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Ma L, Yan Y, Wang X, Wang S, Li F, Zhang K, Fan X, Zhong H, Lou X, Wu X, Xue Y, Wang Y, He L, Yan R, Chen W. Biomechanical evaluation and optimal design of a pedicle screw with double bent rods internal fixation system based on PE-PLIF fusion. Comput Methods Biomech Biomed Engin 2024; 27:1448-1459. [PMID: 37652157 DOI: 10.1080/10255842.2023.2245517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/20/2023] [Accepted: 07/31/2023] [Indexed: 09/02/2023]
Abstract
Problems, such as broken screws, broken rods, and cage subsidence after clinical spinal fusion surgery affect the success rate of fusion surgery and the fixation effect of fusion segments, and these problems still affect the treatment and postoperative recovery of patients. In this study, we used the biomechanical finite element analysis method to analyze and study the fixation effect of three kinds of spinal internal fixation systems on L4-L5 lumbar spine segments in percutaneous endoscopic posterior lumbar interbody fusion (PE-PLIF). The three different fixation systems compared in this study include bilateral pedicle screw fixation (M1); bilateral pedicle screw with cross-link fixation (M2); bilateral pedicle screws with double bent rods fixation (M3). The internal fixation systems with different structures were analyzed with the help of Hypermesh, and Abaqus. It was found that the internal fixation system with double bent rods reduced screw stresses by 23.8 and 22.2% in right and left axial rotation than the traditional bilateral pedicle screw system, while titanium rod stresses were reduced by 9.6, 3.7, 9.6, and 2.9% in flexion, left and right lateral bending, and right axial rotation, respectively, and L5 upper endplate stresses were reduced by 35.5, 18.9, 38.4, 10.2, and 48.3% in flexion, left and right lateral bending, and left and right axial rotation, respectively. The spinal range of motion (ROM) of the M3 internal fixation system was less than that of the M1 and M2 internal fixation systems in left lateral bending, left lateral rotation, and right axial rotation, and the intact vertebral ROM was reduced by 93.7, 94.9, and 90.9%, respectively. The double bent rod structure of the spinal internal fixation system has better biomechanical properties, which can effectively reduce the risk of screw breakage, loosening, cage subsidence, and endplate collapse after fusion surgery.
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Affiliation(s)
- Lei Ma
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, China
| | - Yang Yan
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, China
| | - Xiyu Wang
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, China
| | - Songyuan Wang
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, China
| | - Feng Li
- Department of Spine Surgery, Weifang People's Hospital, Weifang, China
| | - Kai Zhang
- Huajin Orthopaedic Hospital, Taiyuan, China
| | - Xuanze Fan
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, China
| | - Hao Zhong
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, China
| | - Xinqi Lou
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, China
| | - Xiaogang Wu
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, China
| | - Yanru Xue
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, China
| | - Yanqin Wang
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, China
| | - Liming He
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Ruizhong Yan
- Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, China
| | - Weiyi Chen
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, China
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Xie S, Cui L, Liu J, Qing P, Li J. Impact of screw tip design on screw anchorage: mechanical testing and numerical simulation. J Orthop Surg Res 2024; 19:447. [PMID: 39080768 PMCID: PMC11287948 DOI: 10.1186/s13018-024-04841-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 06/07/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND Screw loosening is a commonly reported issue following spinal screw fixation and can lead to various complications. The initial cause of screw loosening is biomechanical deterioration. Previous studies have demonstrated that modifications in screw design can impact the local biomechanical environment, specifically the stress distribution on bone-screw interfaces. There are several different designs of screw tips available for clinically used pedicle screws; however, it remains unclear whether these variations affect the local stress distribution and subsequent screw anchorage ability. METHODS This study conducted comprehensive biomechanical research using polyurethane foam mechanical tests and corresponding numerical simulations to investigate this topic. Models of pedicle screw-fixed osteoporotic polyurethane foam were created with two different clinically used screw tip designs (flat and steep) featuring varying tip lengths, taper angles, and diameters, as well as identical flank overlap areas and thread designs. The anchorage ability of the different models was assessed through toggle and pull-out test. Additionally, numerical mechanical models were utilized to compute the stress distributions at the screw and bone-screw interfaces in the different models. RESULTS Mechanical tests revealed superior anchorage ability in models utilizing flat-tipped screws. Furthermore, numerical modeling indicated improved anchorage ability and reduced stress concentration tendency in these models. CONCLUSION Changes in screw tip design can significantly impact the biomechanical anchoring capability of screws. Specifically, flatter tip pedicle screws may mitigate the risk of screw loosening by alleviating stress concentration on bone-screw interfaces.
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Affiliation(s)
- Shiming Xie
- Department of Spine surgery, Mianyang Orthopedic Hospital, Mianyang, Sichuan Province, 621052, P.R. China
| | - Liqiang Cui
- Department of Spine surgery, Mianyang Orthopedic Hospital, Mianyang, Sichuan Province, 621052, P.R. China
| | - Jinhui Liu
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Department of Bone and Joint Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, PR China
| | - Peidong Qing
- Department of Spine surgery, Mianyang Orthopedic Hospital, Mianyang, Sichuan Province, 621052, P.R. China.
| | - Jingchi Li
- Department of Orthopedics, Luzhou Key Laboratory of Orthopedic Disorders, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan Province, 646000, P.R. China.
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Liu C, Zhao M, Zhang W, Wang C, Hu B, Wang K, Xu W, Li L, Si H. Biomechanical assessment of different transforaminal lumbar interbody fusion constructs in normal and osteoporotic condition: a finite element analysis. Spine J 2024; 24:1121-1131. [PMID: 38316364 DOI: 10.1016/j.spinee.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 01/06/2024] [Accepted: 01/22/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND CONTEXT With the aging population, osteoporosis, which leads to poor fusion, has become a common challenge for lumbar surgery. In addition, most people with osteoporosis are elderly individuals with poor surgical tolerance, and poor bone quality can also weaken the stability of internal fixation. PURPOSE This study compared the fixation strength of the bilateral traditional trajectory screw structure (TT-TT), the bilateral cortical bone trajectory screw structure (CBT-CBT), and the hybrid CBT-TT (CBT screws at the cranial level and TT screws at the caudal level) structure under different bone mineral density conditions. STUDY DESIGN A finite element (FE) analysis study. METHODS Above all, we established a healthy adult lumbar spine model. Second, under normal and osteoporotic conditions, three transforaminal lumbar interbody fusion (TLIF) models were established: bilateral traditional trajectory (TT-TT) screw fixation, bilateral cortical bone trajectory (CBT-CBT) screw fixation, and hybrid cortical bone trajectory screw and traditional trajectory screw (CBT-TT) fixation. Finally, a 500-N compression load with a torque of 10 N/m was applied to simulate flexion, extension, lateral bending, and axial rotation. We compared the range of motion (ROM), adjacent disc stress, cage stress, and posterior fixation stress of the different fusion models. RESULTS Under different bone mineral density conditions, the range of motion of the fusion segment was significantly reduced. Compared to normal bone conditions, the ROM of the L4-L5 segment, the stress of the adjacent intervertebral disc, the surface stress of the cage, and the maximum stress of the posterior fixation system were all increased in osteoporosis. Under most loads, the ROM and surface stress of the cage and the maximum stress of the posterior fixation system of the TT-TT structure are the lowest under normal bone mineral density conditions. However, under osteoporotic conditions, the fixation strength of the CBT-CBT and CBT-TT structures are higher than that of the TT-TT structures under certain load conditions. At the same time, the surface stress of the intervertebral fusion cage and the maximum stress of the posterior fixation system for the two structures are lower than those of the TT-TT structure. CONCLUSION Under normal bone mineral density conditions, transforaminal lumbar interbody fusion combined with TT-TT fixation provides the best biomechanictability. However, under osteoporotic conditions, CBT-CBT and CBT-TT structures have higher fixed strength compared to TT-TT structures. The hybrid CBT-TT structure exhibits advantages in minimal trauma and fixation strength. Therefore, this seems to be an alternative fixation method for patients with osteoporosis and degenerative spinal diseases. CLINICAL SIGNIFICANCE This study provides biomechanical support for the clinical application of hybrid CBT-TT structure for osteoporotic patients undergoing TLIF surgery.
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Affiliation(s)
- Chen Liu
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Mengmeng Zhao
- School of Physics and Electronic Science, Shandong Normal University, Jinan, Shandong, 250014, P.R. China
| | - Wencan Zhang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Chongyi Wang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Bingtao Hu
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Kaibin Wang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Wanlong Xu
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Le Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Haipeng Si
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China; Department of Orthopedics, Qilu Hospital of Shandong University(Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, 266035, P.R. China.
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Werthmann NJ, Gum JL, Nagata K, Djurasovic M, Glassman SD, Owens RK, Crawford CH, Carreon LY. Comparison of No Tap (two-step) and tapping robotic assisted cortical bone trajectory screw insertion. J Robot Surg 2024; 18:204. [PMID: 38714574 DOI: 10.1007/s11701-024-01890-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/28/2024] [Indexed: 05/10/2024]
Abstract
Workflow for cortical bone trajectory (CBT) screws includes tapping line-to-line or under tapping by 1 mm. We describe a non-tapping, two-step workflow for CBT screw placement, and compare the safety profile and time savings to the Tap (three-step) workflow. Patients undergoing robotic assisted 1-3 level posterior fusion with CBT screws for degenerative conditions were identified and separated into either a No-Tap or Tap workflow. Number of total screws, screw-related complications, estimated blood loss, operative time, robotic time, and return to the operating room were collected and analyzed. There were 91 cases (458 screws) in the No-Tap and 88 cases (466 screws) in the Tap groups, with no difference in demographics, revision status, ASA grade, approach, number of levels fused or diagnosis between cohorts. Total robotic time was lower in the No-Tap (26.7 min) versus the Tap group (30.3 min, p = 0.053). There was no difference in the number of malpositioned screws identified intraoperatively (10 vs 6, p = 0.427), screws converted to freehand (3 vs 3, p = 0.699), or screws abandoned (3 vs 2, p = 1.000). No pedicle/pars fracture or fixation failure was seen in the No-Tap cohort and one in the Tap cohort (p = 1.00). No patients in either cohort were returned to OR for malpositioned screws. This study showed that the No-Tap screw insertion workflow for robot-assisted CBT reduces robotic time without increasing complications.
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Affiliation(s)
- Neil J Werthmann
- University of Louisville School of Medicine, 500 South Preston Street. Instructional Building, Room 305, Louisville, KY, 40202, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA
| | - Kosei Nagata
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA
| | - Mladen Djurasovic
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA
| | - Steven D Glassman
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson Street, 1st Floor ACB, Louisville, KY, 40202, USA
| | - R Kirk Owens
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA
| | - Charles H Crawford
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson Street, 1st Floor ACB, Louisville, KY, 40202, USA
| | - Leah Y Carreon
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA.
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Nagashima Y, Ishikawa T, Katsuragi J, Sasaki Y, Suzuki M, Umimura T, Sawada R, Hashiba D, Yamamoto M, Ohtori S. Radiation Exposure During Lumbar Interbody Fusion Surgery Can Be Reduced by Using a Three-Dimensional Patient-Specific Template Guide. Cureus 2024; 16:e58787. [PMID: 38784365 PMCID: PMC11112391 DOI: 10.7759/cureus.58787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND The use of posterior lumber interbody fusion (PLIF) using cortical bone trajectory (CBT) with a patient-specific 3D template guide is increasingly widespread. To our knowledge, no studies have extensively evaluated the reduction of radiation exposure when using patient-specific drill template guides. The purpose of this study is to compare the intra-operative radiation dose and surgeon's exposure to radiation in CBT-PLIF when using a patient-specific drill guide with that in traditional minimally invasive (MIS)-PLIF. METHODS In this observational study, we retrospectively compared data from five patients who were treated with single-level CBT-PLIF using a patient-specific drill guide (G group) and five patients who were treated with single-level traditional MIS-PLIF (M group). We compared the surgical time, surgeon's exposure to radiation, and intra-operative radiation time and dose between the two groups of patients. RESULTS The mean age of the patients was 67.0 years in the M group and 74.2 years in the G group. The average surgical time was 242.8 min in the M group and 189.6 min in the G group (p = 0.020). The surgeon's exposure to radiation was 373.7 µSv in the M group and 81.75 µSv in the G group at chest level outside the protector (p = 0.00092); 42.0 µSv (M group) and 3.6 µSv (G group) at chest level inside the protector (p = 0.0000062); and 4.33 µSv (M group) and 1.20 µSv (G group) at the buttocks of the surgeon (p = 0.0013). Radiation time was 269.8 s (M group) and 56.6 s (G group) (p = 0.0097), and radiation dose was 153.7 mGy (M group) and 30.42 mGy (G group) (p = 0.00057). CONCLUSION The patient-specific drill template guide is an invaluable tool that facilitates the safe insertion of CBT screws with a low radiation dose from the outset.
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Affiliation(s)
| | | | - Joe Katsuragi
- Orthopedic Surgery, Sanmu Medical Center, Sanmu, JPN
| | | | | | | | - Ryohei Sawada
- Orthopedic Surgery, Sanmu Medical Center, Sanmu, JPN
| | | | | | - Seiji Ohtori
- Orthopedic Surgery, Chiba University Hospital, Chiba, JPN
- Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba, JPN
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Yamagishi A, Ishii M, Sakaura H, Yamasaki R, Ohnishi A, Tsukazaki H, Ohwada T, Ando W. The Influence of Titanium-coated Poryetheretherketone Cages in Fusion Status after Posterior Lumbar Interbody Fusion with Cortical Bone Trajectory Screw Fixation. World Neurosurg 2024; 183:e201-e209. [PMID: 38101540 DOI: 10.1016/j.wneu.2023.12.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/08/2023] [Accepted: 12/09/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE Posterior lumbar interbody fusion (PLIF) with cortical bone trajectory (CBT) screw fixation (CBT-PLIF) shows potential for reducing adjacent segmental disease. Previously, our investigations revealed a relatively lower fusion rate with the use of carbon fiber-reinforced polyetheretherketone (CP) cages in CBT-PLIF compared with traditional pedicle screw fixation (PS-PLIF) using CP cages. This study aims to evaluate whether the implementation of titanium-coated polyetheretherketone (TP) cages can enhance fusion outcomes in CBT-PLIF. METHODS A retrospective analysis was conducted on 68 consecutive patients who underwent CBT-PLIF with TP cages (TP group) and 89 patients who underwent CBT-PLIF with CP cages (CP group). Fusion status was assessed using computed tomography at 1 year postoperatively and dynamic plain radiographs at 2 years postoperatively. RESULTS No statistically significant differences in fusion rates were observed at 1 and 2 years postoperatively between the TP group (86.8% and 89.7%, respectively) and the CP group (77.5% and 88.8%, respectively). Notably, the CP group exhibited a significant improvement in fusion rate from 1 to 2 years postoperatively (P = 0.002), while no significant improvement was observed in the TP group. CONCLUSIONS Examination of temporal changes in fusion rates reveals that only the TP group achieved a peak fusion rate 1 year postoperatively. This implies that TP cages may enhance the fusion process even after CBT-PLIF. Nevertheless, the definitive efficacy of TP cages for CBT-PLIF remains uncertain in the context of overall fusion rates.
