Computer-assisted innovations in craniofacial surgery.

Reconstructive surgery for complex craniofacial defects challenges even the most experienced surgeons. Preoperative reconstructive planning requires consideration of both functional and aesthetic properties of the mandible, orbit, and midface. Technological innovations allow for computer-assisted preoperative planning, computer-aided manufacturing of patient-specific implants (PSIs), and computer-assisted intraoperative navigation. Although many case reports discuss computer-assisted preoperative planning and creation of custom implants, a general overview of computer-assisted innovations is not readily available. This article reviews innovations in computer-assisted reconstructive surgery including anatomic considerations when using PSIs, technologies available for preoperative planning, work flow and process of obtaining a PSI, and implant materials available for PSIs. A case example follows illustrating the use of this technology in the reconstruction of an orbital-frontal-temporal defect with a PSI. Computer-assisted reconstruction of complex craniofacial defects provides the reconstructive surgeon with innovative options for challenging reconstructive cases. As technology advances, applications of computer-assisted reconstruction will continue to expand.

Repair of diaphyseal bone defects with calcitriol-loaded PLGA scaffolds and marrow stromal cells.

Calcitriol (1,25(OH)2D3)-loaded porous poly(D,L-lactide-co-glycolide) (PLGA) scaffolds prepared by solvent casting/salt leaching method were used to repair a 1.5 cm diaphyseal segmental bone defect as a fully absorbable osteogenic biomaterial. The in vitro release of sulforhodamine B (SRB) from PLGA scaffold was measured using spectrophotometer, considering SRB as a model drug. The SRB released from SRB-incorporated PLGA scaffold during 3 months was with relatively low initial burst. The calcitriol-loaded PLGA scaffolds with or without marrow stromal cells (MSCs) were implanted in a critical-sized intercalated bone defect in rabbit femur. Defects were assessed by radiographs until 9 weeks. The bony union of the defect was observed only in the calcitriol-loaded groups. RT-PCR results indicated that MSCs, which were seeded into calcitriol-loaded scaffold, expressed an increased level of alkaline phosphatase, osteonectin, and type I collagen mRNA at day 10. After 2 and 4 weeks, the implanted scaffolds were evaluated by histology. New osteoid matrix and direct calcium deposits were more evident in calcitriol/PLGA/MSC group. Three-dimensional computed tomography and frontal tomographic images of repaired femur showed that normal femur anatomy had been restored with cortical bone with no implanted PLGA remnants at 20 weeks. It can be concluded that the porous calcitriol-loaded PLGA scaffold combined with MSCs may be a novel method for repairing the large loaded bone defect.

Correlation between Subjective Nasal Patency and Intranasal Airflow Distribution.

Objectives (1) Analyze the relationship between intranasal airflow distribution and subjective nasal patency in healthy and nasal airway obstruction (NAO) cohorts using computational fluid dynamics (CFD). (2) Determine whether intranasal airflow distribution is an important objective measure of airflow sensation that should be considered in future NAO virtual surgery planning. Study Design Cross-sectional. Setting Academic tertiary medical center and academic dental clinic. Subjects and Methods Three-dimensional models of nasal anatomy were created based on computed tomography scans of 15 patients with NAO and 15 healthy subjects and used to run CFD simulations of nasal airflow and mucosal cooling. Subjective nasal patency was quantified with a visual analog scale (VAS) and the Nasal Obstruction Symptom Evaluation (NOSE). Regional distribution of nasal airflow (inferior, middle, and superior) was quantified in coronal cross sections in the narrowest nasal cavity. The Pearson correlation coefficient was used to quantify the correlation between subjective scores and regional airflows. Results Healthy subjects had significantly higher middle airflow than patients with NAO. Subjective nasal patency had no correlation with inferior and superior airflows but a high correlation with middle airflow (| r| = 0.64 and | r| = 0.76 for VAS and NOSE, respectively). Anterior septal deviations tended to shift airflow inferiorly, reducing middle airflow and reducing mucosal cooling in some patients with NAO. Conclusion Reduced middle airflow correlates with the sensation of nasal obstruction, possibly due to a reduction in mucosal cooling in this region. Further research is needed to elucidate the role of intranasal airflow distribution in the sensation of nasal airflow.

Endoscopic management of the frontal recess in frontal sinus fractures: a shift in the paradigm?

