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Fernandes RJR, Gee A, Kanawati AJ, Siddiqi F, Rasoulinejad P, Zdero R, Bailey CS. Biomechanical Comparison of Subsidence Between Patient-Specific and Non-Patient-Specific Lumbar Interbody Fusion Cages. Global Spine J 2024; 14:1155-1163. [PMID: 36259252 DOI: 10.1177/21925682221134913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Biomechanical study. OBJECTIVES Several strategies to improve the surface of contact between an interbody device and the endplate have been employed to attenuate the risk of cage subsidence. 3D-printed patient-specific cages have been presented as a promising alternative to help mitigate that risk, but there is a lack of biomechanical evidence supporting their use. We aim to evaluate the biomechanical performance of 3D printed patient-specific lumbar interbody fusion cages in relation to commercial cages in preventing subsidence. METHODS A cadaveric model is used to investigate the possible advantage of 3D printed patient-specific cages matching the endplate contour using CT-scan imaging in preventing subsidence in relation to commercially available cages (Medtronic Fuse and Capstone). Peak failure force and stiffness were analyzed outcomes for both comparison groups. RESULTS PS cages resulted in significantly higher construct stiffness when compared to both commercial cages tested (>59%). PS cage peak failure force was 64% higher when compared to Fuse cage (P < .001) and 18% higher when compared to Capstone cage (P = .086). CONCLUSIONS Patient-specific cages required higher compression forces to produce failure and increased the cage-endplate construct' stiffness, decreasing subsidence risk.
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Affiliation(s)
- Renan J R Fernandes
- Combined Orthopaedic and Neurosurgery Spine Program, London Health Science Centre, London, ON, Canada
- Schulich School of Medicine, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Aaron Gee
- Combined Orthopaedic and Neurosurgery Spine Program, London Health Science Centre, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Andrew J Kanawati
- Department of Orthopaedic Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Fawaz Siddiqi
- Combined Orthopaedic and Neurosurgery Spine Program, London Health Science Centre, London, ON, Canada
- Schulich School of Medicine, Western University, London, ON, Canada
| | - Parham Rasoulinejad
- Combined Orthopaedic and Neurosurgery Spine Program, London Health Science Centre, London, ON, Canada
- Schulich School of Medicine, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Radovan Zdero
- Lawson Health Research Institute, London, ON, Canada
| | - Christopher S Bailey
- Combined Orthopaedic and Neurosurgery Spine Program, London Health Science Centre, London, ON, Canada
- Schulich School of Medicine, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
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Jeon JW, Kang KW, Kim WK, Yang S, Kang BJ. Cervical spine reconstruction after total vertebrectomy using customized three-dimensional-printed implants in dogs. J Vet Sci 2024; 25:e2. [PMID: 38311317 PMCID: PMC10839172 DOI: 10.4142/jvs.23241] [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: 09/27/2023] [Revised: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Sufficient surgical resection is necessary for effective tumor control, but is usually limited for vertebral tumors, especially in the cervical spine in small animal neurosurgery. OBJECTIVE To evaluate the primary stability and safety of customized three-dimensional (3D)-printed implants for cervical spine reconstruction after total vertebrectomy. METHODS Customized guides and implants were designed based on computed tomography (CT) imaging of five beagle cadavers and were 3D-printed. They were used to reconstruct C5 after total vertebrectomy. Postoperative CT images were obtained to evaluate the safety and accuracy of screw positioning. After harvesting 10 vertebral specimens (C3-C7) from intact (group A) and implanted spines (group B), implant stability was analyzed using a 4-point bending test comparing with groups A and C (reconstituted with plate and pins/polymethylmethacrylate after testing in Group A). RESULTS All customized implants were applied without gross neurovascular damage. In addition, 90% of the screws were in a safe area, with 7.5% in grade 1 (< 1.3 mm) and 2.5% in grade 2 (> 1.3 mm). The mean entry point and angular deviations were 0.81 ± 0.43 mm and 6.50 ± 5.11°, respectively. Groups B and C significantly decreased the range of motion (ROM) in C3-C7 compared with intact spines (p = 0.033, and 0.018). Both groups reduced overall ROM and neutral zone in C4-C6, but only group B showed significance (p = 0.005, and 0.027). CONCLUSION Customized 3D-printed implants could safely and accurately replace a cervical vertebra in dog cadavers while providing primary stability.
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Affiliation(s)
- Ji-Won Jeon
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul 08826, Korea
| | - Kyu-Won Kang
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul 08826, Korea
| | - Woo-Keyoung Kim
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul 08826, Korea
- BK21 FOUR Future Veterinary Medicine Leading Education and Research Center, Seoul National University, Seoul 08826, Korea
| | - Sook Yang
- CUSMEDI Co., Ltd., Suwon 16675, Korea
| | - Byung-Jae Kang
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul 08826, Korea
- BK21 FOUR Future Veterinary Medicine Leading Education and Research Center, Seoul National University, Seoul 08826, Korea.
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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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Kiapour A, Massaad E, Kodigudla MK, Kelkar A, Begley MR, Goel VK, Block JE, Shin JH. Resisting subsidence with a truss Implant: Application of the "Snowshoe" principle for interbody fusion devices. J Biomech 2023; 155:111635. [PMID: 37216894 DOI: 10.1016/j.jbiomech.2023.111635] [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: 11/03/2022] [Revised: 04/10/2023] [Accepted: 05/09/2023] [Indexed: 05/24/2023]
Abstract
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.
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Affiliation(s)
- Ali Kiapour
- Department of Neurosurgery Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Elie Massaad
- Department of Neurosurgery Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Manoj K Kodigudla
- Engineering Center for Orthopedic Research Excellence, The University of Toledo, Toledo, OH, USA
| | - Amey Kelkar
- Engineering Center for Orthopedic Research Excellence, The University of Toledo, Toledo, OH, USA
| | - Matthew R Begley
- Department of Mechanical Engineering, University of California, Santa Barbara, CA, USA
| | - Vijay K Goel
- Engineering Center for Orthopedic Research Excellence, The University of Toledo, Toledo, OH, USA
| | | | - John H Shin
- Department of Neurosurgery Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Tortolani PJ, Lucas SL, Pivazyan G, Wang W, Cunningham BW. Validation of Impaction Grafting for Single-Level Transforaminal Lumbar Interbody Fusion-Technical Pearls and MicroCT Analysis. Spine (Phila Pa 1976) 2023; 48:E70-E77. [PMID: 36728792 DOI: 10.1097/brs.0000000000004559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 11/11/2022] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Cadaveric study. BACKGROUND CONTEXT Transforaminal lumbar interbody fusion (TLIF) represents a well-documented operative surgical technique utilized in the management of lumbar pathology requiring interbody arthrodesis. The microstructural properties of impaction grafting (IG) after TLIF has yet to be reported. PURPOSE The current study was designed first, to quantify the degree, to which IG augmentation would increase intrabody final bone volume and bone graft surface contact area with the endplates; secondly to quantify the volumes of locally harvested bone and bone needed for maximal impaction. MATERIALS AND METHODS Three cadaveric lumbosacral spine specimens were dissected into L1-L2, L3-L4, and L5-S1 motion segments for a total of 9 functional spinal units. Each interbody unit underwent a TLIF procedure with the implantation of an interbody spacer containing autogenous morselized bone. Microcomputed tomography scans were then performed to evaluate the final bone volume and bone surface contact area (BSCA). Subsequently, IG augmented TLIF procedure was carried and microcomputed tomography scans were repeated. RESULTS IG augmentation of TLIF exhibited a 346% increase in final bone volume (TLIF: 0.30 ± 0.07 cm 3 ; IG-TLIF: 1.34 ± 0.42 cm 3 ; P < 0.05) and a 152% increase in BSCA (TLIF: 45.06 ± 15.47%; IG-TLIF: 68.28 ± 6.85%; P < 0.05) when compared with the nonimpacted TLIF treatment. In addition, the average amount of autogenous bone collected was 8.21±2.08 cm 3 , which sufficiently fulfilled the requirements for bone grafting (TLIF: 1.23 ± 0.40 cm 3 ; IG-TLIF 6.42 ± 1.20 cm 3 ). CONCLUSIONS IG augmentation of TLIF significantly improved final bone volume in the disc space and BSCA with vertebral endplates in vitro. CLINICAL SIGNIFICANCE Greater BSCA and final volume of bone graft reflect promisingly on their potential to increase fusion rates. Clinical studies will be needed to corroborate these findings.
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Affiliation(s)
- Paul Justin Tortolani
- Department of Orthopedic Surgery, University of Maryland St. Joseph Medical Center, Towson, MD
| | | | - Gnel Pivazyan
- Department of Orthopedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, MD
- Department of Neurosurgery, MedStar Georgetown University Hospital, WA
| | | | - Bryan W Cunningham
- Department of Orthopedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, MD
- Department of Orthopedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD
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Zhang X, Yang Y, Shen YW, Zhang KR, Ma LT, Ding C, Wang BY, Meng Y, Liu H. Biomechanical performance of the novel assembled uncovertebral joint fusion cage in single-level anterior cervical discectomy and fusion: A finite element analysis. Front Bioeng Biotechnol 2023; 11:931202. [PMID: 36970630 PMCID: PMC10031026 DOI: 10.3389/fbioe.2023.931202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 02/22/2023] [Indexed: 03/11/2023] Open
Abstract
Introduction: Anterior cervical discectomy and fusion (ACDF) is widely accepted as the gold standard surgical procedure for treating cervical radiculopathy and myelopathy. However, there is concern about the low fusion rate in the early period after ACDF surgery using the Zero-P fusion cage. We creatively designed an assembled uncoupled joint fusion device to improve the fusion rate and solve the implantation difficulties. This study aimed to assess the biomechanical performance of the assembled uncovertebral joint fusion cage in single-level ACDF and compare it with the Zero-P device.Methods: A three-dimensional finite element (FE) of a healthy cervical spine (C2−C7) was constructed and validated. In the one-level surgery model, either an assembled uncovertebral joint fusion cage or a zero-profile device was implanted at the C5–C6 segment of the model. A pure moment of 1.0 Nm combined with a follower load of 75 N was imposed at C2 to determine flexion, extension, lateral bending, and axial rotation. The segmental range of motion (ROM), facet contact force (FCF), maximum intradiscal pressure (IDP), and screw−bone stress were determined and compared with those of the zero-profile device.Results: The results showed that the ROMs of the fused levels in both models were nearly zero, while the motions of the unfused segments were unevenly increased. The FCF at adjacent segments in the assembled uncovertebral joint fusion cage group was less than that that of the Zero-P group. The IDP at the adjacent segments and screw–bone stress were slightly higher in the assembled uncovertebral joint fusion cage group than in those of the Zero-P group. Stress on the cage was mainly concentrated on both sides of the wings, reaching 13.4–20.4 Mpa in the assembled uncovertebral joint fusion cage group.Conclusion: The assembled uncovertebral joint fusion cage provided strong immobilization, similar to the Zero-P device. When compared with the Zero-P group, the assembled uncovertebral joint fusion cage achieved similar resultant values regarding FCF, IDP, and screw–bone stress. Moreover, the assembled uncovertebral joint fusion cage effectively achieved early bone formation and fusion, probably due to proper stress distributions in the wings of both sides.