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Affiliation(s)
- Akira Yamagishi
- Department of Orthopaedic Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan.
| | - Masayoshi Ishii
- Department of Orthopaedic Surgery, Sakai City Medical Center, Sakai, Osaka, Japan
| | - Hironobu Sakaura
- Department of Orthopaedic Surgery, Suita Municipal Hospital, Suita, Osaka, Japan
| | - Ryoji Yamasaki
- Department of Orthopaedic Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Atsunori Ohnishi
- Department of Orthopaedic Surgery, Itami City Hospital, Itami, Hyogo, Japan
| | - Hiroyuki Tsukazaki
- Department of Orthopaedic Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Tetsuo Ohwada
- Department of Orthopaedic Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Wataru Ando
- Department of Orthopaedic Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
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Takeuchi T, Takamizawa Y, Konishi K, Sano H, Takahashi M, Kouno H, Hosogane N. Comparison of the Fixation Strengths of Screws between the Traditional Trajectory and the Single and Double Endplate Penetrating Screw Trajectories Using Osteoporotic Vertebral Body Models Based on the Finite Element Method. Asian Spine J 2024; 18:12-20. [PMID: 38379149 PMCID: PMC10910145 DOI: 10.31616/asj.2023.0238] [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: 07/26/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 02/22/2024] Open
Abstract
STUDY DESIGN This is a finite element (FE) study. PURPOSE To compare the fixation strength of traditional trajectory (TT) and single and double endplate penetrating screw trajectories (SEPST/DEPST) to the osteoporotic vertebral body model based on the FE method. OVERVIEW OF LITERATURE SEPST/DEPST have been developed to enhance the fixation strength in patients with diffuse idiopathic hyperostosis (DISH). This technique was also applied to patients with osteoporosis. However, determining the superiority of SEPST/ DEPST is difficult because of the heterogeneous patient backgrounds. METHODS Twenty vertebrae (T12 and L1) from 10 patients with osteoporosis (two males and eight females; mean age, 74.7 years) were obtained to create the 10 FE models. First, a single screw was placed with TT and SEPST/DEPST, and the fixation strength was compared by axial pullout strength (POS) and multidirectional loading tests. Second, two screws were placed on the bilateral pedicles with TT and SEPST/DEPST, and the fixation force of the vertebrae in the constructs in flexion, extension, lateral flexion, and axial rotation was examined. RESULTS SEPST and DEPST had 140% and 171% higher POS values than TT, respectively, and the DEPST result was statistically significant (p =0.007). The multidirectional fixation strength was significantly higher in DEPST and SEPST than in TT in the cranial, caudal, and medial directions (p <0.05) but not in the lateral direction (p =0.05). The vertebral fracture strength at the lower instrumented vertebra of the DEPST tended to be higher than that of TT. The vertebral motion angles in SEPST and DEPST were significantly smaller in lateral bending (p =0.02) and tended to be smaller in flexion and extension than in TT (p =0.13). CONCLUSIONS This study may provide useful information for spine surgeons in deciding whether to choose the SEPS or DEPS technique for augmenting fixation in osteoporotic vertebral fracture surgery.
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Affiliation(s)
- Takumi Takeuchi
- Department of Orthopaedic Surgery, Kyorin University School of Medicine, Mitaka,
Japan
| | - Yuhei Takamizawa
- Department of Orthopaedic Surgery, Kyorin University School of Medicine, Mitaka,
Japan
| | - Kazumasa Konishi
- Department of Orthopaedic Surgery, Kyorin University School of Medicine, Mitaka,
Japan
| | - Hideto Sano
- Department of Orthopaedic Surgery, Kyorin University School of Medicine, Mitaka,
Japan
| | - Masahito Takahashi
- Department of Orthopaedic Surgery, Kyorin University School of Medicine, Mitaka,
Japan
| | - Hitoshi Kouno
- Spine Surgery Center, Keiyu Orthopaedic Hospital, Tatebayashi,
Japan
| | - Naobumi Hosogane
- Department of Orthopaedic Surgery, Kyorin University School of Medicine, Mitaka,
Japan
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Tuoheti A, Xiao Y, Wang Y, Maimaiti A, Zhang R, Kahaer A, Tuoheti A, Wu X, Rexiti P. Biomechanical evaluation of modified and traditional cortical bone trajectory technique on adjacent segment degeneration in transforaminal lumbar interbody fusion-finite element analysis. BMC Musculoskelet Disord 2024; 25:7. [PMID: 38166794 PMCID: PMC10759649 DOI: 10.1186/s12891-023-07103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVES Modified cortical bone trajectory (MCBT) technique was proposed by our team in previous studies, but its biomechanical properties at adjacent segments have not been discussed yet. Therefore, the purpose of this study is to investigate the biomechanical properties of modified cortical bone trajectory (MCBT) technique on adjacent segment degeneration (ASD) in transforaminal intradiscal lumbar disc fusion (TLIF) compare to traditional bone trajectory (TT) technique and cortical bone trajectory (CBT) technique. METHODS The four human cadaveric lumbar specimens were provided by the anatomy teaching and research department of Xinjiang Medical University and four intact finite element models of the L1-S1 segment were generated. For each of these, three transforaminal lumbar interbody fusion procedures with three different fixation techniques were reconstructed at the L4-L5 segment, as follows: TT-TT (TT at both L4 and L5 segments), CBT-CBT (CBT at both L4 and L5 segments), MCBT-MCBT (MCBT at both L4 and L5 segments). The range of motion and von Mises stress of the intervertebral disc of the L3-L4 and L5-S1 segments were recorded with a 400N compressive load and 7.5 Nm moments in flexion, extension, left-right bending, and left-right rotation. RESULTS The peak ROM of the L3-L4 segment in the MCBT-MCBT group was reduced by 10.5%, 6.1%, 12.2%, 4.1%, and 1.5% in flexion, extension, left-right bending, and left rotation compared to the TT-TT group and reduced by 1.8%, 5.5%, 10.0%, 12.8%, and 8.8% in flexion, left-right bending, and left-right rotation compared to the CBT-CBT group, respectively. The MCBT-MCBT group has the lowest peak ROM of the L3-L4 segment in flexion, left bending, and right rotation, the lowest peak ROM of the L5-S1 segment in extension and right rotation, and the lowest peak von Mises stress of the intervertebral disc at the L5-S1 segment in right rotation compared to the TT-TT and CBT-CBT group. In addition, the peak von Mises stress at the L3-L4 segment was lowest and more dispersed in all motions, the MCBT-MCBT group exhibited lower peak ROM of the L5-S1 segment in flexion, extension, and right rotation, and showed lower peak von Mises stress of the disc at the L5-S1 segment in flexion, extension, and right rotation compared with the TT-TT group. CONCLUSION The modified cortical bone trajectory technique may have a beneficial effect on reducing the incidence of ASD in the L4-L5 TLIF model compared to the traditional bone trajectory technique and cortical bone trajectory technique.
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Affiliation(s)
- Abudusalamu Tuoheti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yang Xiao
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yixi Wang
- Xinjiang Medical University, Urumqi, China
| | - Abulikemu Maimaiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Rui Zhang
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Alafate Kahaer
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | | | - Xianghui Wu
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Paerhati Rexiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.
- Ministrv of Education, Key Laboratory of High Incidence Disease Research in Xingjiang (Xinjiang Medical University), Urumqi, China.
- Xinjiang Clinical Research Center for Orthopedics, Urumqi, China.
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Solitro GF, Welborn MC, Mehta AI, Amirouche F. How to Optimize Pedicle Screw Parameters for the Thoracic Spine? A Biomechanical and Finite Element Method Study. Global Spine J 2024; 14:187-194. [PMID: 35499547 PMCID: PMC10676166 DOI: 10.1177/21925682221099470] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Pedicle screw study. OBJECTIVE The selection of pedicle screw parameters usually involves the surgeon's analysis of preoperative CT imaging along with anatomical landmarks and tactile examination. However, there is minimal consensus on a standardized guideline for selection methods on pedicle screws. We aimed to determine the effects of thoracic screw diameter to pedicle width on pullout strength determined by cortical bone purchase. METHODS Biomechanical study performed with human cadaveric thoracic vertebrae and experimentally validated three-dimensional finite element model instrumented with pedicle screws of various diameters. We used a variable (SD/PW) ratio to express the screw selection. We hypothesized a positive correlation between the pullout load determined by the bone purchase and the SD/PW. This relationship was first investigated in a validated finite element model considering bone purchase related to the strength of an upper thoracic vertebra. Then, the correlation to the entire spine is evaluated. RESULTS The failure load ranged from 371.3 to 1601.0 N, respectively, for 3 and 6 mm screws. The determinant coefficient was increased to R2=.421 when a linear relationship between pullout load and the SD/PW ratio was used. The peak loads of 1216 and 1288N were found for an SD/PW ratio of .83. CONCLUSION We have found that the screw pullout load is more correlated to SD/PW than other pedicle measures for a maximized SD/PW ratio of .83. This particular value should be considered the upper limit of the indicated SD/PW ratio and a means to determine the optimal screw diameter to enhance pullout strength.
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Affiliation(s)
| | - Michelle C. Welborn
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Il, USA
| | - Ankit I. Mehta
- Department of Orthopaedic Surgery, NorthShore University HealthSystem, Evanston, Il, USA
| | - Farid Amirouche
- Department of Orthopaedics, Louisiana State University, Chicago, Il, USA
- College of Medicine, University of Illinois at Chicago, Chicago, Il, USA
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10
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Pan A, Cheng F, Ding Z, Guan L, Xie W, Hai Y, Liu Y. Low profile posterior lumbar-sacral interbody fusion for lumbosacral degenerative diseases: a technical note. BMC Musculoskelet Disord 2023; 24:885. [PMID: 37957682 PMCID: PMC10644593 DOI: 10.1186/s12891-023-06993-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The purpose of this study was to report our surgical experience in patients with lumbosacral degenerative diseases who underwent posterior decompression and interbody fusion fixed with cortical bone trajectory screw and sacral alar screw, which is known as low-profile posterior lumbosacral interbody fusion (LP-PLSIF). METHODS Patients with lumbosacral degenerative disease who underwent LP-PLSIF and traditional PLSIF (control group) internally fixed with pedicle screws were included retrospectively. Patients' demographic data, operative parameters, and perioperative complications were recorded and analyzed. RESULTS A total of 18 patients were enrolled in this study, which included 9 patients (5 male and 4 female) who underwent LP-PLSIF, and 9 patients (4 male and 5 female) who underwent traditional PLSIF. There wasn't a significant difference in the average age between the two groups, 56.78 ± 10.92 years in the LP-PLSIF group and 60.22 ± 8.21 years in the PLSIF group (p = 0.460). The bone mineral density (BMD) of the two groups of patients were -2.00 ± 0.26 T and -2.13 ± 0.19 T, respectively (P = 0.239). The mean postoperative follow-up time was 12.7 months (range, 12-14 months). The mean operation time was 142.78 ± 11.21 min and 156.11 ± 13.41 min in the LP-PLSIF group and PLSIF group respectively (P < 0.05). The average blood loss was 137.78 ± 37.09 ml in the LP-PLSIF group, and 150.00 ± 27.84 ml in the PLSIF group (P = 0.441). The average postoperative drainage was 85.56 ± 37.45 ml and 122.22 ± 22.24 ml in the LP-PLSIF group and control group respectively (P < 0.05). Patients in the LP-PLSIF group had shorter incision length compared with the control group, 61.44 ± 10.56 mm vs. 74.56 ± 10.22 mm (P < 0.05). The average length of hospitalization of 11.33 ± 2.92 days in the LP-PLSIF group, and 11.11 ± 1.62 days in the PLSIF group (p = 0.844). All patients had significant improvement in VAS pain score, ODI, and JOA evaluation. However, patients in the LP-PLSIF group had better improvement in terms of VAS back pain and ODI in the short term after the operation. There were no neurological complications or wound infection. The fusion rate at the last follow-up was 100% (9 of 9) in the LP-PLSIF group, and 88.89% (8 of 9) in the control group based on CT scans. 1 patient in the control group had asymptomatic sacral pedicle screw loosening. CONCLUSIONS LP-PLSIF is a safe and effective surgical technique for patients with lumbosacral degenerative disease, which has the potential strength of less invasive and better clinical improvement.
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Affiliation(s)
- Aixing Pan
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Beijing, 100020, China
| | - Fengqi Cheng
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Beijing, 100020, China
| | - Zihao Ding
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Beijing, 100020, China
| | - Li Guan
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Beijing, 100020, China
| | - Wenguan Xie
- Department of Orthopedics, Dongguan Eighth People's Hospital, Dongguan, Guangdong Province, 523320, China
| | - Yong Hai
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Beijing, 100020, China.
| | - Yuzeng Liu
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Beijing, 100020, China.
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11
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Eastlack RK, Nunley PD, Poelstra KA, Vaccaro AR, Stone M, Miller LE, Legay P, Clin J, Agarwal A. Finite element analysis comparing a PEEK posterior fixation device versus pedicle screws for lumbar fusion. J Orthop Surg Res 2023; 18:855. [PMID: 37950318 PMCID: PMC10636999 DOI: 10.1186/s13018-023-04349-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Pedicle screw loosening and breakage are common causes of revision surgery after lumbar fusion. Thus, there remains a continued need for supplemental fixation options that offer immediate stability without the associated failure modes. This finite element analysis compared the biomechanical properties of a novel cortico-pedicular posterior fixation (CPPF) device with those of a conventional pedicle screw system (PSS). METHODS The CPPF device is a polyetheretherketone strap providing circumferential cortical fixation for lumbar fusion procedures via an arcuate tunnel. Using a validated finite element model, we compared the stability and load transfer characteristics of CPPF to intact conditions under a 415 N follower load and PSS conditions under a 222 N preload. Depending on the instrumented levels, two different interbody devices were used: a lateral lumbar interbody device at L4-5 or an anterior lumbar interbody device at L5-S1. Primary outcomes included range of motion of the functional spinal units and anterior load transfer, defined as the total load through the disk and interbody device after functional motion and follower load application. RESULTS Across all combinations of interbody devices and lumbar levels evaluated, CPPF consistently demonstrated significant reductions in flexion (ranging from 90 to 98%), extension (ranging from 88 to 94%), lateral bending (ranging from 75 to 80%), and torsion (ranging from 77 to 86%) compared to the intact spine. Stability provided by the CPPF device was comparable to PSS in all simulations (range of motion within 0.5 degrees for flexion-extension, 0.6 degrees for lateral bending, and 0.5 degrees for torsion). The total anterior load transfer was higher with CPPF versus PSS, with differences across all tested conditions ranging from 128 to 258 N during flexion, 89-323 N during extension, 135-377 N during lateral bending, 95-258 N during torsion, and 82-250 N during standing. CONCLUSION Under the modeled conditions, cortico-pedicular fixation for supplementing anterior or lateral interbody devices between L4 and S1 resulted in comparable stability based on range of motion measures and less anterior column stress shielding based on total anterior load transfer measures compared to PSS. Clinical studies are needed to confirm these finite element analysis findings.
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Affiliation(s)
- Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego, CA, USA
| | | | - Kornelis A Poelstra
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Marcus Stone
- Spine Institute of Louisiana, Shreveport, LA, USA
| | - Larry E Miller
- Miller Scientific, 3101 Browns Mill Road, Ste 6, #311, Johnson City, TN, 37604, USA.
| | | | | | - Aakash Agarwal
- Departments of Bioengineering and Orthopaedic Surgery, University of Toledo, Toledo, OH, USA
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Gutierrez J, Erwood AM, Malcolm JG, Grogan DP, Greven AC, Gary MF, Rodts GE, Stricsek GP, Refai D. Comparing Cortical Bone Trajectory and Traditional Pedicle Screws in Transforaminal Lumbar Interbody Fusion: A Retrospective Cohort Study of One-Year Outcomes. Cureus 2023; 15:e43237. [PMID: 37692633 PMCID: PMC10491498 DOI: 10.7759/cureus.43237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
INTRODUCTION This is a retrospective study of consecutive patients undergoing transforaminal lumbar interbody fusion (TLIF) at a single institution. The objective of this study was to compare the long-term results associated with cortical bone trajectory (CBT) and traditional pedicle screw (TPS) via posterolateral approach in TLIF. METHODS Consecutive patients treated from November 2014 to March 2019 were included in the CBT TLIF group, while consecutive patients treated from October 2010 to August 2017 were included in the TPS TLIF group. Inclusion criteria comprised single-level or two-level TLIF for degenerative spondylolisthesis with stenosis and at least one year of clinical and radiographic follow-up. Variables of interest included pertinent preoperative, perioperative, and postoperative data. Non-parametric evaluation was performed using the Wilcoxon test. Fisher's exact test was used to assess group differences for nominal data. RESULTS Overall, 140 patients met the inclusion criteria; 69 patients had CBT instrumentation (mean follow-up 526 days) and 71 patients underwent instrumentation placement via TPS (mean follow-up 825 days). Examination of perioperative and postoperative outcomes demonstrate comparable results between the groups with perioperative complications, length of stay, discharge destination, surgical revision rate, and fusion rates all being similar between groups (p = 0.1; p = 0.53; p = 0.091; p = 0.61; p = 0.665, respectively). CONCLUSIONS CBT in the setting of TLIF offer equivalent outcomes to TPS with TLIF at both short- and long-term intervals of care.
