BIOMECHANICAL STRENGTH INFLUENCE OF LATERAL WALL VIOLATION ON SPINAL PEDICLE SCREW FIXATION_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHUANGYan ¹ ,  CAOXiaojian ²

1. Department of Orthopaedics, the Affiliated Jiangyin Hospital of Southeast University Medical College, Jiangyin Jiangsu, 214400, P. R. China;
2. Department of Orthopaedics, Jiangsu Province Hospital;

Corresponding author：

CAOXiaojian, Email: xiaojiancao001@163.com

Keywords：

Pedicle screw; Biomechanics; Lumbar spine; Spinal fixation; Pig

DOI：

10.7507/1002-1892.20150041

Video：

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Objective To compare the fixation strength of optimum placed pedicle screw (OS) with re-directionally correctly placed pedicle screw (RS) following a violation of lateral pedicle. Methods Thirty fresh lumbar vertebrae (L_1-5) were obtained from 6 pigs weighing 95-105 kg, male or female. Each vertebra was instrumented with a monoaxial pedicle screw into each pedicle using two different techniques. On one side, a perfect screw path was created using direct visualization and fluoroscopy. A pedicle screw of 5 mm in diameter and 35 mm in length was placed with a digital torque driver (OS). On the other side, a lateral pedicle wall violation was created at the pedicle-vertebral body junction with a guide wire, a cannulated tap, and a pedicle probe. This path was then redirected into a correct position, developed, and instrumented with a 5-mm-diameter by 35-mm-long pedicle screw (RS). For each pedicle screw, the maximal torque, seating torque, screw loosening force, and post-loosening axial pullout were measured. Screw loosening and axial pullout were assessed using an MTS machine. Results Maximal insertion torque was (111.4±8.2) N·cm and (78.9±6.4) N·cm for OS and RS respectively, showing significant difference (Z=3.038, P=0.002). The seating torque was (86.3±7.7) N·cm and (59.7±5.3) N·cm for OS and RS respectively, showing significant difference (Z=2.802, P=0.005). The screw loosening force was (76.3±6.2) N and (53.0±5.8) N for OS and RS respectively, showing significant difference (Z=2.861, P=0.004). The post-loosening axial pullout force was (343.0±12.6) N and (287.0±10.5) N for OS and RS respectively, showing significant difference (Z=2.964, P=0.003). Conclusion Compared with OS, RS placement after a lateral wall violation shows significantly decreased maximal insertion torque, seating torque, screw loosening force, and post-loosening axial pullout. On this occasion, RS augmentation is a probable option for remediation.

Citation： ZHUANGYan, CAOXiaojian. BIOMECHANICAL STRENGTH INFLUENCE OF LATERAL WALL VIOLATION ON SPINAL PEDICLE SCREW FIXATION. Chinese Journal of Reparative and Reconstructive Surgery, 2015, 29(2): 189-193. doi: 10.7507/1002-1892.20150041 Copy

