L5 with the pedicle screw system instrumented T8-L5, strengthening models with different strategies were created to assess the range of motion in proximal vertebrae, vertebrae stress, pedicle screw stress, and pressure on intervertebral discs during extension, flexion, lateral bending, and axial rotation motions. Strengthening strategies included two- and three-level posterior ligament tethers (TE-T7-T9 and TE-T6-T9), and tethers with T7 &T8 vertebral body augmentation (TECE-T7-T9 and TECE-T6-T9). FINDINGS Compared to the spinal fusion model, the ligament tethers strengthening significantly reduced the flexion-extension range of motion difference among the proximal vertebrae. During the flexion-extension motion, the T8 vertebra stresses in the TE-T7-T9, TE-T6-T9, TECE-T7-T9, and TECE-T6-T9 models were distinctively reduced, the values decreased by 26.8%, 28.3%, 28.8%, and 9.6%, respectively, during flexion, and by 21.9%, 35.2%, 23%, and 18.6%, respectively, during extension. In the strengthening models, the maximum stresses on the T7/T8 intervertebral disc in the TE-T6-T9 model were reduced by 13.8% during flexion and by 14.7% during extension. INTERPRETATION Based on our results, the ligament strengthening configuration of the three-level posterior tethers produced a more gradual transition in range of motion, vertebrae stresses, and intervertebral discs stress between the fused and non-fused segments, especially during flexion-extension, which may significantly decrease the proximal junctional kyphosis biomechanical risk.
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Affiliation(s)
- Gaiping Zhao
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China.
| | - Xiaoyu Wang
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Dongqing Liu
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Kunneng Wu
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Jian Zhao
- Department of Orthopedics, Western Theater General Hospital, Chengdu, China
| | - Wang Fei
- Chang-Hai Hospital, The Second Military Medical University, Shanghai, China
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Tsutsui S, Hashizume H, Yukawa Y, Minamide A, Nakagawa Y, Iwasaki H, Takami M, Yamada H. Optimal Anchor at the Uppermost Instrumented Vertebra in Long Fusion From the Pelvis to the Lower Thoracic Spine in Elderly Patients With Degenerative Spinal Deformity: Hook Versus Pedicle Screw. Clin Spine Surg 2022; 35:E280-E284. [PMID: 34039893 DOI: 10.1097/bsd.0000000000001204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 04/14/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The objective of this study was to compare pedicle screws (PSs) and transverse process hooks (TPHs) as anchors at the uppermost instrumented vertebra (UIV) in the lower thoracic spine in elderly patients with adult spinal deformity. SUMMARY OF BACKGROUND DATA Less-rigid fixation using hooks at the UIV are thought to best prevent proximal junctional kyphosis (PJK) in long spinal fusion surgery. Although adult spinal deformity is commonly treated via spinal fusion from the pelvis to the lower thoracic spine, few studies have focused on UIV anchors in the lower thoracic spine. MATERIALS AND METHODS We retrospectively reviewed 53 patients aged 65 years and above who underwent spinal fusion from the pelvis to T9 or T10, with a minimum follow-up of 1 year. Radiographic outcomes including the incidence of PJK and implant failure were compared between 28 patients with TPHs and 25 patients PSs at the UIV. RESULTS The TPH and PS groups had similar radiographic values for pelvic incidence-lumbar lordosis (preoperative: 42.8 vs. 49.0 degrees, postoperative: 9.9 vs. 7.3 degrees) and the sagittal vertical axis (preoperative: 109.3 vs. 106.8 mm; postoperative: 21.9 vs. 11.2 mm). However, the incidence of PJK was significantly higher in the TPH group (35.7%) than that in the PS group (8.0%) at the 1-year follow-up (P=0.012). PJK in the TPH group was associated with UIV or UIV±1 fracture accompanied by posterior dislodgement of the TPH. CONCLUSION Rigid fixation using PSs at the UIV in the lower thoracic spine produced better radiographic outcomes than did TPHs in elderly patients undergoing spinopelvic fusion. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Shunji Tsutsui
- Department of Orthopedic Surgery, Wakayama Medical University, Wakayama, Wakayama Prefecture, Japan
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Doodkorte RJP, Vercoulen TFG, Roth AK, de Bie RA, Willems PC. Instrumentation techniques to prevent proximal junctional kyphosis and proximal junctional failure in adult spinal deformity correction-a systematic review of biomechanical studies. Spine J 2021; 21:842-854. [PMID: 33482379 DOI: 10.1016/j.spinee.2021.01.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Correction of adult spinal deformity (ASD) by long segment instrumented spinal fusion is an increasingly common surgical intervention. However, it is associated with high rates of complications and revision surgery, especially in the elderly patient population. The high construct stiffness of instrumented thoracolumbar spinal fusion has been postulated to lead to a higher incidence of proximal junctional kyphosis (PJK) and failure (PJF). Several cadaveric biomechanical studies have reported on surgical techniques to reduce the incidence of PJF/PJK. As yet, no overview has been made of these biomechanical studies. PURPOSE To summarize the evidence of all biomechanical studies that have assessed techniques to reduce PJK/PJF following long segment instrumented spinal fusion in the ASD patient population. STUDY DESIGN A systematic review. METHODS EMBASE and MEDLINE databases were searched for human and animal cadaveric biomechanical studies investigating the effect of various surgical techniques to reduce PJK/PJF following long segment instrumented thoracolumbar spinal fusion in the adult patient population. Studied techniques, biomechanical test methods, range of motion (ROM), intervertebral disc pressure (IDP) and other relevant outcome parameters were documented. RESULTS Twelve studies met the inclusion criteria. Four of these studies included non-human cadaveric material. One study investigated the prophylactic application of cement augmentation (vertebroplasty), whereas the remaining studies investigated semi-rigid junctional fixation techniques to achieve a gradual transition zone of forces at the proximal end of a fusion construct, so-called topping-off. An increased gradual transition zone in terms of ROM compared to pedicle screw constructs was demonstrated for sublaminar tethers, sublaminar tape, pretensioned suture loops, transverse hooks and laminar hooks. Furthermore, reduced IDP was found after the application of sublaminar tethers, suture loops, sublaminar tapes and laminar hooks. Finally, two-level prophylactic vertebroplasty resulted in a lower incidence of vertebral compression fractures in a flexion-compression experiment. CONCLUSIONS A variety of techniques, involving either posterior semi-rigid junctional fixation or the reinforcement of vertebral bodies, has been biomechanically assessed. However, the low number of studies and variation in study protocols hampers direct comparison of different techniques. Furthermore, determination of what constitutes an optimal gradual transition zone and its translation to clinical practice, would aid comparison and further development of different semi-rigid junctional fixation techniques. Even though biomechanics are extremely important in the development of PJK/PJF, patient-specific factors should always be taken into account on a case-by-case basis when considering to apply a semi-rigid junctional fixation technique.
