Pedicle Subtraction Osteotomy Construct Optimization: A Cadaveric Study of Various Multirod and Interbody Configurations.

STUDY DESIGN: Fourteen cadaveric specimens were separated into two groups: (1) L3 pedicle subtraction osteotomy (PSO) with transforaminal lumbar interbody fusion (TLIF) or (2) lateral lumbar interbody fusion (LLIF). A 2-rod configuration (2R) was compared with two supplemental rod configurations: 4-rod (4R) with accessory rods (ARs) using connectors or 4R with satellite rods (SRs) without connectors. OBJECTIVE: Compare PSO constructs with different rod configurations and adjacent-level interbody support. SUMMARY OF BACKGROUND DATA: Supplemental rods and anterior column support enhance biomechanical performance. METHODS: Pure moments were applied in (1) intact, (2) pedicle screws and rods, (3) PSO + 2R, (4) 4R AR, and (5) 4R SR conditions. Primary and supplemental rods had strain gauges across the index level. Sacral screw bending moments and range of motion (ROM) were recorded. RESULTS: For TLIF, AR decreased ROM during flexion (P = 0.02) and extension (P < 0.001) versus 2R. For LLIF, AR and SR decreased motion versus 2R during left (AR: P  = 0.03; SR: P  = 0.04) and right (AR: P  = 0.002; SR: P  = 0.01) axial rotation. For LLIF, sacral screw strain increased with SR compared with AR in compression and right lateral bending (P ≤ 0.03). During lateral bending, rod strain increased with PSO+TLIF+SR versus PSO+LLIF+2R and PSO+LLIF+AR (P ≤ 0.02). For LLIF, SR configuration increased rod strain versus AR during flexion, extension, and lateral bending (P≤ 0.01); for TLIF, rod strain increased with SR versus AR during extension (P = 0.03). For LLIF, AR configuration increased posterior supplemental rod strain versus SR during flexion (P = 0.02) and lateral bending (P < 0.001). CONCLUSION: Both supplemental rod configurations reduced motion in both groups. Constructs with the SR configuration increased the primary rod strain and the sacral screw bending moment compared with AR constructs, which can share strain. Deep-seated SRs, which have become increasingly popular, may be more vulnerable to failure than ARs. LLIF provided more stability in sagittal plane. Protective effect of supplemental rods on rod strain was more effective with TLIF.Level of Evidence: NA.

Biomechanical Effects of Proximal Polyetheretherketone Rod Extension on the Upper Instrumented and Adjacent Levels in a Human Long-Segment Construct: A Cadaveric Model.

OBJECTIVE: The high mechanical stress zone at the sudden transition from a rigid to flexible region is involved in proximal junctional kyphosis (PJK) physiopathology. We evaluated the biomechanical performance of polyetheretherketone (PEEK) rods used as a nontraditional long semirigid transition phase from a long-segment metallic rod construct to the nonfused thoracic spine. METHODS: Pure moment range of motion (ROM) tests (7.5 Nm) were performed on 7 cadaveric spine segments followed by compression (200 N). Specimens were tested in the following conditions: (1) intact; (2) T10-pelvis pedicle screws and rods (PSRs); and (3) extending the proximal construct to T6 using PEEK rods (PSR+PEEK). T10-11 rod strain, T9 anterolateral bone strain, and T10 screw bending moments were analyzed. RESULTS: At the upper instrumented vertebra (UIV)+1, PSR+PEEK versus PSR significantly decreased ROM in flexion (115%, p = 0.02), extension (104%, p = 0.003), left lateral bending (46%, p = 0.02), and right lateral bending (63%, p = 0.008). Also, at UIV+1, PSR+PEEK versus intact significantly decreased ROM in flexion (111%, p = 0.01) and extension (105%, p = 0.003). The UIV+1 anterior column bone strain was significantly reduced with PSR+PEEK versus PSR during right lateral bending (p = 0.02). Rod strain polarities reversed with PEEK rods in all loading directions except compression. CONCLUSION: Extending a long-segment construct using PEEK rods caused a decrease in adjacent-level hypermobility as a consequence of long-segment immobilization and also redistributed the strain on the UIV and adjacent levels, which might contribute to PJK physiopathology. Further studies are necessary to observe the clinical outcomes of this technique.

Biomechanics of Circumferential Cervical Fixation Using Posterior Facet Cages: A Cadaveric Study.

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is a common procedure for the treatment of cervical disease. Circumferential procedures are options for multilevel pathology. Potential complications of multilevel anterior procedures are dysphagia and pseudarthrosis, whereas potential complications of posterior surgery include development of cervical kyphosis and postoperative chronic neck pain. The addition of posterior cervical cages (PCCs) to multilevel ACDF is a minimally invasive option to perform circumferential fusion. This study evaluated the biomechanical performance of 3-level circumferential fusion with PCCs as supplemental fixation to anteriorly placed allografts, with and without anterior plate fixation. METHODS: Nondestructive flexibility tests (1.5 Nm) performed on 6 cervical C2-7 cadaveric specimens intact and after discectomy (C3-6) in 3 instrumented conditions: allograft with anterior plate (G+P), PCC with allograft and plate (PCC+G+P), and PCC with allograft alone (PCC+G). Range of motion (ROM) data were analyzed using 1-way repeated-measures analysis of variance. RESULTS: All instrumented conditions resulted in significantly reduced ROM at the 3 instrumented levels (C3-6) compared to intact spinal segments in flexion, extension, lateral bending, and axial rotation (p < 0.001). No significant difference in ROM was found between G+P and PCC+G+P conditions or between G+P and PCC+G conditions, indicating similar stability between these conditions in all directions of motion. CONCLUSION: All instrumented conditions resulted in considerable reduction in ROM. The added reduction in ROM through the addition of PCCs did not reach statistical significance. Circumferential fusion with anterior allograft, without plate and with PCCs, has comparable stability to ACDF with allograft and plate.