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Affiliation(s)
| | - Andrew M Erwood
- Neurosurgery, Emory University School of Medicine, Atlanta, USA
| | - James G Malcolm
- Neurosurgery, Emory University School of Medicine, Atlanta, USA
| | - Dayton P Grogan
- Neurosurgery, Emory University School of Medicine, Atlanta, USA
| | | | - Matthew F Gary
- Neurosurgery, Emory University School of Medicine, Atlanta, USA
| | - Gerald E Rodts
- Neurosurgery, Emory University School of Medicine, Atlanta, USA
| | | | - Daniel Refai
- Neurosurgery, Emory University School of Medicine, Atlanta, USA
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13
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Huang Y, Maimaiti A, Tian Y, Li Z, Kahaer A, Rexiti P. Biomechanical investigation of the hybrid lumbar fixation technique with traditional and cortical bone trajectories in transforaminal lumbar interbody fusion: finite element analysis. J Orthop Surg Res 2023; 18:549. [PMID: 37525283 PMCID: PMC10388474 DOI: 10.1186/s13018-023-04027-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/17/2023] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVE To compare the biomechanical performance of the hybrid lumbar fixation technique with the traditional and cortical bone trajectory techniques using the finite element method. METHODS Four adult wet lumbar spine specimens were provided by the Department of Anatomy and Research of Xinjiang Medical University, and four L1-S1 lumbar spine with transforaminal lumbar interbody fusion (TLIF) models at L4-L5 segment and four different fixation techniques were established: bilateral traditional trajectory screw fixation (TT-TT), bilateral cortical bone trajectory screw fixation (CBT-CBT), hybrid CBT-TT (CBT screws at L4 and TT screws at L5) and TT-CBT (TT screws at L4 and CBT screws at L5). The range of motion (ROM) of the L4-L5 segment, von Mises stress of cage, internal fixation, and rod were compared in flexion, extension, left and right bending, and left and right rotation. RESULTS Compared with the TT-TT group, the TT-CBT group exhibited lower ROM of L4-L5 segment, especially in left-sided bending; the CBT-TT group had the lowest ROM of L4-L5 segment in flexion and extension among the four fixation methods. Compared with the CBT-CBT group, the peak cage stress in the TT-CBT group was reduced by 9.9%, 18.1%, 21.5%, 23.3%, and 26.1% in flexion, left bending, right bending, left rotation, and right rotation conditions, respectively, but not statistically significant (P > 0.05). The peak stress of the internal fixation system in the TT-CBT group was significantly lower than the other three fixation methods in all five conditions except for extension, with a statistically significant difference between the CBT-TT and TT-CBT groups in the left rotation condition (P = 0.017). In addition, compared with the CBT-CBT group, the peak stress of the rod in the CBT-TT group decreased by 34.8%, 32.1%, 28.2%, 29.3%, and 43.0% under the six working conditions of flexion, extension, left bending, left rotation, and right rotation, respectively, but not statistically significant (P > 0.05). CONCLUSIONS Compared with the TT-TT and CBT-CBT fixation methods in TLIF, the hybrid lumbar fixation CBT-TT and TT-CBT techniques increase the biomechanical stability of the internal fixation structure of the lumbar fusion segment to a certain extent and provide a corresponding theoretical basis for further development in the clinic.
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Affiliation(s)
- Ying Huang
- Xinjiang Medical University, Urumqi, China
| | - Abulikemu Maimaiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | | | | | - Alafate Kahaer
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Paerhati Rexiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.
- Key Laboratory of High Incidence Disease Research in Xingjiang (Xinjiang Medical University), Ministry of Education, Urumqi, China.
- Xinjiang Clinical Research Center for Orthopedics, Urumqi, China.
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14
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Mandelka E, Gierse J, Zimmermann F, Gruetzner PA, Franke J, Vetter SY. Implications of navigation in thoracolumbar pedicle screw placement on screw accuracy and screw diameter/pedicle width ratio. BRAIN & SPINE 2023; 3:101780. [PMID: 38020982 PMCID: PMC10668071 DOI: 10.1016/j.bas.2023.101780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/22/2023] [Accepted: 07/10/2023] [Indexed: 12/01/2023]
Abstract
Introduction There is ample evidence that higher accuracy can be achieved in thoracolumbar pedicle screw placement by using spinal navigation. Still, to date, the evidence regarding the influence of the use of navigation on the screw diameter to pedicle width ratio remains limited. Research question The aim of this study was to investigate the implications of navigation in thoracolumbar pedicle screw placement not only on screw accuracy, but on the screw diameter to pedicle width ratio as well. Material and methods In this single-center single-surgeon study, 45 Patients undergoing navigated thoracolumbar pedicle screw placement were prospectively included. The results were compared with a matched comparison group of patients in which screw placement was performed under fluoroscopic guidance. The screw accuracy and the screw diameter to pedicle width ratio of every screw were compared between the groups. Results Screw accuracy was significantly higher in the navigation group compared to the fluoroscopic guidance group, alongside with a significant increase of the screw diameter to pedicle width ratio by approximately 10%. In addition, both the intraoperative radiation dose and the operating time tended to be lower in the study group. Conclusion This study was able to show that navigated thoracolumbar pedicle screw placement not only increases the accuracy of screw placement but also facilitates the selection of the adequate screw sizes, which according to the literature has positive effects on fixation strength. Meanwhile, the use of navigation did not negatively affect the time needed for surgery or the patient's intraoperative exposure to radiation.
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Affiliation(s)
- Eric Mandelka
- Research group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Jula Gierse
- Research group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Felix Zimmermann
- Research group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Paul A. Gruetzner
- Research group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Jochen Franke
- Research group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Sven Y. Vetter
- Research group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
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15
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Schleifenbaum S, Vogl AC, Heilmann R, von der Hoeh NH, Heyde CE, Jarvers JS. Biomechanical comparative study of midline cortical vs. traditional pedicle screw trajectory in osteoporotic bone. BMC Musculoskelet Disord 2023; 24:395. [PMID: 37198565 PMCID: PMC10193652 DOI: 10.1186/s12891-023-06502-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023] Open
Abstract
INTRODUCTION In lumbar spinal stabilization pedicle screws are used as standard. However, especially in osteoporosis, screw anchorage is a problem. Cortical bone trajectory (CBT) is an alternative technique designed to increase stability without the use of cement. In this regard, comparative studies showed biomechanical superiority of the MC (midline cortical bone trajectory) technique with longer cortical progression over the CBT technique. The aim of this biomechanical study was to comparatively investigate the MC technique against the not cemented pedicle screws (TT) in terms of their pullout forces and anchorage properties during sagittal cyclic loading according to the ASTM F1717 test. METHODS Five cadavers (L1 to L5), whose mean age was 83.3 ± 9.9 years and mean T Score of -3.92 ± 0.38, were dissected and the vertebral bodies embedded in polyurethane casting resin. Then, one screw was randomly inserted into each vertebra using a template according to the MC technique and a second one was inserted by freehand technique with traditional trajectory (TT). The screws were quasi-static extracted from vertebrae L1 and L3, while for L2, L4 and L5 they were first tested dynamically according to ASTM standard F1717 (10,000 cycles at 1 Hz between 10 and 110 N) and then quasi-static extracted. In order to determine possible screw loosening, there movements were recorded during the dynamic tests using an optical measurement system. RESULTS The pull-out tests show a higher pull-out strength for the MC technique of 555.4 ± 237.0 N compared to the TT technique 448.8 ± 303.2 N. During the dynamic tests (L2, L4, L5), 8 out of the 15 TT screws became loose before completing 10,000 cycles. In contrast, all 15 MC screws did not exceed the termination criterion and were thus able to complete the full test procedure. For the runners, the optical measurement showed greater relative movement of the TT variant compared to the MC variant. The pull-out tests also revealed that the MC variant had a higher pull-out strength, measuring at766.7 ± 385.4 N, while the TT variant measured 637.4 ± 435.6 N. CONCLUSION The highest pullout forces were achieved by the MC technique. The main difference between the techniques was observed in the dynamic measurements, where the MC technique exhibited superior primary stability compared to the conventional technique in terms of primary stability. Overall, the MC technique in combination with template-guided insertion represents the best alternative for anchoring screws in osteoporotic bone without cement.
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Affiliation(s)
- Stefan Schleifenbaum
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Liebigstraße 20, D-04103, Leipzig, Germany
- ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Semmelweisstraße 14, D-04103, Leipzig, Germany
| | - Ann-Cathrin Vogl
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Liebigstraße 20, D-04103, Leipzig, Germany
- ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Semmelweisstraße 14, D-04103, Leipzig, Germany
| | - Robin Heilmann
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Liebigstraße 20, D-04103, Leipzig, Germany
- ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Semmelweisstraße 14, D-04103, Leipzig, Germany
| | - Nicolas Heinz von der Hoeh
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Liebigstraße 20, D-04103, Leipzig, Germany
| | - Christoph-Eckhard Heyde
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Liebigstraße 20, D-04103, Leipzig, Germany
- ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Semmelweisstraße 14, D-04103, Leipzig, Germany
| | - Jan-Sven Jarvers
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Liebigstraße 20, D-04103, Leipzig, Germany.
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Yuan YF, Ren ZX, Zhang C, Li GJ, Liu BZ, Li XD, Miao J, Li JF. Multitrack and multianchor point screw technique combined with the Wiltse approach for lesion debridement for lumbar tuberculosis. World J Clin Cases 2023; 11:3167-3175. [PMID: 37274032 PMCID: PMC10237128 DOI: 10.12998/wjcc.v11.i14.3167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/01/2023] [Accepted: 04/10/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND The incidence of lumbar tuberculosis is high worldwide, and effective treatment is a continuing problem.
AIM To study the safety and efficacy of the multitrack and multianchor point screw technique combined with the contralateral Wiltse approach for lesion debridement to treat lumbar tuberculosis.
METHODS The C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), visual analogue scale (VAS) score, oswestry disability index (ODI) and American Spinal Injury Association (ASIA) grade were recorded and analysed pre- and postoperatively.
RESULTS The CRP level and ESR returned to normal, and the VAS score and ODI were decreased at 3 mo postoperatively, with significant differences compared with the preoperative values (P < 0.01). Neurological dysfunction was relieved, and the ASIA grade increased, with no adverse events.
CONCLUSION The multitrack, multianchor point screw fixation technique combined with the contralateral Wiltse approach for debridement is an effective and safe method for the treatment of lumbar tuberculosis.
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Affiliation(s)
- Yu-Fei Yuan
- Department of Orthopadics, Handan Center Hospital, Handan 056001, Hebei Provence, China
| | - Zhi-Xin Ren
- Department of Orthopadics, Handan Center Hospital, Handan 056001, Hebei Provence, China
| | - Cun Zhang
- Department of Orthopadics, Handan Center Hospital, Handan 056001, Hebei Provence, China
| | - Guan-Jun Li
- Department of Orthopadics, Handan Center Hospital, Handan 056001, Hebei Provence, China
| | - Bing-Zhi Liu
- Department of Orthopadics, Handan Center Hospital, Handan 056001, Hebei Provence, China
| | - Xiao-Dong Li
- Department of Orthopadics, Handan Center Hospital, Handan 056001, Hebei Provence, China
| | - Jie Miao
- Department of Orthopedic Surgery, Handan Central Hospital, Handan 056001, Hebei Province, China
| | - Jian-Fei Li
- Department of CT, Handan Central Hospital, Handan 056001, Hebei Province, China
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Kahaer A, Zhang R, Wang Y, Luan H, Maimaiti A, Liu D, Shi W, Zhang T, Guo H, Rexiti P. Hybrid pedicle screw and modified cortical bone trajectory technique in transforaminal lumbar interbody fusion at L4-L5 segment: finite element analysis. BMC Musculoskelet Disord 2023; 24:288. [PMID: 37055739 PMCID: PMC10099636 DOI: 10.1186/s12891-023-06385-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/30/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Investigate the biomechanical properties of the hybrid fixation technique with bilateral pedicle screw (BPS) and bilateral modified cortical bone trajectory screw (BMCS) in L4-L5 transforaminal lumbar interbody fusion (TLIF). METHODS Three finite element (FE) models of the L1-S1 lumbar spine were established according to the three human cadaveric lumbar specimens. BPS-BMCS (BPS at L4 and BMCS at L5), BMCS-BPS (BMCS at L4 and BPS at L5), BPS-BPS (BPS at L4 and L5), and BMCS-BMCS (BMCS at L4 and L5) were implanted into the L4-L5 segment of each FE model. The range of motion (ROM) of the L4-L5 segment, von Mises stress of the fixation, intervertebral cage, and rod were compared under a 400-N compressive load with 7.5 Nm moments in flexion, extension, bending, and rotation. RESULTS BPS-BMCS technique has the lowest ROM in extension and rotation, and BMCS-BMCS technique has the lowest ROM in flexion and lateral bending. The BMCS-BMCS technique showed maximal cage stress in flexion and lateral bending, and the BPS-BPS technique in extension and rotation. Compared to the BPS-BPS and BMCS-BMCS technique, BPS-BMCS technique presented a lower risk of screw breakage and BMCS-BPS technique presented a lower risk of rod breakage. CONCLUSION The results of this study support that the use of the BPS-BMCS and BMCS-BPS techniques in TLIF surgery for offering the superior stability and a lower risk of cage subsidence and instrument-related complication.
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Affiliation(s)
- Alafate Kahaer
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Road, Urumqi, China
| | - Rui Zhang
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Road, Urumqi, China
| | - Yixi Wang
- First Clinical Medical Institution, Xinjiang Medical University, Urumqi, China
| | - Haopeng Luan
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Road, Urumqi, China
| | - Abulikemu Maimaiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Road, Urumqi, China
| | - Dongshan Liu
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Road, Urumqi, China
| | - Wenjie Shi
- First Clinical Medical Institution, Xinjiang Medical University, Urumqi, China
| | - Tao Zhang
- Digital Orthopaedic Center of Xinjiang Medical University, Urumqi, China
| | - Hailong Guo
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Road, Urumqi, China
| | - Paerhati Rexiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Road, Urumqi, China.
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Burkhard MD, Cornaz F, Spirig JM, Wanivenhaus F, Fasser MR, Widmer J, Farshad M. Residual motion of cortical versus pedicle screw constructs after decompression, interbody fusion and cross-link augmentation. 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 2023; 32:1401-1410. [PMID: 36877366 DOI: 10.1007/s00586-023-07596-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/07/2023]
Abstract
PURPOSE To compare the residual range of motion (ROM) of cortical screw (CS) versus pedicle screw (PS) instrumented lumbar segments and the additional effect of transforaminal interbody fusion (TLIF) and cross-link (CL) augmentation. METHODS ROM of thirty-five human cadaver lumbar segments in flexion/extension (FE), lateral bending (LB), lateral shear (LS), anterior shear (AS), axial rotation (AR), and axial compression (AC) was recorded. After instrumenting the segments with PS (n = 17) and CS (n = 18), ROM in relation to the uninstrumented segments was evaluated without and with CL augmentation before and after decompression and TLIF. RESULTS CS and PS instrumentations both significantly reduced ROM in all loading directions, except AC. In undecompressed segments, a significantly lower relative (and absolute) reduction of motion in LB was found with CS 61% (absolute 3.3°) as compared to PS 71% (4.0°; p = 0.048). FE, AR, AS, LS, and AC values were similar between CS and PS instrumented segments without interbody fusion. After decompression and TLIF insertion, no difference between CS and PS was found in LB and neither in any other loading direction. CL augmentation did not diminish differences in LB between CS and PS in the undecompressed state but led to an additional small AR reduction of 11% (0.15°) in CS and 7% (0.05°) in PS instrumentation. CONCLUSION Similar residual motion is found with CS and PS instrumentation, except of slightly, but significantly inferior reduction of ROM in LB with CS. Differences between CS and PS in diminish with TLIF but not with CL augmentation.