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Distefano F, Epasto G, Guglielmino E, Amata A, Mineo R. Subsidence of a partially porous titanium lumbar cage produced by electron beam melting technology. J Biomed Mater Res B Appl Biomater 2023; 111:590-598. [PMID: 36208414 PMCID: PMC10092161 DOI: 10.1002/jbm.b.35176] [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: 09/25/2021] [Revised: 07/30/2022] [Accepted: 09/25/2022] [Indexed: 01/21/2023]
Abstract
The lumbar intervertebral devices are widely used in the surgical treatment of lumbar diseases. The subsidence represents a serious clinical issue during the healing process, mainly when the interfaces between the implant and the vertebral bodies are not well designed. The aim of this study is the evaluation of subsidence risk for two different devices. The devices have the same shape, but one of them includes a filling micro lattice structure. The effect of the micro lattice structure on the subsidence behavior of the implant was evaluated by means of both experimental tests and finite element analyses. Compressive tests were carried out by using blocks made of grade 15 polyurethane, which simulate the vertebral bone. Non-linear, quasi-static finite element analyses were performed to simulate experimental and physiologic conditions. The experimental tests and the FE analyses showed that the subsidence risk is higher for the device without micro lattice structure, due to the smaller contact surface. Moreover, an overload in the central zone of the contact surface was detected in the same device and it could cause the implant failure. Thus, the micro lattice structure allows a homogenous pressure distribution at the implant-bone interface.
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Affiliation(s)
- Fabio Distefano
- Department of Engineering, University of Messina, Messina, Italy
| | - Gabriella Epasto
- Department of Engineering, University of Messina, Messina, Italy
| | | | - Aurora Amata
- ABR Srl, Zona Industriale Dittaino, Assoro, Italy
| | - Rosalia Mineo
- Mt Ortho srl, via fossa lupo sn Aci Sant'Antonio, Catania, Italy
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Yan Y, Li J, Yu J, Wang Y, Dong H, Sun Y, Wu X, He L, Chen W, Feng H. Biomechanical evaluation of two fusion techniques based on finite element analysis: percutaneous endoscopic and minimally invasive transforaminal lumbar interbody fusion. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2022. [DOI: 10.1016/j.medntd.2022.100138] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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10
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Skinner S, Guo L. Intraoperative neuromonitoring during surgery for lumbar stenosis. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:205-227. [PMID: 35772887 DOI: 10.1016/b978-0-12-819826-1.00005-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The indications for neuromonitoring during lumbar stenosis surgery are defined by the risks associated with patient positioning, the approach, decompression of neural elements, deformity correction, and instrument implantation. The routine use of EMG and SEP alone during lumbar stenosis surgery is no longer supported by the literature. Lateral approach neuromonitoring with EMG only is also suspect. Lumbar stenosis patients often present with multiple co-morbidities which put them at risk during routine pre-surgical positioning. Frequently encountered morbid obesity and/or diabetes mellitus may play a role in monitorable and preventable brachial plexopathy after "superman" positioning or femoral neuropathy from groin pressure after prone positioning, for example. Deformity correction in lumbar stenosis surgery often demands advanced implementation of multiple neuromonitoring modalities: EMG, SEP, and MEP. Because the bulbocavernosus reflex detects the function of the conus medullaris and sacral somato afferent/efferent fibers of the cauda equina, it may also be recorded. The recommendation to record pedicle screw thresholds has become more nuanced as surgeon dependence on 3D imaging, navigation, and robotics has increased. Neuromonitoring in lumbar stenosis surgery has been subject mainly to uncontrolled case series; prospective cohort trials are also needed.
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Affiliation(s)
- Stanley Skinner
- Department of Intraoperative Neurophysiology, Abbott Northwestern Hospital, Minneapolis, MN, United States.
| | - Lanjun Guo
- Department of Surgical Neuromonitoring, University of California San Francisco, San Francisco, CA, United States
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Falowski SM, Koga SF, Northcutt T, Garamszegi L, Leasure J, Block JE. Improving the Management of Patients with Osteoporosis Undergoing Spinal Fusion: The Need for a Bone Mineral Density-Matched Interbody Cage. Orthop Res Rev 2021; 13:281-288. [PMID: 34934366 PMCID: PMC8684416 DOI: 10.2147/orr.s339222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/03/2021] [Indexed: 11/23/2022] Open
Abstract
With an increasingly aging population globally, a confluence has emerged between the rising prevalence of degenerative spinal disease and osteoporosis. Fusion of the anterior spinal column remains the mainstay surgical intervention for many spinal degenerative disorders. However, decreased vertebral bone mineral density (BMD), quantitatively measured by dual x-ray absorptiometry (DXA), complicates treatment with surgical interbody fusion as weak underlying bone stock increases the risk of post-operative implant-related adverse events, including cage subsidence. There is a necessity for developing cages with advanced structural designs that incorporate bioengineering and architectural principles to tailor the interbody fusion device directly to the patient’s BMD status. Specifically, lattice-designed cages that mimic the web-like structure of native cancellous bone have demonstrated excellent resistance to post-operative subsidence. This article provides an introductory profile of a spinal interbody implant designed intentionally to simulate the lattice structure of human cancellous bone, with a similar modulus of elasticity, and specialized to match a patient’s bone status across the BMD continuum. The implant incorporates an open pore design where the degree of pore compactness directly corresponds to the patient’s DXA-defined BMD status, including patients with osteoporosis.
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Affiliation(s)
- Steven M Falowski
- Argires-Marotti Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | | | | | | | | | - Jon E Block
- Independent Clinical Consultant, San Francisco, CA, USA
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Russo AJ, Schopler SA, Stetzner KJ, Shirk T. Minimally invasive transforaminal lumbar interbody fusion with expandable articulating interbody spacers significantly improves radiographic outcomes compared to static interbody spacers. JOURNAL OF SPINE SURGERY 2021; 7:300-309. [PMID: 34734134 DOI: 10.21037/jss-20-630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 03/15/2021] [Indexed: 12/22/2022]
Abstract
Background The goal of minimally invasive transforaminal lumbar interbody fusion (MI TLIF) is to restore and maintain disc height and lordosis until arthrodesis occurs, while minimizing muscle disruption and improving recovery time. The purpose of this study was to compare the radiographic outcomes in patients treated with an articulating expandable spacer in MI TLIF to more traditional static spacers. Methods This was a multi-site, multi-surgeon, Institutional Review Board-exempt, retrospective clinical study from a prospectively collected database. It included 48 patients with a diagnosis of degenerative disc disease (DDD) at one level from L2 to S1 with or without Grade 1 spondylolisthesis who underwent MI TLIF using either an articulating expandable or static interbody spacer. Twenty-seven patients were in the banana-shaped articulating expandable interbody spacer (ALTERA®, Globus Medical, Inc., Audubon, PA, USA) group, while 21 patients were in the static interbody spacer group. Both groups had supplemental posterior pedicle screw and rod fixation. Radiographic records were assessed for disc height, neuroforaminal height, and lordosis at baseline, 3 and 6 months, and final follow-up. Results The articulating expandable spacer group displayed significantly greater improvement in anterior disc height from baseline compared to the static spacer group at 6 weeks, 3 and 6 months, and final follow-up by averages of 2.6 mm (79%), 2.8 mm (92%), 3.4 mm (105%), and 3.8 mm (139%), respectively (P<0.05). Mean increases in posterior disc height were significantly greater in the expandable group compared to the static group by 1.2 mm (65%) and 1.7 mm (104%) at 6 months and final follow-up, respectively (P<0.05). Articulating expandable spacers produced significantly greater average improvement by 4.0 mm in neuroforaminal height from baseline to final follow-up compared to static spacers (P<0.05). Increases in intervertebral angle from baseline were significantly greater in the expandable group than in the static group at 3 and 6 months, and final follow-up by averages of 2.5°, 2.8°, and 3.1°, respectively (P<0.05). The articulating expandable spacer group resulted in significantly greater improvements in lumbar lordosis from baseline to 3 and 6 months than the static spacer group by 4.4° and 4.0°, respectively (P<0.05). Conclusions MI TLIF with articulating expandable interbody spacers provides significant restoration and maintenance of disc height, neuroforaminal height, and lordosis compared to static spacers in this comparative cohort. Long-term clinical outcomes are needed to correlate with these radiographic improvements.
