Current benchtop protocols are not appropriate for the evaluation of distraction-based growing rods: a literature review to justify a new protocol and its development.

PURPOSE: Although distraction-based growing rods (GR) are the gold standard for the treatment of early onset scoliosis, they suffer from high failure rates. We have (1) performed a literature search to understand the deficiencies of the current protocols, (2) in vitro evaluation of GRs using our proposed protocol and performed a finite element (FE) model validation, and (3) identified key features which should be considered in mechanical testing setups. METHODS: PubMed, Embase, and Web of Science databases were searched for articles published on (a) in vivo animal, in vitro cadaveric, and biomechanical studies analyzing the use of GRs as well as (b) failure mechanisms and risk factors for GRs. Both FE and benchtop models of a proposed TGR test construct were developed and evaluated for two cases, long tandem connectors (LT), and side-by-side connectors (SBS). The test construct consisted of five polymer blocks representing vertebral bodies, joined with springs to simulate spinal stiffness. The superior and inferior blocks accepted the pedicle screw anchors, while the three middle blocks were floating. After the pedicle screws, rods, and connectors were assembled onto this construct, distraction was performed, mimicking scoliosis surgery. The resulting distracted constructs were then subjected to static compression-bending loading. Yield load and stiffness were calculated and used to verify/validate the FE results. RESULTS: From the literature search, key features identified as significant were axial and transverse connectors, contoured rods, and distraction, distraction being the most challenging feature to incorporate in testing. The in silico analyses, once they are validated, can be used as a complementing technique to investigate other anatomical features which are not possible in the mechanical setup (like growth/scoliosis curvature). Based on our experiment, the LT constructs showed higher stiffness and yield load compared to SBS (78.85 N/mm vs. 59.68 N/mm and 838.84 N vs. 623.3 N). The FE predictions were in agreement with the experimental outcomes (within 10% difference). The maximum von Mises stresses were predicted adjacent to the distraction site, consistent with the location of observed failures in vivo. CONCLUSION: The two-way approach presented in this study can lead to a robust prediction of the contributing factors to the in vivo failure.

Validation of a patient-specific finite element analysis framework for identification of growing rod-failure regions in early onset scoliosis patients.

PURPOSE: Growing rods are the gold-standard for treatment of early onset scoliosis (EOS). However, these implanted rods experience frequent fractures, requiring additional surgery. A recent study by the U.S. Food and Drug Administration (FDA) identified four common rod fracture locations. Leveraging this data, Agarwal et al. were able to correlate these fractures to high-stress regions using a novel finite element analysis (FEA) framework for one patient. The current study aims to further validate this framework through FEA modeling extended to multiple patients. METHODS: Three patient-specific FEA models were developed to match the pre-operative patient data taken from both registry and biplanar radiographs. The surgical procedure was then simulated to match the post-operative deformity. Body weight and flexion bending (1 Nm) loads were then applied and the output stress data on the rods were analyzed. RESULTS: Radiographic data showed fracture locations at the mid-construct, adjacent to the distal and tandem connector across the patients. Stress analysis from the FEA showed these failure locations matched local high-stress regions for all fractures observed. These results qualitatively validate the efficacy of the FEA framework by showing a decent correlation between localized high-stress regions and the actual fracture sites in the patients. CONCLUSIONS: This patient-specific, in-silico framework has huge potential to be used as a surgical tool to predict sites prone to fracture in growing rod implants. This prospective information would therefore be vital for surgical planning, besides helping optimize implant design for reducing rod failures.

Pelvic Ring Fractures: A Biomechanical Comparison of Sacral and Lumbopelvic Fixation Techniques.