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Affiliation(s)
- Remco J P Doodkorte
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - Timon F G Vercoulen
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Alex K Roth
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Rob A de Bie
- Department of Epidemiology, Research School CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, P. Debyeplein1, 6229 HA, Maastricht, The Netherlands
| | - Paul C Willems
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
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Kim HJ, Yang JH, Chang DG, Suk SI, Suh SW, Kim SI, Song KS, Park JB, Cho W. Proximal Junctional Kyphosis in Adult Spinal Deformity: Definition, Classification, Risk Factors, and Prevention Strategies. Asian Spine J 2021; 16:440-450. [PMID: 33910320 PMCID: PMC9260397 DOI: 10.31616/asj.2020.0574] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/15/2021] [Indexed: 12/03/2022] Open
Abstract
Proximal junctional problems are among the potential complications of surgery for adult spinal deformity (ASD) and are associated with higher morbidity and increased rates of revision surgery. The diverse manifestations of proximal junctional problems range from proximal junctional kyphosis (PJK) to proximal junctional failure (PJF). Although there is no universally accepted definition for PJK, the most common is a proximal junctional angle greater than 10° that is at least 10° greater than the preoperative measurement. PJF represents a progression from PJK and is characterized by pain, gait disturbances, and neurological deficits. The risk factors for PJK can be classified according to patient-related, radiological, and surgical factors. Based on an understanding of the modifiable factors that contribute to reducing the risk of PJK, prevention strategies are critical for patients with ASD.
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Affiliation(s)
- Hong Jin Kim
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jae Hyuk Yang
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Dong-Gune Chang
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Se-Il Suk
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Seung Woo Suh
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sang-Il Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kwang-Sup Song
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Woojin Cho
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Biomechanical Evaluation of a Dynamic Stabilization System for the Prevention of Proximal Junctional Failure in Adult Deformity Surgery. Spine (Phila Pa 1976) 2021; 46:E356-E363. [PMID: 33306610 DOI: 10.1097/brs.0000000000003862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Biomechanical spine model. Comparison of stress in the implant and the adjacent cranial segment was done with conventional rigid versus dynamic stabilization system (DS) fixation. OBJECTIVE The aim of this study was to study stress at the proximal end of spinal fixation with a novel DS. SUMMARY OF BACKGROUND DATA High stress at the implant bone junction may cause proximal junctional failure (PJF) in adult deformity surgery. METHODS Five life-size spine models were instrumented with pedicle screws and a 5.5-mm Titanium rod from T8-S1. The same models were subsequently instrumented with a similar rod and DS between T8-9 pedicle screws. The spine model was loaded with 25 Nm static load cranial to the proximal fixation in six directions. Strains were measured from the proximal screws. Disc pressure was measured from the proximal instrumented segment (T8-9) and cranial adjacent segment (T7-8). RESULTS Rigid fixation produced highest strain at T8, followed by T10 then T9. In contrast, DS fixation produced highest strain at T10, followed by T9 then T8. Strain at T8 was significantly less with DS fixation than rigid fixation (P = 0.019). The T10 screw strain was not significantly higher with DS stabilization compared to rigid fixation (P = 0.091). Rigid fixation allowed no load-sharing or pressure rise at T8-9 but an abrupt rise at T7-8. DS system permitted load-sharing and pressure rise in T8-9; the difference compared to rigid fixation was significant in flexion loading (P = 0.04) and similar trend but not significant in extension (P = 0.09). DS system produced a rise in the adjacent segment disc pressure (T7-8), which was smaller than rigid fixation but not significant. CONCLUSION Long spinal fixation using rigid rods produces maximum stress at the proximal end screw and increases adjacent disc pressure, possibly leading to PJF. Dynamic stabilization at the cranial end segment may prevent PJF by reducing these factors.Level of Evidence: N/A.
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Cazzulino A, Gandhi R, Woodard T, Ackshota N, Janjua MB, Arlet V, Saifi C. Soft Landing technique as a possible prevention strategy for proximal junctional failure following adult spinal deformity surgery. JOURNAL OF SPINE SURGERY 2021; 7:26-36. [PMID: 33834125 DOI: 10.21037/jss-20-622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This cross sectional study describes a "Soft Landing" strategy utilizing hooks for minimizing proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). The technique creates a gradual transition from a rigid segmental construct to unilateral hooks at the upper instrumented level and preservation of the soft tissue attachments on the contralateral side of the hooks. Authors devise a novel classification system for better grading of PJK severity. Methods Thirty-nine consecutive adult spinal deformity (ASD) patients at a single institution received the "Soft Landing" technique. The proximal junctional angle was measured preoperatively and at last follow-up using standing 36-inch spinal radiographs. Changes in proximal junctional angle and rates of PJK and PJF were measured and used to create a novel classification system for evaluating and categorizing ASD patients postoperatively. Results The mean age of the cohort was 61.4 years, and 90% of patients were women. Average follow up was 2.2 years. The mean change in proximal junctional angle was 8° (SD 7.4°) with the majority of patients (53%) experiencing less than 10° and only 1 patients with proximal junctional angle over 20°. Four patients (10%) needed additional surgery for proximal extension of the uppermost instrumented vertebra (UIV) secondary to PJF. Conclusions Soft Landing technique is a possibly effective treatment strategy to prevent PJK and PJF following ASD that requires further evaluation. The described classification system provides management framework for better grading of PJK. The "Soft Landing" technique warrants further comparison to other techniques currently used to prevent both PJK and failure.
