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Calek AK, Cornaz F, Suter M, Fasser MR, Farshad M, Widmer J. Endplate weakening during cage bed preparation significantly reduces endplate load capacity. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2621-2629. [PMID: 38733400 DOI: 10.1007/s00586-024-08289-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/17/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024]
Abstract
PURPOSE To analyze the effect of endplate weakness prior to PLIF or TLIF cage implantation and compare it to the opposite intact endplate of the same vertebral body. In addition, the influence of bone quality on endplate resistance was investigated. METHODS Twenty-two human lumbar vertebrae were tested in a ramp-to-failure test. One endplate of each vertebral body was tested intact and the other after weakening with a rasp (over an area of 200 mm2). Either a TLIF or PLIF cage was then placed and the compression load was applied across the cage until failure of the endplate. Failure was defined as the first local maximum of the force measurement. Bone quality was assessed by determining the Hounsfield units (HU) on CT images. RESULTS With an intact endplate and a TLIF cage, the median force to failure was 1276.3N (693.1-1980.6N). Endplate weakening reduced axial endplate resistance to failure by 15% (0-23%). With an intact endplate and a PLIF cage, the median force to failure was 1057.2N (701.2-1735.5N). Endplate weakening reduced axial endplate resistance to failure by 36.6% (7-47.9%). Bone quality correlated linearly with the force at which endplate failure occurred. Intact and weakened endplates showed a strong positive correlation: intact-TLIF: r = 0.964, slope of the regression line (slope) = 11.8, p < 0.001; intact-PLIF: r = 0.909, slope = 11.2, p = 5.5E-05; weakened-TLIF: r = 0.973, slope = 12.5, p < 0.001; weakened-PLIF: r = 0.836, slope = 6, p = 0.003. CONCLUSION Weakening of the endplate during cage bed preparation significantly reduces the resistance of the endplate to subsidence to failure: endplate load capacity is reduced by 15% with TLIF and 37% with PLIF. Bone quality correlates with the force at which endplate failure occurs.
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Affiliation(s)
- Anna-Katharina Calek
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Frédéric Cornaz
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Mauro Suter
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marie-Rosa Fasser
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jonas Widmer
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Calek AK, Cornaz F, Suter M, Fasser MR, Baumgartner S, Sager P, Farshad M, Widmer J. Load distribution on intervertebral cages with and without posterior instrumentation. Spine J 2024; 24:889-898. [PMID: 37924848 DOI: 10.1016/j.spinee.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/18/2023] [Accepted: 10/28/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND CONTEXT Posterior and transforaminal lumbar interbody fusion (PLIF, TLIF) are well-established procedures for spinal fusion. However, little is known about load sharing between cage, dorsal construct, and biological tissue within the instrumented lumbar spine. PURPOSE The aim of this study was to quantify the forces acting on cages under axial compression force with and without posterior instrumentation. STUDY DESIGN Biomechanical cadaveric study. METHODS Ten lumbar spinal segments were tested under uniaxial compression using load cell instrumented intervertebral cages. The force was increased in 100N increments to 1000N or a force greater than 500N on one load cell. Each specimen was tested after unilateral PLIF (uPLIF), bilateral PLIF (bPLIF) and TLIF each with/without posterior instrumentation. Dorsal instrumentation was performed with 55N of compression per side. RESULTS Cage insertion resulted in median cage preloads of 16N, 29N and 35N for uPLIF, bPLIF, and TLIF. The addition of compressed dorsal instrumentation increased the median preload to 224N, 328N, and 317N, respectively. With posterior instrumentation, the percentage of the external load acting on the intervertebral cage was less than 25% at 100N (uPLIF: 14.2%; bPLIF: 16%; TLIF: 11%), less than 45% at 500N (uPLIF: 31.8%; bPLIF: 41.1%; TLIF: 37.9%) and less than 50% at 1000N (uPLIF: 40.3%; bPLIF: 49.7%; TLIF: 43.4%). Without posterior instrumentation, the percentage of external load on the cages was significantly higher with values above 50% at 100N (uPLIF: 55.6%; bPLIF: 75.5%; TLIF: 66.8%), 500N (uPLIF: 71.7%; bPLIF: 79.2%; TLIF: 65.4%), and 1000N external load (uPLIF: 73%; bPLIF: 80.5%; TLIF: 66.1%). For absolute loads, preloads and external loads must be added together. CONCLUSIONS Without posterior instrumentation, the intervertebral cages absorb more than 50% of the axial load and the load distribution is largely independent of the loading amplitude. With posterior instrumentation, the external load acting on the cages is significantly lower and the load distribution becomes load amplitude dependent, with a higher proportion of the load transferred by the cages at high loads. The bPLIF cages tend to absorb more force than the other two cage configurations. CLINICAL SIGNIFICANCE Cage instrumentation allows some of the compression force to be transmitted through the cage to the screws below, better distributing and reducing the overall force on the pedicle screws at the end of the construct and on the rods.