BACKGROUND CONTEXT: Pelvic ring fractures are becoming more common in the aging population and can prove to be fatal, having mortality rates between 10% and 16%. Stabilization of these fractures is challenging and often require immediate internal fixation. Therefore, it is necessary to have a biomechanical understanding of the different fixation techniques for pelvic ring fractures. METHODS: A previously validated three-dimensional finite element model of the lumbar spine, pelvis, and femur was used for this study. A unilateral pelvic ring fracture was simulated by resecting the left side of the sacrum and pelvis. Five different fixation techniques were used to stabilize the fracture. A compressive follower load and pure moment was applied to compare different biomechanical parameters including range of motion (contralateral sacroiliac joint, L1-S1 segment, L5-S1 segment), and stresses (L5-S1 nucleus stresses, instrument stresses) between different fixation techniques. RESULTS: Trans-iliac-trans-sacral screw fixation at S1 and S2 showed the highest stabilization for horizontal and vertical displacement at the sacral fracture site and reduction of contralateral sacroiliac joint for bending and flexion range of motion by 165% and 121%, respectively. DTSF (Double transiliac rod and screw fixation) model showed highest stabilization in horizontal displacement at the pubic rami fracture site, while the L5_PF_W_CC (L5-Ilium posterior screw fixation with cross connectors) and L5_PF_WO_CC (L5-Ilium posterior screw fixation without cross connectors) showed higher rod stresses, reduced L1-S1 (approximately 28%), and L5-S1 (approximately 90%) range of motion. CONCLUSIONS: Longer sacral screw fixations were superior in stabilizing sacral and contralateral sacroiliac joint range of motion. Lumbopelvic fixations displayed a higher degree of stabilization in the horizontal displacement compared to vertical displacement of pubic rami fracture, while also indicating the highest rod stresses. When determining the surgical approach for pelvic ring fractures, patient-specific factors should be accounted for to weigh the advantages and disadvantages for each technique.

The Effect of Anterior-Only, Posterior-Only, and Combined Anterior Posterior Fixation for Cervical Spine Injury with Soft Tissue Injury: A Finite Element Analysis.

OBJECTIVE: This finite element analysis aimed to investigate the effects of surgical procedures for cervical spine injury. METHODS: A three-dimensional finite element model of the cervical spine (C2-C7) was created from computed tomography. This model contained vertebrae, intervertebral discs, anterior longitudinal ligament, and posterior ligament complex. To create the cervical spine injury model, posterior ligament complex and anterior longitudinal ligament at C3-C4 were resected and the center of the intervertebral disc was resected. We created posterior-only fixation (PF), anterior-only fixation (AF), and combined anterior-posterior fixation (APF) models. A pure moment with a compressive follower load was applied, and range of motion, annular/nucleus stress, instrument stress, and facet forces were analyzed. RESULTS: In all motion except for flexion, range of motion of PF, AF, and APF models decreased by 80%-95%, 85%-93%, and 97%-99% compared with the intact model. C3-C4 annulus stress of PF, AF, and APF models decreased by 28%-72%, 96%-100%, and 99%-100% compared with the intact model. Facet contact forces of PF, AF, and APF models decreased by 77%-79%, 97%-99%, and 77%-86% at C3-C4 compared with the intact model. Screw stress in the PF model was higher than in the APF model, and plate stress in the AF model was lower than in the APF model, but bone graft stress in the AF model was higher than in the APF model. CONCLUSIONS: Cervical stabilization was preserved by the APF model. Regarding range of motion, the PF model had an advantage compared with the AF model except for flexion. An understanding of biomechanics provides useful information for the clinician.

The Effect of Posterior Lumbar Interbody Fusion in Lumbar Spine Stenosis with Diffuse Idiopathic Skeletal Hyperostosis: A Finite Element Analysis.

OBJECTIVE: Lumbar spinal canal stenosis (LSS) with diffuse idiopathic skeletal hyperostosis (DISH) can require revision surgery because of the intervertebral instability after decompression. However, there is a lack of mechanical analyses for decompression procedures for LSS with DISH. METHODS: This study used a validated, three-dimensional finite element model of an L1-L5 lumbar spine, L1-L4 DISH, pelvis, and femurs to compare the biomechanical parameters (range of motion [ROM], intervertebral disc, hip joint, and instrumentation stresses) with an L5-sacrum (L5-S) and L4-S posterior lumbar interbody fusion (PLIF). A pure moment with a compressive follower load was applied to these models. RESULTS: ROM of L5-S and L4-S PLIF models decreased by more than 50% at L4-L5, respectively, and decreased by more than 15% at L1-S compared with the DISH model in all motions. The L4-L5 nucleus stress of the L5-S PLIF increased by more than 14% compared with the DISH model. In all motions, the hip stress of DISH, L5-S, and L4-S PLIF had very small differences. The sacroiliac joint stress of L5-S and L4-S PLIF models decreased by more than 15% compared with the DISH model. The stress values of the screws and rods in the L4-S PLIF model was higher than in the L5-S PLIF model. CONCLUSIONS: The concentration of stress because of DISH may influence adjacent segment disease on the nonunited segment of PLIF. A shorter-level lumbar interbody fixation is recommended to preserve ROM; however, it should be used with caution because it could provoke adjacent segment disease.