1.	张宁, 殷国勇. 脊柱脊髓损伤的修复与重建进展. 中国修复重建外科杂志, 2008, 22(4):385-389.
2.	Boachie-Adjei O, Girardi FP, Bansal M, et al. Safety and efficacy of pedicle screw placement for adult spinal deformity with a pedicle-probing conventional anatomic technique. J Spinal Disord, 2000, 13(6):496-500.
3.	Lehman RA Jr, Lenke LG, Keeler KA, et al. Computed tomography evaluation of pedicle screws placed in the pediatric deformed spine over an 8-year period. Spine (Phila Pa 1976), 2007, 32(24):2679-2684.
4.	Karapinar L, Erel N, Ozturk H, et al. Pedicle screw placement with a free hand technique in thoracolumbar spine:is it safe? J Spinal Disord Tech, 2008, 21(1):63-67.
5.	Parker SL, Mcgirt MJ, Farber SH, et al. Accuracy of free-hand pedicle screws in the thoracic and lumbar spine:analysis of 6816 consecutive screws. Neurosurgery, 2011, 68(1):170-178.
6.	Kosmopoulos V, Schizas C. Pedicle screw placement accuracy:a meta-analysis. Spine (Phila Pa 1976), 2007, 32(3):E111-120.
7.	Gelalis ID, Paschos NK, Pakos EE, et al. Accuracy of pedicle screw placement:a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques. Eur Spine J, 2012, 21(2):247-255.
8.	Nottmeier EW, Seemer W, Young PM. Placement of thoracolumbar pedicle screws using three-dimensional image guidance:experience in a large patient cohort. J Neurosurg Spine, 2009, 10(1):33-39.
9.	Silbermann J, Riese F, Allam Y, et al. Computer tomography assessment of pedicle screw placement in lumbar and sacral spine:comparison between free-hand and O-arm based navigation techniques. Eur Spine J, 2011, 20(6):875-881.
10.	Tian NF, Xu HZ. Image-guided pedicle screw insertion accuracy:a meta-analysis. Int Orthop, 2009, 33(4):895-903.
11.	Castro WH, Halm H, Jerosch J, et al. Accuracy of pedicle screw placement in lumbar vertebrae. Spine (Phila Pa 1976), 1996, 21(11):1320-1324.
12.	Laine T, Lund T, Ylikoski M, et al. Accuracy of pedicle screw insertion with and without computer assistance:a randomised controlled clinical study in 100 consecutive patients. Eur Spine J, 2000, 9(3):235-240.
13.	Schulze CJ, Munzinger E, Weber U. Clinical relevance of accuracy of pedicle screw placement. A computed tomographic-supported analysis. Spine (Phila Pa 1976), 1998, 23(20):2215-2221.
14.	Tsai KJ, Murakami H, Horton WC, et al. Pedicle screw fixation strength:a biomechanical comparison between 4.5-mm and 5.5-mm diameter screws in osteoporotic upper thoracic vertebrae. J Surg Orthop Adv, 2009, 18(1):23-27.
15.	Kim JH, Horton W, Hamasaki T, et al. Spinal instrumentation for sacral-pelvic fixation:a biomechanical comparison between constructs ending with either S2 bicortical, bitriangulated screws or iliac screws. J Spinal Disord Tech, 2010, 23(8):506-512.
16.	王宇, 邑晓东, 李淳德. 可注射硫酸钙强化椎弓根螺钉内固定的实验研究. 中国脊柱脊髓杂志, 2009, 19(1):5.
17.	Brasiliense LB, Theodore N, Lazaro BC, et al. Quantitative analysis of misplaced pedicle screws in the thoracic spine:how much pullout strength is lost?:presented at the 2009 Joint Spine Section Meeting. J Neurosurg Spine, 2010, 12(5):503-508.
18.	Lehman RA, Kuklo TR. Use of the anatomic trajectory for thoracic pedicle screw salvage after failure/violation using the straight-forward technique:a biomechanical analysis. Spine (Phila Pa 1976), 2003, 28(18):2072-2077.
19.	Daftari TK, Horton WC, Hutton WC. Correlations between screw hole preparation, torque of insertion, and pullout strength for spinal screws. J Spinal Disord, 1994, 7(2):139-145.
20.	Inceoglu S, Ferrara L, Mclain RF. Pedicle screw fixation strength:pullout versus insertional torque. Spine J, 2004, 4(5):513-518.
21.	Kwok AW, Finkelstein JA, Woodside T, et al. Insertional torque and pull-out strengths of conical and cylindrical pedicle screws in cadaveric bone. Spine (Phila Pa 1976), 1996, 21(21):2429-2434.
22.	Myers BS, Belmont PJ, Richardson WJ, et al. The role of imaging and in situ biomechanical testing in assessing pedicle screw pull-out strength. Spine (Phila Pa 1976), 1996, 21(17):1962-1968.
23.	Okuyama K, Abe E, Suzuki T, et al. Can insertional torque predict screw loosening and related failures? An in vivo study of pedicle screw fixation augmenting posterior lumbar interbody fusion. Spine (Phila Pa 1976), 2000, 25(7):858-864.
24.	Ozawa T, Takahashi K, Yamagata M, et al. Insertional torque of the lumbar pedicle screw during surgery. J Orthop Sci, 2005, 10(2):133-136.
25.	Pashman RS, Hu SS, Schendel MJ, et al. Sacral screw loads in lumbosacral fixation for spinal deformity. Spine (Phila Pa 1976), 1993, 18(16):2465-2470.
26.	Zindrick MR, Wiltse LL, Widell EH, et al. A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop Relat Res, 1986, (203):99-112.
27.	Zdeblick TA, Kunz DN, Cooke ME, et al. Pedicle screw pullout strength. Correlation with insertional torque. Spine (Phila Pa 1976), 1993, 18(12):1673-1676.
28.	Paxinos O, Tsitsopoulos PP, Zindrick MR, et al. Evaluation of pullout strength and failure mechanism of posterior instrumentation in normal and osteopenic thoracic vertebrae. J Neurosurg Spine, 2010, 13(4):469-476.