OBJECTIVES: To evaluate alternative management strategies for anterior table frontal sinus fractures involving the frontal sinus outflow tract. STUDY DESIGN: A prospective cohort of patients with anterior table frontal sinus fracture with frontal outflow tract involvement documented by computed tomography (CT) scan was examined between 1999 and 2001. METHODS: A select group of patients with anterior table frontal sinus fracture involving the frontal outflow tract was treated with open reduction of bony fracture without osteoplastic obliteration of the frontal sinus. Serial CT scans were obtained starting at 8 weeks after injury. Patients with persistent frontal sinus obstruction after medical treatment underwent an extended endoscopic frontal sinusotomy or a modified endoscopic Lothrop procedure. RESULTS: Fourteen patients sustained frontal sinus fractures and were treated during the study period. Seven patients were included in the modified treatment algorithm, with a mean follow-up of 18 months. All patients had concurrent facial fractures: superior orbital rim (n = 5), naso-orbital-ethmoid complex (n = 2), mandible (n = 2), and midface (n = 2). All 7 patients underwent open repair of the facial fractures. Postoperatively, 5 patients had spontaneous frontal sinus ventilation. Two patients, both of whom had naso-orbito-ethmoid fractures, had persistent frontal sinus obstruction clinically and radiographically. These patients were successfully managed with an endoscopic frontal sinus procedure. CONCLUSIONS: A select group of patients with frontal sinus and outflow tract fracture may be managed with open repair of the anterior table fracture without obliteration. In these cases, suspected frontal outflow tract obstruction can be managed expectantly. Failed frontal sinus ventilation may require endoscopic frontal sinus surgery to reestablish mucociliary clearance.

Preparation and characterization of fentanyl-loaded PLGA microspheres: in vitro release profiles.

We developed several kinds of fentanyl-loaded poly(L-lactide-co-glycolide) (PLGA) microspheres (FMS) for sustained release of fentanyl. FMS were prepared by an emulsion solvent-evaporation method. In this study, the influences of several preparation parameters, such as initial drug loading, polymer concentration, and solvent volume on the release patterns of fentanyl were investigated. Furthermore, it has been well noted that the detection of fentanyl is extremely difficult because its clinical dose level is very low, about 1-3 ng/ml, in cancer-patient treatment. Therefore, we also developed a rapid and sensitive determination method for fentanyl in systemic circulation by employing gas chromatography (GC) system. Fentanyl was slowly released from FMS over 15 days with a quasi-zero order property. From the results, our FMS may be good formulations to deliver the analgesics and suitable for the treatment of severe pain over long periods.

A local delivery system for fentanyl based on biodegradable poly(L-lactide-co-glycolide) oligomer.

To obtain a sustained fentanyl delivery with effective and precise control, fentanyl loaded wafer was fabricated using poly(L-lactide-co-glycolide) (PLGA) oligomer by direct compression method. XRD and DSC analysis indicated the presence of crystalline drug in the wafers. The release of fentanyl from PLGA wafer was determined to be primarily diffusion controlled, but swelling and erosion also contributed to the release process. In vitro release studies showed that different release patterns and rates could be achieved by simply modifying factors in the preparation conditions. The wafer degradation profiles were also investigated to understand the drug release mechanism. Gravimetric studies of mass loss of wafers during the incubation revealed that the weight loss increased apparently after 4 days. These results indicate that the polymer degradation was contributed to drug release followed by diffusion. From the results, this constant localized release system can potentially provide anesthesia for a longer period than injection or topical administration.

Stabilization of nontoxic PVC formulation for gamma irradiation sterilization, I. Effect of additives.

In order to investigate the fundamental data for the resistance of gamma radiation sterilization of polyvinylchloride (PVC), the formulations of the additives such as plasticizers of dioctylphthalate, trioctyltrimellitate and polyester, second plasticizers, Ca/Zn nontoxic metallic stabilizers with powder, paste and liquid state, and phosphite stabilizers have been carried out. The control and irradiated PVC samples with 1.5, 2.5 and 4.0 Mrads were characterized by mechanical tester, colorimetry, and extractant in water. The effect of plasticizers observed in the order of dioctylphthalate approximately equal trioctyltrimellitate > polymeric plasticizer. It was observed in the order of Ca/Zn metallic stabilizers of paste > liquid approximately equal powder state for the color change and liquid > paste > powder for the extractant. The mechanism of the discoloration of PVC in our experiment was predominant the formation of polyene by the dehydrochlorination rather than the formation of keton and aldehyde by the oxidation and chain dissociation by the measurement of gel permeation chromatography and mechanical property. The proposed mechanisms of stabilization and discolorization with various additives are also discussed.