Resisting subsidence with a truss Implant: Application of the "Snowshoe" principle for interbody fusion devices.

The primary objective was to compare the subsidence resistance properties of a novel 3D-printed spinal interbody titanium implant versus a predicate polymeric annular cage. We evaluated a 3D-printed spinal interbody fusion device that employs truss-based bio-architectural features to apply the snowshoe principle of line length contact to provide efficient load distribution across the implant/endplate interface as means of resisting implant subsidence. Devices were tested mechanically using synthetic bone blocks of differing densities (osteoporotic to normal) to determine the corresponding resistance to subsidence under compressive load. Statistical analyses were performed to compare the subsidence loads and evaluate the effect of cage length on subsidence resistance. The truss implant demonstrated a marked rectilinear increase in resistance to subsidence associated with increase in the line length contact interface that corresponds with implant length irrespective of subsidence rate or bone density. In blocks simulating osteoporotic bone, comparing the shortest with the longest length truss cage (40 vs. 60 mm), the average compressive load necessary to induce subsidence of the implant increased by 46.4% (383.2 to 561.0 N) and 49.3% (567.4 to 847.2 N) for 1 and 2 mm of subsidence, respectively. In contrast, for annular cages, there was only a modest increase in compressive load when comparing the shortest with the longest length cage at a 1 mm subsidence rate. The Snowshoe truss cages demonstrated substantially more resistance to subsidence than corresponding annular cages. Clinical studies are required to support the biomechanical findings in this work.

Sagittal Imbalance May Lead to Higher Risks of Vertebral Compression Fractures and Disc Degeneration-A Finite Element Analysis.

BACKGROUND: Sagittal balance is an important clinical parameter of the spine for its normal function. Maintenance of the sagittal balance is crucial in the clinical management of spinal problems. METHODS: Three different finite element models with spinal alignments based on Schwab's classification were developed: (1) Balanced/Normal model (sagittal vertical axis [SVA] = 0 mm, lumbar lordosis [LL] = 50°, thoracic kyphosis [TK] = 25°, pelvic incidence [PI] = 45°, pelvic tilt [PT] = 10°, sacral slope [SS] = 35°); (2) Balanced with compensatory mechanisms/Flatback model (SVA = 50 mm, LL = 20°, TK = 20°, PI = 45°, PT = 30°, SS = 15°); and (3) Imbalanced/Hyperkyphotic model (SVA = 150 mm, LL = -5°, TK = 25°, PI = 45°, PT = 40°, SS = 5°). All 3 models were subjected to the follower loads simulating bodyweight/muscular contractions along with the moments to simulate flexion, extension, lateral bending, and axial rotation. The maximum cortical vertebral stress, annular stress, and intradiscal pressure (IDP) were calculated and compared. RESULTS: The results showed that the hyperkyphotic model had higher stresses in the vertebrae (25% higher), the annulus fibrosus (48% higher) and the IDP (8% higher) than the normal models in flexion. The segments near the thoracolumbar junction (T10-L1) showed the highest increase in the vertebral body stress, the annulus fibrosus stress, and the IDP. CONCLUSIONS: This study showed that the imbalance in sagittal alignment might be responsible for disc degeneration and atraumatic vertebral fractures at the thoracolumbar regions, supporting clinical findings.

Total disc replacement alters the biomechanics of cervical spine based on sagittal cervical alignment: A finite element study.