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Affiliation(s)
| | | | | | - Torrey Shirk
- Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc., Audubon, PA, USA
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Armocida D, Pesce A, Cimatti M, Proietti L, Santoro A, Frati A. Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Expandable Cages: Increased Risk of Late Postoperative Subsidence Without a Real Improvement of Perioperative Outcomes: A Clinical Monocentric Study. World Neurosurg 2021; 156:e57-e63. [PMID: 34492389 DOI: 10.1016/j.wneu.2021.08.127] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is one of several approaches to lumbar interbody fusion that has proven to be a safe and effective treatment for symptomatic lumbar degenerative disease The clinical outcomes of MIS-TLIF are generally favorable, but there is still controversy regarding its ability to restore sagittal alignment. For this reason, expandable transforaminal lumbar interbody fusion cages have been developed and designed to improve ability to restore disc height and segmental lordosis. The use of expandable cages in transforaminal lumbar interbody fusion has increased drastically; however, it is not clear how effective cage expansion is in regard to disc space lordosis, distraction, and long-term outcome. METHODS We reviewed a cohort of patients with symptomatic lumbar degenerative disc pathology who underwent MIS-TLIF at our institution. We compared clinical and radiographic outcomes of expandable versus nonexpandable cage use in MIS-TLIF focusing on mean changes in segmental lordosis, disc height, and postoperative complications. The results were compared with other studies reported in the international literature. RESULTS Mean change in segmental lordosis was not significantly different between the 2 groups. A significantly higher rate of postoperative subsidence was demonstrated in the expandable cage group. CONCLUSION This study established that expandable cage use in single-level transforaminal lumbar interbody fusion did not reduce the rate of postoperative complications, but rather significantly increased a patient's risk of postoperative subsidence. Expandable cages do not presently demonstrate improved clinical outcomes or improved sagittal alignment compared with static cages.
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Affiliation(s)
- Daniele Armocida
- Human Neurosciences Department, Sapienza University, Rome, Italy.
| | | | - Marco Cimatti
- Human Neurosciences Department, Sapienza University, Rome, Italy
| | - Luca Proietti
- Division of Spinal Surgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy; Institute of Orthopaedics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Santoro
- Human Neurosciences Department, Sapienza University, Rome, Italy
| | - Alessandro Frati
- Human Neurosciences Department, Sapienza University, Rome, Italy; IRCCS Neuromed, Pozzilli, Italy
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Kreinest M, Kelka S, Grützner PA, Vetter SY, Kobbe P, Pishnamaz M. Influence of endplate size and implant positioning of vertebral body replacements on biomechanics and outcome. Clin Biomech (Bristol, Avon) 2021; 81:105251. [PMID: 33373970 DOI: 10.1016/j.clinbiomech.2020.105251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 12/15/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Spinal stabilization by an anterior vertebral body replacement is frequently used in patients suffering from destroyed vertebral bodies. The aim of this study was to analyse (i) the choice of endplate size and positioning of vertebral body replacements in daily patient care and (ii) if these factors have an influence on clinical and radiological outcomes. METHOD Patients' outcomes were analysed three years after vertebral body replacement implantation using the visual analogue scale spine score. Safe zones on the vertebral body endplates were defined. Overall endplate coverage and implant subsidence were evaluated by CT and X-ray. Compression tests were performed on 22 lumbar vertebral bodies to analyse endplates sizes' influence on subsidence. FINDING Mean coverage of the vertebral body's superior and inferior endplates by the vertebral body replacement was 27.8% and 30.8%, respectively. Mean overlap of the safe zone by the implant was 49.8% and 40.6%. Mean subsidence was 1.1 ± 1.2 mm, but it did not have any effect on the outcome. In the compression tests, no significant difference (p = 0.468) was found between the two endplate sizes. INTERPRETATION Coverage of vertebral body endplates and positioning of implants in the safe zone did not entirely comply with the given recommendations. The amount of endplate coverage had no influence on subsidence or long-term outcomes in daily patient care. On the other hand, correct positioning of the implant may influence its subsidence.
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Affiliation(s)
- Michael Kreinest
- BG Klinik Ludwigshafen, Zentrum für Wirbelsäulenchirurgie, Klinik für Unfallchirurgie und Orthopädie, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany.
| | - Sabine Kelka
- BG Klinik Ludwigshafen, Zentrum für Wirbelsäulenchirurgie, Klinik für Unfallchirurgie und Orthopädie, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany; Bundeswehrkrankenhaus Hamburg, Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Lesserstraße 180, 22049 Hamburg, Germany.
| | - Paul A Grützner
- BG Klinik Ludwigshafen, Zentrum für Wirbelsäulenchirurgie, Klinik für Unfallchirurgie und Orthopädie, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany.
| | - Sven Y Vetter
- BG Klinik Ludwigshafen, Zentrum für Wirbelsäulenchirurgie, Klinik für Unfallchirurgie und Orthopädie, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany.
| | - Philipp Kobbe
- Universitätsklinikum Aachen, Klinik für Unfall- und Wiederherstellungschirurgie, Pauwelsstr. 30, 52074 Aachen, Germany.
| | - Miguel Pishnamaz
- Universitätsklinikum Aachen, Klinik für Unfall- und Wiederherstellungschirurgie, Pauwelsstr. 30, 52074 Aachen, Germany.
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McCaffrey K, McCaffrey MH, Pelletier MH, Lovric V, Mobbs RJ, Walsh WR. Load Sharing and Endplate Pressure Distribution in Anterior Interbody Fusion Influenced by Graft Choice. World Neurosurg 2020; 146:e336-e340. [PMID: 33228956 DOI: 10.1016/j.wneu.2020.10.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/16/2020] [Accepted: 10/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cage subsidence is a known complication of spinal fusion. Various aspects of cage design have been investigated for their influence on cage subsidence, whereas the potential contribution of graft material to load sharing is often overlooked. We aimed to determine whether graft in the aperture affects endplate pressure distribution. METHODS The pressure distributions of a polyetheretherketone interbody cage with 3 different aperture graft conditions were evaluated: empty, demineralized bone matrix, and supercritical CO2-treated allograft bone crunch (SCCO2). RESULTS Graft materials contributed as much as half the load transmission for SCCO2, whereas demineralized bone matrix contributed one third. Endplate areas in contact with the cage demonstrated decreased areas within the highest-pressure spectrum with SCCO2 graft materials compared with empty cages. CONCLUSIONS Graft choice plays a role in reducing peak endplate pressures. This finding is relevant to implant subsidence, as well as graft loading and remodeling.
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Affiliation(s)
- Kieran McCaffrey
- Surgical and Orthopedic Research Laboratories (SORL), Prince of Wales Clinical School, UNSW Sydney, Sydney, Australia
| | - Miles H McCaffrey
- Surgical and Orthopedic Research Laboratories (SORL), Prince of Wales Clinical School, UNSW Sydney, Sydney, Australia
| | - Matthew H Pelletier
- Surgical and Orthopedic Research Laboratories (SORL), Prince of Wales Clinical School, UNSW Sydney, Sydney, Australia.
| | - Vedran Lovric
- Surgical and Orthopedic Research Laboratories (SORL), Prince of Wales Clinical School, UNSW Sydney, Sydney, Australia
| | - Ralph J Mobbs
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Hospital, Sydney, Australia
| | - William R Walsh
- Surgical and Orthopedic Research Laboratories (SORL), Prince of Wales Clinical School, UNSW Sydney, Sydney, Australia
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Collino RR, Kiapour A, Begley MR. Subsidence of Additively-Manufactured Cages in Foam Substrates: Effect of Contact Topology. J Biomech Eng 2020; 142:1075792. [DOI: 10.1115/1.4046584] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Indexed: 01/21/2023]
Abstract
Abstract
Subsidence of implants into bone is a major source of morbidity. The underlying mechanics of the phenomenon are not clear, but are likely related to interactions between contact stresses and the underlying porous trabecular bone structure. To gain insight into these interactions, we studied the penetration of three-dimensional (3D)-printed indenters with systematically varying geometries into Sawbones® foam substrates and isolated the effects of contact geometry from those of overall contact size and area. When size, contact area, and indented material stiffness and strength are controlled for, we show that resistance to penetration is in fact a function of topology only. Indenters with greater line contact lengths support higher subsidence loads in compression. These results have direct implications for the design of implants to resist subsidence into bone.
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Affiliation(s)
- Rachel R. Collino
- Materials Science and Technology Division, Los Alamos National Laboratory, Los Alamos, NM 87545
| | - Ali Kiapour
- Research & Development 4WEB Medical, Inc., Frisco, TX 75034
| | - Matthew R. Begley
- Departments of Mechanical Engineering and Materials, University of California, Santa Barbara, CA 93106
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Bonnheim NB, Keaveny TM. Load-transfer in the human vertebral body following lumbar total disc arthroplasty: Effects of implant size and stiffness in axial compression and forward flexion. JOR Spine 2020; 3:e1078. [PMID: 32211590 PMCID: PMC7084059 DOI: 10.1002/jsp2.1078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 11/07/2022] Open
Abstract
Adverse clinical outcomes for total disc arthroplasty (TDA), including subsidence, heterotopic ossification, and adjacent-level vertebral fracture, suggest problems with the underlying biomechanics. To gain insight, we investigated the role of size and stiffness of TDA implants on load-transfer within a vertebral body. Uniquely, we accounted for the realistic multi-scale geometric features of the trabecular micro-architecture and cortical shell. Using voxel-based finite element analysis derived from a micro-computed tomography scan of one human L1 vertebral body (74-μm-sized elements), a series of generic elliptically shaped implants were analyzed. We parametrically modeled three implant sizes (small, medium [a typical clinical size], and large) and three implant materials (metallic, E = 100 GPa; polymeric, E = 1 GPa; and tissue-engineered, E = 0.01 GPa). Analyses were run for two load cases: 800 N in uniform compression and flexion-induced anterior impingement. Results were compared to those of an intact model without an implant and loaded instead via a disc-like material. We found that TDA implantation increased stress in the bone tissue by over 50% in large portions of the vertebra. These changes depended more on implant size than material, and there was an interaction between implant size and loading condition. For the small implant, flexion increased the 98th-percentile of stress by 32 ± 24% relative to compression, but the overall stress distribution and trabecular-cortical load-sharing were relatively insensitive to loading mode. In contrast, for the medium and large implants, flexion increased the 98th-percentile of stress by 42 ± 9% and 87 ± 29%, respectively, and substantially re-distributed stress within the vertebra; in particular overloading the anterior trabecular centrum and cortex. We conclude that TDA implants can substantially alter stress deep within the lumbar vertebra, depending primarily on implant size. For implants of typical clinical size, bending-induced impingement can substantially increase stress in local regions and may therefore be one factor driving subsidence in vivo.