Does the Choice of Spinal Interbody Fusion Approach Significantly Affect Adjacent Segment Mobility?

STUDY DESIGN: Biomechanical study of range of motion (ROM) at the vertebral levels adjacent to the construct of posterior pedicle screw-rod fixation with different types of lumbar interbody fusion techniques (LIF). OBJECTIVE: To investigate the differences in adjacent segment mobility among three types of LIF: lateral lumbar interbody fusion (LLIF), transforaminal lumbar interbody fusion (TLIF), and posterior lumbar interbody fusion (PLIF). SUMMARY OF BACKGROUND DATA: Previous studies have concluded that LLIF, TLIF, and PLIF with posterior pedicle screw-rod fixation (PSR) provide equivalent stability in cadaveric specimens and are comparable in fusion rate and functional outcome. However, long-term complications, such as adjacent segment degeneration associated with each type of interbody device, are currently unclear. Little is known about the biomechanical effects of interbody fusion technique on the mobility of adjacent segments. METHODS: Normalized ROM data at the levels adjacent to L3-L4 PSR fixation with three different types of lumbar interbody fusion approaches (LLIF, TLIF, and PLIF) were analyzed. Intact (n = 21) and instrumented (n = 7 per group) L2-L5 cadaveric specimens were tested multidirectionally under pure moment loading (7.5 Nm). Analysis of variance of adjacent segment ROM among the groups was performed. Statistical significance was set at P < 0.05. RESULTS: Normalized ROM was significantly greater with PLIF than with LLIF in all directions at both proximal and distal adjacent segments (P ≤ 0.02) except for axial rotation at the distal adjacent segment (P = 0.07). TLIF also had greater normalized ROM than LLIF during lateral bending at the proximal adjacent segment (P = 0.008) and during flexion, extension, and lateral bending at the distal adjacent segment (P ≤ 0.03). Normalized ROM was not significantly different between PLIF and TLIF. CONCLUSION: The choice of lumbar interbody fusion approach influences adjacent segment motion in a cadaveric model. LLIF had the least adjacent segment motion.Level of Evidence: 3.

Minimally Invasive Anterior Longitudinal Ligament Release for Anterior Column Realignment.

STUDY DESIGN: Review of the literature. OBJECTIVES: Anterior column realignment (ACR) is a powerful but relatively new minimally invasive technique for deformity correction. The purpose of this study is to provide a literature review of the ACR surgical technique, reported outcomes, and future directions. METHODS: A review of the literature was performed regarding the ACR technique. A review of patients at our single center who underwent ACR was performed, with illustrative cases selected to demonstrate basic and nuanced aspects of the technique. RESULTS: Clinical and cadaveric studies report increases in segmental lordosis in the lumbar spine by 73%, approximately 10° to 33°, depending on the degree of posterior osteotomy and lordosis of the hyperlordosis interbody spacer. These corrections have been found to be associated with a similar risk profile compared with traditional surgical options, including a 30% to 43% risk of proximal junctional kyphosis in early studies. CONCLUSIONS: ACR represents a powerful technique in the minimally invasive spinal surgeon's toolbox for treatment of complex adult spinal deformity. The technique is capable of significant sagittal plane correction; however, future research is necessary to ascertain the safety profile and long-term durability of ACR.

Optimizing biomechanics of anterior column realignment for minimally invasive deformity correction.

BACKGROUND CONTEXT: Anterior column realignment (ACR) is a powerful but destabilizing minimally invasive technique for sagittal deformity correction. Optimal biomechanical design of the ACR construct is unknown. PURPOSE: Evaluate the effect of ACR design on radiographic lordosis, range of motion (ROM) stability, and rod strain (RS) in a cadaveric model. STUDY DESIGN/SETTING: Cadaveric biomechanical study. PATIENT SAMPLE: Seven fresh-frozen lumbar spine cadaveric specimens (T12-sacrum) underwent ACR at L3-L4 with a 30° implant. OUTCOME MEASURES: Primary outcome measure of interest was maximum segmental lordosis measured using lateral radiograph. Secondary outcomes were ROM stability and posterior RS at L3/4. METHODS: Effect of grade 1 and grade 2 osteotomies with single-screw anterolateral fixation (1XLP) or 2-screw anterolateral fixation (2XLP) on lordosis was determined radiographically. Nondestructive flexibility tests were used to assess ROM and RS at L3-L4 in flexion, extension, lateral bending, and axial rotation. Conditions included (1) intact, (2) pedicle screw fixation and 2 rods (2R), (3) ACR+1XLP with 2R, (4) ACR+2XLP+2R, (5) ACR+1XLP with 4 rods (4R) (+4R), and (6) ACR+2XLP+4R. RESULTS: Segmental lordosis was similar between ACR+1XLP and ACR+2XLP (p>.28). ACR+1XLP+2R was significantly less stable than all other conditions in flexion, extension, and axial rotation (p<.014); however, adding an extra screw improved stability to levels equal to 4R conditions (p>.36). Adding 4R to ACR+1XLP reduced RS in all directions of loading (p<.048), whereas adding a second screw did not (p>.12). There was no difference in strain between ACR+1XLP+4R and ACR+2XLP+4R (p>.55). CONCLUSIONS: For maximum stability, ACR constructs should contain either fixation into both vertebral bodies (2XLP) or accessory rods (4R). 2XLP can be used without compromising the maximal achievable lordosis but does not provide the same RS reduction as 4R. CLINICAL SIGNIFICANCE: ACR is a highly destabilizing technique that is increasingly being used for minimally invasive deformity correction. These biomechanical data will help clinicians optimize ACR construct design.