Introduction: The correlation between cervical alignment and clinical outcome of total disc replacement (TDR) surgery is arguable. We believe that this conflict exists because the parameters that influence the biomechanics of the cervical spine are not well understood, specifically the effect of TDR on different cervical alignments. Methods: A validated osseo-ligamentous model from C2-C7 was used in this study. The C2-C7 Cobb angle of the base model was modified to represent: lordotic (-10°), straight (0°), and kyphotic (+10°) cervical alignment. The TDR surgery was simulated at the C5-C6 segment. The range of motion (ROM), intradiscal pressure, annular stresses, and facet loads were computed for all the models. Results: The ROM results demonstrated kyphotic alignment after TDR surgery to be the most mobile when compared to intact base model (41% higher in flexion-extension, 51% higher in lateral bending, and 27% higher in axial rotation) followed by straight and lordotic alignment, respectively. The annular stresses for the kyphotic alignment when compared to intact base model were higher at the index level (33% higher in flexion-extension and 48% higher in lateral bending) compared to other alignments. The lordotic model demonstrated higher facet contact forces at the index level (75% higher in extension than kyphotic alignment, 51% higher in lateral bending than kyphotic alignment, and 78% higher in axial rotation than kyphotic alignment) when compared among the three alignment models. Conclusion: Preoperative cervical alignment should be an integral part of surgical planning for TDR surgery as different cervical alignments may significantly alter the postsurgical outcomes.

C1-C2 arthroplasty for craniovertebral junction instability: A preliminary proof of concept in human cadavers.

Background: The atlantoaxial complex contributes to significant neck movements, especially the axial rotation. Its instability is currently treated with various C1-C2 fusion techniques. This however, considerably hampers the neck movements and affects the quality of life; a C1-C2 motion preserving arthroplasty could potentially overcome this drawback. Objectives: We evaluate the range of motion (ROM) of lateral C1-C2 artificial joints in cadaveric models. Materials and Methods: This is an in vitro cadaveric biomechanical study. After C1-C2 arthroplasty through a posterior approach, the C1-C2 ROM was tested in 4 fresh-frozen human cadaveric specimens, before and after destabilization. Results: The mean axial rotation demonstrated after the placement of C1-C2 joint implants was 15.46 degrees on the right and 16.03 degrees on the left side; the prosthesis provided stability, with 46% of the baseline C1-C2 axial rotation on either side. The ROM achieved in the other axes was less compared with that of intact specimens. To initiate rotation, a higher moment of 1.5 Nm was required in the presence of joint implants compared to 0.5 NM in unimplanted specimens. Conclusions: In our preliminary ROM evaluation, the C1-C2 arthroplasty appears to be stable and provides about half of the range of atlantoaxial rotation. It has the potential for joint motion preservation in the treatment of atlantoaxial instability resulting from lateral C1-C2 joint pathologies.

Biomechanical analysis of laminectomy, laminoplasty, posterior decompression with instrumented fusion, and anterior decompression with fusion for the kyphotic cervical spine.

PURPOSE: Anterior and posterior decompressions for cervical myelopathy and radiculopathy may lead to clinical improvements. However, patients with kyphotic cervical alignment have sometimes shown poor clinical outcomes with posterior decompression. There is a lack on report of mechanical analysis of the decompression procedures for kyphotic cervical alignment. METHODS: This study employed a three-dimensional finite element (FE) model of the cervical spine (C2-C7) with the pre-operative kyphotic alignment (Pre-OK) model and compared the biomechanical parameters (range of motion (ROM), annular stresses, nucleus stresses, and facet contact forces) for four decompression procedures at two levels (C3-C5); laminectomy (LN), laminoplasty (LP), posterior decompression with fusion (PDF), and anterior decompression with fusion (ADF). Pure moment with compressive follower load was applied to these models. RESULTS: PDF and ADF models' global ROM were 40% at C2-C7 less than the Pre-OK, LN, and LP models. The annular and nucleus stresses decreased more than 10% at the surgery levels for ADF, and PDF, compared to the Pre-OK, LN, and LP models. However, the annular stresses at the adjacent cranial level (C2-C3) of ADF were 20% higher. The nucleus stresses of the caudal adjacent level (C5-C6) of PDF were 20% higher, compared to other models. The PDF and ADF models showed a less than 70% decrease in the facet forces at the surgery levels, compared to the Pre-OK, LN, and LP models. CONCLUSION: The study concluded that posterior decompression, such as LN or LP, increases ROM, disc stress, and facet force and thus can lead to instability. Although there is the risk of adjacent segment disease (ASD), PDF and ADF can stabilize the cervical spine even for kyphotic alignments.