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Affiliation(s)
- Marco D Burkhard
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Frédéric Cornaz
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - José Miguel Spirig
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Florian Wanivenhaus
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Marie-Rosa Fasser
- Institute for Biomechanics, Balgrist Campus, ETH Zurich, Lengghalde 5, 8008, Zurich, Switzerland.,Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jonas Widmer
- Institute for Biomechanics, Balgrist Campus, ETH Zurich, Lengghalde 5, 8008, Zurich, Switzerland.,Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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19
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Burkhard MD, Spirig JM, Wanivenhaus F, Cornaz F, Fasser MR, Widmer J, Farshad M. Residual motion of different posterior instrumentation and interbody fusion constructs. 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 2023; 32:1411-1420. [PMID: 36820922 DOI: 10.1007/s00586-023-07597-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE To elucidate residual motion of cortical screw (CS) and pedicle screw (PS) constructs with unilateral posterior lumbar interbody fusion (ul-PLIF), bilateral PLIF (bl-PLIF), facet-sparing transforaminal lumbar interbody fusion (fs-TLIF), and facet-resecting TLIF (fr-TLIF). METHODS A total of 35 human cadaver lumbar segments were instrumented with PS (n = 18) and CS (n = 17). Range of motion (ROM) and relative ROM changes were recorded in flexion/extension (FE), lateral bending (LB), axial rotation (AR), lateral shear (LS), anterior shear (AS), and axial compression (AC) in five instrumentational states: without interbody fusion (wo-IF), ul-PLIF, bl-PLIF, fs-TLIF, and fr-TLIF. RESULTS Whereas FE, LB, AR, and AC noticeably differed between the instrumentational states, AS and LS were less prominently affected. Compared to wo-IF, ul-PLIF caused a significant increase in ROM with PS (FE + 42%, LB + 24%, AR + 34%, and AC + 77%), however, such changes were non-significant with CS. ROM was similar between wo-IF and all other interbody fusion techniques. Insertion of a second PLIF (bl-PLIF) significantly decreased ROM with CS (FE -17%, LB -26%, AR -20%, AC -51%) and PS (FE - 23%, LB - 14%, AR - 20%, AC - 45%,). Facet removal in TLIF significantly increased ROM with CS (FE + 6%, LB + 9%, AR + 17%, AC of + 23%) and PS (FE + 7%, AR + 12%, AC + 13%). CONCLUSION bl-PLIF and TLIF show similarly low residual motion in both PS and CS constructs, but ul-PLIF results in increased motion. The fs-TLIF technique is able to further decrease motion compared to fr-TLIF in both the CS and PS constructs.
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Affiliation(s)
- Marco D Burkhard
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - José M Spirig
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Florian Wanivenhaus
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Frédéric Cornaz
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Marie-Rosa Fasser
- Institute for Biomechanics, Balgrist Campus, ETH Zurich, Lengghalde 5, CH-8008, Zurich, Switzerland.,Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jonas Widmer
- Institute for Biomechanics, Balgrist Campus, ETH Zurich, Lengghalde 5, CH-8008, Zurich, Switzerland.,Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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20
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Di Perna G, Marengo N, Matsukawa K, Mahieu G, Baldassarre BM, Petrone S, De Marco R, Zeppa P, Ajello M, Fiumefreddo A, Zenga F, Garbossa D, Cofano F. Three-Dimensional Patient-Matched Template Guides Are Able to Increase Mean Diameter and Length and to Improve Accuracy of Cortical Bone Trajectory Screws: A 5-Year International Experience. World Neurosurg 2023; 170:e542-e549. [PMID: 36402304 DOI: 10.1016/j.wneu.2022.11.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To analyze whether significant differences exist between free-hand three-dimensional (3D) planning-guided cortical bone trajectory (CBT) screw placement and 3D-printed template-guided CBT screw positioning in terms of accuracy, size of screws, and potential complications. METHODS In this retrospective study, data of adult patients in whom CBT screws were placed for lumbar degenerative pathologies were extracted from a prospectively collected database and analyzed. Patients in whom screws were placed using free-hand 3D planning-guided technique were compared with patients in whom screws were positioned using customized 3D-printed templates. Size of the screws, accuracy, clinical outcomes, and complications were analyzed. RESULTS The study evaluated 251 patients (1004 screws). The free-hand 3D planning-guided group included 158 patients (632 screws), and the 3D-printed template-guided group included 93 patients (372 screws). The 3D-printed template-guided group involved screws of larger size from L3 to S1. Differences between the 2 groups in terms of accuracy parameters reached statistical significance (P ≤ 0.05). CONCLUSIONS With the use of 3D patient-matched template guides, mean diameter and length of CBT screws could be safely increased due to improved accuracy of screw placement. Based on previous evidence regarding CBT biomechanical properties, these advantages could allow increased fixation strength over traditional convergent pedicle screw trajectories. Further biomechanics studies are needed.
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Affiliation(s)
- Giuseppe Di Perna
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy; Spine Surgery Unit, "Casa di Cura Clinica Città di Bra", Bra, Italy
| | - Nicola Marengo
- Neurosurgery Unit, "Città della Salute e della Scienza" University Hospital, Turin, Italy
| | - Keitaro Matsukawa
- Department of Orthopaedic Surgery, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan
| | - Geert Mahieu
- Orthopaedic Surgery Department, ORTHOCA - AZ Monica Hospital, Antwerp, Belgium
| | | | | | - Raffaele De Marco
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy.
| | - Pietro Zeppa
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Marco Ajello
- Neurosurgery Unit, "Città della Salute e della Scienza" University Hospital, Turin, Italy
| | - Alessandro Fiumefreddo
- Neurosurgery Unit, "Città della Salute e della Scienza" University Hospital, Turin, Italy
| | - Francesco Zenga
- Neurosurgery Unit, "Città della Salute e della Scienza" University Hospital, Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy; Neurosurgery Unit, "Città della Salute e della Scienza" University Hospital, Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy; Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
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21
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Tai CL, Chen WP, Liu MY, Li YD, Tsai TT, Lai PL, Hsieh MK. Biomechanical comparison of pedicle screw fixation strength among three different screw trajectories using single vertebrae and one-level functional spinal unit. Front Bioeng Biotechnol 2022; 10:1054738. [PMID: 36568298 PMCID: PMC9780459 DOI: 10.3389/fbioe.2022.1054738] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022] Open
Abstract
Three key factors are responsible for the biomechanical performance of pedicle screw fixation: screw mechanical characteristics, bone quality and insertion techniques. To the best of the authors' knowledge, no study has directly compared the biomechanical performance among three trajectories, i.e., the traditional trajectory (TT), modified trajectory (MT) and cortical bone trajectory (CBT), in a porcine model. This study compared the pullout strength and insertion torque of three trajectory methods in single vertebrae, the pullout strength and fixation stiffness including flexion, extension, and lateral bending in a one-level instrumented functional spinal unit (FSU) that mimics the in vivo configuration were clarified. A total of 18 single vertebrae and 18 FSUs were randomly assigned into three screw insertion methods (n = 6 in each trajectory group). In the TT group, the screw converged from its entry point, passed completely inside the pedicle, was parallel to the superior endplate, was located in the superior third of the vertebral body and reached to at least the anterior third of the vertebral body. In the MT group, the convergent angle was similar to that of the TT method but directed caudally to the anterior inferior margin of the vertebral body. The results of insertion torque and pullout strength in single vertebrae were analyzed; in addition, the stiffness and pullout strength in the one-level FSU were also investigated. This study demonstrated that, in single vertebrae, the insertion torque was significantly higher in CBT groups than in TT and MT groups (p < 0.05). The maximal pullout strength was significantly higher in MT groups than in TT and CBT groups (p < 0.05). There was no significant difference in stiffness in the three motions among all groups. The maximal pullout strength in FSUs of MT and CBT groups were significantly higher than the TT groups (p < 0.05). We concluded that either MT or CBT provides better biomechanical performance than TT in single vertebrae or FSUs. The lack of significance of stiffness in FSUs among three methods suggested that MT or CBT could be a reasonable alternative to TT if the traditional trajectory was not feasible.
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Affiliation(s)
- Ching-Lung Tai
- Department of Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan,Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Weng-Pin Chen
- Department of Mechanical Engineering, National Taipei University of Technology, Taipei, Taiwan
| | - Mu-Yi Liu
- Department of Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Yun-Da Li
- Department of Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan,Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Kai Hsieh
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan,*Correspondence: Ming-Kai Hsieh,
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22
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Shi W, Aini M, Dang L, Kahaer A, Zhou Z, Wang Y, Maimaiti A, Wang S, Guo H, Rexiti P. Feasibility and improvement of a three-dimensional printed navigation template for modified cortical bone trajectory screw placement in the lumbar spine. Front Surg 2022; 9:1028276. [PMID: 36406344 PMCID: PMC9666697 DOI: 10.3389/fsurg.2022.1028276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/05/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES Compared with traditional pedicle screw trajectory, cortical bone trajectory (CBT) increases the contact surface between the screw and cortical bone where the screw is surrounded by dense cortical bone, which does not deform remarkably due to degeneration. We aimed to provide detailed information about the improvement of three-dimensional (3D)-printed navigation templates for modified CBT screw placement in the lumbar spine and evaluate the safety and accuracy thereof. METHODS Four human cadaveric lumbar spine specimens were selected. After CT scanning data were reconstructed to 3D models, either the left or right side of each specimen was randomly selected to establish a 3D-navigation template, mutually complemented with the surface anatomical structure of the lateral margin of the lumbar isthmus, vertebral plate, and spinous process. The corresponding 3D centrum was printed according to the CT scanning data, and a navigation template of supporting design was made according to modified cortical bone technique. The same template was used to insert CBT screws into 3D printed and cadaveric specimens. After the screws were inserted, the screw path of the 3D printed specimens was directly observed, and that of the anatomical specimens was scanned by CT, to determine the position and direction of the screws to analyze the success rate of screw placement. RESULTS Twenty cortical bone screws were placed in each of the 3D printed and anatomical specimens, with excellent rates of screw placement of 100% and 95%, respectively. CONCLUSIONS We report the easy, safe, accurate, and reliable use of a 3D-printed navigation template to carry out screw placement by modified cortical bone technique in the lumbar spine.
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Affiliation(s)
- Wenjie Shi
- Xinjiang Uygur Autonomous Region, Xinjiang Medical University, Urumqi, China
| | - Mijiti Aini
- Department of Orthopedics Second People's Hospital Kashgar District, Xinjiang Uygur Autonomous Region, Kashgar City, China
| | - Limin Dang
- Xinjiang Uygur Autonomous Region, Xinjiang Medical University, Urumqi, China
| | - Alafate Kahaer
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Zhihao Zhou
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Yixi Wang
- Xinjiang Uygur Autonomous Region, Xinjiang Medical University, Urumqi, China
| | - Abulikemu Maimaiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Shuiquan Wang
- Department of Anatomy, College of Basic Medicine, Xinjiang Medical University, Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Hailong Guo
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region, Urumqi, China,Correspondence: Paerhati Rexiti Hailong Guo
| | - Paerhati Rexiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region, Urumqi, China,Correspondence: Paerhati Rexiti Hailong Guo
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23
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Wu J, Lin T, Jiang H, Ma J, Zhang K, Zhao J, Zhou X, Wang C. The treatment efficacy of cortical bone trajectory (CBT) pedicle screws for lumbar degenerative disease in the Chinese Han population. Front Surg 2022; 9:421815. [PMID: 36386519 PMCID: PMC9659752 DOI: 10.3389/fsurg.2022.421815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/15/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose To provide reference data on CBT pedicle screws from CT measurements of L1 to L5 in the Chinese Han population and to assess the treatment efficacy of CBT pedicle screws in cases of lumbar degenerative disease. Methods In total, 100 patients were identified from the CT database for CBT morphometric measurement of the lumbar spine. According to sex and age, patients were divided into four groups. The diameter, length, and angle of the vertebral pedicle and trajectory were measured. Then, a total of 36 patients with lumbar degenerative disease were included in this study for clinical and radiographic evaluation. Demographic characteristics, health-related quality of life (HRQOL), and extent of intervertebral disc herniation and spondylolisthesis were evaluated. Results The mean diameter and the mean length varied from L1 to L5 in Groups I to IV. The lateral angles ranging from L1 to L5 were 8.9 to 9.2°, 8.7 to 12.2°, 8.7 to 11.2°, and 9.2 to 10.1° in Groups I to IV, respectively. The cephalad angles from L1 to L5 were 23.5 to 28.6°, 24.7 to 26.6°, 25.0 to 28.2°, and 24.7 to 27.9° in Groups I to IV, respectively. In the case series, all patients’ neurological function and HRQOL were significantly improved at the final follow-up (p < 0.0001), and 75% of patients achieved satisfaction. Conclusions The morphology of the lumbar vertebral pedicle varied from L1 to L5, and the trajectory was feasible and safe. CBT pedicle screws were effective in treating lumbar degenerative diseases and benefited the patients.
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Wu J, Yang D, Han Y, Xu H, Wen W, Xu H, Li K, Liu Y, Miao J. Application of dual-trajectory screws in revision surgery for lumbar adjacent segment disease: a finite element study. J Orthop Surg Res 2022; 17:427. [PMID: 36153558 PMCID: PMC9509616 DOI: 10.1186/s13018-022-03317-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 09/07/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Advancements in medicine and the popularity of lumbar fusion surgery have made lumbar adjacent segment disease (ASDz) increasingly common, but there is no mature plan for guiding its surgical treatment. Therefore, in this study, four different finite element (FE) ASDz models were designed and their biomechanical characteristics were analysed to provide a theoretical basis for clinical workers to choose the most appropriate revision scheme for ASDz. METHODS According to whether internal fixation was retained, different FE models were created to simulate ASDz revision surgery, and flexion, extension, axial rotation and lateral bending were simulated by loading. The biomechanical characteristics of the adjacent segments of the intervertebral disc and the internal fixation system and the range of motion (ROM) of the lumbar vertebrae were analysed. RESULTS The difference in the ROM of the fixed segment between FE models that did or did not retain the original internal fixation was less than 0.1°, and the difference was not significant. However, the stress of the screw-rod system when the original internal fixation was retained and prolonged fixation was performed with dual-trajectory screws was less than that when the original internal fixation was removed and prolonged fixation was performed with a long bar. Especially in axial rotation, the difference between models A and B is the largest, and the difference in peak stress reached 30 MPa. However, for the ASDz revision surgery segment, the endplate stress between the two models was the lowest, and the intradiscal pressure (IDP) of the adjacent segment was not significantly different between different models. CONCLUSION Although ASDz revision surgery by retaining the original internal fixation and prolonging fixation with dual-trajectory screws led to an increase in stress in the fusion segment endplate, it provides stability similar to ASDz revision surgery by removing the original internal fixation and prolonging fixation with a long bar and does not lead to a significant change in the IDP of the adjacent segment while avoiding a greater risk of rod fracture.