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Affiliation(s)
- Alejandro Cazzulino
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Rikesh Gandhi
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Thaddeus Woodard
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Nissim Ackshota
- Department of Orthopedic Surgery, The Chaim Sheba Medical Center at Tel-Hashomer, Tel-Aviv, Israel
| | | | - Vincent Arlet
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Comron Saifi
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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14
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Iyer S, Lovecchio F, Elysée JC, Lafage R, Steinhaus M, Schwab FJ, Lafage V, Kim HJ. Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity. Global Spine J 2020; 10:692-699. [PMID: 32707020 PMCID: PMC7383783 DOI: 10.1177/2192568219868472] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Violation of the posterior soft tissues is believed to contribute to the development of proximal junctional kyphosis (PJK). Biomechanical and clinical studies suggest that augmentation of the posterior ligamentous structures (PLS) may help prevent PJK. The purpose of this study was to evaluate the effect of PLS augmentation on the rate of PJK at 1 year. METHODS A retrospective single-surgeon cohort study was performed of 108 adult spinal deformity patients who underwent 5 level fusions to the pelvis. Patients were divided into 2 groups: PLS+ patients had reconstruction of the PLS between upper instrumented vertebrae +1 (UIV+1) and UIV-1 with a surgical nylon tape while PLS- patients did not. Demographics, surgical data, and sagittal alignment parameters were compared between the cohorts. The primary outcome of interest was the development of PJK at final follow-up. A subgroup propensity match and logistic regression model were utilized to control for differences in the cohorts. RESULTS A total of 108 patients met final criteria, 31 patients (28.7%) were PLS+. There were no differences with regard to preoperative or final sagittal alignment parameters, number of levels fused, rates of 3-column osteotomies, and body mass index (P > .05), though the PLS+ cohort was older and had larger initial sagittal corrections (P < .05). The rates of PJK for PLS+ (27.3%) and PLS- (28.6%) were similar (P = .827). After controlling for sagittal correction via propensity matching, PLS+ had no impact on PJK (29% vs 38.7%, P = .367). In our multivariate analysis, only increased sagittal malalignment and failure to restore sagittal balance were retained as significant predictors of PJK. CONCLUSION Even after controlling for extent of correction and preoperative sagittal alignment, PLS reinforcement at UIV+1 using a hand-tensioned nylon tape does not reduce the incidence of PJK at 1 year.
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Affiliation(s)
| | | | | | | | | | | | | | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA,Han Jo Kim, Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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15
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Anchor type at upper instrumented vertebra and postoperative shoulder imbalance in patients with Lenke type 1 adolescent idiopathic scoliosis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:245-251. [PMID: 32803280 DOI: 10.1007/s00590-020-02766-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 08/09/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To clarify the impact of anchor type at upper instrumented vertebra (UIV) on postoperative shoulder imbalance in patients with Lenke type 1 adolescent idiopathic scoliosis (AIS) who underwent posterior spinal fusion. METHODS Subjects were 81 patients with Lenke type 1 AIS who underwent posterior spinal fusion between 2004 and 2013. Twenty-five patients agreed to participate in the study. We divided the patients into two groups: Hook group (15 patients with hooks at UIV who underwent surgery between 2004 and 2011) and PS group (ten patients with pedicle screws at UIV who underwent surgery between 2012 and 2013). To evaluate shoulder balance, first thoracic vertebra tilt angle (T1 tilt), clavicle angle (CA), and radiographic shoulder height (RSH) were measured. RESULTS There were no significant differences in preoperative T1 tilt, CA, or RSH between the both groups. The postoperative 1-week, 2-year, and most recently observed T1 tilts were significantly smaller in the Hook group than in the PS group. There were no significant differences in postoperative 1-week, 2-year, and most recently observed CAs between the two groups. Although there were no significant differences in 1-week postoperative RSH between the groups, the 2-year postoperative RSH was significantly smaller in the Hook group than in the PS group. The most recently observed RSH tended to be smaller in the Hook group than in the PS group, but the difference was not significant. CONCLUSIONS In the PS group, poor shoulder balance remained over the long term. The hooks at UIV adjusted postoperative shoulder balance.
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16
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Wilke HJ, Herkommer A, Werner K, Liebsch C. In vitro Analysis of the Intradiscal Pressure of the Thoracic Spine. Front Bioeng Biotechnol 2020; 8:614. [PMID: 32626699 PMCID: PMC7311578 DOI: 10.3389/fbioe.2020.00614] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/20/2020] [Indexed: 11/13/2022] Open
Abstract
The hydrostatic pressure of the nucleus pulposus represents an important parameter in the characterization of spinal biomechanics, affecting the segmental stability as well as the stress distribution across the anulus fibrosus and the endplates. For the development of experimental setups and the validation of numerical models of the spine, intradiscal pressure (IDP) values under defined boundary conditions are therefore essential. Due to the lack of data regarding the thoracic spine, the purpose of this in vitro study was to quantify the IDP of human thoracic spinal motion segments under pure moment loading. Thirty fresh-frozen functional spinal units from 19 donors, aged between 43 and 75 years, including all segmental levels from T1-T2 to T11-T12, were loaded up to 7.5 Nm in flexion/extension, lateral bending, and axial rotation. During loading, the IDP was measured using a flexible sensor tube, which was inserted into the nucleus pulposus under x-ray control. Pressure values were evaluated from third full loading cycles at 0.0, 2.5, 5.0, and 7.5 Nm in each motion direction. Highest IDP increase was found in flexion, being significantly (p < 0.05) increased compared to extension IDP. Median pressure values were lowest in lateral bending while exhibiting a large variation range. Flexion IDP was significantly increased in the upper compared to the mid- and lower thoracic spine, whereas extension IDP was significantly higher in the lower compared to the upper thoracic spine, both showing significant (p < 0.01) linear correlation with the segmental level at 7.5 Nm (flexion: r = -0.629, extension: r = 0.500). No significant effects of sex or age were detected, however trends toward higher IDP in specimens from female donors and decreasing IDP with increasing age, potentially caused by fibrotic degenerative changes in the nucleus pulposus tissue. Sagittal and transversal cuttings after testing revealed possible relationships between nucleus pulposus quality and pressure moment characteristics, overall leading to low or negative intrinsic IDP and non-linear pressure-moment behavior in case of fibrotic tissue alterations. In conclusion, this study provides insights into thoracic spinal IDP and offers a large dataset for the validation of numerical models of the thoracic spine.