Soft Tissue Injury in Cervical Spine Is a Risk Factor for Intersegmental Instability: A Finite Element Analysis.

OBJECTIVE: Soft tissue cervical spine injury (CSI) has the possibility of causing cervical segmental instability, which can lead to spinal cord injury. There is a lack of certainty in assessing whether soft tissue CSI is unstable or not. This biomechanical study aimed to investigate the risk factors of soft tissue CSI. METHODS: A 3-dimensional finite element model of the ligamentous cervical spine (C2-C7) was created from medical images. Three soft tissue injury models were simulated at C4-C5: 1) posterior ligament complex (PLC) injury, 2) intervertebral disk (ID) with anterior longitudinal ligament injury (IDI), and 3) anterior longitudinal ligament, PLC, and ID injury (API) model. Pure moment with compressive follower load was applied, and the range of motion, annular stress, nucleus stress, and facet forces were analyzed. RESULTS: For the IDI and API models, the range of motion increased at the injury level in extension (by 101%) and left/right axial rotations (>30%) compared with the intact model. The IDI and API models showed an increase of >50% in annular and nucleus stresses at the injury level in extension and left/right rotations compared with the intact model. The PLC injury showed similar stresses as the intact model except for flexion. The facet contact forces of IDI and API models increased more than 100% compared with other models in all motions. CONCLUSIONS: In CSI, all soft tissues have a key role in stabilizing cervical spine, but ID is the most important component of all.

Electrical Stimulation-Mediated Tissue Healing in Porcine Intervertebral Disc Under Mechanically Dynamic Organ Culture Conditions.

STUDY DESIGN: Porcine intervertebral discs (IVDs) were excised and then drilled to simulate degeneration before being electrically stimulated for 21 days while undergoing mechanical loading. The discs were then analyzed for gene expression and morphology to assess regeneration. OBJECTIVE: The purpose of this study was to investigate the effectiveness of the electrical stimulation of IVD treatment as an early intervention method in halting the progression of degenerative disc disease using an ex-vivo porcine model. SUMMARY OF BACKGROUND DATA: Treatments for degenerative disc disease are limited in their efficacy and tend to treat the symptoms of the disease rather than repairing the degenerated disc itself. There is a dire need for an early intervention treatment that not only halts the progression of the disease but contributes to reviving the degenerated disc. METHODS: Lumbar IVDs were extracted from a mature pig within 1 hour of death and were drilled with a 1.5 mm bit to simulate degenerative disc disease. Four IVDs at a time were then cultured in a dynamic bioreactor system under mechanical loading for 21 days, two with and two without the electrical stimulation treatment. The IVDs were assessed using histological analysis, magnetic resonance imaging, and quantitative reverse transcriptase polymerase chain reaction to quantify the effectiveness of the treatment on the degenerated discs. RESULTS: IVDs with electrical stimulation treatment exhibited extensive annular regeneration and prevented herniation of the nucleus pulposus (NP). In contrast, the untreated group of IVDs were unable to maintain tissue integrity and exhibited NP herniation through multiple layers of the annulus fibrosus. Gene expression showed an increase of extracellular matrix markers and antiinflammatory cytokine interleukin-4 (IL-4), while decreasing in pro-inflammatory markers and pain markers in electrically stimulated IVDs when compared to the untreated group. CONCLUSION: The direct electrical stimulation application in NP of damaged IVDs can be a viable option to regenerate damaged NP and annulus fibrosus tissues.

Finite Element Comparison of the Spring Distraction System and the Traditional Growing Rod for the Treatment of Early Onset Scoliosis.