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Affiliation(s)
- Jincheng Wu
- grid.33763.320000 0004 1761 2484Department of Spine Surgery, Tianjin Hospital, Tianjin University, Jiefangnanlu 406, Hexi District, Tianjin, 300210 China
| | - Dongmei Yang
- grid.284723.80000 0000 8877 7471Southern Medical University, Guangzhou City, Guangdong China
| | - Ye Han
- grid.459324.dThe Affiliated Hospital of Hebei University, Baoding City, Hebei China
| | - Hanpeng Xu
- grid.33763.320000 0004 1761 2484Department of Spine Surgery, Tianjin Hospital, Tianjin University, Jiefangnanlu 406, Hexi District, Tianjin, 300210 China
| | - Wangqiang Wen
- The First Affiliated Hospital of Hainan Medical University, Haikou City, Hainan China
| | - Haoxiang Xu
- The Second People’s Hospital of Hefei, Hefei, Anhui China
| | - Kepeng Li
- Second Central Hospital of Baoding, Zhuozhou City, Hebei China
| | - Yong Liu
- Pingyao County Traditional Chinese Medicine Hospital, Jinzhong City, Shanxi China
| | - Jun Miao
- grid.33763.320000 0004 1761 2484Department of Spine Surgery, Tianjin Hospital, Tianjin University, Jiefangnanlu 406, Hexi District, Tianjin, 300210 China
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NIE JIACHEN, DING LI, ZHANG QING, LIU SHENGHUI, SHI HUIJUAN, ZHANG ZHONGCAI, ZOU HAIBO. THE FIXATION EFFECT OF DIFFERENT TYPES OF SCREWS IN THE WHOLE OSTEOPOROTIC LUMBAR VERTEBRAE: AN FEA STUDY. J MECH MED BIOL 2022. [DOI: 10.1142/s0219519422500348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Purpose: The aim of this study is to explore how pedicle screws (PSs) and cortical bone trajectory (CBT) screws differ in fixation strength when implanted in L1–L5 with osteoporosis, providing support for choosing implants and trajectories in spine internal fixation surgeries. Methods: We filtered 30 lumbar segments out from CT images of eight osteoporotic participants and simulated PS or CBT screw implantation in each segment, generating 60 vertebra-screw assembly FE models. To evaluate the fixation effect, we performed a pull-out force test simulation in each model and analyzed the maximal pull-out force, pull-out stiffness, and equivalent stress of vertebrae and screws. Results: The maximal pull-out force of PS and CBT screws in L1–L5 was in the range of 905–1552 (N) and 587–1012 (N), while the pull-out stiffness was in the range of 1990–2617 (N/mm) and 1007–1681 (N/mm). The fixation strength of PS in L4 and L5 was higher ([Formula: see text]), while in L1–L3 PS and CBT screws are similar ([Formula: see text]). The maximal stress of vertebrae and screws when PS was pulled at 0.25[Formula: see text]mm was larger than that of CBT screws. Conclusions: For patients with moderate osteoporosis, it is recommended to insert PS into L4 and L5 to attain better fixation strength, but vertebrae are more prone to fracture. Consequently, under severe osteoporosis, the implantation of CBT screws should be considered first. Bone cement injection may be necessary to consolidate the screw-vertebrae interface with osteoporosis.
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Affiliation(s)
- JIACHEN NIE
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, P. R. China
- Spine Division of Orthopaedic Department, China-Japan Friendship Hospital, Beijing 100029 P. R. China
| | - LI DING
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, P. R. China
- Spine Division of Orthopaedic Department, China-Japan Friendship Hospital, Beijing 100029 P. R. China
| | - QING ZHANG
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, P. R. China
- Spine Division of Orthopaedic Department, China-Japan Friendship Hospital, Beijing 100029 P. R. China
| | - SHENGHUI LIU
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, P. R. China
- Spine Division of Orthopaedic Department, China-Japan Friendship Hospital, Beijing 100029 P. R. China
| | - HUIJUAN SHI
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, P. R. China
- Spine Division of Orthopaedic Department, China-Japan Friendship Hospital, Beijing 100029 P. R. China
| | - ZHONGCAI ZHANG
- Spine Division of Orthopaedic Department, China-Japan Friendship Hospital, Beijing 100029 P. R. China
| | - HAIBO ZOU
- Spine Division of Orthopaedic Department, China-Japan Friendship Hospital, Beijing 100029 P. R. China
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Kahaer A, Maimaiti X, Maitirouzi J, Wang S, Shi W, Abuduwaili N, Zhou Z, Liu D, Maimaiti A, Rexiti P. Biomechanical investigation of the hybrid modified cortical bone screw–pedicle screw fixation technique: Finite-element analysis. Front Surg 2022; 9:911742. [PMID: 35923441 PMCID: PMC9339714 DOI: 10.3389/fsurg.2022.911742] [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: 04/03/2022] [Accepted: 06/28/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundHybrid fixation techniques including the both modified cortical bone trajectory (MCBT) and traditional trajectory (TT) at the L4 and L5 lumbar segment are firstly proposed by our team. Therefore, the purpose of this study is to evaluate and provide specific biomechanical data of the hybrid fixation techniques including the MCBT and TT.MethodsFour human cadaveric specimens were from the anatomy laboratory of Xinjiang Medical University. Four finite-element (FE) models of the L4–L5 lumbar spine were generated. For each of them, four implanted models with the following fixations were established: TT-TT (TT screw at the cranial and caudal level), MCBT-MCBT (MCBT screw at the cranial and caudal level), hybrid MCBT-TT (MCBT screw at the cranial level and TT screw at the caudal level), and TT-MCBT (TT screw at the cranial level and MCBT screw at the caudal level). A 400-N compressive load with 7.5 N/m moments was applied to simulate flexion, extension, lateral bending, and rotation, respectively. The range of motion (ROM) of the L4–L5 segment and the posterior fixation, the von Mises stress of the intervertebral disc, and the posterior fixation were compared.ResultsCompared to the TT-TT group, the MCBT-TT showed a significant lower ROM of the L4–L5 segment (p ≤ 0.009), lower ROM of the posterior fixation (p < 0.001), lower intervertebral disc stress (p < 0.001), and lower posterior fixation stress (p ≤ 0.041). TT-MCBT groups showed a significant lower ROM of the L4–L5 segment (p ≤ 0.012), lower ROM of the posterior fixation (p < 0.001), lower intervertebral disc stress (p < 0.001), and lower posterior fixation stress (p ≤ 0.038).ConclusionsThe biomechanical properties of the hybrid MCBT-TT and TT-MCBT techniques at the L4–L5 segment are superior to that of stability MCBT-MCBT and TT-TT techniques, and feasibility needs further cadaveric study to verify.
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Affiliation(s)
- Alafate Kahaer
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xieraili Maimaiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | | | - Shuiquan Wang
- Department of Anatomy, College of Basic Medicine, Xinjiang Medical University, Urumqi, China
| | - Wenjie Shi
- First Clinical Medical College, Xinjiang Medical University, Urumqi, China
| | - Nueraihemaiti Abuduwaili
- Department of Imaging Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Zhihao Zhou
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Dongshan Liu
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Abulikemu Maimaiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Paerhati Rexiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Correspondence: Paerhati Rexiti
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Controversies in Spine Surgery: Is a Cortical Bone Trajectory Superior to Traditional Pedicle Screw Trajectory? Clin Spine Surg 2022; 35:225-228. [PMID: 32205518 DOI: 10.1097/bsd.0000000000000965] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fujiwara S, Ohnishi Y, Iwatsuki K, Kishima H. Cortical bone trajectory fixation cause low compression force in anterior vertebral column. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2022; 10:100113. [PMID: 35434674 PMCID: PMC9005947 DOI: 10.1016/j.xnsj.2022.100113] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 11/16/2022]
Abstract
Background The cortical bone trajectory (CBT) screws follow a caudocephalad and lateral path from the pedicle to the vertebral body. The bone fusion rate of CBT fixation is equal to or lower than conventional pedicle screw fixation. It remains unclear whether or not CVT screws exert equally compressive forces across the vertebral column. In this study, we intraoperatively examined the insertional torque of CBT screws, and investigated the compression loading and pressure distribution in conventional and CBT fixation using pig bones. Methods The insertional torque was measured for a total of 115 CBT screws. Detailed positions of these screws were retrospectively confirmed using CT scans. Screw loosening and interbody fusion were examined 1 year after surgery. In the experiment using pig bones, we inserted screws by conventional trajectory (n = 3) and CBT (n = 4). Results Multiple regression analysis showed that the total screw length, the distance from the screw to the medial border of the pedicle and the distance from the superior endplate of the vertebrae were significant independent factors affecting the insertional torque. There was no significant association between the insertional torque and the radiographic bone fusion rate 12 months after surgery. The average pressure and the compression loading in the anterior column were significantly lower in CBT group. Conclusion These results suggested that the long CBT screws as close to the endplate had high insertional torque, but the anterior column in CBT fixation showed low compression force leading to the insufficient holding intervertebral cage. CBT screws may cause the micromotion of cages, which lowers the bone fusion rate.
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Han B, Ding H, Hai Y, Liu Y, Guan L, Pan A, Zhang X, Yin P. May the midline lumbar interbody fusion (MIDLIF) prevent the early radiographic adjacent segment degeneration? A minimum 3-year follow-up comparative study of MIDLIF in L4/5 with cortical bone trajectory screw versus traditional pedicle screw fixation. BMC Musculoskelet Disord 2022; 23:480. [PMID: 35596180 PMCID: PMC9121621 DOI: 10.1186/s12891-022-05363-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 04/26/2022] [Indexed: 11/29/2022] Open
Abstract
Study design Retrospective cohort study. Objective To compare the early radiographic adjacent segment degeneration (R-ASD) and regional lumbar sagittal alignment after midline lumbar interbody fusion (MIDLIF) with cortical bone trajectory (CBT) screw fixation (CBT-MIDLIF) and posterior lumbar interbody fusion (PLIF) with the traditional pedicle screw fixation (PS-PLIF) during long-term follow-up. Methods All patients who underwent CBT-MIDLIF or PS-PLIF were identified by a retrospective consecutive case review. Radiographic parameters in cephalad adjacent segment (L3/4), including intervertebral space height (ISH), foraminal height (FH), foraminal width (FW), range of motion were assessed. Lumbar lordosis (LL), sacral slope (SS), L4–L5 Cobb angle, Cobb angle of the intervertebral space at L4–L5, and height of the anterior and posterior edges of the intervertebral space at L4–L5, were measured and compared on preoperative, postoperative, and 3-year follow-up radiographic evaluation. Results Seventy-four patients underwent CBT-MIDLIF (CBT-MIDLIF group) and 114 patients underwent conventional PS-PLIF (PS-PLIF group). ISH, FH and FW were significantly smaller at 6-month follow-up than before operation with PS-PLIF (p < 0.001) but showed no significant changes with CBT-MIDLIF (p > 0.05). At the last follow-up, the changes in cephalad R-ASD parameters were more remarkable after PS-PLIF than after CBT-MIDLIF (p < 0.01). LL and SS were significant larger at the last follow-up than before operation in both groups (p < 0.001). Regarding long-term outcomes, the symptoms caused by degenerative spinal disorders significantly improved in both groups (p < 0.01). Conclusion CBT-MIDLIF had less radiographic degeneration in the adjacent segment than PS-PLIF at 3-year follow-up. The lumbar sagittal alignment could be improved significantly and the surgical outcomes were satisfactory after either CBT-MIDLIF or PS-PLIF.
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Affiliation(s)
- Bo Han
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, GongTiNanLu 8#, Chao-Yang District, Beijing, 100020, China
| | - Hongtao Ding
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, GongTiNanLu 8#, Chao-Yang District, Beijing, 100020, China
| | - Yong Hai
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, GongTiNanLu 8#, Chao-Yang District, Beijing, 100020, China.
| | - Yuzeng Liu
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, GongTiNanLu 8#, Chao-Yang District, Beijing, 100020, China.
| | - Li Guan
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, GongTiNanLu 8#, Chao-Yang District, Beijing, 100020, China
| | - Aixing Pan
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, GongTiNanLu 8#, Chao-Yang District, Beijing, 100020, China
| | - Xinuo Zhang
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, GongTiNanLu 8#, Chao-Yang District, Beijing, 100020, China
| | - Peng Yin
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, GongTiNanLu 8#, Chao-Yang District, Beijing, 100020, China
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Maitirouzi J, Luo H, Zhou Z, Ren H, Rexiti P. Finite element analysis of human lumbar vertebrae in internal fixation system model with different bone density trajectories. Int J Artif Organs 2022; 45:478-487. [PMID: 35441547 DOI: 10.1177/03913988221088613] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE To evaluate the biomechanics effect of modified cortical bone screw technique (MCBT) with other traditional internal fixation systems on lumbar osteoporotic wet specimen. METHODS Four different finite element models were established using CT data: (1) lumbar osteoporosis model without internal fixation system; (2) traditional pedicle screw technology (TT) model; (3) traditional cortical bone screw technology (CBT) model; (4) MCBT model. The changes of global displacement, intervertebral disc displacement of all models and internal fixation system Von Mises stress among the three models were compared under the same physiological load. RESULTS Compared with the other three models, the total displacement of the modified CBT screw model was the smallest, with the maximum displacement of 0.216 mm; The intervertebral disc displacement of the modified CBT screw model was the smallest, with the maximum displacement of 0.149 mm; the internal fixation system Von Mises stress of the modified CBT screw technique model was the largest compared with the other three models, The maximum Von Mises stress is 232.73 MPa. CONCLUSION Compared to traditional pedicle screw and traditional CBT, MCBT has better mechanical stability, and it is of certain clinical application value.
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Affiliation(s)
- Julaiti Maitirouzi
- College of Mechanical Engineering, Xin jiang University, Urumqi, Xin jiang, China
| | - Huiqing Luo
- College of Mechanical Engineering, Xin jiang University, Urumqi, Xin jiang, China
| | - Zhihao Zhou
- Departments of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Hangning Ren
- College of Mechanical Engineering, Xin jiang University, Urumqi, Xin jiang, China
| | - Paerhati Rexiti
- Departments of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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Li JC, Xie TH, Zhang Z, Song ZT, Song YM, Zeng JC. The Mismatch Between Bony Endplates and Grafted Bone Increases Screw Loosening Risk for OLIF Patients With ALSR Fixation Biomechanically. Front Bioeng Biotechnol 2022; 10:862951. [PMID: 35464717 PMCID: PMC9023805 DOI: 10.3389/fbioe.2022.862951] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/24/2022] [Indexed: 12/26/2022] Open
Abstract
The mismatch between bony endplates (BEPs) and grafted bone (GB) triggers several complications biomechanically. However, no published study has identified whether this factor increases the risk of screw loosening by deteriorating the local stress levels. This study aimed to illustrate the biomechanical effects of the mismatch between BEP and GB and the related risk of screw loosening. In this study, radiographic and demographic data of 56 patients treated by single segment oblique lumbar interbody fusion (OLIF) with anterior lateral single rod (ALSR) fixation were collected retrospectively, and the match sufficiency between BEP and GB was measured and presented as the grafted bony occupancy rate (GBOR). Data in patients with and without screw loosening were compared; regression analyses identified independent risk factors. OLIF with different GBORs was simulated in a previously constructed and validated lumbosacral model, and biomechanical indicators related to screw loosening were computed in surgical models. The radiographic review and numerical simulations showed that the coronal plane’s GBOR was significantly lower in screw loosening patients both in the cranial and caudal vertebral bodies; the decrease in the coronal plane’s GBOR has been proven to be an independent risk factor for screw loosening. In addition, numerical mechanical simulations showed that the poor match between BEP and GB will lead to stress concentration on both screws and bone-screw interfaces. Therefore, we can conclude that the mismatch between the BEP and GB will increase the risk of screw loosening by deteriorating local stress levels, and the increase in the GBOR by modifying the OLIF cage’s design may be an effective method to optimize the patient’s prognosis.
