Doniel Drazin, Mir Hussain, Jonathan Harris, John Hao, Matt Phillips, Terrence T. Kim, J. Patrick Johnson and Brandon Bucklen
Abnormal sacral slope (SS) has shown to increase progression of spondylolisthesis, yet there exists a paucity in biomechanical studies investigating its role in the correction of adult spinal deformity, its influence on lumbosacral shear, and its impact on the instrumentation selection process. This in vitro study investigates the effect of SS on 3 anterior lumbar interbody fusion constructs in a biomechanics laboratory.
Nine healthy, fresh-frozen, intact human lumbosacral vertebral segments were tested by applying a 550-N axial load to specimens with an initial SS of 20° on an MTS Bionix test system. Testing was repeated as SS was increased to 50°, in 10° increments, through an angulated testing fixture. Specimens were instrumented using a standalone integrated spacer with self-contained screws (SA), an interbody spacer with posterior pedicle screws (PPS), and an interbody spacer with anterior tension band plate (ATB) in a randomized order. Stiffness was calculated from the linear portion of the load-deformation curve. Ultimate strength was also recorded on the final construct of all specimens (n = 3 per construct) with SS of 40°.
Axial stiffness (N/mm) of the L5–S1 motion segment was measured at various angles of SS: for SA 292.9 ± 142.8 (20°), 277.2 ± 113.7 (30°), 237.0 ± 108.7 (40°), 170.3 ± 74.1 (50°); for PPS 371.2 ± 237.5 (20°), 319.8 ± 167.2 (30°), 280.4 ± 151.7 (40°), 233.0 ± 117.6 (50°); and for ATB 323.9 ± 210.4 (20°), 307.8 ± 125.4 (30°), 249.4 ± 126.7 (40°), 217.7 ± 99.4 (50°). Axial compression across the disc space decreased with increasing SS, indicating that SS beyond 40° threshold shifted L5–S1 motion into pure shear, instead of compression-shear, defining a threshold. Trends in ultimate load and displacement differed from linear stiffness with SA > PPS > ATB.
At larger SSs, bilateral pedicle screw constructs with spacers were the most stable; however, none of the constructs were significantly stiffer than intact segments. For load to failure, the integrated spacer performed the best; this may be due to angulations of integrated plate screws. Increasing SS significantly reduced stiffness, which indicates that surgeons need to consider using more aggressive fixation techniques.
Anthony J. Kwon, William D. Hunter, Mark Moldavsky, Kanaan Salloum and Brandon Bucklen
The lateral transpsoas approach to the lumbar spine is a well-defined procedure for the management of discogenic spinal pathology necessitating surgical intervention. Intervertebral device subsidence is a postoperative clinical risk that can lead to recurrence of symptomatic pathology and the need for surgical reintervention. The current study was designed to investigate static versus expandable lateral intervertebral spacers in indirect decompression for preserving vertebral body endplate strength.
Using a cadaveric biomechanical study and a foam-block vertebral body model, researchers compared vertebral body endplate strength and distraction potential. Fourteen lumbar motion segments (7 L2–3 and 7 L4–5 specimens) were distributed evenly between static and expandable spacer groups. In each specimen discectomy was followed by trialing and spacer impaction. Motion segments were axially sectioned through the disc, and a metal stamp was used to apply a compressive load to superior and inferior vertebral bodies to quantify endplate strength. A paired, 2-sample for means t-test was performed to determine statistically significant differences between groups (p ≤ 0.05). A foam-block endplate model was used to control simulated disc tension when a spacer with 2- and 3-mm desired distraction was inserted. One-way ANOVA and a post hoc Student Newman-Keuls test were performed (p ≤ 0.05) to determine differences in distraction.
Both static and expandable spacers restored intact neural foramen and disc heights after device implantation (p > 0.05). Maximum peak loads at endplate failure for static and expandable spacers were 1764 N (± 966 N) and 2284 N (± 949 N), respectively (p ≤ 0.05). The expandable spacer consistently produced greater desired distraction than was created by the static spacer in the foam-block model (p ≤ 0.05). Distraction created by fully expanding the spacer was significantly greater than the predetermined goals of 2 mm and 3 mm (p ≤ 0.05).
The current investigation shows that increased trialing required for a static spacer may lead to additional iatrogenic endplate damage, resulting in less distraction and increased propensity for postoperative implant subsidence secondary to endplate disruption.