STUDY DESIGN: Finite element analysis (FEA). OBJECTIVE: The aim of this study was to determine biomechanical differences between traditional growing rod (TGR) and spring distraction system (SDS) treatment of early-onset scoliosis. SUMMARY OF BACKGROUND DATA: Many "growth-friendly" implants like the TGR show high rates of implant failure, spinal stiffening, and intervertebral disc (IVD) height loss. We developed the SDS, which employs continuous, dynamic forces to mitigate these limitations. The present FEA compares TGR and SDS implantation, followed by an 18-month growth period. METHODS: Two representative, ligamentous, scoliotic FEA models were created for this study; one representing TGR and one representing SDS. initial implantation, and up to 18 months of physeal spinal growth were simulated. The SDS model was continuously distracted over this period; the TGR model included two additional distractions following index surgery. Outcomes included differences in rod stress, spinal morphology and iVD stress-shielding. RESULTS: Maximum postoperative von Mises stress was 249MPa for SDS, and 205MPa for TGR. During the 6-month TGR distraction, TGR rod stress increased over two-fold to a maximum stress of 417MPa, compared to a maximum of 262 MPa in the SDS model at 6-month follow-up. During subsequent follow-up periods, TGR rod stress remained consistently higher than stresses in the SDS model. Additional lengthenings in the TGR model led to a smaller residual curve (16.08) and higher T1-S1 growth (359 mm) at 18-month follow-up compared to the SDS model (26.98, 348 mm). During follow-up, there was less stress-shielding of the IVDs in the SDS model, compared to the TGR model. At 18-month follow-up, upper and lower IVD surfaces of the SDS model were loaded more in compression than their TGR counterparts (mean upper: +112 ±â€Š19N; mean lower: +100 ±â€Š17N). CONCLUSION: In the present FEA, TGR treatment resulted in slightly larger curve correction compared to SDS, at the expense of increased IVD stress-shielding and a higher risk of rod fractures. LEVEL OF EVIDENCE: N/A.

Towards a validated patient-specific computational modeling framework to identify failure regions in traditional growing rods in patients with early onset scoliosis.

BACKGROUND: While growing rods are an important contribution to early-onset scoliosis treatment, rod fractures are a common complication that require reoperations. A recent retrieval analysis study performed on failed traditional growing rods revealed that there are commonalities among patient characteristics based on the location of rod fracture. However, it remains unknown if these locations correspond to high stress regions in the implanted construct. METHODS: A patient-specific finite element scoliotic model was developed to match the pre-operative (pre-op) scoliotic curve of a patient as described in previously published articles, and by using the patient registry information along with biplanar radiographs. A dual stainless-steel traditional growing rod construct was implanted into this scoliotic model and the surgical procedure was simulated to match the post-operative (post-op) scoliotic curve parameters. Muscle stabilization and gravity was simulated through follower load application. Rod distraction magnitudes were chosen based on pre-op to post-op cobb angle correction, and flexion bending load was simulated to identify the high stress regions on the rods. RESULTS: The patient-specific finite element model identified two high stress regions on the posterior surface of the rods, one at mid construct and the other adjacent to the distal anchors. This correlated well with the data obtained from the retrieval analysis performed by researchers at U.S. Food and Drug Administration (FDA) which showed the posterior surface of the rod as the fracture initiation site, and the three locations of failure as mid-construct, adjacent to distal anchors, and adjacent to tandem connector. CONCLUSIONS: The result of this study confirms that the high stress regions on the growing rods, as identified by the FEA, match the fracture prone sites identified in the retrieval analysis performed at the FDA. This proof-of-concept patient-specific approach can be used to predict sites prone to fracture in growing rods.

Biomechanical evaluation of a novel decompression surgery: Transforaminal full-endoscopic lateral recess decompression (TE-LRD).