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Affiliation(s)
- Hans-Joachim Wilke
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Centre Ulm, Ulm University, Ulm, Germany
| | - Andrea Herkommer
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Centre Ulm, Ulm University, Ulm, Germany
| | - Karin Werner
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Centre Ulm, Ulm University, Ulm, Germany
| | - Christian Liebsch
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Centre Ulm, Ulm University, Ulm, Germany
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17
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Rosinski A, Odeh K, Ungurean V, Leasure J, Kondrashov D. Non-Pedicular Fixation Techniques for the Treatment of Spinal Deformity: A Systematic Review. JBJS Rev 2020; 8:e0150. [PMID: 32427778 DOI: 10.2106/jbjs.rvw.19.00150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND In recent years, the use of pedicle screws has become the gold standard for achieving stable, 3-column fixation of the spine. However, pedicle screw placement may not always be ideal, such as in adolescent idiopathic scoliosis, because of pedicle morphology. An understanding of the alternatives to pedicle screw fixation is therefore important in the treatment of patients with spinal deformity. The purpose of this article is to review the indications, advantages, disadvantages, and complications associated with non-pedicular fixation techniques of the thoracolumbar spine. METHODS Comprehensive literature searches of PubMed, Scopus, and Web of Science databases were performed for 10 methods of non-pedicular fixation. Articles published between January 1, 1990, and June 1, 2019, were considered. Non-English-language articles and studies involving fixation of the cervical spine were excluded from our review. RESULTS After reviewing >1,600 titles and abstracts pertaining to non-pedicular fixation, a total of 213 articles met our inclusion criteria. Non-pedicular fixation may be preferred in certain cases of spinal deformity and may provide stronger fixation in osteoporotic bone. The use of non-pedicular fixation techniques is often limited by the inability to place multilevel constructs on intact posterior elements. Additionally, some methods of non-pedicular fixation, such as spinous process tethering, primarily have utility for the end of constructs to minimize junctional problems. CONCLUSIONS Pedicle screws remain the anchor of choice in spinal deformity surgery because of their ability to engage all 3 columns of the spine and provide safe correction in all 3 planes. Nevertheless, non-pedicular fixation may be useful in cases in which pedicle screw placement is extremely difficult. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Khalid Odeh
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | | | - Jeremi Leasure
- The Taylor Collaboration, San Francisco, California.,San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | - Dimitriy Kondrashov
- The Taylor Collaboration, San Francisco, California.,San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
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18
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Bivertebral autostable claws for the proximal fixation in thoracic adolescent idiopathic scoliosis surgery. Spine Deform 2020; 8:77-84. [PMID: 31950478 DOI: 10.1007/s43390-020-00040-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/19/2019] [Indexed: 10/25/2022]
Abstract
STUDY DESIGN Retrospective monocentric study. OBJECTIVES To report radiologic outcomes of a consecutive series of AIS patients, operated with a bivertebral autostable claw for the upper instrumentation over a 5-year period. The upper fixation represents the weakest part of long constructs because of local anatomy and the high pull-out forces. Various implants have been proposed, but proximal junctional failures (PJF) and shoulder imbalance still occur with variable incidence. The autostable claw is a new implant, safe, and low profile, combining the mechanical strength of hooks with the initial stability of pedicle screws. METHODS All AIS patients operated between January 2010 and July 2015 for a Lenke 1 or 2 curve with the bivertebral autostable claw were included. A minimum 2-year follow-up was required. Full-spine biplanar stereoradiographs were performed preoperatively, within 8 weeks postoperative and at latest examination. Local and global sagittal and coronal parameters were analyzed and complications were reported. RESULTS 237 patients (191 Lenke 1 and 46 Lenke 2) were included, with a mean follow-up of 4.1 ± 0.6 years. PJF occurred in 2 patients (0.8%), and radiologic PJKs were observed in 8.4% of the series. Shoulder balance was efficiently restored or maintained in 88.2%. CONCLUSIONS The bivertebral autostable claw is a safe and robust alternative to pedicle screws for proximal fixation in AIS long constructs. Compression and/or distraction can be applied to level shoulders, and mechanical failures remain rare at 4-year follow-up. LEVEL OF EVIDENCE IV.
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19
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Gaume M, Persohn S, Vergari C, Glorion C, Skalli W, Miladi L. Biomechanical cadaver study of proximal fixation in a minimally invasive bipolar construct. Spine Deform 2020; 8:33-38. [PMID: 31925759 DOI: 10.1007/s43390-019-00014-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/14/2019] [Indexed: 12/27/2022]
Abstract
STUDY DESIGN Biomechanical human cadaver study. OBJECTIVE To determine the three-dimensional intervertebral ranges of motion (ROMs) of intact and hook-instrumented thoracic spine specimens subjected to physiological loads, using an in vitro experimental protocol with EOS biplane radiography. Pedicle screws are commonly used in thoracic instrumentation constructs, and their biomechanical properties have been widely studied. Promising clinical results have been reported using a T1-T5 thoracic hook-claw construct for proximal rod anchoring. Instrumentation stability is a crucial factor in minimizing mechanical complications rates but had not been assessed for this construct in a biomechanical study. METHODS Six fresh-frozen human cadaver C6-T7 thoracic spines were studied. The first thoracic vertebrae were instrumented using two claws of supra-laminar and pedicle hooks, each fixed on two adjacent vertebrae, on either side of a single free vertebra. Quasi-static pure-moment loads up to 5 Nm were applied to each specimen before and after instrumentation, in flexion-extension, right and left bending, and axial rotation. Five steel beads impacted in each vertebra allowed 3D tracking of vertebral movements on EOS biplanar radiographs acquired after each loading step. The relative ranges of motion (ROMs) of each pair of vertebras were computed. RESULTS Mean ROMs with the intact specimens were 17° in flexion-extension, 27.9° in lateral bending, and 29.5° in axial rotation. Corresponding values with the instrumented specimens were 0.9°, 2.6°, and 7.3°, respectively. Instrumentation significantly (P < 0.05) decreased flexion-extension (by 92-98%), lateral bending (by 87-96%), and axial rotation (by 68-84%). CONCLUSION This study establishes the biomechanical stability of a double claw-hook construct in the upper thoracic spine, which may well explain the low mechanical complication rate in previous clinical studies. LEVEL OF EVIDENCE Not applicable, experimental cadaver study.
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Affiliation(s)
- M Gaume
- Arts et Métiers ParisTech, LBM/Institut de Biomécanique Humaine Georges Charpak, 151 Bd. de l'Hôpital, 75013, Paris, France. .,Pediatrics Orthopedics Department, Necker Hospital, Paris Descartes University, Assistance Publique Hôpitaux de Paris, Paris, France.