Stabilization of nontoxic PVC formulation for gamma irradiation sterilization, II. Effect of antioxidants.

In order to investigate the fundamental data for the resistance of gamma radiation sterilization of polyvinylchloride (PVC), the formulations of the antioxidants such as commercial Irganox series and inorganic, processing aids, stabilizer aids, trans-stilbene oxide (StO) and so on have been carried out. The control and irradiated PVC samples with 1.5, 2.5 and 4.0 Mrad were characterized by mechanical tester, colorimetry, and extractant in water. Irganox 1010 was more effective than Irganox 1076 for color changes whereas Irganox 1076 was more effective than Irganox 1010 for the change of extractant. It was also observed the significant diminution of color changes for inorganic antioxidants as CaO and ZnO. Oxidized paraffin wax as lubricant, styrene-methylmetacrylate copolymers as processing aids, and nontoxic debenzoylmethane as secondary stabilizer did not show good stabilization for the irradiation. The new proposed radiation stabilizer in this study, StO, showed the significant improvement of gamma radiation resistance for the plasticized PVC. The possible mechanism could be explained that an epoxy functional group stabilizes effectively the processes of dehydrogenation, the formation of hydroperoxides, and the formation of oxygen containing groups, and the synergetic effects of an epoxy compound are more notable for the prevention of radiation oxidation in the presence of an aromatic group.

Pressure-Specifying Sensory Device: quantitative sensory measurement in the oral cavity and oropharynx of normal adults.

We conducted a study to quantitatively determine the pressure perception thresholds in the oral cavity and oropharynx of a normal population with the Pressure-Specifying Sensory Device (PSSD). The PSSD measured pressure perception thresholds for both static and moving one- and two-point discrimination modalities at a variety of sites in the oral cavity and oropharynx as well as in the forearm of 11 adults. We also evaluated the ability of the PSSD to enhance sensory discrimination in four of these subjects by the process of sensory re-education for 11 days over a 15-day period. We found that the buccal mucosa and the tongue tip were the most sensitive sites in the oral cavity and oropharynx and that the floor of the mouth and the soft palate were the least sensitive. Sensory discrimination in the oral cavity was enhanced in all four subjects who underwent sensory re-education, although it returned to baseline levels over time after re-education was discontinued. The degree of intra- and intertester variability was minimal. Our data can be used as an aid in the development of techniques to surgically restore sensation in the oral cavity and oropharynx.

[Sandwiched osmotic pump tablet for controlled release of water-insoluble drug].

AIM: To study sandwiched osmotic pump tablet for delivering water-insoluble drug for 24 hours. METHODS: Sandwiched osmotic pump tablet was prepared using nifedipine as the model drug. The effects of various formulation variables and orifice size on drug release were studied. The mechanical properties of cellulose acetate membrane were also investigated. RESULTS: Polyethylene oxide of drug layer and potassium chloride of push layer showed marked positive effects on drug release. In the range of 0.50 mm to 1.40 mm, orifice size hardly affects drug release. Cellulose acetate membrane is strong enough to assure the integrity of osmotic pump tablet and could sustain an internal pressure ranging from 0.34 MPa to 2.85 MPa. CONCLUSION: Sandwiched osmotic pump tablet can deliver water-insoluble drug constantly for 24 hours. Release media and agitation rate scarcely affect drug release. Compared with the commercialized push-pull osmotic pump tablet, sandwiched osmotic pump tablet is easy in preparation with exempting identification of drug layer before drilling.

[Unitary-core osmotic pump tablet for controlled release of water-insoluble drug].

AIM: To study unitary-core osmotic pump tablet for delivering water-insoluble drug for 24 hours. METHODS: Unitary-core osmotic pump tablet was prepared using nifedipine as the model drug. The effects of various core formulation variables on drug release were studied. RESULTS: Polyethylene oxide and potassium chloride have comparable positive effects on drug release, whereas, nifedipine has markedly negative effect on drug release. CONCLUSION: Unitary-core osmotic pump tablet is very easy in preparation and it can deliver water-insoluble drug in substantially constant rate for 24 hours.

