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Ryan C. Hofler, Muturi G. Muriuki, Robert M. Havey, Kenneth R. Blank, Joseph N. Frazzetta, Avinash G. Patwardhan, and G. Alexander Jones


The authors conducted a study to determine whether a change in T1 tilt results in a compensatory change in the cervical sagittal vertical axis (SVA) in a cadaveric spine model.


Six fresh-frozen cadavers (occiput [C0]–T1) were cleaned of soft tissue and mounted on a customized test apparatus. A 5-kg mass was applied to simulate head weight. Infrared fiducials were used to track segmental motion. The occiput was constrained to maintain horizontal gaze, and the mounting platform was angled to change T1 tilt. The SVA was altered by translating the upper (occipital) platform in the anterior-posterior plane. Neutral SVA was defined by the lowest flexion-extension moment at T1 and recorded for each T1 tilt. Lordosis was measured at C0–C2, C2–7, and C0–C7.


Neutral SVA was positively correlated with T1 tilt in all specimens. After increasing T1 tilt by a mean of 8.3° ± 2.2°, neutral SVA increased by 27.3 ± 18.6 mm. When T1 tilt was reduced by 6.7° ± 1.4°, neutral SVA decreased by a mean of 26.1 ± 17.6 mm.

When T1 tilt was increased, overall (C0–C7) lordosis at the neutral SVA increased from 23.1° ± 2.6° to 32.2° ± 4.4° (p < 0.01). When the T1 tilt decreased, C0–C7 lordosis at the neutral SVA decreased to 15.6° ± 3.1° (p < 0.01). C0–C2 lordosis increased from 12.9° ± 9.3° to 29.1° ± 5.0° with increased T1 tilt and decreased to −4.3° ± 6.8° with decreased T1 tilt (p = 0.047 and p = 0.041, respectively).


Neutral SVA is not a fixed property but, rather, is positively correlated with T1 tilt in all specimens. Overall lordosis and C0–C2 lordosis increased when T1 tilt was increased from baseline, and vice versa.

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Odysseas Paxinos, Parmenion P. Tsitsopoulos, Michael R. Zindrick, Leonard I. Voronov, Mark A. Lorenz, Robert M. Havey, and Avinash G. Patwardhan


There is limited data on the pullout strength of spinal fixation devices in the thoracic spine among individuals with different bone quality. An in vitro biomechanical study on the thoracic spine was performed to compare the pullout strength and the mechanism of failure of 4 posterior fixation thoracic constructs in relation to bone mineral density (BMD).


A total of 80 vertebrae from 11 fresh-frozen thoracic spines (T2–12) were used. Based on the results from peripheral quantitative CT, specimens were divided into 2 groups (normal and osteopenic) according to their BMD. They were then randomly assigned to 1 of 4 different instrumentation systems (sublaminar wires, pedicle screws, lamina claw hooks, or pedicle screws with wires). The construct was completed with 2 titanium rods and 2 transverse connectors, creating a stable frame. The pullout force to failure perpendicular to the rods as well as the pattern of fixation failure was recorded.


Mean pullout force in the osteopenic Group A (36 vertebrae) was 473.2 ± 179.2 N and in the normal BMD Group B (44 vertebrae) was 1414.5 ± 554.8 N. In Group A, no significant difference in pullout strength was encountered among the different implants (p = 0.96). In Group B, the hook system failed because of dislocation with significantly less force than the other 3 constructs (931.9 ± 345.1 N vs an average of 1538.6 ± 532.7 N; p = 0.02). In the osteopenic group, larger screws demonstrated greater resistance to pullout (p = 0.011). The most common failure mechanism in both groups was through pedicle base fracture.


Bone quality is an important factor that influences stability of posterior thoracic implants. Fixation strength in the osteopenic group was one-fourth of the value measured in vertebrae with good bone quality, irrespective of the instrumentation used. However, in normal bone quality vertebrae, the lamina hook claw system dislocated with significantly less force when compared with other spinal implants. Further studies are needed to investigate the impact of different transpedicular screw designs on the pullout strength in normal and osteopenic thoracic spines.