| | - S Persohn
- Arts et Métiers ParisTech, LBM/Institut de Biomécanique Humaine Georges Charpak, 151 Bd. de l'Hôpital, 75013, Paris, France
| | - C Vergari
- Arts et Métiers ParisTech, LBM/Institut de Biomécanique Humaine Georges Charpak, 151 Bd. de l'Hôpital, 75013, Paris, France
| | - C Glorion
- Pediatrics Orthopedics Department, Necker Hospital, Paris Descartes University, Assistance Publique Hôpitaux de Paris, Paris, France
| | - W Skalli
- Arts et Métiers ParisTech, LBM/Institut de Biomécanique Humaine Georges Charpak, 151 Bd. de l'Hôpital, 75013, Paris, France
| | - L Miladi
- Pediatrics Orthopedics Department, Necker Hospital, Paris Descartes University, Assistance Publique Hôpitaux de Paris, Paris, France
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Natarajan RN, Watanabe K, Hasegawa K. Posterior bone graft in lumbar spine surgery reduces the stress in the screw-rod system- A finite element study. J Mech Behav Biomed Mater 2020; 104:103628. [PMID: 31929096 DOI: 10.1016/j.jmbbm.2020.103628] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/03/2020] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Analyze the biomechanical effect of postero-lateral instrumentation with and without posterior bone graft as well as effect of consolidation of the graft. Study objectives are (1) whether bone graft alone will provide enough additional strength to the weakened spine, (2) how the addition of posterior bone graft help in extending the life of the fusion construct, and (3) compare the effect of gradual consolidation of the bone-graft on the spine biomechanics. METHODS A lumbar spine finite element model was used to analyze the effects of bone-graft alone and varying grades of bone-graft consolidation with postero-lateral instrumentation on spine biomechanics. The spine stiffness and stresses in the posterior rods and screws were determined for moments applied in the three physiological directions in addition to pre-load. RESULTS Stiffness of a normal lumbar spine with a solid consolidated posterior bone graft was found to be 10 times that of an intact lumbar spine. Posterior instrumentation further increased the spine stiffness by 20 fold. A 50% solid consolidation of the graft reduced the screw-rod maximum von-Mises stress by 45% and a 65% reduction in screw-rod stress was calculated with completely fused graft. CONCLUSION A fused graft with posterior instrumentation provided a 200 fold increase in stiffness of an intact spine while producing stress shielding to the Ti rod-screw system. Considerable reduction of the maximum von-Mises stresses in the postero-lateral rod and screw fusion system (65%) will contribute to prevention of implant failure under repetitive loading highlighting the importance of consolidation of posterior bone-graft.
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Affiliation(s)
- Raghu N Natarajan
- Rush University Medical Center, Suite 204 F, Orthopedic Ambulatory Building, 1611 West Harrison, Chicago, IL, 60612, USA.
| | - Kei Watanabe
- Niigata University Medical and Dental General Hospital, Niigata, Japan
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21
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Rahm MD, Brooks DM, Harris JA, Hart RA, Hughes JL, Ferrick BJ, Bucklen BS. Stabilizing effect of the rib cage on adjacent segment motion following thoracolumbar posterior fixation of the human thoracic cadaveric spine: A biomechanical study. Clin Biomech (Bristol, Avon) 2019; 70:217-222. [PMID: 31669919 DOI: 10.1016/j.clinbiomech.2019.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/19/2019] [Accepted: 10/05/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the rib cage provides substantial stability to the thoracic spine, few biomechanical studies have incorporated it into their testing model, and no studies have determined the influence of the rib cage on adjacent segment motion of long fusion constructs. The present biomechanical study aimed to determine the mechanical contribution of the intact rib cage during the testing of instrumented specimens. METHODS A cyclic loading (CL) protocol with instrumentation (T4-L2 pedicle screw-rod fixation) was conducted on five thoracic spines (C7-L2) with intact rib cages. Range of motion (±5 Nm pure moment) in flexion-extension, lateral bending, and axial rotation was captured for intact ribs, partial ribs, and no ribs conditions. Comparisons at the supra-adjacent (T2-T3), adjacent (T3-T4), first instrumented (T4-T5), and second instrumented (T5-T6) levels were made between conditions (P ≤ 0.05). FINDINGS A trend of increased motion at the adjacent level was seen for partial ribs and no ribs in all 3 bending modes. This trend was also observed at the supra-adjacent level for both conditions. No significant changes in motion compared to the intact ribs condition were seen at the first and second instrumented levels (P > 0.05). INTERPRETATION The segment adjacent to long fusion constructs, which may appear more grossly unstable when tested in the disarticulated spine, is reinforced by the rib cage. In order to avoid overestimating adjacent level motion, when testing the effectiveness of surgical techniques of the thoracic spine, inclusion of the rib cage may be warranted to better reflect clinical circumstances.
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Affiliation(s)
- Mark D Rahm
- Department of Orthopaedic Surgery, Baylor Scott and White Health/Texas A&M University College of Medicine, 2401 S 31(st) Street, Temple, Texas, 76508, USA.
| | - Daina M Brooks
- Musculoskeletal Education and Research Center, Globus Medical, Inc., 2560 General Armistead Avenue, Audubon, PA 19403, USA.
| | - Jonathan A Harris
- Musculoskeletal Education and Research Center, Globus Medical, Inc., 2560 General Armistead Avenue, Audubon, PA 19403, USA.
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, 601 Broadway, Seattle, WA 98122, USA.
| | - Jessica L Hughes
- Department of Orthopaedic Surgery, Baylor Scott and White Health/Texas A&M University College of Medicine, 2401 S 31(st) Street, Temple, Texas, 76508, USA.
| | - Bryan J Ferrick
- Drexel University School of Biomedical Engineering, Science and Health Systems, 3141 Chestnut Street, Philadelphia, PA 19104, USA
| | - Brandon S Bucklen
- Musculoskeletal Education and Research Center, Globus Medical, Inc., 2560 General Armistead Avenue, Audubon, PA 19403, USA.
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Biomechanical analysis of pedicle screw density in posterior spine instrumentation. CURRENT ORTHOPAEDIC PRACTICE 2019. [DOI: 10.1097/bco.0000000000000778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Daniels AH, Patel SA, Reid DBC, Gao B, Kuris EO, Babu JM, Depasse JM. Proximal junctional failure prevention in adult spinal deformity surgery utilizing interlaminar fixation constructs. Orthop Rev (Pavia) 2019; 11:8068. [PMID: 31210915 PMCID: PMC6551454 DOI: 10.4081/or.2019.8068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 05/09/2019] [Indexed: 11/23/2022] Open
Abstract
Proximal junctional kyphosis (PJK) is a common complication following fusion for Adult Spinal Deformity. PJK and proximal junctional failure (PJF) may lead to pain, neurological injury, reoperation, and increased healthcare costs. Efforts to prevent PJK and PJF have aimed to preserve or reconstruct the posterior spinal tension band and/or modifying instrumentation to allow for more gradual transitions in stiffness at the cranial end of long spinal constructs. We describe placement of an interlaminar fixation construct at the upper instrumented vertebra which may decrease PJK/PJF severity, and is placed with little additional operative time and minimal posterior soft tissue trauma.
