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.
Abbreviation used in this paper: BMD = bone mineral density.
Address correspondence to: Avinash G. Patwardhan, Ph.D., Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 South First Avenue, Maywood, Illinois 60153. email: firstname.lastname@example.org.
CoeJDWardenKEHerzigMAMcAfeePC: Influence of bone mineral density on the fixation of thoracolumbar implants. A comparative study of transpedicular screws, laminar hooks, and spinous process wires. Spine15:902–9071990
KukloTRPotterBKLenkeLGPollyDWJrSidesBBridwellKH: Surgical revision rates of hooks versus hybrid versus screws versus combined anteroposterior spinal fusion for adolescent idiopathic scoliosis. Spine32:2258–22642007
SawadaKMorishigeKOhmichiMNishioYYamamotoTHayakawaJ: Peripheral quantitative computed tomography (pQCT) is useful for monitoring bone mineral density of the patients who receive hormone replacement therapy. Maturitas56:343–3492007