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Affiliation(s)
- Noah B. Bonnheim
- Department of Mechanical EngineeringUniversity of CaliforniaBerkeleyCalifornia
| | - Tony M. Keaveny
- Department of Mechanical EngineeringUniversity of CaliforniaBerkeleyCalifornia
- Department of BioengineeringUniversity of CaliforniaBerkeleyCalifornia
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18
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Kucharzyk DW, Miller LE. Two-year Clinical and Radiographic Results with a Multidimensional, Expandable Interbody Implant in Minimally Invasive Lumbar Spine Surgery. Cureus 2020; 12:e7070. [PMID: 32226671 PMCID: PMC7089633 DOI: 10.7759/cureus.7070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Minimally invasive spine surgery has become more prevalent in recent years, but the delivery of interbody devices with small footprints may insufficiently restore the disc space, which may lead to instability and non-union. Vertically expandable interbody implants have partially addressed this limitation, but lateral fusion support remains a concern. The purpose of this study was to evaluate two-year safety and effectiveness outcomes with a multidimensional, expandable interbody fusion device (Luna 3D Interbody Fusion System, Benvenue Medical, Inc., Santa Clara, CA) that is delivered through a minimally invasive approach (6-8 mm) that expands in situ to approximate an anterior lumbar interbody fusion footprint of 25 mm diameter. Material and methods This was a retrospective, single-center study that evaluated the clinical utility of a multi-expandable interbody cage in patients undergoing posterior or transforaminal lumbar interbody fusion. Key patient-reported outcomes included back pain severity, leg pain severity, and the Oswestry Disability Index (ODI). Radiographic assessments included disc height (anterior, posterior, and average), foraminal height, segmental lordosis, subsidence, implant migration, and pseudarthrosis. Patients were followed at regular intervals over two years postprocedure. Results A total of 50 consecutive patients were treated with transforaminal lumbar interbody fusion (TLIF) using the multidimensional expandable implant. Procedural blood loss was minimal (median 200 ml) and the mean hospital stay was 2.1 days. Perioperative complications were reported in three patients and included a dural tear, postoperative ileus, and end-plate violation. All complications were successfully managed conservatively. There were no nerve root injuries or perioperative infections. Over the two-year follow-up period, one case of subsidence and one case of implant migration were noted on radiographic imaging but required no treatment. Comparing the values reported at baseline and two years, the mean ODI score decreased by 61%, back pain severity decreased by 67%, and leg pain severity decreased by 80% (all p<0.001). Comparing radiographic measures from baseline to two years, anterior disc height increased from 7.6 mm to 15.5 mm, posterior disc height increased from 2.9 mm to 10.1 mm, average disc height increased from 5.6 mm to 13.3 mm, foraminal height increased from 12.2 mm to 20.2 mm, and segmental lordosis increased from 6.2 degrees to 14.0 degrees (all changes p<0.001). One case of non-union was observed and the corresponding two-year fusion rate was 98%. Conclusions The utilization of a minimally invasive, multidimensional, expandable interbody implant was safe and effective over two years of clinical follow-up. The implant allows the surgeon to re-establish sagittal balance and to provide a larger surface area for fusion as compared to traditional minimally invasive interbody devices.
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Wang J, Qian Z, Ren L. Biomechanical Comparison of Optimal Shapes for the Cervical Intervertebral Fusion Cage for C5-C6 Cervical Fusion Using the Anterior Cervical Plate and Cage (ACPC) Fixation System: A Finite Element Analysis. Med Sci Monit 2019; 25:8379-8388. [PMID: 31697650 PMCID: PMC6859788 DOI: 10.12659/msm.918489] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The fifth and sixth cervical vertebrae (C5-C6) represent the high-risk segment requiring surgical correction in cervical spondylosis. Anterior cervical discectomy and fusion (ACDF) of C5-C6 includes an intervertebral fusion cage to maintain foraminal height and is combined with anterior plate fixation. The shape of the intervertebral cage can affect the postoperative outcome, including the rates of fusion, subsidence, and neck pain. This study aimed to use finite element (FE) parametric analysis to compare biomechanical properties of changes in intervertebral cage shape for C5-C6 cervical fusion using the anterior cervical plate and cage (ACPC) fixation system. MATERIAL AND METHODS Five shapes were designed for cervical intervertebral cages, square, oval, kidney-shaped, clover-shaped, and 12-leaf-shaped. The performance was evaluated following implantation into the validated normal C5-C6 FE model using simulation with five physiological conditions. The indicators included the maximum von Mises stress of the endplates, the fusion cages, and the cervical vertebrae. The postoperative subsidence-resistance properties were determined, including the interior stress responses of the intervertebral cages and the surrounding tissues. The fusion-promoting properties were evaluated by the interior stress responses of the bone grafts. RESULTS The optimal shape of the cervical intervertebral cage was the 12-leaf-shape for postoperative subsidence resistance. The kidney shape for the cervical intervertebral cage was optimal for postoperative fusion. CONCLUSIONS FE analysis identified the optimal cervical intervertebral cage design for ACPC fixation of C5-C6. This method may be useful for future developments in the design of spinal implants.
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Affiliation(s)
- Jiajia Wang
- College of Agricultural Equipment Engineering, Henan University of Science and Technology, Luoyang, Henan, China (mainland).,Key Laboratory of Bionic Engineering (Ministry of Education, China), Jilin University, Changchun, Jilin, China (mainland)
| | - Zhihui Qian
- Key Laboratory of Bionic Engineering (Ministry of Education, China), Jilin University, Changchun, Jilin, China (mainland)
| | - Luquan Ren
- Key Laboratory of Bionic Engineering (Ministry of Education, China), Jilin University, Changchun, Jilin, China (mainland)
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20
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Choi WS, Kim JS, Hur JW, Seong JH. Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Banana-Shaped and Straight Cages: Radiological and Clinical Results from a Prospective Randomized Clinical Trial. Neurosurgery 2019; 82:289-298. [PMID: 28499016 DOI: 10.1093/neuros/nyx212] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 04/23/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), cage type and position play important roles in fusion achievement and sagittal alignment correction. However, no prospective randomized comparison of the results using different types of cage has been reported to date. OBJECTIVE To compare the radiological and clinical outcomes of unilateral MIS-TLIF using 2 types of cage. METHODS All candidates for single-level MIS-TLIF were randomized into banana-shaped cage and straight-cage groups. Plain radiographs and computed tomography scans were used for assessment of cage positions, fusion status, disc height, segmental lordotic angle, cage subsidence, and pelvic parameters. Clinical outcome was assessed using visual analog scale and Oswestry Disability Index scores. RESULTS Forty-four and 40 consecutive patients were operated on using banana-shaped and straight cages, respectively. Cage position was more anterior and lateral in the straight-cage group and more medial and posterior in the banana-shaped cage group. Solid fusion was achieved in 95.2% and 96.6% of the 2 groups, respectively, at 12 mo. The change in disc height and segmental lordotic angle postoperatively was significantly greater in the banana-shaped cage group. The incidence of subsidence during follow-up was significantly higher in the banana-shaped cage group (P < .04). Clinically, the visual analog scale and Oswestry Disability Index scores decreased significantly after surgery in both groups, with no significant difference between the groups. CONCLUSION Our preliminary outcomes suggest that the subsidence rate may be higher using banana-shaped cages in MIS-TLIF, possibly due to their more medial final position.
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Affiliation(s)
- Won-Suh Choi
- Department of Neurosurgery, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Korea
| | - Jin-Sung Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Korea
| | - Jung-Woo Hur
- Department of Neurosurgery, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Korea
| | - Ji-Hoon Seong
- Department of Neurosurgery, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Korea
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21
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Stinchfield T, Vadapalli S, Pennington Z, Sivagnanam R, Prevost J, Schroeder G, Sciubba DM. Improvement in vertebral endplate engagement following anterior column reconstruction using a novel expandable cage with self-adjusting, multiaxial end cap. J Clin Neurosci 2019; 67:249-254. [DOI: 10.1016/j.jocn.2019.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/09/2019] [Indexed: 10/26/2022]
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22
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Soriano-Baron H, Newcomb AGUS, Malhotra D, Martinez Del Campo E, Palma AE, Theodore N, Crawford NR, Kelly BP, Kaibara T. Biomechanical Effects of an Oblique Lumbar PEEK Cage and Posterior Augmentation. World Neurosurg 2019; 126:e975-e981. [PMID: 30876999 DOI: 10.1016/j.wneu.2019.02.200] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Lumbar interbody spacers are widely used in lumbar spinal fusion. The goal of this study is to analyze the biomechanics of a lumbar interbody spacer (Clydesdale Spinal System, Medtronic Sofamor Danek, Memphis, Tennessee, USA) inserted via oblique lumbar interbody fusion (OLIF) or direct lateral interbody fusion (DLIF) approaches, with and without posterior cortical screw and rod (CSR) or pedicle screw and rod (PSR) instrumentation. METHODS Lumbar human cadaveric specimens (L2-L5) underwent nondestructive flexibility testing in intact and instrumented conditions at L3-L4, including OLIF or DLIF, with and without CSR or PSR. RESULTS OLIF alone significantly reduced range of motion (ROM) in flexion-extension (P = 0.005) but not during lateral bending or axial rotation (P ≥ 0.63). OLIF alone reduced laxity in the lax zone (LZ) during flexion-extension (P < 0.001) but did not affect the LZ during lateral bending or axial rotation (P ≥ 0.14). The stiff zone (SZ) was unaffected in all directions (P ≥ 0.88). OLIF plus posterior instrumentation (cortical, pedicle, or hybrid) reduced the mean ROM in all directions of loading but only significantly so with PSR during lateral bending (P = 0.004), without affecting the compressive stiffness (P > 0.20). The compressive stiffness with the OLIF device without any posterior instrumentation did not differ from that of the intact condition (P = 0.97). In terms of ROM, LZ, or SZ, there were no differences between OLIF and DLIF as standalone devices or OLIF and DLIF with posterior instrumentation (CSR or PSR) (P > 0.5). CONCLUSIONS OLIF alone significantly reduced mobility during flexion-extension while maintaining axial compressive stiffness compared with the intact condition. Adding posterior instrumentation to the interbody spacer increased the construct stability significantly, regardless of cage insertion trajectory or screw type.