A squeeze-type osmotic tablet for controlled delivery of nifedipine.

Osmotic delivery systems are based on osmotic driving force. Nifedipine tablets, available under the trade names Procardia XL (Pfizer) and Adalat (Bayer), are commercialized drug-delivery systems of an elemental osmotic pump that the push-pull osmotic tablet operates successfully in delivering water-insoluble drugs. For the improvement of the release pattern and the solubility of the drug, we developed a squeeze-type osmotic tablet (SQT) for nifedipine as a model drug. The SQT was composed of one or more ring type of squeeze-push layer (squeeze-disc) and a centered drug core. Squeeze-discs were stacked up with different physicochemical properties with gradient such as viscosity, swelling ratio and water absorption ratio using the osmotic agents from a disc of bottom to top. The present work investigated the effect of different preparation factors, such as hydrophilic polymers, the molecular weight of polymers, coating process, orifice size and types of excipient on release performance of nifedipine. With the purpose of delivering water-insoluble nifedipine at an approximate zero-order rate and step-function rate for 24 h, SQT has been successfully prepared, and significantly improved in the release rate and patterns in comparison with the Adalat push-pull system in vitro release features.

Reduction of inflammatory reaction of poly(d,l-lactic-co-glycolic Acid) using demineralized bone particles.

Poly(lactide-co-glycolic acid) (PLGA) has been widely applied to tissue engineering as a good biocompatible material because of its biodegradability and nontoxic metabolites, but how the inflammatory reaction of PLGA on the surrounding tissue in vivo is reduced has not been discussed sufficiently. We hypothesized that the cells neighboring the PLGA implant might have an inflammatory response that could be reduced by impregnating demineralized bone particles (DBPs) into the PLGA. We manufactured five different ratios of DBP/PLGA hybrid materials, with each material containing 0, 10, 20, 40, and 80 wt% of DBPs of PLGA. For biocompatibility test, NIH/3T3 mouse fibroblasts were cultured on the DBP/PLGA scaffold for 3 days. The inflammatory potential of PLGA was evaluated using messenger ribonucleic acid expression of tumor necrosis factor alpha (TNF-alpha) and interleukin 1-beta (IL-1beta) on a human acute promyelocytic leukemic cell (HL-60). The in vivo response of DBP/PLGA film was compared with that of PLGA film implanted subcutaneously; the local inflammatory response was observed according to histology. The DBP/PLGA scaffold had no adverse effect on NIH/3T3 initial cell attachment and did not affect cell viability. DBP/PLGA films, especially PLGA films containing 80% DBP, elicited a significantly lower expression of IL-1beta and TNF-alpha from HL-60 cells than PLGA film alone. In vivo, DBP/PLGA film demonstrated a more favorable tissue response profile than PLGA film, with significantly less inflammation and fibrous capsule formation as below only 20% of DBP in PLGA film during implantation. This study shows that application of DBPs reduces the fibrous tissue encapsulation and foreign body giant cell response that commonly occurs at the interface of PLGA.

Correlation of proliferation, morphology and biological responses of fibroblasts on LDPE with different surface wettability.

In order to find a correlation between cell adhesion, growth and biological response with different wettability, NIH/3T3 fibroblast cells were cultured on plasma-treated low-density polyethylene (LDPE) film generated with radio frequency. Different surface wettabilities (water contact angle 90-40 degrees ) were created by varying the duration of plasma treatment between 0 and 15 s, respectively. Growth and proliferation rate of cells on LDPE surfaces was evaluated by MTT assay, and cell morphology, by means of spreading and adhesion, was characterized by scanning electron microscopy (SEM). The expression of particular genes in cells contacted on films with different wettability was analyzed by RT-PCR. Using the MTT assay, we confirmed that the amount of cell adhesion was higher on surface of film with a water contact angle of 60 degrees than with other water contact angle. Also, the proliferation rate of cells was highest with a water contact angle of 60 degrees . It was confirmed by SEM that the morphology of cells adhered with a water contact angle of 50-60 degrees was more flattened and activated than on other surfaces. Furthermore, c-fos mRNA in cells showed maximum expression on the film with contact angle range of 50-60 degrees and c-myc mRNA expressed highly on the film with a contact angle of 50 degrees . Finally, p53 gene expression increased as wettability increase. These results indicate that a water contact angle of the polymer surfaces of 50-60 degrees was suitable for cell adhesion and growth, as well as biological responses, and the surface properties play an important role for the morphology of adhesion, growth and differentiation of cells.

