Biomechanical evaluation of the ProDisc-C stability following graded posterior cervical injury

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OBJECTIVE

There are limited data regarding the implications of revision posterior surgery in the setting of previous cervical arthroplasty (CA). The purpose of this study was to analyze segmental biomechanics in human cadaveric specimens with and without CA, in the context of graded posterior resection.

METHODS

Fourteen human cadaveric cervical spines (C3–T1 or C2–7) were divided into arthroplasty (ProDisc-C, n = 7) and control (intact disc, n = 7) groups. Both groups underwent sequential posterior element resections: unilateral foraminotomy, laminoplasty, and finally laminectomy. Specimens were studied sequentially in two different loading apparatuses during the induction of flexion-extension, lateral bending, and axial rotation.

RESULTS

Range of motion (ROM) after artificial disc insertion was reduced relative to that in the control group during axial rotation and lateral bending (13% and 28%, respectively; p < 0.05) but was similar during flexion and extension. With sequential resections, ROM increased by a similar magnitude following foraminotomy and laminoplasty in both groups. Laminectomy had a much greater effect: mean (aggregate) ROM during flexion-extension, lateral bending, and axial rotation was increased by a magnitude of 52% following laminectomy in the setting of CA, compared to an 8% increase without arthroplasty. In particular, laminectomy in the setting of CA introduced significant instability in flexion-extension, characterized by a 90% increase in ROM from laminoplasty to laminectomy, compared to a 16% increase in ROM from laminoplasty to laminectomy without arthroplasty (p < 0.05).

CONCLUSIONS

Foraminotomy and laminoplasty did not result in significant instability in the setting of CA, compared to controls. Laminectomy alone, however, resulted in a significant change in biomechanics, allowing for significantly increased flexion and extension. Laminectomy alone should be used with caution in the setting of previous CA.

ABBREVIATIONS BMD = bone mineral density; CA = cervical arthroplasty; IAR = instantaneous axis of rotation; LZ = lax zone; PLL = posterior longitudinal ligament; RM-ANOVA = repeated-measures analysis of variance; ROM = range of motion; SZ = stiff zone.

Article Information

Correspondence Neil Duggal: Western University, London, ON, Canada. neil.duggal@lhsc.on.ca.

INCLUDE WHEN CITING Published online August 31, 2018; DOI: 10.3171/2018.3.SPINE171248.

Disclosures Dr. Crawford is an employee of and has direct stock ownership in Globus Medical. Dr. Duggal is a consultant for Synergy Disc Replacement Inc., has received clinical or research support from DePuy Synthes for the study described, and has received support from Medtronic for non–study-related clinical or research effort.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Photographs of representative specimens demonstrating the surgical procedures studied. A: Anterior view showing ProDisc-C device positioned at the C5–6 disc space. B: Posterolateral view showing the extent of the foraminotomy. C: Posterolateral view showing the laminoplasty construct. D: Posterior view showing the extent of the laminectomy. Note that the transected PLL is visible across the empty spinal canal. Figure is available in color online only.

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    Loading apparatuses used in the experiments. Left: Pure-moment apparatus: Adjustable pulleys are used in conjunction with a standard servohydraulic test frame, enabling two equal and opposite forces separated by a small distance (pure moment) to be applied through a looped string when the piston advances upward. Right: Flexion-compression apparatus: A stepper motor connected to the specimen with a heavy belt applies flexion or extension. Weights hung from the motor apply a constant compressive preload. Because of the orientation of the pulleys, the direction of the preload stays aligned with the axis of the specimen throughout movement. Figure is available in color online only.

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    Mean normalized angular ROM at the index level in each condition studied. Error bars show standard deviations. *Indicates significant difference of arthroplasty group (upper) compared to control group (lower). Significant within-group differences from intact specimens without posterior resection are indicated by # (including foraminotomy and laminoplasty), @ (excluding foraminotomy), and + (including laminoplasty, but excluding foraminotomy).

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    Mean normalized angular LZ at the index level in each condition studied. Error bars show standard deviations. *Indicates significant difference of arthroplasty group (upper) compared to control group (lower). Significant within-group differences from intact specimens without posterior resection are indicated by # (including foraminotomy and laminoplasty).

  • View in gallery

    Mean normalized angular SZ at the index level in each condition studied. Error bars show standard deviation. *Indicates significant difference of arthroplasty group (upper) compared to control group (lower). Significant within-group differences from intact specimens without posterior resection are indicated by # (including foraminotomy, but not laminoplasty).

  • View in gallery

    Coupled lateral bending per degree of primary axial rotation (A and B) and coupled axial rotation per degree of primary lateral bending (C and D) at the index level. Error bars show standard deviations. Significant within-group differences from intact specimens without posterior resection are indicated by # (including foraminotomy and laminoplasty).

  • View in gallery

    Mean location of the axis of rotation at the index level in the sagittal plane in the intact condition for the arthroplasty group and the control group. Error bars show standard deviation among 7 specimens per group. Figure is available in color online only.

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