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Affiliation(s)
- Alan H Daniels
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
| | - Shyam A Patel
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
| | - Daniel B C Reid
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
| | - Burke Gao
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
| | - Eren O Kuris
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
| | - Jacob M Babu
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
| | - J Mason Depasse
- Division of Spine Surgery, Spinal Deformity Service, Department of Orthopedic Surgery, Alpert Medical School of Brown University, Providence RI, USA
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Shah AA, Lemans JV, Zavatsky J, Agarwal A, Kruyt MC, Matsumoto K, Serhan H, Agarwal AK, Goel V. Spinal Balance/Alignment - Clinical Relevance and Biomechanics. J Biomech Eng 2019; 141:2733054. [PMID: 31049580 DOI: 10.1115/1.4043650] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Indexed: 02/28/2024]
Abstract
In the normal spine due to its curvature in various regions, C7 plumb line (C7PL) passes through the sacrum so that the head is centered over the pelvis-ball and socket hip joints and ankle joints. This configuration leads to the least muscular activities to maintain the spinal balance. For any reason like deformity, scoliosis, kyphosis, trauma, and/or surgery this optimal configuration gets disturbed requiring higher muscular activity to maintain the posture and balance. Several parameters like the thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), Hip- and leg position influence the sagittal balance and thus the optimal configuration of spinal alignment. Global sagittal imbalance is energy consuming and often painful compensatory mechanisms are developed, that in turn negatively influence the quality of life. This review looks at the clinical aspects of spinal imbalance, and the biomechanics of spinal balance as dictated by the deformities- ankylosing spondylitis, scoliosis and kyphosis; surgical corrections- pedicle subtraction osteotomies and long segment stabilizations and consequent postural complications like the proximal and distal junctional kyphosis. This review suggests several potential research topics as well.
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Affiliation(s)
- Anoli A Shah
- Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedic Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, OH
| | | | | | - Aakash Agarwal
- Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedic Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, OH
| | - Moyo C Kruyt
- University Medical Center Utrecht, Utrecht, Netherlands
| | - Koji Matsumoto
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo, Japan
| | | | - Anand K Agarwal
- Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedic Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, OH
| | - Vijay Goel
- Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedic Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, OH
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Viswanathan VK, Minnema AJ, Viljoen S, Farhadi HF. Sublaminar banding as an adjunct to pedicle screw-rod constructs: a review and technical note on novel hybrid constructs in spinal deformity surgery. J Neurosurg Spine 2019; 30:807-813. [PMID: 30835710 DOI: 10.3171/2018.11.spine181154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 11/28/2018] [Indexed: 11/06/2022]
Abstract
Sublaminar implants that encircle cortical bone are well-established adjuncts to pedicle screw-rod constructs in pediatric deformity surgery. Sublaminar bands (SLBs) in particular carry the advantage of relatively greater bone contact surface area as compared to wires and pullout loads that are independent of bone mineral density, in contrast to pedicle screws. Whereas the relevant technical considerations have been reported for pediatric deformity correction, an understanding of the relative procedural specifics of these techniques is missing for adult spinal deformity (ASD), despite several case series that have used distinct posterior tethering techniques for proximal junctional kyphosis prevention. In this paper, the authors summarize the relevant literature and describe a novel technique wherein bilateral tensioned SLBs are introduced at the nonfused proximal junctional level of long-segment ASD constructs.
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Viswanathan VK, Ganguly R, Minnema AJ, DeVries Watson NA, Grosland NM, Fredericks DC, Grossbach AJ, Viljoen SV, Farhadi HF. Biomechanical assessment of proximal junctional semi-rigid fixation in long-segment thoracolumbar constructs. J Neurosurg Spine 2019; 30:184-192. [DOI: 10.3171/2018.7.spine18136] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 07/11/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEProximal junctional kyphosis (PJK) and failure (PJF) are potentially catastrophic complications that result from abrupt changes in stress across rigid instrumented and mobile non-fused segments of the spine (transition zone) after adult spinal deformity surgery. Recently, data have indicated that extension (widening) of the transitional zone via use of proximal junctional (PJ) semi-rigid fixation can mitigate this complication. To assess the biomechanical effectiveness of 3 semi-rigid fixation constructs (compared to pedicle screw fixation alone), the authors performed cadaveric studies that measured the extent of PJ motion and intradiscal pressure changes (ΔIDP).METHODSTo measure flexibility and ΔIDP at the PJ segments, moments in flexion, extension, lateral bending (LB), and torsion were conducted in 13 fresh-frozen human cadaveric specimens. Five testing cycles were conducted, including intact (INT), T10–L2 pedicle screw-rod fixation alone (PSF), supplemental hybrid T9 Mersilene tape insertion (MT), hybrid T9 sublaminar band insertion (SLB1), and hybrid T8/T9 sublaminar band insertion (SLB2).RESULTSCompared to PSF, SLB1 significantly reduced flexibility at the level rostral to the upper-instrumented vertebral level (UIV+1) under moments in 3 directions (flexion, LB, and torsion, p ≤ 0.01). SLB2 significantly reduced motion in all directions at UIV+1 (flexion, extension, LB, torsion, p < 0.05) and at UIV+2 (LB, torsion, p ≤ 0.03). MT only reduced flexibility in extension at UIV+1 (p = 0.02). All 3 constructs revealed significant reductions in ΔIDP at UIV+1 in flexion (MT, SLB1, SLB2, p ≤ 0.02) and torsion (MT, SLB1, SLB2, p ≤ 0.05), while SLB1 and SLB2 significantly reduced ΔIDP in extension (SLB1, SLB2, p ≤ 0.02) and SLB2 reduced ΔIDP in LB (p = 0.05). At UIV+2, SLB2 similarly significantly reduced ΔIDP in extension, LB, and torsion (p ≤ 0.05).CONCLUSIONSCompared to MT, the SLB1 and SLB2 constructs significantly reduced flexibility and ΔIDP in various directions through the application of robust anteroposterior force vectors at UIV+1 and UIV+2. These findings indicate that semi-rigid sublaminar banding can most effectively expand the transition zone and mitigate stresses at the PJ levels of long-segment thoracolumbar constructs.