Surface and chemical properties of surface-modified UHMWPE powder and mechanical and thermal properties of its impregnated PMMA bone cement, IV: effect of MMA/accelerator on the surface modification of UHMWPE powder.

In our previous study, we manufactured a reinforced poly(methylmethacrylate) (PMMA) bone cement with 3 wt% of the surface-modified ultra high molecular weight polyethylene (UHMWPE) powder to improve its poor mechanical and thermal properties resulting from unreacted methylmethacrylate (MMA), the generation of bubble and shrinkage, and high curing temperature. In the present study, the effect of ratios of MMA and N,N'-dimethyl-p-toluidine (DMPT) solutions in redox polymerization system was investigated for the surface modification of UHMWPE powder. We characterized physical and chemical properties of surface-modified UHMWPE powder and reinforced bone cements by a scanning electron microscope, ultimate tensile strength (UTS) and curing temperature (Tmax). It was found that UTSs (41.3-51.3 MPa) of the reinforced PMMA bone cements were similar to those (44.5 MPa) of conventional PMMA bone cement (control), as well as significantly higher (P < 0.05) than those (33.8 MPa) of 3 wt% unmodified UHMWPE powder-impregnated bone cement. In particular, the UTS of redox polymerization system using MMA/DMPT solution was better than that of radical system using MMA/xylene solution. Also, Tmax of the reinforced PMMA bone cements decreased from 103 to 72-84 degrees C. From these results, we confirmed that the surface-modified UHMWPE powder can be used as reinforcing agent to improve the mechanical and thermal properties of conventional PMMA bone cement.

Surface and chemical properties of surface-modified UHMWPE powder and mechanical and thermal properties of it impregnated PMMA bone cement, III: effect of various ratios of initiator/inhibitor on the surface modification of UHMWPE powder.

From our previous study, 3 wt% of ultra-high-molecular-weight polyethylene (UHMWPE) powder surface-modified by various ratios of methyl methacrylate (MMA) and poly(methyl methacrylate) (PMMA) solution was impregnated to improve the poor mechanical and thermal properties of conventional PMMA bone cement. In this study, various amounts of benzoyl peroxide (BPO) and hydroquinone were used for the adhesion reinforcement of UHMWPE powder with PMMA polymerized from MMA monomer (polyMMA) by the mixture of BPO and hydroquinone and ultimately to strengthen the poor mechanical and thermal properties of conventional PMMA bone cement. The tensile strengths of 3 wt% of UHMWPE powders surface-precoated with polyMMA prepared by various amounts of BPO- and hydroquinone-impregnated composite PMMA bone cements were similar to that of conventional PMMA bone cement. In particular, 3 wt% of UHMWPE powder surface precoated with polyMMA prepared with 0.75 wt% of BPO and 300 ppm of hydroquinone impregnated composite PMMA bone cement revealed the maximum tensile strength. However, no obvious significant difference was revealed, although the curing temperatures of the composite PMMA bone cements decreased from 103 degrees C to 91-97 degrees C. From these results, it was determined that the mixture of BPO and hydroquinone plays an important role in improving the poor mechanical properties of conventional PMMA bone cement. However, the thermal properties of the composite PMMA bone cements were not remarkably improved. The mechanical, chemical and thermal properties were individually confirmed using a scanning electron microscope (SEM), universal transverse mercator (UTM), Fourier transform infrared-attenuated total reflectance (FT-IR-ATR) and digital thermometer, respectively.

Open vertebral cement augmentation combined with lumbar decompression for the operative management of thoracolumbar stenosis secondary to osteoporotic burst fractures.