BACKGROUND: Transforaminal full endoscopic lateral recess decompression (TE-LRD) can decompress lateral recess stenosis transforaminally under the endoscopy procedure. However, the biomechanical effects of the TE-LRD compared to the conventional decompression techniques are not reported. The purpose of this study is to compare the biomechanical effects of TE-LRD with conventional decompression techniques using finite element method. METHODS: Three finite element models of lumbar functional spinal unit (FSU) of the L4-L5 levels were created: 1) normal disc 2) moderate grade disc degeneration 3) severe grade disc degeneration. For each of these three models, the following decompression techniques were simulated, 1) 50% TE-LRD, 2) 100% TE-LRD, 3) Unilateral laminectomy, 4) Bilateral laminectomy. The lower endplate of the fifth lumbar vertebra was fixed and 10Nm of moment in flexion/extension, left/right bending and axial rotation was applied to the upper endplate of the fourth lumbar vertebra, under a follower load of 400N. The range of motion, intervertebral disc stress, and facet joint stress were compared. RESULTS: 50% TE-LRD was found to be the most stable decompression technique in all intervertebral disc models. Though the increase in the range of motion of 100% TE-LRD was higher than other decompression techniques in the normal disc model, it was not significantly different from 50% TE-LRD or unilateral laminectomy techniques in the degenerated disc models. The increase in the intervertebral disc stress was lowest for the 50% TE-LRD surgery in all intervertebral disc models. The increase in the facet stresses for 50% TE-LRD was lower than in the conventional decompression techniques for all intervertebral disc models. CONCLUSIONS: 50% TE-LRD was the decompression surgical technique with the least effect on spinal instability. 100% TE-LRD showed to be effective for cases with degenerative discs. 50% TE-LRD may decrease the risk of postoperative intervertebral disc and facet joint degeneration.

The Transverse Process Trajectory Technique: An Alternative for Thoracic Pedicle Screw Implantation-Radiographic and Biomechanical Analysis.

BACKGROUND: This study evaluates the accuracy, biomechanical profile, and learning curve of the transverse process trajectory technique (TPT) compared to the straightforward (SF) and in-out-in (IOI) techniques. SF and IOI have been used for fixation in the thoracic spine. Although widely used, there are associated learning curves and symptomatic pedicular breaches. We have found the transverse process to be a reproducible pathway into the pedicle. METHODS: Three surgeons with varying experience (experienced [E] with 20 years in practice, surgeon [S] with less than 10 years in practice, and senior resident trainee [T] with no experience with TPT) operated on 8 cadavers. In phase 1, each surgeon instrumented 2 cadavers, alternating between TPT and SF from T1 to T12 (n = 48 total levels). In phase 2, the E and T surgeons instrumented 1 cadaver each, alternating between TPT and IOI. Computed tomography scans were analyzed for accuracy of screw placement, defined as the percentage of placements without critical breaches. Axial pullout and derotational force testing were performed. Statistical analyses include paired t test and analysis of variance with Tukey correction. RESULTS: Overall accuracy of screw placement was comparable between techniques (TPT: 92.7%; SF: 97.2%; IOI: 95.8%; P = .4151). Accuracy by technique did not differ for each individual surgeon (E: P = .7733; S: P = .3475; T: P = .4191) or by experience level by technique (TPT: P = .1127; FH: P = .5979; IOI: P = .5935). Pullout strength was comparable between TPT and SF (571 vs 442 N, P = .3164) but was greater for TPT versus IOI (454 vs 215 N, P = .0156). There was a trend toward improved derotational force for TPT versus SF (1.06 vs 0.93 Nm/degrees, P = .0728) but not for TPT versus IOI (1.36 vs 1.16 Nm/degrees, P = .74). Screw placement time was shortest for E and longest for T for TPT and SF and not different for IOI (TPT: P = .0349; SF: P < .0001; IOI: P = .1787) but did not vary by technique. CONCLUSIONS: We describe the TPT, which uses the transverse process as a corridor through the pedicle. TPT is an accurate method of thoracic pedicle screw placement with potential biomechanical advantages and with acceptable learning curve characteristics. CLINICAL RELEVANCE: This study provides the surgeon with a new trajectory for pedicle screw placement that can be used in clinical practice.

Device-Related Complications Associated with Magec Rod Usage for Distraction-Based Correction of Scoliosis.