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Affiliation(s)
- Vibhu K. Viswanathan
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - Ranjit Ganguly
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - Amy J. Minnema
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | | | - Nicole M. Grosland
- Departments of 2Orthopaedics and Rehabilitation and
- 3Biomedical Engineering, and
- 4Center for Computer Aided Design, University of Iowa, Iowa City, Iowa
| | | | - Andrew J. Grossbach
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - Stephanus V. Viljoen
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - H. Francis Farhadi
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
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Fradet L, Wang X, Crandall D, Aubin CE. Biomechanical Analysis of Acute Proximal Junctional Failure After Surgical Instrumentation of Adult Spinal Deformity: The Impact of Proximal Implant Type, Osteotomy Procedures, and Lumbar Lordosis Restoration. Spine Deform 2019; 6:483-491. [PMID: 30122382 DOI: 10.1016/j.jspd.2018.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 12/24/2017] [Accepted: 02/11/2018] [Indexed: 11/28/2022]
Abstract
STUDY DESIGN Computer biomechanical simulations to analyze risk factors of proximal junctional failure (PJF) following adult scoliosis instrumentation. OBJECTIVE To evaluate the biomechanical effects on the proximal junctional spine of the proximal implant type, tissue dissection, and lumbar lordosis (LL) restoration. SUMMARY OF BACKGROUND DATA PJF is a severe proximal junctional complication following adult spinal instrumentation requiring revision surgery. Potential risk factors have been reported in the literature, but knowledge on their biomechanics is still lacking to address the issues. METHODS A patient-specific multibody and finite-element hybrid modeling technique was developed for a 54-year-old patient having undergone instrumented spinal fusion for multilevel stenosis resulting in PJF. Based on the actual surgery, 30 instrumentation scenarios were derived and simulated by changing the implant type at the upper instrumented vertebra (UIV), varying the extent of proximal osteotomy and the degree of LL creation. Five functional loads were simulated, and stresses and strains were analyzed for each of the 30 tested scenarios. RESULTS There was 80% more trabecular bone with stress greater than 0.5 MPa in the UIV with screws compared to hooks. Hooks allowed 96% more mobility of the proximal instrumented functional unit compared to screws. The bilateral complete facetectomy along with posterior ligaments dissection caused a significant increase of the range of motion of the functional unit above the UIV. LL creation increased the flexion moment applied on the proximal vertebra from 7.5 to 17.5 Nm, which generated damage at the bone-screw interface that affected the screw purchase. CONCLUSION Using hooks at UIV and reducing posterior proximal spinal element dissection lowered stress levels in the proximal junctional spinal segment and thus reduced the biomechanical risks of PJF. LL restoration was associated with increased stress levels in postoperative functional upper body flexion.
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Affiliation(s)
- Leo Fradet
- Department of Mechanical Engineering, Polytechnique Montréal, P.O. Box 6079, Downtown Station, Montreal, Quebec H3C 3A7, Canada; Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, Quebec H3T 1C5, Canada; iLab-Spine (International Laboratory-Spine Imaging and Biomechanics), Montreal, Canada and Marseille, France
| | - Xiaoyu Wang
- Department of Mechanical Engineering, Polytechnique Montréal, P.O. Box 6079, Downtown Station, Montreal, Quebec H3C 3A7, Canada; Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, Quebec H3T 1C5, Canada
| | - Dennis Crandall
- Sonoran Spine Center, 1255 W. Rio Salado Parkway, Tempe, AZ 85281, USA
| | - Carl-Eric Aubin
- Department of Mechanical Engineering, Polytechnique Montréal, P.O. Box 6079, Downtown Station, Montreal, Quebec H3C 3A7, Canada; Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, Quebec H3T 1C5, Canada; iLab-Spine (International Laboratory-Spine Imaging and Biomechanics), Montreal, Canada and Marseille, France.
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Buell TJ, Chen CJ, Quinn JC, Buchholz AL, Mazur MD, Mullin JP, Nguyen JH, Taylor DG, Bess S, Line BG, Ames CP, Schwab FJ, Lafage V, Shaffrey CI, Smith JS. Alignment Risk Factors for Proximal Junctional Kyphosis and the Effect of Lower Thoracic Junctional Tethers for Adult Spinal Deformity. World Neurosurg 2019; 121:e96-e103. [DOI: 10.1016/j.wneu.2018.08.242] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 11/25/2022]
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Cho SK, Caridi J, Kim JS, Cheung ZB, Gandhi A, Inzana J. Attenuation of Proximal Junctional Kyphosis Using Sublaminar Polyester Tension Bands: A Biomechanical Study. World Neurosurg 2018; 120:e1136-e1142. [DOI: 10.1016/j.wneu.2018.08.244] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 08/28/2018] [Accepted: 08/30/2018] [Indexed: 01/16/2023]
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Natarajan RN, Watanabe K, Hasegawa K. Biomechanical Analysis of a Long-Segment Fusion in a Lumbar Spine—A Finite Element Model Study. J Biomech Eng 2018; 140:2679248. [PMID: 29801167 DOI: 10.1115/1.4039989] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Indexed: 11/08/2022]
Abstract
Examine the biomechanical effect of material properties, geometric variables, and anchoring arrangements in a segmental pedicle screw with connecting rods spanning the entire lumbar spine using finite element models (FEMs). The objectives of this study are (1) to understand how different variables associated with posterior instrumentation affect the lumbar spine kinematics and stresses in instrumentation, (2) to compare the multidirectional stability of the spinal instrumentation, and (3) to determine how these variables contribute to the rigidity of the long-segment fusion in a lumbar spine. A lumbar spine FEM was used to analyze the biomechanical effects of different materials used for spinal rods (TNTZ or Ti or CoCr), varying diameters of the screws and rods (5 mm and 6 mm), and different fixation techniques (multilevel or intermittent). The results based on the range of motion and stress distribution in the rods and screws revealed that differences in properties and variations in geometry of the screw-rod moderately affect the biomechanics of the spine. Further, the spinal screw-rod system was least stable under the lateral bending mode. Stress analyzes of the screws and rods revealed that the caudal section of the posterior spinal instrumentation was more susceptible to high stresses and hence possible failure. Although CoCr screws and rods provided the greatest spinal stabilization, these constructs were susceptible to fatigue failure. The findings of the present study suggest that a posterior instrumentation system with a 5-mm screw-rod diameter made of Ti or TNTZ is advantageous over CoCr instrumentation system.