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Affiliation(s)
- Jing-Chi Li
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine for Sichuan University, Chengdu, China
| | - Tian-Hang Xie
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine for Sichuan University, Chengdu, China
| | - Zhuang Zhang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine for Sichuan University, Chengdu, China
| | - Zhe-Tao Song
- Department of Imaging, West China Hospital, Chengdu, China
| | - Yue-Ming Song
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine for Sichuan University, Chengdu, China
- *Correspondence: Yue-Ming Song, ; Jian-Cheng Zeng,
| | - Jian-Cheng Zeng
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine for Sichuan University, Chengdu, China
- *Correspondence: Yue-Ming Song, ; Jian-Cheng Zeng,
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Biomechanical Investigation of the Posterior Pedicle Screw Fixation System at Level L4-L5 Lumbar Segment with Traditional and Cortical Trajectories: A Finite Element Study. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:4826507. [PMID: 35388332 PMCID: PMC8979679 DOI: 10.1155/2022/4826507] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 02/14/2022] [Accepted: 02/24/2022] [Indexed: 01/16/2023]
Abstract
There is no detailed biomechanical research about the hybrid CBT-TT (CBT screws at cranial level and TT screws at caudal level) and TT-CBT (TT screws at cranial level and CBT screws at caudal level) techniques with finite element (FE) method. Therefore, the purpose of this study was to evaluate and provide specific biomechanical data of the hybrid lumbar posterior fixation system and compare with traditional pedicle screw and cortical screw trajectories without fusion, in FE method. Specimens were from the anatomy laboratory of Xinjiang Medical University. Four FE models of the L4-L5 lumbar spine segment were generated. For each of these, four implanted models with the following instruments were created: bilateral traditional trajectory screw fixation (TT-TT), bilateral cortical bone trajectory screw fixation (CBT-CBT), hybrid CBT-TT fixation, and hybrid TT-CBT fixation. A 400 N compressive load with 7.5 Nm moments was applied so as to simulate flexion, extension, left lateral bending, right lateral bending, left rotation, and right rotation, respectively. The range of motion (ROM) of the L4-L5 segment and the posterior fixation, the von Mises stress of the intervertebral disc, and the posterior fixation in four implanted models were compared. CBT-TT displayed a lower ROM of the fixation segment (3.82 ± 0.633°) compared to TT-TT (4.78 ± 0.306°) and CBT-CBT (4.23 ± 0.396°). In addition, CBT-TT showed a lower ROM of the posterior fixation (0.595 ± 0.108°) compared to TT-TT (0.795 ± 0.103°) and CBT-CBT (0.758 ± 0.052°). The intervertebral disc stress of CBT-TT (4.435 ± 0.604 MPa) was lower than TT-TT (7.592 ± 0.387 MPa) and CBT-CBT (6.605 ± 0.600 MPa). CBT-TT (20.228 ± 3.044 MPa) and TT-CBT (12.548 ± 2.914 MPa) displayed a lower peak von Mises stress of the posterior fixation compared to TT-TT (25.480 ± 3.737 MPa). The hybrid CBT-TT and TT-CBT techniques offered superior fixation strength compared to the CBT-CBT and TT-TT techniques.
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Sakaura H, Ikegami D, Fujimori T, Sugiura T, Mukai Y. Early Fusion Status After Posterior Lumbar Interbody Fusion With Cortical Bone Trajectory Screw Fixation or Traditional Trajectory Screw Fixation: A Comparison Between the Titanium-coated Polyetheretherketone Cage and the Same Shape Polyetheretherketone Cage. Clin Spine Surg 2022; 35:E47-E52. [PMID: 34369910 DOI: 10.1097/bsd.0000000000001237] [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: 02/25/2021] [Accepted: 06/20/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN A retrospective analysis of prospectively collected data. OBJECTIVE The aim was to examine whether posterior lumbar interbody fusion with cortical bone trajectory screw fixation (CBT-PLIF) is inferior to PLIF using traditional trajectory screw fixation (TT-PLIF) regarding early fusion status and whether the titanium-coated polyetheretherketone (PEEK) cage (TP cage) improves early fusion status compared with the same shape pure PEEK cage (P cage). SUMMARY OF BACKGROUND DATA We recently reported that the fusion rate was relatively lower after CBT-PLIF than after TT-PLIF, although no significant difference was found and that compared with the carbon PEEK cage, the TP cage significantly reduced the incidence of vertebral endplate cysts (cyst signs) and slightly improved the early fusion rate at 1 year after CBT-PLIF. MATERIALS AND METHODS The subjects were 37 patients undergoing TT-PLIF using P cages (TT-P group), 24 patients undergoing CBT-PLIF using P cages (CBT-P group), 32 patients undergoing TT-PLIF using TP cages (TT-TP group), and 20 patients undergoing CBT-PLIF using TP cages (CBT-TP group). On multiplanar reconstruction computed tomography at 6 months after surgery, cyst signs were evaluated and classified into diffuse or local cysts. Early fusion status was assessed using both dynamic plain radiographs and multiplanar reconstruction computed tomography at 1-year postoperatively. RESULTS The incidence of the diffuse cyst was 27.0% in the TT-P group, 29.2% in the CBT-P group, 25.0% in the TT-TP group and 25.0% in the CBT-TP group (P>0.05). The early fusion rate was 75.7% in the TT-P group, 75.0% in the CBT-P group, 71.9% in the TT-TP group and 75.0% in the CBT-TP group (P>0.05). CONCLUSIONS These results indicate that CBT-PLIF resulted in the equivalent early fusion status to TT-PLIF and that compared with the same shape P cage, the TP cage did not improve early fusion status after both TT-PLIF and CBT-PLIF.
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Affiliation(s)
- Hironobu Sakaura
- Department of Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka City
| | - Daisuke Ikegami
- Department of Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka City
| | - Takahito Fujimori
- Department of Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka City
| | - Tsuyoshi Sugiura
- Department of Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka City
| | - Yoshihiro Mukai
- Department of Orthopaedic Surgery, Nishinokyo Hospital, Nara City, Japan
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Herrero CFPS, Marangoni RCF. Análise tomográfica dos parâmetros anatômicos para inserção dos parafusos de trajeto cortical. Rev Bras Ortop 2022; 57:47-54. [PMID: 35198108 PMCID: PMC8856847 DOI: 10.1055/s-0041-1731672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 02/11/2021] [Indexed: 11/13/2022] Open
Abstract
Objective
To study the parameters related to the insertion path of cortical screws and to describe this technique.
Methods
Computed tomography (CT) scans of 30 patients, as well as the measurements from the L1 to the L5 vertebrae, were studied. A second observer evaluated ten randomly-selected exams. The parameters studied included the lateral angle (LA) and the screw diameter (SD) as axial variables, and the cranial angle (CA) and screw length (SL) as sagittal variables.
Results
We studied 15 male patients (mean age: 31.33 years) and 15 female patients (mean age: 32.01 years). The LA varied between 13.8° and 20.89°, with a tendency to increase in the proximal to distal direction. The CA varied from 17.5° to 24.9°, with a tendency to decrease in the caudal direction. The SD ranged from 2.3 mm to 7.2 mm, with a tendency to increase as we progressed from proximal to distal. The SL varied from 19 mm to 45 mm, with a tendency to decrease as we proceeded from proximal (L1) to distal (L5). No statistical difference was observed between the genders or in the interobserver agreement regarding the values studied when comparing the sides.
Conclusion
The path of insertion of the cortical screw shows a variation in different populations. Therefore, we recommend a preoperative imaging study to reduce the surgical risks related to the technique.
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Affiliation(s)
- Carlos Fernando Pereira Silva Herrero
- Departamento de Ortopedia e Anestesiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, SP, Brasil
| | - Rafael Campos Fróes Marangoni
- Departamento de Ortopedia e Anestesiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, SP, Brasil
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Kuo YH, Kuo CH, Chang HK, Ko CC, Tu TH, Chang CC, Cheng H, Lirng JF, Huang WC, Wu JC. Cortical-bone-trajectory-based dynamic stabilization. World Neurosurg 2021; 159:e416-e424. [PMID: 34954054 DOI: 10.1016/j.wneu.2021.12.061] [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: 08/11/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Cortical-bone-trajectory (CBT) screws have demonstrated similar biomechanical strength and fusion rates as conventional pedicle screws for short-segment lumbar fusion. However, very few studies have verified the viability of CBT screws in dynamic stabilization. OBJECTIVE To compare the clinical outcomes of CBT-based Dynesys dynamic stabilization (CBT-DDS) with standard minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). METHODS Consecutive patients who received CBT-DDS or MI-TLIF at L4-5 or L3-4-5 were retrospectively reviewed. All the radiological and clinical outcomes were compared between the two groups. The patient-reported outcomes (PRO) included visual analog scales of back and leg pain, Japanese Orthopaedic Association Scores, and the Oswestry Disability Index. The pre- and post-operative radiological evaluations were also reviewed. RESULTS A total of 60 patients (20 patients of the CBT-DDS and 40 of the MI-TLIF groups) were analyzed. The MI-TLIF group had a longer operation time (p=0.010) than the CBT-DSS group, but with similar estimated blood loss (p=0.484). Perioperative complications, including screw loosening, wound infection and radiculopathy, were similar in both groups (all p>0.05). The degree of decreased range of motion after surgery was similar between the two groups (p=0.781), and there was no pseudarthrosis in the MI-TLIF group. CONCLUSION Since the clinical and radiologic outcomes of CBT-DDS were similar to that of MI-TLIF in patients of L4-5 or L3-4-5 spondylosis and spondylolisthesis, CBT-DDS appeared to be a viable and effective alternative to MI-TLIF, and with less operation time and similarly limited segmental motility.
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Affiliation(s)
- Yi-Hsuan Kuo
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chao-Hung Kuo
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Biomedical Engineering, School of Biomedical Science and Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsuan-Kan Chang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chin-Chu Ko
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Tsung-Hsi Tu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Chang Chang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Biomedical Engineering, School of Biomedical Science and Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Henrich Cheng
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Cheng Huang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jau-Ching Wu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Matsukawa K, Yanai Y, Fujiyoshi K, Kato T, Yato Y. Depth of vertebral screw insertion using a cortical bone trajectory technique in lumbar spinal fusion: radiological significance of a long cortical bone trajectory. J Neurosurg Spine 2021; 35:601-606. [PMID: 34388711 DOI: 10.3171/2021.2.spine202229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 02/11/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Contrary to original cortical bone trajectory (CBT), "long CBT" directed more anteriorly in the vertebral body has recently been recommended because of improved screw fixation and load sharing within the vertebra. However, to the authors' knowledge there has been no report on the clinical significance of the screw length and screw insertion depth used with the long CBT technique. The aim of the present study was to investigate the influence of the screw insertion depth in the vertebra on lumbar spinal fusion using the CBT technique. METHODS A total of 101 consecutive patients with L4 degenerative spondylolisthesis who underwent single-level posterior lumbar interbody fusion at L4-5 using the CBT technique were included (mean follow-up 32.9 months). Screw loosening and bone fusion were radiologically assessed to clarify the factors contributing to these outcomes. Investigated factors were as follows: 1) age, 2) sex, 3) body mass index, 4) bone mineral density, 5) intervertebral mobility, 6) screw diameter, 7) screw length, 8) depth of the screw in the vertebral body (%depth), 9) facetectomy, 10) crosslink connector, and 11) cage material. RESULTS The incidence of screw loosening was 3.1% and bone fusion was achieved in 91.7% of patients. There was no significant factor affecting screw loosening. The %depth in the group with bone fusion [fusion (+)] was significantly higher than that in the group without bone fusion [fusion (-)] (50.3% ± 8.2% vs 37.0% ± 9.5%, respectively; p = 0.001), and multivariate logistic regression analysis revealed that %depth was a significant independent predictor of bone fusion. Receiver operating characteristic curve analysis identified %depth > 39.2% as a predictor of bone fusion (sensitivity 90.9%, specificity 75.0%). CONCLUSIONS This study is, to the authors' knowledge, the first to investigate the significance of the screw insertion depth using the CBT technique. The cutoff value of the screw insertion depth in the vertebral body for achieving bone fusion was 39.2%.
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Tong Z, Xiao B, Yan K, Xing Y, Zhang Y. Biomechanical Evaluation of the Transcortical and Transpedicular Trajectories for Pedicle Screw Insertion in Thoracolumbar Fracture Fixation for Ankylosing Spondylitis. Front Surg 2021; 8:706597. [PMID: 34568415 PMCID: PMC8456994 DOI: 10.3389/fsurg.2021.706597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/09/2021] [Indexed: 01/22/2023] Open
Abstract
Background: Ankylosing spondylitis (AS) is a chronic disorder characterized by an imbalance between bone formation and resorption. Spinal fractures often occur after minor trauma in patients with AS. For thoracolumbar fractures, transpedicular screw (TPS) fixation through the posterior approach has been suggested. The cortical bone trajectory (CBT) technique has also been used to prevent screw pull-out in patients with poor bone quality. The aim of current study was to assess the biomechanical characteristics of the TPS and CBT technique in thoracolumbar AS fracture fixation by finite element analysis. Methods: The three-dimensional finite element models of the AS spine were created. The CBT and TPS methods of screw insertion were used in AS spinal fracture models. An intact AS spine model was considered the control. An axial force and torsion in rotation, flexion/extension and lateral flexion were applied in all models in CBT, TPS, and control groups. Results: The AS spine showed similar construct stiffness after posterior fixation by CBT and TPS techniques under axial, rotational, and flexion/extension loading conditions. The TPS technique showed better intact stability under all loading conditions. Similarly, the TPS technique provided superior fracture regional stability against axial and rotational loads than did the CBT technique. The maximum von Mises stresses were 1714.4 ± 129.8 MPa and 1208.7 ± 107.3 MPa (p < 0.001), which occurred in the CBT and TPS groups under compressive loading. Conclusions: The TPS technique provides better biomechanical strength under axial, rotational, flexion/extension, and lateral flexion loading than does the CBT technique. Compared with CBT, TPS is more effective in maintaining the stability of AS thoracolumbar fractures from a finite element analysis perspective.
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Affiliation(s)
- Zhizhong Tong
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Bin Xiao
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Kai Yan
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Yonggang Xing
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Yanbin Zhang
- Department of Education, Beijing Jishuitan Hospital, Beijing, China
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Sakaura H, Ikegami D, Fujimori T, Sugiura T, Yamada S, Mukai Y. Surgical outcomes after posterior lumbar interbody fusion using traditional trajectory screw fixation or cortical bone trajectory screw fixation: A comparative study between the polyetheretherketone cage and the same shape titanium-coated polyetheretherketone cage. Clin Neurol Neurosurg 2021; 209:106945. [PMID: 34555798 DOI: 10.1016/j.clineuro.2021.106945] [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: 08/19/2021] [Revised: 09/08/2021] [Accepted: 09/12/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To investigate whether or not the fusion rate after posterior lumbar interbody fusion with cortical bone trajectory screw fixation (CBT-PLIF) is lower than after PLIF using traditional trajectory screw fixation (TT-PLIF) and whether or not the titanium-coated polyetheretherketone (PEEK) cage (TiP cage) improves fusion status compared to the same shape uncoated PEEK cage (P cage). METHODS The subjects were 37 patients undergoing TT-PLIF using P cages (P-TT group), 24 patients undergoing CBT-PLIF using P cages (P-CBT group), 32 patients undergoing TT-PLIF using TiP cages (TiP-TT group), and 20 patients undergoing CBT-PLIF using TiP cages (TiP-CBT group). All patients from the 4 groups underwent our unified PLIF procedure (total facetectomy, subtotal discectomy, and the same bone graft technique using the same shape cages) except for the screw trajectories and the surface materials of the cages. Clinical symptoms were assessed using the Japanese Orthopedic Association (JOA) score before surgery and at 2-year postoperatively. None of age at the time of surgery, gender, fused segment and preoperative JOA score showed significant differences among the 4 groups. On multiplanar reconstruction computed tomography (MPR-CT) at 6months after surgery, vertebral end plate cysts were evaluated and classified into local or diffuse cysts. Fusion status was assessed using both dynamic plain radiographs and MPR-CT at postoperative 2-year. RESULTS Neither the mean JOA score nor the mean recovery rate of the JOA score at 2-year after surgery showed significant differences among the 4 groups. The incidence of the diffuse cyst (a known predictor of non-union) was 27.0% in the P-TT group, 29.2% in the P-CBT group, 25.0% in the TiP-TT group and 25.0% in the TiP-CBT group (P > 0.05). The fusion rate was 89.2% in the P-TT group, 91.7% in the P-CBT group, 90.6% in the TiP-TT group and 90.0% in the TiP-CBT group (P > 0.05). CONCLUSIONS After our unified PLIF procedure except for the screw trajectories and the surface materials of the cages, CBT-PLIF resulted in the equivalent fusion rate to TT-PLIF and the TiP cage did not lead to the improved fusion rate compared to the same shape P cage.