1. 张宁, 殷国勇. 脊柱脊髓损伤的修复与重建进展. 中国修复重建外科杂志, 2008, 22(4):385-389.
2. Boachie-Adjei O, Girardi FP, Bansal M, et al. Safety and efficacy of pedicle screw placement for adult spinal deformity with a pedicle-probing conventional anatomic technique. J Spinal Disord, 2000, 13(6):496-500.
3. Lehman RA Jr, Lenke LG, Keeler KA, et al. Computed tomography evaluation of pedicle screws placed in the pediatric deformed spine over an 8-year period. Spine (Phila Pa 1976), 2007, 32(24):2679-2684.
4. Karapinar L, Erel N, Ozturk H, et al. Pedicle screw placement with a free hand technique in thoracolumbar spine:is it safe? J Spinal Disord Tech, 2008, 21(1):63-67.
5. Parker SL, Mcgirt MJ, Farber SH, et al. Accuracy of free-hand pedicle screws in the thoracic and lumbar spine:analysis of 6816 consecutive screws. Neurosurgery, 2011, 68(1):170-178.
6. Kosmopoulos V, Schizas C. Pedicle screw placement accuracy:a meta-analysis. Spine (Phila Pa 1976), 2007, 32(3):E111-120.
7. Gelalis ID, Paschos NK, Pakos EE, et al. Accuracy of pedicle screw placement:a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques. Eur Spine J, 2012, 21(2):247-255.
8. Nottmeier EW, Seemer W, Young PM. Placement of thoracolumbar pedicle screws using three-dimensional image guidance:experience in a large patient cohort. J Neurosurg Spine, 2009, 10(1):33-39.
9. Silbermann J, Riese F, Allam Y, et al. Computer tomography assessment of pedicle screw placement in lumbar and sacral spine:comparison between free-hand and O-arm based navigation techniques. Eur Spine J, 2011, 20(6):875-881.
10. Tian NF, Xu HZ. Image-guided pedicle screw insertion accuracy:a meta-analysis. Int Orthop, 2009, 33(4):895-903.
11. Castro WH, Halm H, Jerosch J, et al. Accuracy of pedicle screw placement in lumbar vertebrae. Spine (Phila Pa 1976), 1996, 21(11):1320-1324.
12. Laine T, Lund T, Ylikoski M, et al. Accuracy of pedicle screw insertion with and without computer assistance:a randomised controlled clinical study in 100 consecutive patients. Eur Spine J, 2000, 9(3):235-240.
13. Schulze CJ, Munzinger E, Weber U. Clinical relevance of accuracy of pedicle screw placement. A computed tomographic-supported analysis. Spine (Phila Pa 1976), 1998, 23(20):2215-2221.
14. Tsai KJ, Murakami H, Horton WC, et al. Pedicle screw fixation strength:a biomechanical comparison between 4.5-mm and 5.5-mm diameter screws in osteoporotic upper thoracic vertebrae. J Surg Orthop Adv, 2009, 18(1):23-27.
15. Kim JH, Horton W, Hamasaki T, et al. Spinal instrumentation for sacral-pelvic fixation:a biomechanical comparison between constructs ending with either S2 bicortical, bitriangulated screws or iliac screws. J Spinal Disord Tech, 2010, 23(8):506-512.
16. 王宇, 邑晓东, 李淳德. 可注射硫酸钙强化椎弓根螺钉内固定的实验研究. 中国脊柱脊髓杂志, 2009, 19(1):5.
17. Brasiliense LB, Theodore N, Lazaro BC, et al. Quantitative analysis of misplaced pedicle screws in the thoracic spine:how much pullout strength is lost?:presented at the 2009 Joint Spine Section Meeting. J Neurosurg Spine, 2010, 12(5):503-508.
18. Lehman RA, Kuklo TR. Use of the anatomic trajectory for thoracic pedicle screw salvage after failure/violation using the straight-forward technique:a biomechanical analysis. Spine (Phila Pa 1976), 2003, 28(18):2072-2077.
19. Daftari TK, Horton WC, Hutton WC. Correlations between screw hole preparation, torque of insertion, and pullout strength for spinal screws. J Spinal Disord, 1994, 7(2):139-145.
20. Inceoglu S, Ferrara L, Mclain RF. Pedicle screw fixation strength:pullout versus insertional torque. Spine J, 2004, 4(5):513-518.
21. Kwok AW, Finkelstein JA, Woodside T, et al. Insertional torque and pull-out strengths of conical and cylindrical pedicle screws in cadaveric bone. Spine (Phila Pa 1976), 1996, 21(21):2429-2434.
22. Myers BS, Belmont PJ, Richardson WJ, et al. The role of imaging and in situ biomechanical testing in assessing pedicle screw pull-out strength. Spine (Phila Pa 1976), 1996, 21(17):1962-1968.
23. Okuyama K, Abe E, Suzuki T, et al. Can insertional torque predict screw loosening and related failures? An in vivo study of pedicle screw fixation augmenting posterior lumbar interbody fusion. Spine (Phila Pa 1976), 2000, 25(7):858-864.
24. Ozawa T, Takahashi K, Yamagata M, et al. Insertional torque of the lumbar pedicle screw during surgery. J Orthop Sci, 2005, 10(2):133-136.
25. Pashman RS, Hu SS, Schendel MJ, et al. Sacral screw loads in lumbosacral fixation for spinal deformity. Spine (Phila Pa 1976), 1993, 18(16):2465-2470.
26. Zindrick MR, Wiltse LL, Widell EH, et al. A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop Relat Res, 1986, (203):99-112.
27. Zdeblick TA, Kunz DN, Cooke ME, et al. Pedicle screw pullout strength. Correlation with insertional torque. Spine (Phila Pa 1976), 1993, 18(12):1673-1676.
28. Paxinos O, Tsitsopoulos PP, Zindrick MR, et al. Evaluation of pullout strength and failure mechanism of posterior instrumentation in normal and osteopenic thoracic vertebrae. J Neurosurg Spine, 2010, 13(4):469-476.

Chinese Journal of Reparative and Reconstructive Surgery

BIOMECHANICAL STRENGTH INFLUENCE OF LATERAL WALL VIOLATION ON SPINAL PEDICLE SCREW FIXATION

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