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Affiliation(s)
- Anna-Katharina Calek
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, Zurich CH-8008, Switzerland.
| | - Frédéric Cornaz
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, Zurich CH-8008, Switzerland
| | - Mauro Suter
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marie-Rosa Fasser
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Sina Baumgartner
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp Sager
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, Zurich CH-8008, Switzerland; University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jonas Widmer
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
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Essa A, Shehade M, Rabau O, Smorgick Y, Mirovsky Y, Anekstein Y. Fusion's Location and Quality within the Fixated Segment Following Transforaminal Interbody Fusion (TLIF). Healthcare (Basel) 2023; 11:2814. [PMID: 37957959 PMCID: PMC10648832 DOI: 10.3390/healthcare11212814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/02/2023] [Accepted: 10/14/2023] [Indexed: 11/15/2023] Open
Abstract
Transforaminal interbody fusion (TLIF) has gained increased popularity over recent decades and is being employed as an established surgical treatment for several lumbar spine pathologies, including degenerative spondylosis, spondylolisthesis, infection, tumor and some cases of recurrent disc herniation. Despite the seemingly acceptable fusion rates after TLIF (up to 94%), the literature is still limited regarding the specific location and quality of fusion inside the fixated segment. In this single-institution, retrospective population-based study, we evaluated all post-operative computed tomography (CT) of patients who underwent TLIF surgery at a medium-sized medical center between 2010 and 2020. All CT studies were performed at a minimum of 1 year following the surgery, with a median of 2 years. Each CT study was evaluated for post-operative fusion, specifically in the posterolateral and intervertebral body areas. The fusion's quality was determined and classified in each area according to Lee's criteria, as follows: (1) definitive fusion: definitive bony trabecular bridging across the graft host interface; (2) probable fusion: no definitive bony trabecular crossing but with no gap at the graft host interface; (3) possible arthrosis: no bony trabecular crossing with identifiable gap at the graft host interface; (4) definite pseudarthrosis: no traversing trabecular bone with definitive gap. A total of 48 patients were included in this study. The median age was 55.6 years (SD ± 15.4). The median time from surgery to post-operative CT was 2 years (range: 1-10). Full definitive fusion in both posterolateral and intervertebral areas was observed in 48% of patients, and 92% showed definitive fusion in at least one area (either posterolateral or intervertebral body area). When comparing the posterolateral and the intervertebral area fusion rates, a significantly higher definitive fusion rate was observed in the posterolateral area as compared to the intervertebral body area in the long term follow-up (92% vs. 52%, p < 0.001). In the multivariable analysis, accounting for several confounding factors, including the number of fixated segments and cage size, the results remained statistically significant (p = 0.048). In conclusion, a significantly higher definitive fusion rate at the posterolateral area compared to the intervertebral body area following TLIF surgery was found. Surgeons are encouraged to employ bone augmentation material in the posterolateral area (as the primary site of fusion) when performing TLIF surgery.