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Affiliation(s)
- Hironobu Sakaura
- Department of Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, 4-2-78 Fukushima, Fukushimaku, Osaka City, Osaka 553-0003, Japan.
| | - Daisuke Ikegami
- Department of Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, 4-2-78 Fukushima, Fukushimaku, Osaka City, Osaka 553-0003, Japan
| | - Takahito Fujimori
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Tsuyoshi Sugiura
- Department of Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, 4-2-78 Fukushima, Fukushimaku, Osaka City, Osaka 553-0003, Japan
| | - Shutaro Yamada
- Department of Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, 4-2-78 Fukushima, Fukushimaku, Osaka City, Osaka 553-0003, Japan
| | - Yoshihiro Mukai
- Department of Orthopaedic Surgery, Nishinokyo Hospital, 102-2 Rokujyocho, Nara City, Nara 630-8041, Japan
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Rosinski AA, Mittal A, Odeh K, Ungurean V, Leasure J, Telles C, Kondrashov D. Alternatives to Traditional Pedicle Screws for Posterior Fixation of the Degenerative Lumbar Spine. JBJS Rev 2021; 9:01874474-202107000-00016. [PMID: 34319968 DOI: 10.2106/jbjs.rvw.20.00177] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Traditional pedicle screws are currently the gold standard to achieve stable 3-column fixation of the degenerative lumbar spine. However, there are cases in which pedicle screw fixation may not be ideal. Due to their starting point lateral to the pars interarticularis, pedicle screws require a relatively wide dissection along with a medialized trajectory directed toward the centrally located neural elements and prevertebral vasculature. In addition, low bone mineral density remains a major risk factor for pedicle screw loosening, pullout, and pseudarthrosis. The purpose of this article is to review the indications, advantages, disadvantages, and complications associated with posterior fixation techniques of the degenerative lumbar spine beyond the traditional pedicle screws. METHODS Comprehensive literature searches of the PubMed, Scopus, and Web of Science databases were performed for 5 methods of posterior spinal fixation, including (1) cortical bone trajectory (CBT) screws, (2) transfacet screws, (3) translaminar screws, (4) spinous process plates, and (5) fusion mass screws and hooks. Articles that had been published between January 1, 1990, and January 1, 2020, were considered. Non-English-language articles and studies involving fixation of the cervical or thoracic spine were excluded from our review. RESULTS After reviewing over 1,700 articles pertaining to CBT and non-pedicular fixation techniques, a total of 284 articles met our inclusion criteria. CBT and transfacet screws require less-extensive exposure and paraspinal muscle dissection compared with traditional pedicle screws and may therefore reduce blood loss, postoperative pain, and length of hospital stay. In addition, several methods of non-pedicular fixation such as translaminar and fusion mass screws have trajectories that are directed away from or posterior to the spinal canal, potentially decreasing the risk of neurologic injury. CBT, transfacet, and fusion mass screws can also be used as salvage techniques when traditional pedicle screw constructs fail. CONCLUSIONS CBT and non-pedicular fixation may be preferred in certain lumbar degenerative cases, particularly among patients with osteoporosis. Limitations of non-pedicular techniques include their reliance on intact posterior elements and the lack of 3-column fixation of the spine. As a result, transfacet and translaminar screws are infrequently used as the primary method of fixation. CBT, transfacet, and translaminar screws are effective in augmenting interbody fixation and have been shown to significantly improve fusion rates and clinical outcomes compared with stand-alone anterior lumbar interbody fusion. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander A Rosinski
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | - Ashish Mittal
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | - Khalid Odeh
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | | | | | | | - Dimitriy Kondrashov
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
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40
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Wang L, Zhao YH, Cai XB, Liang JL, Luo HT, Ma YL, Xu YQ, Lu S. Feasibility of cortical bone trajectory screws for bridging fixation in revision surgery for lumbar adjacent segment degeneration. Medicine (Baltimore) 2021; 100:e26666. [PMID: 34260574 PMCID: PMC8284764 DOI: 10.1097/md.0000000000026666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/29/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To investigate the feasibility of using cortical bone trajectory (CBT) screws for bridging fixation in revision surgery for lumbar adjacent segment degeneration and to provide a reference for clinical practice. METHODS Computed tomography scans of the lumbar spines of 36 patients in our hospital were used. Sixteen males and 20 females with an average age of 65.5 ± 10.5 years (range: 46 to 83 years) were included. Three-dimensional reconstruction was performed using computer software. Screws with appropriate sizes were selected for the L1 to L5 vertebral segments, and traditional pedicle screws were placed using the standard method. After completing screw placement, simulated placement of CBT screws was performed separately. No overlap occurred between the two screws in the process of CBT screw placement, and the placement point and direction were adjusted until screw placement completion. After all screw placement simulations were complete, according to the contact area of the cortical bone of the screw trajectory and the screw puncture position and distance through the trajectory, the screw placement results were categorized as excellent, good, general, and failure. Excellent and good ratings were considered successful, while a general rating was regarded as acceptable. Then, the success rate and acceptable rate of each segment of the lumbar spine were calculated. RESULTS Three hundred and sixty screw placement simulations were performed in lumbar pedicles, and 72 CBT screws were implanted in each vertebral body of the lumbar spine. The success rates in the L1 to L5 segments were 73.6%, 80.6%, 83.3%, 88.9%, and 77.8%, respectively, and the acceptable rates were 91.7%, 97.2%, 97.2%, 100%, and 91.7%, respectively. The overall success rate and acceptable rate of CBT screw placement in the lumbar spine were 80.8% and 95.6%, respectively. CONCLUSION CBT screws are feasible for bridging fixation in lumbar adjacent segment degeneration revision surgery, and the accuracy of screw placement in different lumbar vertebrae varies.
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Affiliation(s)
- Long Wang
- Postgraduate College of Kunming Medical University, No. 1168 Chunrong Xi Road, Kunming, China
- Department of Orthopedics, 920th Hospital of Joint Logistics Support Force, 212 Daguan Road, Kunming, China
| | - Yong-Hui Zhao
- Department of Orthopedics, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, The Key Laboratory of Digital Orthopedics of Yunnan Province, No. 157 Jinbi Road, Kunming, China
| | - Xing-Bo Cai
- Postgraduate College of Kunming Medical University, No. 1168 Chunrong Xi Road, Kunming, China
- Department of Orthopedics, 920th Hospital of Joint Logistics Support Force, 212 Daguan Road, Kunming, China
| | - Jin-Long Liang
- Department of Orthopedics, 920th Hospital of Joint Logistics Support Force, 212 Daguan Road, Kunming, China
| | - Hao-Tian Luo
- Department of Orthopedics, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, The Key Laboratory of Digital Orthopedics of Yunnan Province, No. 157 Jinbi Road, Kunming, China
| | - Yu-Long Ma
- Department of Orthopedics, 920th Hospital of Joint Logistics Support Force, 212 Daguan Road, Kunming, China
| | - Yong-Qing Xu
- Department of Orthopedics, 920th Hospital of Joint Logistics Support Force, 212 Daguan Road, Kunming, China
| | - Sheng Lu
- Department of Orthopedics, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, The Key Laboratory of Digital Orthopedics of Yunnan Province, No. 157 Jinbi Road, Kunming, China
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Chang MC, Choo YJ, Lee GW. Pedicle screws versus cortical screws in posterior lumbar interbody fusion surgery for degenerative spondylolisthesis: a systematic review and meta-analysis. Spine J 2021; 21:1126-1134. [PMID: 33640584 DOI: 10.1016/j.spinee.2021.02.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/17/2021] [Accepted: 02/19/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT A few meta-analyses have compared conventional pedicle screws (PS) with cortical bone trajectory-pedicle screws (cortical screw [CS]) in posterior lumbar fusion surgery. However, these studies did not control for diagnosis, which has been shown to impact surgical outcomes. PURPOSE To compare PS with CS as a posterior fixation technique in posterior lumbar interbody fusion (PLIF) for degenerative spondylolisthesis (DS). STUDY DESIGN Systematic review and meta-analysis. METHODS We searched the Cochrane, Embase, and Medline databases for articles that compared postoperative outcomes between PS and CS for posterior stabilization in PLIF for DS with November 11, 2020, as the publication cutoff. The differences in primary and secondary outcome measures were calculated and analyzed for significance (p<.05). All the reported means were pooled. RESULTS A total of 916 publications were assessed; 5 studies met all the study criteria. The fusion rates between PS and CS groups were not significantly different (p=.41). Blood loss and operative time were significantly less in the CS group than the PS group (p=.04 and 0.02, respectively), but the length of stay was not significantly different (p=.08). The total complication rate was significantly less in CS group than that in PS group (p=.002). The rates of adjacent segment pathology (ASP) and operation for ASP in the CS group were significantly less than the PS group (p=.03 and .04, respectively). CONCLUSIONS Though CS and PS appear to have similar 1-year fusion rates and length of stay, there appears to lower blood loss and operative time with CS. Though encouraging, these findings were based on low-quality evidence from a small number of retrospective studies that are prone to bias.
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Affiliation(s)
- Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Yeungnam University Hospital, Daegu, South Korea
| | - Yoo Jin Choo
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Yeungnam University Hospital, Daegu, South Korea
| | - Gun Woo Lee
- Department of Orthopaedic Surgery, Yeungnam University College of Medicine, Yeungnam University Hospital, Daegu, South Korea.
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Cornaz F, Widmer J, Fasser MR, Snedeker JG, Matsukawa K, Spirig JM, Farshad M. Is a cross-connector beneficial for single level traditional or cortical bone trajectory pedicle screw instrumentation? PLoS One 2021; 16:e0253076. [PMID: 34115816 PMCID: PMC8195405 DOI: 10.1371/journal.pone.0253076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 05/27/2021] [Indexed: 01/14/2023] Open
Abstract
The cortical bone trajectory (CBT) has been introduced with the aim of better screw hold, however, screw-rod constructs with this trajectory might provide less rigidity in lateral bending (LB) and axial rotation (AR) compared to the constructs with the traditional trajectory (TT). Therefore, the addition of a horizontal cross-connector could be beneficial in counteracting this possible inferiority. The aim of this study was to compare the primary rigidity of TT with CBT screw-rod constructs and to quantify the effect of cross-connector-augmentation in both. Spines of four human cadavers (T9 –L5) were cropped into 15 functional spine units (FSU). Eight FSUs were instrumented with TT and seven FSUs with CBT pedicle screws. The segments were tested in six loading directions in three configurations: uninstrumented, instrumented with and without cross-connector. The motion between the cranial and caudal vertebra was recorded. The range of motion (ROM) between the CBT and the TT group did not differ significantly in either configuration. Cross-connector -augmentation did reduce the ROM in AR (16.3%, 0.27°, p = 0.02), LB (2.9%, 0.07°, p = 0.03) and flexion-extension FE (2.3%, 0.04°, p = 0.02) for the TT group and in AR (20.6%, 0.31°, p = 0.01) for the CBT-group. The primary rigidity of TT and CBT single level screw-rod constructs did not show significant difference. The minimal reduction of ROM due to cross-connector-augmentation seems clinically not relevant. Based on the findings of these study there is no increased necessity to use a cross-connector in a CBT-construct.
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Affiliation(s)
- Frédéric Cornaz
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Jonas Widmer
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
- * E-mail:
| | - Marie-Rosa Fasser
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Jess Gerrit Snedeker
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Keitaro Matsukawa
- Department of Orthopaedic Surgery, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan
| | - José Miguel Spirig
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
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43
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Spirig JM, Winkler E, Cornaz F, Fasser MR, Betz M, Snedeker JG, Widmer J, Farshad M. Biomechanical performance of bicortical versus pericortical bone trajectory (CBT) pedicle screws. 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 2021; 30:2292-2300. [PMID: 34057540 DOI: 10.1007/s00586-021-06878-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 04/18/2021] [Accepted: 05/13/2021] [Indexed: 01/12/2023]
Abstract
PURPOSE The cortical bone trajectory (CBT) is an alternative to the traditional pedicle screw trajectory (TT) in posterior spinal instrumentation, enhancing screw contact with cortical bone and therefore increasing fixation strength. Additional to the trajectory, insertion depth (pericortical vs. bicortical placement) could be a relevant factor affecting the fixation strength. However, the potential biomechanical benefit of a bicortical placement of CBT screws is unknown. Therefore, the aim of this study was to quantify the fixation strength of pericortical- versus bicortical-CBT (pCBT versus bCBT) screws in a randomized cadaveric study. METHODS Pedicle screws were either placed pericortical or bicortical with a CBT in 20 lumbar vertebrae (2 × 20 instrumented pedicles) from four human spine cadavers by using patient-specific templates. Instrumented specimens underwent physiological cyclic loading testing (1'800'000 cycles, 10 Hz), including shear and tension loads as well as bending moments. Translational and angular displacements of the screws were quantified and compared between the two techniques. RESULTS There was a slight decrease in translational (0.2 mm ± 0.09 vs. 0.24 mm ± 0.11) and angular displacements (0.06° ± 0.05 vs. 0.13° ± 0.11) of bCBT screws when compared with pCBT screws after 1'800'000 cycles. However, the results were non-significant (p > 0.05). CONCLUSION The authors do not recommend placing CBT screws bicortically, as no relevant biomechanical advantage is gained while the potential risk for iatrogenic injury to structures anterior to the spine is increased.
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Affiliation(s)
- José M Spirig
- Department of Orthopaedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
| | - Elin Winkler
- Department of Orthopaedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Frédéric Cornaz
- Department of Orthopaedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Marie-Rosa Fasser
- Department of Orthopaedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.,Institute for Biomechanics, ETH Zürich, Zürich, Switzerland
| | - Michael Betz
- Department of Orthopaedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Jess G Snedeker
- Department of Orthopaedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.,Institute for Biomechanics, ETH Zürich, Zürich, Switzerland
| | - Jonas Widmer
- Department of Orthopaedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.,Institute for Biomechanics, ETH Zürich, Zürich, Switzerland
| | - Mazda Farshad
- Department of Orthopaedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Jarvers JS, Schleifenbaum S, Pfeifle C, Oefner C, Edel M, von der Höh N, Heyde CE. Comparison of three different screw trajectories in osteoporotic vertebrae: a biomechanical investigation. BMC Musculoskelet Disord 2021; 22:418. [PMID: 33952236 PMCID: PMC8101169 DOI: 10.1186/s12891-021-04254-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 04/13/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Pedicle screw insertion in osteoporotic patients is challenging. Achieving more screw-cortical bone purchase and invasiveness minimization, the cortical bone trajectory and the midline cortical techniques represent alternatives to traditional pedicle screws. This study compares the fatigue behavior and fixation strength of the cement-augmented traditional trajectory (TT), the cortical bone trajectory (CBT), and the midline cortical (MC). METHODS Ten human cadaveric spine specimens (L1 - L5) were examined. The average age was 86.3 ± 7.2 years. CT scans were provided for preoperative planning. CBT and MC were implanted by using the patient-specific 3D-printed placement guide (MySpine®, Medacta International), TT were implanted freehand. All ten cadaveric specimens were randomized to group A (CBT vs. MC) or group B (MC vs. TT). Each screw was loaded for 10,000 cycles. The failure criterion was doubling of the initial screw displacement resulting from the compressive force (60 N) at the first cycle, the stop criterion was a doubling of the initial screw displacement. After dynamic testing, screws were pulled out axially at 5 mm/min to determine their remaining fixation strength. RESULTS The mean pull-out forces did not differ significantly. Concerning the fatigue performance, only one out of ten MC of group A failed prematurely due to loosening after 1500 cycles (L3). Five CBT already loosened during the first 500 cycles. The mean displacement was always lower in the MC. In group B, all TT showed no signs of failure or loosening. Three MC failed already after 26 cycles, 1510 cycles or 2144 cycles. The TT showed always a lower mean displacement. In the subsequent pull-out tests, the remaining mean fixation strength of the MC (449.6 ± 298.9 N) was slightly higher compared to the mean pull-out force of the CBT (401.2 ± 261.4 N). However, MC (714.5 ± 488.0 N) were inferior to TT (990.2 ± 451.9 N). CONCLUSION The current study demonstrated that cement-augmented TT have the best fatigue and pull-out characteristics in osteoporotic lumbar vertebrae, followed by the MC and CBT. MC represent a promising alternative in osteoporotic bone if cement augmentation should be avoided. Using the patient-specific placement guide contributes to the improvement of screws' biomechanical properties.