Osteoporotic burst fractures with neurologic symptoms are typically treated with neural decompression and multilevel instrumented fusion. These large surgical interventions are challenging because of patients' advanced ages, medical co-morbidities, and poor fixation secondary to osteoporosis. The purpose of this retrospective clinical study was to describe a novel technique for the treatment of osteoporotic burst fractures and symptomatic spinal stenosis via a limited thoracolumbar decompression with open cement augmentation [vertebroplasty (VP) or kyphoplasty (KP)]. Indications for decompression and cement augmentation were intractable pain at the level of a known osteoporotic burst fracture with symptoms of spinal stenosis. As such, 25 patients (mean age, 76.1 years) with low-energy, osteoporotic, thoracolumbar burst fractures (7 males, 18 females; 39 fractures) were included. In all cases, laminectomy of the stenotic level(s) was followed by vertebral cement augmentation (9 VP; 16 KP). When a spondylolisthesis at the decompressed level was present, instrumentation was applied across the listhetic level (n = 9). Clinical outcome (1 = poor to 4 = excellent) was assessed on last clinical follow-up (mean, 44.8 wks). In addition, a modified MacNab's grading criteria was used to objectively assess patient outcomes postoperatively. Radiographic analysis of sagittal contour was assessed preoperatively, immediately postoperatively, and at final follow-up. The average time from onset of symptoms to intervention was 19 weeks (range, 0.3-94 wks). A mean of 1.6 fractures/patient was augmented (range, 1-3 fractures) and 2.8 levels were decompressed (range, 1-6 levels). No statistical difference in anatomic distribution or number of fractures between the VP and KP groups or in the instrumented versus noninstrumented patients was noted (P > 0.05). An overall subjective outcome score of 3.4 was noted. Twenty of 25 patients were graded as excellent/good according to the modified MacNab's criteria. The choice of augmentation procedure or use of instrumentation did not predict outcome (P = 0.08). Overall, 1.7 degrees of sagittal correction was obtained at final follow-up. One patient was noted to have progressive kyphosis after KP. The use of a limited-posterior decompression and open cement augmentation via VP or KP is a safe treatment option for patients who have osteoporotic burst fractures and who are incapacitated from fracture pain and concomitant stenosis. After thoracolumbar decompression, open VP/KP provides direct visualization of the posterior vertebral body wall, allowing for safe cement augmentation of burst fractures, stabilizing the spine, and obviating the need for extensive spinal reconstruction. Although clinically successful, this technique warrants careful patient selection.

Transdiscal L5-S1 screws for the fixation of isthmic spondylolisthesis: a biomechanical evaluation.

The current study is a biomechanical study using a cadaveric model of L5-S1 spondylolisthesis. The purpose of the current study was to compare, in a cadaveric model of simulated L5-S1 spondylolisthesis, the biomechanical stiffness of transdiscal fixation with traditional pedicle screw fixation, and transdiscal fixation with combined interbody/pedicle screw fixation. The surgical management of L5-S1 spondylolisthesis is a challenge because of the difficulties in achieving a reliable arthrodesis in the face of high mechanical forces. A method of lumbosacral fixation that has been used successfully in moderate grades of spondylolisthesis at our institution involves the use of transdiscal S1 pedicle screws. With this technique, S1 pedicle screws are placed through the S1 pedicle, through the superior endplate of S1, through the inferior endplate of L5, to terminate in the L5 body. Eighteen fresh human cadaveric (age 59-88 years) L5-S1 motion segments were obtained. The end of each intact motion segment was potted up to its midbody in a 10-cm-diameter polyvinylchloride end-cap using dental cement. The intact specimen was then biomechanically tested as follows: 1) axial compression (500 N), 2) flexion (10 Nm), 3) extension (10 Nm), 4) right lateral bending (10 Nm), and 5) left lateral bending (10 Nm). Stiffness values were calculated from the load-deflection curves obtained. Spondylolisthesis was then simulated by displacing L5 on S1 (% slip average = 41.3%) after performing a radical L5-S1 discectomy, L5 laminectomy, and bilateral L5-S1 facetectomies. The 18 motion segments were divided into two groups. Group I (n = 10) was biomechanically tested (as above) after pedicle screw fixation and again after replacing the S1 pedicle screws with transdiscal screws. Group II (n = 8) was biomechanically tested (as above) after combined interbody/pedicle screw fixation and again after fixation with transdiscal screws. Load-deflection curves were obtained each time, and stiffness values were calculated from the curves. Transdiscal fixation was 1.6-1.8 times stiffer than pedicle screw fixation (p < 0.05) in all loading modes tested. There were no differences in stiffness between transdiscal fixation and combined interbody/pedicle screw fixation. In a cadaveric model of simulated L5-S1 spondylolisthesis, transdiscal L5-S1 fixation produced a 1.6-1.8 times stiffer construct than traditional pedicle screw fixation. Further, the stiffness of the transdiscal fixation was equal to that of a combined interbody/pedicle screw fixation.