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Affiliation(s)
- Hector Soriano-Baron
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Anna G U S Newcomb
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Devika Malhotra
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Eduardo Martinez Del Campo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Atilio E Palma
- Department of Neurosurgery, Wake Forest Baptist Hospital, Winston Salem, North Carolina, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | | | - Brian P Kelly
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Taro Kaibara
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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DeLucca JF, Amin D, Peloquin JM, Vresilovic EJ, Costi JJ, Elliott DM. Off-axis response due to mechanical coupling across all six degrees of freedom in the human disc. JOR Spine 2019; 2:e1047. [PMID: 31463461 PMCID: PMC6686826 DOI: 10.1002/jsp2.1047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/14/2019] [Accepted: 02/15/2019] [Indexed: 12/24/2022] Open
Abstract
The kinematics of the intervertebral disc are defined by six degrees of freedom (DOF): three translations (Tz: axial compression, Tx: lateral shear, and Ty: anterior-posterior shear) and three rotations (Rz: torsion, Rx: flexion-extension, and Ry: lateral bending). There is some evidence that the six DOFs are mechanically coupled, such that loading in one DOF affects the mechanics of the other five "off-axis" DOFs, however, most studies have not controlled and/or measured all six DOFs simultaneously. Additionally, the relationships between disc geometry and disc mechanics are important for evaluation of data from different sized donor and patient discs. The objectives of this study were to quantify the mechanical behavior of the intervertebral disc in all six degrees of freedom (DOFs), measure the coupling between the applied motion in each DOF with the resulting off-axis motions, and test the hypothesis that disc geometry influences these mechanical behaviors. All off-axis displacements and rotations were significantly correlated with the applied DOF and were of similar magnitude as physiologically relevant motion, confirming that off-axis coupling is an important mechanical response. Interestingly, there were pairs of DOFs that were especially strongly coupled: lateral shear (Tx) and lateral bending (Ry), anterior-posterior shear (Ty) and flexion-extension (Rx), and compression (Tz) and torsion (Rz). Large off-axis shears may contribute to injury risk in bending and flexion. In addition, the disc responded to shear (Tx, Ty) and rotational loading (Rx, Ry, and Rz) by increasing in disc height in order to maintain the applied compressive load. Quantifying these mechanical behaviors across all six DOF are critical for designing and testing disc therapies, such as implants and tissue engineered constructs, and also for validating finite element models.
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Affiliation(s)
- John F. DeLucca
- Department of Biomedical EngineeringUniversity of DelawareNewarkDelaware
| | - Dhara Amin
- Biomechanics and Implants Research Group, The Medical Device Research InstituteCollege of Science and Engineering, Flinders UniversityAdelaideAustralia
| | - John M. Peloquin
- Department of Biomedical EngineeringUniversity of DelawareNewarkDelaware
| | | | - John J. Costi
- Biomechanics and Implants Research Group, The Medical Device Research InstituteCollege of Science and Engineering, Flinders UniversityAdelaideAustralia
| | - Dawn M. Elliott
- Department of Biomedical EngineeringUniversity of DelawareNewarkDelaware
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McKissack HM, Levene HB. Does the Cage Position in Transforaminal Lumbar Interbody Fusion Determine Unilateral versus Bilateral Screw Placement?: A Review of the Literature. Asian Spine J 2018; 13:325-333. [PMID: 30518200 PMCID: PMC6454278 DOI: 10.31616/asj.2018.0087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/25/2018] [Indexed: 01/03/2023] Open
Abstract
This literature review examines the relative placement of the interbody cage with respect to the unilateral screw construct to address the need for bilateral screw placement versus unilateral screw placement. Transforaminal lumbar interbody fusion (TLIF) has become a widely used technique for correcting lumbar intervertebral pathologies. This review addresses the necessity for further study on the effects of the relative position of intervertebral cage placement on the outcome of lumbar spine surgery after TLIF with unilateral pedicle screw fixation. Previous studies have addressed various factors, including posterior screw fixation, cage size, cage shape, and number of levels fused, that impact the biomechanics of the lumbar spine following TLIF. A simple survey of the literature was conducted. A search of the English literature was conducted using the keywords ‘TLIF,’ ‘transforaminal lumbar interbody fusion,’ ‘graft placement,’ ‘graft position,’ ‘cage position,’ ‘cage placement,’ ‘unilateral pedicle screw,’ ‘unilateral TLIF cage placement,’ ‘lumbar biomechanics,’ ‘lumbar stability,’ ‘lumbar fusion,’ and ‘lumbar intervertebral cage’ with various combinations of the operators ‘AND’ and ‘OR’ and no date restrictions. Seventeen articles in the English literature that were most relevant to this research question were identified. To the best of our knowledge, there are no published data addressing the effects of cage placement relative to the unilateral screw on lumbar stability in TLIF with unilateral pedicle screw fixation. Investigation of the effects of cage placement is, thus, warranted to achieve optimal clinical outcomes in patients undergoing TLIF with unilateral pedicle screw fixation.
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Affiliation(s)
- Haley M McKissack
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Howard Benjamin Levene
- Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
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Elmekaty M, ElMehy E, Försth P, MacDowall A, Elemi AE, Hosni M, Robinson Y. Safety of a novel modular cage for transforaminal lumbar interbody fusion - clinical cohort study in 20 patients with degenerative disc disease. SICOT J 2018; 4:24. [PMID: 29956661 PMCID: PMC6024593 DOI: 10.1051/sicotj/2018019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 04/06/2018] [Indexed: 12/16/2022] Open
Abstract
Introduction: Transforaminal lumbar interbody fusion (TLIF) is used to reconstruct disc height and reduce degenerative deformity in spinal fusion. Patients with osteoporosis are at high risk of TLIF cage subsidence; possibly due to the relatively small footprint compared to anterior interbody devices. Recently, modular TLIF cage with an integral rail and slot system was developed to reduce cage subsidence and allow early rehabilitation. Objective: To study the safety of a modular TLIF device in patients with degenerative disc disorders (DDD) with regard to surgical complications, non-union, and subsidence. Methods: Patients with DDD treated with a modular TLIF cage (Polyetheretherketone (PEEK), VTI interfuse S) were analysed retrospectively with one-year follow-up. Lumbar sagittal parameters were collected preoperatively, postoperatively and at one year follow-up. Cage subsidence, fusion rate, screw loosening and proportion of endplate coverage were assessed in computed tomography scan. Results: 20 patients (age 66 ± 10 years, 65% female, BMI 28 ± 5 kg/m2) with a total of 37 fusion levels were included. 15 patients had degenerative spondylosis and 5 patients had degenerative scoliosis. The cages covered >60% of the vertebral body diameters. Lumbar lordosis angle and segmental disc angle increased from 45.2 ± 14.5 and 7.3 ± 3.6 to 52.7 ± 9.1 and 10.5 ± 3.5 (p = 0.029 and 0.0002) postoperatively for each parameter respectively without loss of correction at one year follow up. One case of deep postoperative infection occurred (5%). No cage subsidence occurred. No non-union or screw loosening occurred. Conclusions: The modular TLIF cage was safe with regard to subsidence and union-rate. It restored and maintained lumbar lordosis angle, segmental disc angle and disc height, which can be attributed to the large footprint of this modular cage.
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Affiliation(s)
- Mohamed Elmekaty
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden - Orthopedic and Traumatology Department, Tanta University, Tanta, Egypt
| | - Emad ElMehy
- Orthopedic and Traumatology Department, Tanta University, Tanta, Egypt
| | - Peter Försth
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Anna MacDowall
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Ahmed El Elemi
- Orthopedic and Traumatology Department, Tanta University, Tanta, Egypt
| | - Mohamed Hosni
- Orthopedic and Traumatology Department, Tanta University, Tanta, Egypt
| | - Yohan Robinson
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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Length of Lumbar Interbody Cage Using Radiological Measurements of Chinese Endplates and the Apophyseal Ring. World Neurosurg 2018; 116:e1204-e1213. [PMID: 29886299 DOI: 10.1016/j.wneu.2018.05.234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To radiologically measure the parameters of endplates and the apophyseal ring and to suggest an applicable length for a lumbar interbody cage for Chinese patients. METHODS Twenty-four volunteers were enrolled to undergo lumbar computed tomography (CT). On the endplate plane, the diameters of the endplates (L1-S1) were measured along the axis of the cage with different lumbar interbody fusion procedures. Whereas the mid-oblique diameter (mid-OD) and maximum oblique diameter (max-OD) were defined as the minimal and maximal diameters of the endplates in transforaminal lumbar interbody fusion (TLIF), side-sagittal diameter (side-SD), mid-sagittal diameter (mid-SD), and transverse diameter (TD) represented the diameters of endplates in posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion (ALIF); and oblique lateral interbody fusion (OLIF)/extreme lateral interbody fusion (XLIF), /direct lateral interbody fusion (DLIF), respectively. R1-R10 were the widths of the apophyseal ring covered by diameters at both ends. We used the proposed formula to calculate the cage length: 1) minimal length of TLIF cage = mid-OD - ½ (R1 + R2), 2) maximal length of TLIF cage = max-OD - ½ (R3 + R4), 3) length of PLIF cage = side-SD - ½ (R5 + R6), 4) length of OLIF/XLIF/DLIF cage = TD - ½ (R7 + R8), and 5) length of ALIF cage = mid-SD - ½ (R9 + R10). RESULTS The lengths of the TLIF cage were more than 30 mm for men and 26 mm for women in L1/2-L4/5, with a large range in L5-S1. For PLIF, the lengths were 28 to 30 mm for men and 24 to 26 mm for women in L1/2-L4/5, with 26 mm and 22 mm, respectively, in L5-S1. For the OLIF/XLIF/DLIF cage, the lengths were 38 mm in L1/2 and 41 to 43 mm in L2/3-L4/5 for men and 35 mm in L1/2-L2/3 and 38 mm in L3/4-L4/5 for women. The ALIF cage lengths were 27 mm in L1/2 and L5-S1 and 29 mm in L2/3-L4/5 for men and 23 mm in L1/2 and L5-S1 and 25 mm in L2/3-L4/5 for women. CONCLUSIONS The choice of an appropriate length for a lumbar interbody cage should be based on the procedure and fusion level, which can match the endplates anatomically. The size of the lumbar interbody cage is affected by many factors, and a simple calculation may not be clinically relevant.