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Affiliation(s)
- Ahmad Essa
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center, Zerifin 7033001, Israel; (M.S.); (O.R.); (Y.S.); (Y.M.); (Y.A.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Munder Shehade
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center, Zerifin 7033001, Israel; (M.S.); (O.R.); (Y.S.); (Y.M.); (Y.A.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Oded Rabau
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center, Zerifin 7033001, Israel; (M.S.); (O.R.); (Y.S.); (Y.M.); (Y.A.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Spine Unit, Department of Orthopedic Surgery, Shamir (Assaf Harofeh) Medical Center, Zerifin 7033001, Israel
| | - Yossi Smorgick
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center, Zerifin 7033001, Israel; (M.S.); (O.R.); (Y.S.); (Y.M.); (Y.A.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Spine Unit, Department of Orthopedic Surgery, Shamir (Assaf Harofeh) Medical Center, Zerifin 7033001, Israel
| | - Yigal Mirovsky
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center, Zerifin 7033001, Israel; (M.S.); (O.R.); (Y.S.); (Y.M.); (Y.A.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Spine Unit, Department of Orthopedic Surgery, Shamir (Assaf Harofeh) Medical Center, Zerifin 7033001, Israel
| | - Yoram Anekstein
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center, Zerifin 7033001, Israel; (M.S.); (O.R.); (Y.S.); (Y.M.); (Y.A.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Spine Unit, Department of Orthopedic Surgery, Shamir (Assaf Harofeh) Medical Center, Zerifin 7033001, Israel
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Rickert M, Fennema P, Wehner D, Rahim T, Hölper B, Eichler M, Makowski M, Meurer A, Brenneis M. Postoperative cage migration and subsidence following TLIF surgery is not associated with bony fusion. Sci Rep 2023; 13:12597. [PMID: 37537231 PMCID: PMC10400549 DOI: 10.1038/s41598-023-38801-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 07/14/2023] [Indexed: 08/05/2023] Open
Abstract
Pseudarthrosis following transforaminal interbody fusion (TLIF) is not infrequent. Although cage migration and subsidence are commonly regarded as evidence of the absence of solid fusion, there is still no evidence of the influence of cage migration and subsidence on fusion. This study aimed to evaluate cage migration and subsidence using computed tomography (CT) DICOM data following lumbar interbody fusion. The effects of cage migration and subsidence on fusion and clinical outcomes were also assessed. A postoperative CT data set of 67 patients treated with monosegmental TLIF was analyzed in terms of cage position. To assess the effects of cage migration and subsidence on fusion, 12-month postoperative CT scans were used to assess fusion status. Clinical evaluation included the visual analog scale for pain and the Oswestry Disability Index. Postoperative cage migration occurred in 85.1% of all patients, and cage subsidence was observed in 58.2%. Radiological signs of pseudarthrosis was observed in 7.5% of the patients Neither cage migration nor subsidence affected the clinical or radiographic outcomes. No correlation was found between clinical and radiographic outcomes. The incidence of cage migration was considerable. However, as cage migration and subsidence were not associated with bony fusion, their clinical significance was considered limited.
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Affiliation(s)
- Marcus Rickert
- Spine Department, Schön Klinik Lorsch, Wilhelm Leuschner Strasse 10, Lorsch, Germany.
| | - Peter Fennema
- ARM Advanced Medical Research, Hofenstrasse 89b, 8708, Männedorf, Switzerland
| | - Diana Wehner
- Wirbelsäulenzentrum Fulda/Main/Kinzig, Hailerer Straße 16, 63571, Gelnhausen, Germany
| | - Tamim Rahim
- Asklepios Klinik Wiesbaden GmbH, Geisenheimer Straße 10, 65197, Wiesbaden, Germany
| | - Bernd Hölper
- Wirbelsäulenzentrum Fulda/Main/Kinzig, Hailerer Straße 16, 63571, Gelnhausen, Germany
| | - Michael Eichler
- Wirbelsäulenzentrum Fulda/Main/Kinzig, Hailerer Straße 16, 63571, Gelnhausen, Germany
| | - Marcus Makowski
- Department of Radiology, MRI TU Munich, Klinikum rechts der isar der TU München, Ismaninger Strasse 22, Munich, Germany
| | - Andrea Meurer
- Department of Orthopedics, Orthopadische Universitatsklinik Friedrichsheim gGmbH, Frankfurt am Main, Hessen, Germany
| | - Marco Brenneis
- Department of Trauma and Orthopaedic Surgery, Goethe University Frankfurt, University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
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Heinz von der Hoeh N, Villa T, Galbusera F, Voelker A, Spiegl UA, Jarvers JS, Heyde CE. Analysis of a Unilateral Bridging Cage for Lumbar Interbody Fusion: 2-Year Clinical Results and Fusion Rate with a Focus on Subsidence. World Neurosurg 2018; 116:e308-e314. [DOI: 10.1016/j.wneu.2018.04.195] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/24/2018] [Accepted: 04/25/2018] [Indexed: 10/17/2022]
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