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Affiliation(s)
- Raghu N. Natarajan
- Rush University Medical Center, Suite 204 F, Orthopedic Ambulatory Building, 1611 West Harrison, Chicago, IL 60612 e-mail:
| | - Kei Watanabe
- Department of Orthopaedic Surgery, Niigata University Medical and Dental General Hospital, 1-757, Asahimachidori, Chuoku, Niigata City, Niigata 951-8510, Japan e-mail:
| | - Kazuhiro Hasegawa
- Niigata Spine Surgery Center, 2-5-22 Nishi-machi, Konan-ku, Niigata 950-0165, Japan e-mail:
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Lange T, Schulte TL, Gosheger G, Schulze Boevingloh A, Mayr R, Schmoelz W. Effects of multilevel posterior ligament dissection after spinal instrumentation on adjacent segment biomechanics as a potential risk factor for proximal junctional kyphosis: a biomechanical study. BMC Musculoskelet Disord 2018; 19:57. [PMID: 29444669 PMCID: PMC5813396 DOI: 10.1186/s12891-018-1967-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 02/06/2018] [Indexed: 11/17/2022] Open
Abstract
Background Spinous processes and posterior ligaments, such as inter- and supraspinous ligaments are often sacrificed either deliberately to harvest osseous material for final spondylodesis e.g. in deformity corrective surgery or accidentally after posterior spinal instrumentation. This biomechanical study evaluates the potential destabilizing effect of a progressive dissection of the posterior ligaments (PL) after instrumented spinal fusion as a potential risk factor for proximal junctional kyphosis (PJK). Methods Twelve calf lumbar spines were instrumented from L3 to L6 (L3 = upper instrumented vertebra, UIV) and randomly assigned to one of the two study groups (dissection vs. control group). The specimens in the dissection group underwent progressive PL dissection, followed by cyclic flexion motion (250 cycles, moment: + 2.5 to + 20.0 Nm) to simulate physical activity and range of motion (ROM) testing of each segment with pure moments of ±15.0 Nm after each dissection step. The segmental ROM in flexion and extension was measured. The control group underwent the same loading and ROM testing protocol, but without PL dissection. Results In the treatment group, the normalized mean ROM at L2-L3 (direct adjacent segment of interest, UIV/UIV + 1, PJK-level) increased to 104.7%, 107.3%, and 119.4% after dissection of the PL L4–L6, L3–L6, and L2–L6, respectively. In the control group the mean ROM increased only to 103.2%, 106.7%, and 108.7%. The ROM difference at L2-L3 with regard to the last dissection of the PL was statistically significant (P = 0.017) and a PL dissection in the instrumented segments showed a positive trend towards an increased ROM at UIV/UIV + 1. Conclusions A dissection of the PL at UIV/UIV + 1 leads to a significant increase in ROM at this level which can be considered to be a risk factor for PJK and should be definitely avoided during surgery. However, a dissection of the posterior ligaments within the instrumented segments while preserving the ligaments at UIV/UIV + 1 leads to a slight but not significant increase in ROM in the adjacent cranial segment UIV/UIV + 1 in the used experimental setup. Using this experimental setup we could not confirm our initial hypothesis that the posterior ligaments within a long posterior instrumentation should be preserved.
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Affiliation(s)
- Tobias Lange
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
| | - Tobias L Schulte
- Department of Orthopedics and Trauma Surgery, St. Josef-Hospital, University Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791, Bochum, Germany
| | - Georg Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Albert Schulze Boevingloh
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Raul Mayr
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Werner Schmoelz
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
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Diebo BG, Shah NV, Stroud SG, Paulino CB, Schwab FJ, Lafage V. Realignment surgery in adult spinal deformity. DER ORTHOPADE 2018; 47:301-309. [DOI: 10.1007/s00132-018-3536-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Birkenmaier C. Expert's comment concerning Grand Rounds case entitled "Type V osteogenesis imperfecta undergoing surgical correction for scoliosis" by M. Jones et al. (Eur Spine J; 2018: doi 10.1007/s00586-018-5465-8). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2085-2087. [PMID: 29388091 DOI: 10.1007/s00586-018-5491-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 01/18/2018] [Indexed: 10/18/2022]
Affiliation(s)
- C Birkenmaier
- Department for Orthopedics, Physical Medicine and Rehabilitation, Ludwig Maximilian University Munich, Marchioninistr. 15, 81377, Munich, Germany.
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Full-field strain distribution in multi-vertebra spine segments: An in vitro application of digital image correlation. Med Eng Phys 2018; 52:76-83. [DOI: 10.1016/j.medengphy.2017.11.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 11/08/2017] [Accepted: 11/22/2017] [Indexed: 11/17/2022]
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Brummund M, Brailovski V, Petit Y, Facchinello Y, Mac-Thiong JM. Impact of spinal rod stiffness on porcine lumbar biomechanics: Finite element model validation and parametric study. Proc Inst Mech Eng H 2017; 231:1071-1080. [PMID: 28927347 DOI: 10.1177/0954411917732596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A three-dimensional finite element model of the porcine lumbar spine (L1-L6) was used to assess the effect of spinal rod stiffness on lumbar biomechanics. The model was validated through a comparison with in vitro measurements performed on six porcine spine specimens. The validation metrics employed included intervertebral rotations and the nucleus pressure in the first instrumented intervertebral disc. The numerical results obtained suggest that rod stiffness values as low as 0.1 GPa are required to reduce the mobility gradient between the adjacent and instrumented segments and the nucleus pressures across the porcine lumbar spine significantly. Stiffness variations above this threshold value have no significant effect on spine biomechanics. For such low-stiffness rods, intervertebral rotations in the instrumented zone must be monitored closely in order to guarantee solid fusion. Looking ahead, the proposed model will serve to examine the transverse process hooks and variable stiffness rods in order to further smooth the transition between the adjacent and instrumented segments, while preserving the stability of the instrumented zone, which is needed for fusion.
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Affiliation(s)
- Martin Brummund
- 1 Department of Mechanical Engineering, École de technologie supérieure, Montreal, QC, Canada.,2 Research Center, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Vladimir Brailovski
- 1 Department of Mechanical Engineering, École de technologie supérieure, Montreal, QC, Canada.,2 Research Center, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Yvan Petit
- 1 Department of Mechanical Engineering, École de technologie supérieure, Montreal, QC, Canada.,2 Research Center, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Yann Facchinello
- 1 Department of Mechanical Engineering, École de technologie supérieure, Montreal, QC, Canada.,2 Research Center, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Jean-Marc Mac-Thiong
- 2 Research Center, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada.,3 Department of Surgery, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
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Wang H, Ding W, Ma L, Zhang L, Yang D. Prevention of Proximal Junctional Kyphosis: Are Polyaxial Pedicle Screws Superior to Monoaxial Pedicle Screws at the Upper Instrumented Vertebrae? World Neurosurg 2017; 101:405-415. [DOI: 10.1016/j.wneu.2017.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 02/01/2017] [Accepted: 02/02/2017] [Indexed: 10/20/2022]
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