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Soriano-Baron H, Newcomb AG, Malhotra D, Palma AE, Martinez-del-Campo E, Crawford NR, Theodore N, Kelly BP, Kaibara T. Biomechanical Analysis of an Expandable Lumbar Interbody Spacer. World Neurosurg 2018; 114:e616-e623. [DOI: 10.1016/j.wneu.2018.03.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 03/06/2018] [Indexed: 10/17/2022]
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Vertebral body replacement using patient-specific three-dimensional-printed polymer implants in cervical spondylotic myelopathy: an encouraging preliminary report. Spine J 2018; 18:892-899. [PMID: 29408349 DOI: 10.1016/j.spinee.2018.01.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/09/2018] [Accepted: 01/19/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Resulting from recent studies that suggest a benefit of implant design on the achievement of fusion and stability in cervical spinal disease management, manufacturing development has increased over the past years. This article attempts to describe how the development of patient-specific implants, which are used during the procedures of anterior cervical corpectomy and vertebral body replacement (VBR), impacts the outcomes of cervical spondylotic myelopathy (CSM) management. MATERIALS AND METHODS This prospective clinical study included six patients who were implanted with patient-specific VBR for single-level or multilevel CSM. The following clinical scores were collected: visual analog scale (VAS), modified Japanese Orthopaedic Association (mJOA), Neck Dysfunction Index (NDI), and European myelopathy score (EMS), along with radiological measurements. RESULTS Six patients reached a mean follow-up date of 21months (12-24). Angle measurements remained constant during follow-up, including the C2-C7 Cobb angle and the corpectomy Cobb angle. Furthermore, no deformations, such as hyperlordosis or kyphosis, were detected. The anterior height (Ha) and the posterior height (Hp) of the corpectomy segment remained constant (ratio close to 1) with no severe subsidence (>3 mm) at the last follow-up. No height differences were detected between the preoperative and the last follow-up dates, neither for the upper Hp and Ha (0.97±0.09 and 1.00±0.06, respectively) nor for the lower adjacent vertebrate Hp and Ha (0.96±0.04 and 1.02±0.12). The mean mJOA and EMS recovery rates were 60.4% (standard deviation [SD] 20.4) and 77.0% (SD 29.7), respectively, at last the follow-up. An EMS of at least 16 of 18 was observed in 83% (5 of 6) of the patients. We recorded a preoperative NDI score at 47.1% (SD 18.6) that improved to 11.2% (SD 4.1) at the last follow-up (p<.01). The preoperative VAS neck (6.3, range 4-7) and the VAS arm (6.1, range 3- 9) scores improved to 1.3 (range 0-3) and 2.8 (range 0-5), respectively, at the last follow-up. CONCLUSIONS This preliminary report suggests a possible benefit of the use of patient-specific implants in CSM treatment. The favorable clinical and radiological outcomes were associated with a correct achievement rate; these are promising elements toward the development of the concept of personalized therapy. Nonetheless, these encouraging results have to be confirmed now with a longer follow-up and a larger cohort.
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Oberkircher L, Krüger A, Hörth D, Hack J, Ruchholtz S, Fleege C, Rauschmann M, Arabmotlagh M. Anterior cement augmentation of adjacent levels after vertebral body replacement leads to superior stability of the corpectomy cage under cyclic loading-a biomechanical investigation. Spine J 2018; 18:525-531. [PMID: 29174458 DOI: 10.1016/j.spinee.2017.10.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/08/2017] [Accepted: 10/26/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND In the operative treatment of osteoporotic vertebral body fractures, a dorsal stabilization in combination with a corpectomy of the fractured vertebral body might be necessary with respect to the fracture morphology, whereby the osteoporotic bone quality may possibly increase the risk of implant failure. To achieve better stability, it is recommended to use cement-augmented screws for dorsal instrumentation. Besides careful end plate preparation, cement augmentation of the adjacent end plates has also been reported to lead to less reduction loss. PURPOSE The aim of the study was to evaluate biomechanically under cyclic loading whether an additional cement augmentation of the adjacent end plates leads to improved stability of the inserted cage. STUDY DESIGN/SETTING Methodical cadaver study. MATERIALS AND METHODS Fourteen fresh frozen human thoracic spines with proven osteoporosis were used (T2-T7). After removal of the soft tissues, the spine was embedded in Technovit (Kulzer, Germany). Subsequently, a corpectomy of T5 was performed, leaving the dorsal ligamentary structures intact. After randomization with respect to bone quality, two groups were generated: Dorsal instrumentation (cemented pedicle screws, Medtronic, Minneapolis, MN, USA)+cage implantation (CAPRI Corpectomy Cage, K2M, Leesburg, VA, USA) without additional cementation of the adjacent endplates (Group A) and dorsal instrumentation+cage implantation with additional cement augmentation of the adjacent end plates (Group B). The subsequent axial and cyclic loading was performed at a frequency of 1 Hz, starting at 400 N and increasing the load within 200 N after every 500 cycles up to a maximum of 2,200 N. Load failure was determined when the cages sintered macroscopically into the end plates (implant failure) or when the maximum load was reached. RESULTS One specimen in Group B could not be clamped appropriately into the test bench for axial loading because of a pronounced scoliotic misalignment and had to be excluded. The mean strength for implant failure was 1,000 N±258.2 N in Group A (no cement augmentation of the adjacent end plates, n=7); on average, 1,622.1±637.6 cycles were achieved. In Group B (cement augmentation of the adjacent end plates, n=6), the mean force at the end of loading was 1,766.7 N±320.4 N; an average of 3,572±920.6 cycles was achieved. Three specimens reached a load of 2,000 N. The differences between the two groups were significant (p=.006 and p=.0047) regarding load failure and number of cycles. CONCLUSIONS Additional cement augmentation of the adjacent end plates during implantation of a vertebral body replacement in osteoporotic bone resulted in a significant increased stability of the cage in the axial cyclic loading test.
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Affiliation(s)
- Ludwig Oberkircher
- Center for Orthopaedics and Trauma Surgery, Philipps University Marburg, Germany.
| | - Antonio Krüger
- Center for Orthopaedics and Trauma Surgery, Philipps University Marburg, Germany
| | - Dominik Hörth
- Center for Orthopaedics and Trauma Surgery, Philipps University Marburg, Germany
| | - Juliana Hack
- Center for Orthopaedics and Trauma Surgery, Philipps University Marburg, Germany
| | - Steffen Ruchholtz
- Center for Orthopaedics and Trauma Surgery, Philipps University Marburg, Germany
| | - Christoph Fleege
- Department of Spine Surgery, Johann Wolfgang Goethe University Frankfurt, Germany
| | - Michael Rauschmann
- Department of Spine Surgery, Johann Wolfgang Goethe University Frankfurt, Germany
| | - Mohammad Arabmotlagh
- Department of Spine Surgery, Johann Wolfgang Goethe University Frankfurt, Germany
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Wang L, Kang J, Shi L, Fu J, Li D, Guo Z, Liu C, Dong S, Jiang X. Investigation into factors affecting the mechanical behaviours of a patient-specific vertebral body replacement. Proc Inst Mech Eng H 2018; 232:378-387. [PMID: 29383959 DOI: 10.1177/0954411918754926] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Most vertebral body implants that are currently designed and produced in batches have difficulty meeting the patient-specific demands. Moreover, several complications, including a low fusion rate, subsidence occurrence, and rod displacement, are associated with these implants. This study aims to investigate the effects of patient-specific geometric and clinical parameters on the biomechanics of a vertebral body replacement. A three-dimensional patient-specific vertebral body replacement model was established as the basic model for parametric studies, including the anatomic design of the endplates, tilting angle, thickness, and dislocation of the vertebral body implant. A finite element analysis was applied to determine the stress distribution of the vertebral body implant when under various loading conditions. The model with an anatomical interfacing design generates 75% less stress concentration compared to a flat design; the peak stress of the model with a tilted angle closely matching the replaced vertebra segment is decreased by 30%; and the thickness close to the cortical bone can offer better bone growth capability and long-term stability. Patient-specific geometrical parameters were found to significantly affect the biomechanics of a vertebral body replacement, and therefore, a design customized especially for the endplates is necessary for better stability and long-term longevity of the prostheses. Regardless of such progress, how to balance the stability of a vertebral body implant and the safety of the peripheral nervous system remains a clinical challenge.
