Biomechanical evaluation of traditional posterior versus anterior spondylolisthesis reduction in a cadaveric grade I slip model

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OBJECTIVE

Posterior reduction with pedicle screws is often used for stabilization of unstable spondylolisthesis to directly reduce misalignment or protect against micromotion while fusion of the affected level occurs. Optimal treatment of spondylolisthesis combines consistent reduction with a reduced risk of construct failure. The authors compared the reduction achieved with a novel anterior integrated spacer with a built-in reduction mechanism (ISR) to the reduction achieved with pedicle screws alone, or in combination with an anterior lumbar interbody fusion (ALIF) spacer, in a cadaveric grade I spondylolisthesis model.

METHODS

Grade I slip was modeled in 6 cadaveric L5–S1 segments by creation of a partial nucleotomy and facetectomy and application of dynamic cyclic loading. Following the creation of spondylolisthesis, reduction was performed under increasing axial loads, simulating muscle trunk forces between 50 and 157.5 lbs, in the following order: bilateral pedicle screws (BPS), BPS with an anterior spacer (BPS+S), and ISR. Percent reduction and reduction failure load—the axial load at which successful reduction (≥ 50% correction) was not achieved—were recorded along with the failure mechanism. Corrections were evaluated using lateral fluoroscopic images.

RESULTS

The average loads at which BPS and BPS+S failed were 92.5 ± 6.1 and 94.2 ± 13.9 lbs, respectively. The ISR construct failed at a statistically higher load of 140.0 ± 27.1 lbs. Reduction at the largest axial load (157.5 lbs) by the ISR device was tested in 67% (4 of 6) of the specimens, was successful in 33% (2 of 6), and achieved 68.3 ± 37.4% of the available reduction. For the BPS and BPS+S constructs, the largest axial load was 105.0 lbs, with average reductions of 21.3 ± 0.0% (1 of 6) and 32.4 ± 5.7% (3 of 6) respectively.

CONCLUSIONS

While both posterior and anterior reduction devices maintained reduction under gravimetric loading, the reduction capacity of the novel anterior ISR device was more effective at greater loads than traditional pedicle screw techniques. Full correction was achieved with pedicle screws, with or without ALIF, but under significantly lower axial loads. The anterior ISR may prove useful when higher reduction forces are required; however, additional clinical studies will be needed to evaluate the effectiveness of anterior devices with built-in reduction mechanisms.

ABBREVIATIONS ALIF = anterior lumbar interbody fusion; AP = anterior-posterior; BPS = bilateral pedicle screw; BPS+S = BPS with an anterior spacer; ISR = integrated spacer with a built-in reduction mechanism; TLIF = transforaminal lumbar interbody fusion.

Article Information

Correspondence Jonathan M. Mahoney: Globus Medical, Audubon, PA. jmahoney@globusmedical.com.

INCLUDE WHEN CITING Published online May 3, 2019; DOI: 10.3171/2019.2.SPINE18726.

Disclosures Surgeons P.W.H. and D.D. have no financial relationship with Globus Medical, Inc. (GMI). Investigator J.C.H. was a visiting research intern and compensated hourly by GMI. Cadaveric specimens and related materials were provided by GMI, at which J.M.M., J.A.H., M.M.H., N.F.K., and B.S.B. are, or were at one point, full-time employees. J.A.H. reports GMI direct stock ownership. The study was performed at GMI, using its 6-degrees-of-freedom motion simulator.

Note: The integrated spacer with a built-in reduction mechanism (ISR) device (MONUMENT, Globus Medical, Inc.), pedicle screws and rods (REVERE, Globus Medical, Inc.), and anterior lumbar interbody spacer (CONTINENTAL, Globus Medical, Inc.) examined in this study are FDA cleared for this indication.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Photograph of an anterior lumbar interbody spacer designed to facilitate reduction of grade I spondylolisthesis. Its translating component (left) can be manually adjusted to fit patient anatomy while optimal screw placement is attained in cortical bone.

  • View in gallery

    A: L4–sacrum model, where α is the angle of the L5–S1 disc from horizontal. Trunk weight (W) is distributed into shear (W × sinα) and compression (W × cosα) forces, making the creation of spondylolisthesis angle dependent. B: Illustration of lumbosacral segment in a custom articulating fixture to achieve 50° of angulation. C: Photograph showing the L5–S1 segment during spondylolisthesis model creation. D: Photograph of an L5–S1 segment in the radiolucent polyurethane structure used to apply an axial load via weighted plate during capture of fluoroscopic images.

  • View in gallery

    Representative lateral fluoroscopic image of the lumbosacral specimen following spondylolisthesis creation. S1 AP diameter (short-dashed line) and anterior displacement of L5 posterior cortical wall relative to S1 (long-dashed lines and double arrow). Maximum grade I spondylolisthesis was achieved once the anterior displacement (mm) was approximately 25% of the total AP diameter of the S1 superior endplate. Cyclic loading was essential to shift L5 to its final targeted slip from the original anterior slip created following discectomy.

  • View in gallery

    Line graph showing mean percentage of spondylolisthesis correction at successive axial loads until reduction failure.

  • View in gallery

    Bar graph showing the axial load (mean ± SD) at which a successful spondylolisthesis reduction failed to occur. For specimens that did not fail, the maximum tested load (157.5 lbs) was used to represent the maximum load for spondylolisthesis correction.

  • View in gallery

    Radiographs showing the 3 reduction techniques tested, and corresponding failure modes. The dashed lines show the L5 position with respect to the S1 endplate under 50 lbs of loading before and after reduction. The circles show the mode of failure associated with each technique. The BPS construct failed because of L5 screw pullout, and the BPS+S construct failed because of S1 polyaxial screw head position changes. The ISR construct failed because the S1 screw toggle caused a sacral fracture.

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