INTRODUCTION: Recent literature identifies similar failure rates such as anchor pull-out and rod breakage, but a higher unplanned revision surgery with MAGEC rods than with traditional growth rods. Besides known failure modes such as rod fracture, infection, etc., failure to noninvasively distract the rods was cited as the main cause of such unplanned surgeries. The source of these data ranges from multicenter cohort studies to singular case series. These studies included explanted implants that had undergone failure in distraction mechanism, rod fracture, or infection, or had reached their maximum length. Nevertheless, in addition to identifying the overall mode of failure, it is equally important to identify the large-scale incidence of exclusive failures in comparison with standard instrumentation failure modes in spine surgery. METHODS: The US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) databases were searched for reports on MAGEC rods, and on standard instrumentation used for spinal fusion. The adverse events were recorded, tabulated, and analyzed. RESULTS: A search of the US FDA MAUDE database yielded reports of 163 device-related adverse events. These included distraction mechanism failure (n=129), rod fracture (n=24), and minor voluntary reports of infection and tissue discoloration (n=10). For standard instrumentation usage in spine surgery, pedicle screw breakage post surgery (n=336), set screw damage during surgery (n=257), rod breakage post surgery (n=175), interbody cage breakage during surgery (n=118), and pedicle screw breakage during surgery (n=75) were identified as the top 5 failure modes. CONCLUSIONS: The study identified the distraction mechanism failure as the most common and growing complication associated with MAGEC rod usage in children with scoliosis, leading to unplanned invasive revision surgeries.

A new lumbar fixation device alternative to pedicle-based stabilization for lumbar spine: In vitro cadaver investigation.

Context: To evaluate the stability provided by a new bilateral fixation technique using an in vitro investigation for posterior lumbar segmental instrumentation.Design: Experimental cadaver study. In this study, we propose an alternative technique for a posterior lumbar fixation technique called "inferior-oblique transdiscal fixation" (IOTF).Setting: Study performed at Engineering Center for Orthopedic Research Exellence (ECORE) in Toledo University-Ohio.Participants: Six human lumbar cadaveric specimen used in this study.Interventions: In this study, we propose an alternative technique for a posterior lumbar fixation technique called "inferior-oblique transdiscal fixation" (IOTF). As a novel contribution to the classical technique, the entry point of the screw is the supero-lateral point of the intersecting line drawn between the corpus and the pedicle of the upper vertebra. This approach enables the fixation of two adjacent vertebrae using a single screw on each side without utilizing connecting rods.Outcome Measures: Flexion (Flex), extension (Ext), right and left lateral bending (LB & RB), and right and left axial rotation (LR & RR), and the position data were captured at each load step using the Optotrak motion measurement system and compared for IOTF and posterior transpedicular stabilization.Results: The Posterior stabilization system (PSS) and IOTF significantly reduced the ROM of L4-L5 segment compared to intact segment's ROM. During axial rotation (AR) IOTF fused index segment more than PSS. Besides this, addition of transforaminal lumbar interbody fusion (TLIF) cage improved the stabilization of IOTF system during flexion, extension and lateral bending. Whereas, PSS yielded better fusion results during extension compared to IOTF with and without interbody fusion cages.Conclusions: We hypothesized that the new posterior bilateral system would significantly decrease motion compared to the intact spine. This cadaver study showed that the proposed new posterior fusion technique IOTF fused the index segment in a similar fashion to the classical pedicle screw fusion technique.

Implant Retention or Removal for Management of Surgical Site Infection After Spinal Surgery.

STUDY DESIGN: A literature review. OBJECTIVE: To summarize the implant removal rate, common bacterial organisms found, time of onset, ratio of superficial to deep infection, and regurgitating the prevalence among all the retrospective and prospective studies on management and characterization of surgical site infections (SSIs). METHODS: PubMed was searched for articles published between 2000 and 2018 on the management or characterization of SSIs after spinal surgery. Only prospective and retrospective studies were included. RESULTS: A total of 49 articles were found relevant to the objective. These studies highlighted the importance of implant removal to avoid recurrence of SSI. The common organisms detected were methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus epidermis, Staphylococcus epidermis, Staphylococcus aureus, and Propionibacterium acnes, with prevalence of 1% to 15%. A major proportion of all were deep SSI, with minority reporting on late-onset SSI. CONCLUSION: Long-term antibiotics administration, and continuous irrigation and debridement were common suggestion among the authors; however, the key measure undertaken or implied by most authors to avoid risk of recurrence was removal or replacement of implants for late-onset SSI.