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Affiliation(s)
- Ling Wang
- State Key Laboratory for Manufacturing System Engineering, Xi’an Jiaotong University, Xi’an, China
| | - Jianfeng Kang
- State Key Laboratory for Manufacturing System Engineering, Xi’an Jiaotong University, Xi’an, China
| | - Lei Shi
- Department of Orthopaedics, Xijing Hospital, The Fourth Military Medical University, Xi’an, China
| | - Jun Fu
- Department of Orthopaedics, Xijing Hospital, The Fourth Military Medical University, Xi’an, China
| | - Dichen Li
- State Key Laboratory for Manufacturing System Engineering, Xi’an Jiaotong University, Xi’an, China
| | - Zheng Guo
- Department of Orthopaedics, Xijing Hospital, The Fourth Military Medical University, Xi’an, China
| | - Chaozong Liu
- John Scale Centre for Biomedical Engineering, University College London, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Shuangpeng Dong
- Tianjin Medical Device Supervision and Testing Center, Tianjin, China
| | - Xi Jiang
- Tianjin Medical Device Supervision and Testing Center, Tianjin, China
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Hijji FY, Narain AS, Bohl DD, Ahn J, Long WW, DiBattista JV, Kudaravalli KT, Singh K. Lateral lumbar interbody fusion: a systematic review of complication rates. Spine J 2017; 17:1412-1419. [PMID: 28456671 DOI: 10.1016/j.spinee.2017.04.022] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 02/24/2017] [Accepted: 04/21/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lateral lumbar interbody fusion (LLIF) is a frequently used technique for the treatment of lumbar pathology. Despite its overall success, LLIF has been associated with a unique set of complications. However, there has been inconsistent evidence regarding the complication rate of this approach. PURPOSE To perform a systematic review analyzing the rates of medical and surgical complications associated with LLIF. STUDY DESIGN Systematic review. PATIENT SAMPLE 6,819 patients who underwent LLIF reported in clinical studies through June 2016. OUTCOME MEASURES Frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and spine (MSK) categories. METHODS This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies that identified rates of any complication following LLIF procedures were obtained from PubMed, MEDLINE, and EMBASE databases. Articles were excluded if they did not report complications, presented mixed complication data from other procedures, or were characterized as single case reports, reviews, or case series containing less than 10 patients. The primary outcome was frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and MSK categories. All rates of complications were based on the sample sizes of studies that mentioned the respective complications. The authors report no conflicts of interest directly or indirectly related to this work, and have not received any funds in support of this work. RESULTS A total of 2,232 articles were identified. Following screening of title, abstract, and full-text availability, 63 articles were included in the review. A total of 6,819 patients had 11,325 levels fused. The rate of complications for the categories included were as follows: wound (1.38%; 95% confidence interval [CI]=1.00%-1.85%), cardiac (1.86%; CI=1.33%-2.52%), vascular (0.81%; CI=0.44%-1.36%), pulmonary (1.47; CI=0.95%-2.16%), gastrointestinal (1.38%; CI=1.00%-1.87%), urologic (0.93%; CI=0.55%-1.47%), transient neurologic (36.07%; CI=34.74%-37.41%), persistent neurologic (3.98%; CI=3.42%-4.60%), and MSK or spine (9.22%; CI=8.28%-10.23%). CONCLUSIONS The current study is the first to comprehensively analyze the complication profile for LLIFs. The most significant reported complications were transient neurologic in nature. However, persistent neurologic complications occurred at a much lower rate, bringing into question the significance of transient symptoms beyond the immediate postoperative period. Through this analysis of complication profiles, surgeons can better understand the risks to and expectations for patients following LLIF procedures.
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Affiliation(s)
- Fady Y Hijji
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Ankur S Narain
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Daniel D Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Junyoung Ahn
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - William W Long
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Jacob V DiBattista
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Krishna T Kudaravalli
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA.
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Arnold M, Zhao S, Ma S, Giuliani F, Hansen U, Cobb JP, Abel RL, Boughton O. Microindentation - a tool for measuring cortical bone stiffness? A systematic review. Bone Joint Res 2017; 6:542-549. [PMID: 28924020 PMCID: PMC5631024 DOI: 10.1302/2046-3758.69.bjr-2016-0317.r2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 07/07/2017] [Indexed: 01/26/2023] Open
Abstract
Objectives Microindentation has the potential to measure the stiffness of an individual patient’s bone. Bone stiffness plays a crucial role in the press-fit stability of orthopaedic implants. Arming surgeons with accurate bone stiffness information may reduce surgical complications including periprosthetic fractures. The question addressed with this systematic review is whether microindentation can accurately measure cortical bone stiffness. Methods A systematic review of all English language articles using a keyword search was undertaken using Medline, Embase, PubMed, Scopus and Cochrane databases. Studies that only used nanoindentation, cancellous bone or animal tissue were excluded. Results A total of 1094 abstracts were retrieved and 32 papers were included in the analysis, 20 of which used reference point indentation, and 12 of which used traditional depth-sensing indentation. There are several factors that must be considered when using microindentation, such as tip size, depth and method of analysis. Only two studies validated microindentation against traditional mechanical testing techniques. Both studies used reference point indentation (RPI), with one showing that RPI parameters correlate well with mechanical testing, but the other suggested that they do not. Conclusion Microindentation has been used in various studies to assess bone stiffness, but only two studies with conflicting results compared microindentation with traditional mechanical testing techniques. Further research, including more studies comparing microindentation with other mechanical testing methods, is needed before microindentation can be used reliably to calculate cortical bone stiffness. Cite this article: M. Arnold, S. Zhao, S. Ma, F. Giuliani, U. Hansen, J. P. Cobb, R. L. Abel, O. Boughton. Microindentation – a tool for measuring cortical bone stiffness? A systematic review. Bone Joint Res 2017;6:542–549. DOI: 10.1302/2046-3758.69.BJR-2016-0317.R2.
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Affiliation(s)
- M Arnold
- Imperial College London, The MSk Lab, Imperial College London, Charing Cross Hospital, London W6 8RF, UK
| | - S Zhao
- Imperial College London, The MSk Lab, Imperial College London, Charing Cross Hospital, London W6 8RF, UK
| | - S Ma
- Imperial College London, The MSk Lab, Imperial College London, Charing Cross Hospital, London W6 8RF, UK and Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - F Giuliani
- Imperial College London, Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - U Hansen
- Imperial College London, Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - J P Cobb
- Imperial College London, The MSk Lab, Imperial College London, Charing Cross Hospital, London W6 8RF, UK
| | - R L Abel
- Imperial College London, The MSk Lab, Imperial College London, Charing Cross Hospital, London W6 8RF, UK
| | - O Boughton
- Imperial College London, The MSk Lab, Imperial College London, Charing Cross Hospital, London W6 8RF, UK
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Weckbach S, Reichel H, Kraus M, Kocak T, Lattig F. Modified technique of transforaminal lumbar interbody fusion for segmental correction of lumbar kyphosis: a safe alternative to osteotomies? Patient Saf Surg 2017; 11:19. [PMID: 28690681 PMCID: PMC5497383 DOI: 10.1186/s13037-017-0135-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 06/28/2017] [Indexed: 11/18/2022] Open
Abstract
Background Sagittal rebalancing of a fixated lumbar hypolordosis (kyphosis) is very important to gain satisfactory results. To correct a misalignment vertebral column resection or pedicle subtraction osteotomies are favored, disregarding the relatively high complication rates. The aim of this study was to evaluate the efficiency and safety of a new modified transforaminal lumbar fusion technique as an alternative. Methods We conducted a retrospective review (06/2011-06/2015 ) of a prospective database at an University hospital. Inclusion criteria were adult patients with a fixated lumbar hypolordosis and the need of monosegmental correction of more than 10° with an mTLIF. Exclusion criteria consisted of minor aged patients and polysegmental corrections. Study parameters were the perioperative complications and the achieved postsurgical lordosis. The follow up period was 6 months. Results A total of 11 patients could be included. The mean segmental lordosis was -2.3° ± 12.4° (range -22° to 14°) preoperative and 15.5° ± 10.5° (range 0° to 29°) postoperative. The degree of correction was 17° ± 5.7° in mean per treated segment (range 12° to 29°). No neurologic or vascular complications occurred. No substantial loss of correction or implant failure was noted during the 6-month follow-up. Conclusion The modified transforaminal lumbar fusion technique is a safe method to correct a fixated lumbar kyphosis. The potential of segmental correction is comparable to pedicle subtraction osteotomies but sparing potentially healthy segments.
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Affiliation(s)
- Sebastian Weckbach
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Heiko Reichel
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Michael Kraus
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Tugrul Kocak
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Friederike Lattig
- Spine Center, Berit Paracelsus Clinic, Voegelinsegg 5, 9042 Speicher, Switzerland
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He EX, Guo J, Ling QJ, Yin ZX, Wang Y, Li M. Application of a narrow-surface cage in full endoscopic minimally invasive transforaminal lumbar interbody fusion. Int J Surg 2017; 42:83-89. [DOI: 10.1016/j.ijsu.2017.04.053] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 04/14/2017] [Indexed: 10/19/2022]
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Zhang F, Xu HC, Yin B, Xia XL, Ma XS, Wang HL, Yin J, Shao MH, Lyu FZ, Jiang JY. Can an Endplate-conformed Cervical Cage Provide a Better Biomechanical Environment than a Typical Non-conformed Cage?: A Finite Element Model and Cadaver Study. Orthop Surg 2017; 8:367-76. [PMID: 27627721 DOI: 10.1111/os.12261] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 03/21/2016] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To evaluate the biomechanical characteristics of endplate-conformed cervical cages by finite element method (FEM) analysis and cadaver study. METHODS Twelve specimens (C2 -C7 ) and a finite element model (C3 -C7 ) were subjected to biomechanical evaluations. In the cadaver study, specimens were randomly assigned to intact (I), endplate-conformed (C) and non-conformed (N) groups with C4-5 discs as the treated segments. The morphologies of the endplate-conformed cages were individualized according to CT images of group C and the cages fabricated with a 3-D printer. The non-conformed cages were wedge-shaped and similar to commercially available grafts. Axial pre-compression loads of 73.6 N and moment of 1.8 Nm were used to simulate flexion (FLE), extension (EXT), lateral bending (LB) and axial rotation (AR). Range of motion (ROM) at C4-5 of each specimen was recorded and film sensors fixed between the cages and C5 superior endplates were used to detect interface stress. A finite element model was built based on the CT data of a healthy male volunteer. The morphologies of the endplate-conformed and wedge-shaped, non-conformed cervical cages were both simulated by a reverse engineering technique and implanted at the segment of C4-5 in the finite element model for biomechanical evaluation. Force loading and grouping were similar to those applied in the cadaver study. ROM of C4-5 in group I were recorded to validate the finite element model. Additionally, maximum cage-endplate interface stresses, stress distribution contours on adjoining endplates, intra-disc stresses and facet loadings at adjacent segments were measured and compared between groups. RESULTS In the cadaver study, Group C showed a much lower interface stress in all directions of motion (all P < 0.05) and the ROM of C4-5 was smaller in FLE-EXT (P = 0.001) but larger in AR (P = 0.017). FEM analysis produced similar results: the model implanted with an endplate-conformed cage presented a lower interface stress with a more uniform stress distribution than that implanted with a non-conformed cage. Additionally, intra-disc stress and facet loading at the adjacent segments were obviously increased in both groups C and N, especially those at the supra-jacent segments. However, stress increase was milder in group C than in group N for all directions of motion. CONCLUSIONS Endplate-conformed cages can decrease cage-endplate interface stress in all directions of motion and increase cervical stability in FLE-EXT. Additionally, adjacent segments are possibly protected because intra-disc stress and facet loading are smaller after endplate-conformed cage implantation. However, axial stability was reduced in group C, indicating that endplate-conformed cage should not be used alone and an anterior plate system is still important in anterior cervical discectomy and fusion.