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Affiliation(s)
- J-S Jarvers
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany.
| | - S Schleifenbaum
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany.,ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Leipzig University, Semmelweisstraße 14, 04103, Leipzig, Germany
| | - C Pfeifle
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany
| | - C Oefner
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany.,ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Leipzig University, Semmelweisstraße 14, 04103, Leipzig, Germany
| | - M Edel
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany.,ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Leipzig University, Semmelweisstraße 14, 04103, Leipzig, Germany
| | - N von der Höh
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany
| | - C-E Heyde
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany.,ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Leipzig University, Semmelweisstraße 14, 04103, Leipzig, Germany
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45
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Kim KT, Song MG, Park YJ, Lee DY, Kim DH. Cortical Trajectory Screw Fixation in Lumbar Spine Surgery: A Review of the Existing Literature. Asian Spine J 2021; 16:127-140. [PMID: 33915615 PMCID: PMC8873998 DOI: 10.31616/asj.2020.0575] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 12/13/2020] [Indexed: 11/23/2022] Open
Abstract
Posterior lumbar fusion is a safe and effective surgical method for diseases, such as lumbar stenosis, spondylolisthesis, lumbar instability, spinal deformity, and tumor. Pedicle screw (PS) fixation was first introduced by Bouche and has been adopted as the gold standard for posterior lumbar fusion. Santoni and colleagues introduced a new methodological screw insertion technique that uses a cortical bone trajectory (CBT), described as that from a medial to lateral path in the transverse axial plane and caudal to the cephalad path in the sagittal plane through the pedicle for maximum contact of the screw with the cortical bone. Owing to the lower invasiveness, superior cortical bone contact, and reduced neurovascular injury incidence, the CBT technique has been widely used in posterior lumbar fusion; however, these advantages have not been proven in clinical/radiological and biomechanical studies. We designed the present study to review the existing evidence and evaluate the merit of CBT screw fixation. Six electronic databases were searched for relevant articles published in August 2020 using the search terms "cortical bone trajectory," "CBT spine," "CBT fixation," "cortical pedicle screws," and "cortical screws." Studies were analyzed and divided into the following groups: "biomechanics investigation," "surgical technique," and "clinical/radiological studies." Most studies compared CBT and PS fixation, and the CBT screw fixation method showed better or similar outcomes.
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Affiliation(s)
- Kun-Tae Kim
- Regional Trauma Center, Gyeongsang National University Hospital, Jinju, Korea.,Department of Orthopaedic Surgery and Institute of Health Science, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Myung-Geun Song
- Department of Orthopaedic Surgery and Institute of Health Science, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Young-Jin Park
- Department of Orthopaedic Surgery and Institute of Health Science, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Dong-Yeong Lee
- Department of Orthopaedic Surgery and Joint Center, Barun Hospital, Jinju, Korea
| | - Dong-Hee Kim
- Department of Orthopaedic Surgery and Institute of Health Science, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Korea
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Zhang L, Li HM, Zhang R, Zhang H, Shen CL. Biomechanical Changes of Adjacent and Fixed Segments Through Cortical Bone Trajectory Screw Fixation versus Traditional Trajectory Screw Fixation in the Lumbar Spine: A Finite Element Analysis. World Neurosurg 2021; 151:e447-e456. [PMID: 33895371 DOI: 10.1016/j.wneu.2021.04.061] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The finite element method was used to investigate the biomechanical adjustments of adjacent and fixed segments after lumbar fusion and fixation with traditional trajectory (TT) and cortical bone trajectory (CBT) screws. METHODS The model used was a validated nonlinearly L3-S1 finite element model. Interbody fusion cages and 2 types of screws were used to work on the L4-L5. To simulate flexion, extension, lateral bending, and axial rotation, all models were loaded in 3 planes with a compressive pre-load of 400 N and a bending moment of 7.5 N/m. Under various loading conditions, the range of motion (ROM), peak Von Mises stress of the vertebral body, stress of the intervertebral disc, stress of the facet joints, stress of the endplate, and stress of internal fixation were compared. RESULTS In all instrumentation models, the ROM at fixed segments decreased. At adjacent segments, the ROM of the CBT model was greater than that of the TT model. The CBT model had a greater peak Von Mises stress of the L4 and L5 vertebral bodies, as well as greater stress of internal fixation, than the TT model. Furthermore, as compared with the TT model, the CBT model's facet joint and endplate stress were lower at fixed segments but higher at adjacent segments. The stress on the L3-L4 and L5-S1 intervertebral discs in the CBT and TT models, on the other hand, was nearly equivalent. CONCLUSIONS At the fixed section, CBT may provide slightly better stability, endplate tension, and facet joint stress than TT. The greater ROM, endplate stress, and facet joint stress of CBT in adjacent segments, on the other hand, should be taken into account in the future.
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Affiliation(s)
- Lai Zhang
- Department of Orthopedics & Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Hui-Min Li
- Department of Orthopedics & Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Renjie Zhang
- Department of Orthopedics & Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Huaqing Zhang
- Department of Orthopedics & Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Cai-Liang Shen
- Department of Orthopedics & Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China.
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Tani S, Ishikawa K, Kudo Y, Tsuchiya K, Matsuoka A, Maruyama H, Emori H, Yamamura R, Hayakawa C, Sekimizu M, Oshita Y, Ozawa T, Shirahata T, Nagai T, Toyone T, Inagaki K. The effect of denosumab on pedicle screw fixation: a prospective 2-year longitudinal study using finite element analysis. J Orthop Surg Res 2021; 16:219. [PMID: 33771178 PMCID: PMC7995779 DOI: 10.1186/s13018-021-02360-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pedicle screw loosening is a major complication following spinal fixation associated with osteoporosis in elderly. However, denosumab is a promising treatment in patients with osteoporosis. The effect of denosumab on pedicle screw fixation is unknown. Therefore, we investigated whether denosumab treatment improves pedicle screw fixation in elderly patients with osteoporosis. METHODS This was a 2-year prospective open-label study. From February 2015 to January 2016, we included 21 patients with postmenopausal osteoporosis who received initial denosumab treatment. At baseline, 12 months, and 24 months, we measured volumetric bone mineral density (BMD) using quantitative computed tomography (QCT) and performed CT-based finite element analysis (FEA). Finite element models of L4 vertebrae were created to analyze the bone strength and screw fixation. RESULTS BMD increased with denosumab treatment. FEA revealed that both pullout strength of pedicle screws and compression force of the vertebra increased significantly at 12 and 24 months following denosumab treatment. Notably, pullout strength showed a stronger correlation with three-dimensional volumetric BMD around pedicle screw placement assessed by QCT (r = 0.83, at 24 months) than with two-dimensional areal BMD assessed by dual energy X-ray absorptiometry (r = 0.35, at 24 months). CONCLUSION To our knowledge, this is the first study to reveal that denosumab treatment achieved strong pedicle screw fixation with an increase in BMD around the screw assessed by QCT and FEA; therefore, denosumab could be useful for osteoporosis treatment during spinal surgery in elderly patients with osteoporosis.
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Affiliation(s)
- Soji Tani
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Koji Ishikawa
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan.
| | - Yoshifumi Kudo
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Koki Tsuchiya
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
- Department of Orthopaedic Surgery, Yamanashi Red Cross Hospital, 6663-1 Funatsu Fujikawaguchiko-machi, Minamitsuru-gun, Yamanashi, 401-0301, Japan
| | - Akira Matsuoka
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Hiroshi Maruyama
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Haruka Emori
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
- Department of Orthopaedic Surgery, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo Tsuzuki-ku, Yokohama, Kanagawa, Japan
| | - Ryo Yamamura
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Chikara Hayakawa
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Masaya Sekimizu
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Yusuke Oshita
- Department of Orthopaedic Surgery, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo Tsuzuki-ku, Yokohama, Kanagawa, Japan
| | - Tomoyuki Ozawa
- Department of Orthopaedic Surgery, Tokyo Kyosai Hospital, 2-3-8, Nakameguro, Meguro, Tokyo, 153-0061, Japan
| | - Toshiyuki Shirahata
- Department of Orthopaedic Surgery, Showa University Koto Toyosu Hospital, 5-1-38 Toyosu, Koto-ku, Tokyo, 135-8577, Japan
| | - Takashi Nagai
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Tomoaki Toyone
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Katsunori Inagaki
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
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Ding H, Han B, Hai Y, Liu Y, Guan L, Pan A, Liu T. The Feasibility of Assessing the Cortical Bone Trajectory Screw Placement Accuracy Using a Traditional Pedicle Screw Insertion Evaluation System. Clin Spine Surg 2021; 34:E112-E120. [PMID: 33633068 DOI: 10.1097/bsd.0000000000001059] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 07/24/2020] [Indexed: 01/02/2023]
Abstract
STUDY DESIGN This was a retrospective observational study. OBJECTIVE We aimed to characterize the feasibility of assessing the accuracy of cortical bone trajectory (CBT) screw placement in midline lumbar interbody fusion using a traditional pedicle screw insertion accuracy evaluation system based on computed tomography (CT). SUMMARY OF BACKGROUND DATA Since Santoni and colleagues proposed CBT as an alternative approach for the treatment of lumbar degenerative disease, CBT has been biomechanically and clinically investigated in detail. The reported misplacement rate was 0%-12.5%. Therefore, these cortical screws may result in severe complications, such as nerve root, vascular, and spinal cord injuries. However, to the best of our knowledge, the accuracy of the current assessment system of cortical bone screw placement has not been described clearly. MATERIALS AND METHODS Overall, 342 cortical screws of 69 consecutive patients with lumbar degenerative disease who underwent midline lumbar interbody fusion surgery in one surgeon's initial phase were examined retrospectively. A comprehensive and detailed pedicle screw accuracy classification and grading system was introduced in our study, including 5 types of misplacement: (1) medial and (2) lateral cortical bone perforation (MCP and LCP) of the corresponding pedicle, (3) anterior cortical bone perforation of the vertebral body, (4) endplate perforation, and (5) foraminal perforation (FP). The degree of interobserver and intraobserver agreement with regard to the screw positions based on CT were used as indicators of the reliability of the modified classification system. All patients were retrospectively assessed for screw placement-related complications throughout the entire treatment course to evaluate the relationship between the procedure adequacy and neurological symptoms. RESULTS The interobserver and intraobserver agreements were substantial-to-almost perfect (κ=0.78 and 0.88, respectively) in distinguishing the acceptable-placed pedicle screws from those with partial or complete cortical perforation. In the MCP and LCP-the most common types of misplacement-the interobserver agreement was substantial (κ=0.70 and 0.76, respectively), and the intraobserver agreement was almost perfect (κ=0.85 and 0.89, respectively). In total, there are 7 (2.05%) MCP and 65 (19.01%) LCP screws. The screw placement-related complication rate is significantly higher in the MCP and FP groups than that in the LCP group. CONCLUSIONS Our study demonstrated that using a pedicle screw classification and grading system based on CT to assess the accuracy of CBT screw placement is feasible and practical. MCP and FP screws are more likely to cause neurological deficits with statistical significance, especially grade 2 MCP. We recommend inexperienced surgeons choose a lateral trajectory rather than a medial one if they cannot ensure accurate screw insertion. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hongtao Ding
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University of China, Beijing, China
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Irie TY, Irie T, Espinoza Orías AA, Segami K, Iwasaki N, An HS, Inoue N. Three-dimensional distribution of CT attenuation in the lumbar spine pedicle wall. Sci Rep 2021; 11:1709. [PMID: 33462307 PMCID: PMC7813842 DOI: 10.1038/s41598-020-80676-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/23/2020] [Indexed: 11/16/2022] Open
Abstract
This study investigated in vivo the three-dimensional distribution of CT attenuation in the lumbar spine pedicle wall measured in Hounsfield Unit (HU). Seventy-five volunteers underwent clinical lumbar spine CT scans. Data was analyzed with custom-written software to determine the regional variation in pedicle wall attenuation values. A cylindrical coordinate system oriented along the pedicle's long axis was used to calculate the pedicular wall attenuation distribution three-dimensionally and the highest attenuation value was identified. The pedicular cross-section was divided into four quadrants: lateral, medial, cranial, and caudal. The mean HU value for each quadrant was calculated for all lumbar spine levels (L1-5). The pedicle wall attenuation was analyzed by gender, age, spinal levels and anatomical quadrant. The mean HU values of the pedicle wall at L1 and L5 were significantly lower than the values between L2-4 in both genders and in both age groups. Furthermore, the medial quadrant showed higher HU values than the lateral quadrant at all levels and the caudal quadrant showed higher HU values at L1-3 and lower HU values at L4-5 than the cranial quadrant. These findings may explain why there is a higher incidence of pedicle screw breach in the pedicle lateral wall.
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Affiliation(s)
- Tomoyo Y Irie
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, 60612, USA
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, 060-8638, Japan
| | - Tohru Irie
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, 60612, USA
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, 060-8638, Japan
| | | | - Kazuyuki Segami
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, 60612, USA
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, 060-8638, Japan
| | - Howard S An
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, 60612, USA
| | - Nozomu Inoue
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, 60612, USA.
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50
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Zhang L, Tian N, Yang J, Ni W, Jin L. Risk of pedicle and spinous process violation during cortical bone trajectory screw placement in the lumbar spine. BMC Musculoskelet Disord 2020; 21:536. [PMID: 32781995 PMCID: PMC7422524 DOI: 10.1186/s12891-020-03535-4] [Citation(s) in RCA: 3] [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: 03/09/2020] [Accepted: 07/23/2020] [Indexed: 01/09/2023] Open
Abstract
Background Previous studies have confirmed the feasibility of the cortical bone trajectory (CBT) technique. However, there are few reports on spinous process violation and screw penetration during the screw insertion. The purpose of this study was to evaluate the incidence of spinous process violation and screw penetration through the pedicle during CBT screw insertion. Methods Computed tomography (CT) scans with normal lumbar structures were consecutively obtained and three-dimensional (3D) reconstructions of the lumbar spine were created. Bilateral CBT screw placement was simulated on each segment using a screw diameter of 4.5 mm, 5.0 mm, or 5.5 mm. Incidences of these complications were recorded and analyzed. Results A total of 90 patients were enrolled. Spinous process violation was observed in 68.3, 53.3, 25.5, 1.7, and 0% from L1 to L5, respectively, using 4.5 mm screws. A significant difference was found among the five segments but this was unconnected to gender or screw diameter. The incidence of screw penetration through the inner wall decreased from L1 to L4; in turn, L1 (16.7–35.5%), L2 (12.7–34.4%), L3 (2.8–23.8%) and L4 (1.1–6.7%). This trend was reversed in L5 (6.7–16.7%). Moreover, screw penetration through the outer wall was rare. The incidence of screw penetration varied with screw size as well as lumbar level, but not with gender. Conclusions There are more difficulties of CBT screw fixation in upper lumbar spine. The low rate of screw penetration, using 4.5 mm screws, suggests the safety for CBT fixation in the lumbar spine. Larger screws (5.0 mm or 5.5 mm) are more recommended for use in the lower lumbar spine. Moreover, CBT fixation in L5 deserves greater attention because of the unique morphology of the pedicle.
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Affiliation(s)
- Lilian Zhang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China
| | - Naifeng Tian
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China
| | - Jian Yang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China
| | - Wenfei Ni
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China
| | - Liya Jin
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China.
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