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Affiliation(s)
- Fan Zhang
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Hao-Cheng Xu
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Bo Yin
- Department of Clinical Medicine, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xin-Lei Xia
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiao-Sheng Ma
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Hong-Li Wang
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Jun Yin
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Ming-Hao Shao
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Fei-Zhou Lyu
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai, China. .,Department of Orthopaedics, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China.
| | - Jian-Yuan Jiang
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai, China
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Two-piece ALIF cage optimizes the bone–implant interface in a 360° setting. 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 2017; 26:2747-2753. [DOI: 10.1007/s00586-017-5009-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 01/30/2017] [Accepted: 02/13/2017] [Indexed: 12/20/2022]
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The Effect of Cervical Interbody Cage Morphology, Material Composition, and Substrate Density on Cage Subsidence. J Am Acad Orthop Surg 2017; 25:160-168. [PMID: 28009709 DOI: 10.5435/jaaos-d-16-00390] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Interbody cages used in spinal fusion surgery can subside into the adjacent vertebral bodies after implantation, leading to loss of spinal height, malalignment, and possible radicular symptoms. Several factors may contribute to cage subsidence. METHODS This in vitro investigation examined the possible contribution of substrate density, cage contact area (ie, cage footprint), cage filling, cage end plate surface texture, and cage material composition on the magnitude of subsidence. Commercially available cervical interbody cages of two sizes (16 × 12 mm and 17 × 14 mm) were implanted between foam blocks of two different densities and were cyclically loaded. Cages were made of titanium alloy (Ti4Al6V), silicon nitride ceramic (Si3N4), or polyether ether ketone (n = 8 cages of each material type). Additional testing was performed on Si3N4 cages of the smaller size with nontextured surfaces and with filled cores. RESULTS Subsidence measurements showed that lower foam density had the greatest influence on subsidence, followed by smaller cage footprint. Cage material had no effect on subsidence. In the additional testing of small-footprint Si3N4 cages, the cages in which the core was filled with a load-bearing porous material had less subsidence in lower-density foam than the cages with an empty core had, whereas cage end plate surface texture had no effect on subsidence. CONCLUSION Ranking of the relative impact of these factors indicated that substrate density had the greatest contribution to the measured subsidence (approximately 1.7 times and approximately 67 times greater than the contributions of cage footprint area and material, respectively). The contribution of cage footprint area to subsidence was found to be 40 times greater than the contribution of cage material to subsidence.
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Liang B, Huang G, Ding L, Kang L, Sha M, Ding Z. Early results of thoraco lumbar burst fracture treatment using selective corpectomy and rectangular cage reconstruction. Indian J Orthop 2017; 51:43-48. [PMID: 28216750 PMCID: PMC5296848 DOI: 10.4103/0019-5413.197524] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Subsidence and late fusion are commonly observed in anterior subtotal corpectomy and reconstruction for treating thoracolumbar burst fractures. The subsidence rate of this surgical method was reported from 19.6% to 75% in the literatures, which would cause treatment failure. Thus, an improvement of anterior surgery technique should be studied to reduce these complications. MATERIALS AND METHODS 130 patients of thoracolumbar burst fractures treated by minimal corpectomy, decompression and U cage, between January 2009 and December 2010 were included in this study. The hospital Ethical Committee approved the protocols. The American Spinal Injury Association (ASIA) scale, visual analog scales, and Oswestry Disability Index (ODI) scores were used for clinical evaluation. The local kyphosis angle, vertebral height (one level above the fractured vertebral to one level below), canal stenosis, and fusion status were used to assess radiological outcome. All complications and demographic data such as number of male/female patients, average age, mode of trauma, burst level involved, mean surgery time and blood lost were reported. RESULTS 120 patients were followed up for 24 months. Most patients had improvement of at least 1 ASIA grade, and all experienced pain reduction. The mean ODI score steadily decreased after the surgery (P < 0.01). Approximately, 83.3% of patients achieved solid fusion at 3 months and reached 98.3% at 6 months. The kyphosis angle and radiographic height were corrected significantly after the surgery and with a nonsignificant loss of correction at 24 months (P > 0.05). The average canal stenosis index was increased from 39% to 99% after surgery. No cage subsidence or implant failure was observed. CONCLUSIONS The clinical outcomes described here suggest that the selective corpectomy and rectangular cage reconstruction can effectively promote solid fusion and eliminate complications related to subsidence or implant failure.
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Affiliation(s)
- Bowei Liang
- Department of Orthopedics, The 175th Hospital of PLA, Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, Fujian 363000, China
| | - Guofeng Huang
- Department of Orthopedics, The 175th Hospital of PLA, Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, Fujian 363000, China
| | - Luobing Ding
- Department of Orthopedics, The 175th Hospital of PLA, Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, Fujian 363000, China
| | - Liangqi Kang
- Department of Orthopedics, The 175th Hospital of PLA, Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, Fujian 363000, China
| | - Mo Sha
- Department of Orthopedics, The 175th Hospital of PLA, Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, Fujian 363000, China
| | - Zhenqi Ding
- Department of Orthopedics, The 175th Hospital of PLA, Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, Fujian 363000, China,Address for correspondence: Dr. Zhenqi Ding, 269 Zhanghua Zhong Road, Zhangzhou, Fujian 363000, China. E-mail:
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Coe JD, Zucherman JF, Kucharzyk DW, Poelstra KA, Miller LE, Kunwar S. Multiexpandable cage for minimally invasive posterior lumbar interbody fusion. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2016; 9:341-347. [PMID: 27729817 PMCID: PMC5047724 DOI: 10.2147/mder.s112523] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The increasing adoption of minimally invasive techniques for spine surgery in recent years has led to significant advancements in instrumentation for lumbar interbody fusion. Percutaneous pedicle screw fixation is now a mature technology, but the role of expandable cages is still evolving. The capability to deliver a multiexpandable interbody cage with a large footprint through a narrow surgical cannula represents a significant advancement in spinal surgery technology. The purpose of this report is to describe a multiexpandable lumbar interbody fusion cage, including implant characteristics, intended use, surgical technique, preclinical testing, and early clinical experience. Results to date suggest that the multiexpandable cage allows a less invasive approach to posterior/transforaminal lumbar interbody fusion surgery by minimizing iatrogenic risks associated with static or vertically expanding interbody prostheses while providing immediate vertebral height restoration, restoration of anatomic alignment, and excellent early-term clinical results.
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Affiliation(s)
| | | | | | - Kornelis A Poelstra
- Department of Surgery, Sacred Heart Hospital on the Emerald Coast, Miramar Beach, FL
| | | | - Sandeep Kunwar
- Bell Neuroscience Institute, Washington Hospital Healthcare System, Fremont, CA, USA
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Cadman J, Sutterlin C, Dabirrahmani D, Appleyard R. The importance of loading the periphery of the vertebral endplate. JOURNAL OF SPINE SURGERY (HONG KONG) 2016; 2:178-184. [PMID: 27757430 PMCID: PMC5067271 DOI: 10.21037/jss.2016.09.08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 09/21/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Commercial fusion cages typically provide support in the central region of the endplate, failing to utilize the increased compressive strength around the periphery. This study demonstrates the increase in compressive strength that can be achieved if the bony periphery of the endplate is loaded. METHODS Sixteen cadaveric lumbar vertebrae (L1-L5) were randomly divided into two even groups. A different commercial mass produced implant (MPI) was allocated to each group: (I) a Polyether-ether-ketone (PEEK) anterior lumber inter-body fusion (ALIF) MPI; and (II) a titanium ALIF MPI. Uniaxial compression at a displacement rate of 0.5 mm/sec was applied to all vertebrae during two phases: (I) with the allocated MPI situated in the central region of the endplate; (II) with an aluminum plate, designed to load the bony periphery of the endplate. The failure load and mode of failure was recorded. RESULTS From phase 1 to phase 2, the failure load increased from 1.1±0.4 to 2.9±1.4 kN for group 1; and from 1.3±1.0 to 3.0±1.9 kN for group 2. The increase in strength from phase 1 to phase 2 was statistically significant for each group (group 1: P<0.01, group 2: P<0.05, paired t-test). There was no significant difference between the groups in either phase (P>0.05, t-test). The mode of failure in phase 1 was the implant being forced through the endplate for both groups. In phase 2, the mode of failure was either a fracture of the epiphyseal rim or buckling of the side wall of the vertebral body. CONCLUSIONS Loading the periphery of the vertebral endplate achieved significant increase in compressive load capacity compared to loading the central region of the endplate. Clinically, this implies that patient-specific implants which load the periphery of the vertebral endplate could decrease the incidence of subsidence and improve surgical outcomes.
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Affiliation(s)
- Joseph Cadman
- Orthopaedic Biomechanics Group, Department of Biomedical Science, Faculty of Medicine and Health Science, Macquarie University, NSW, Australia
| | - Chester Sutterlin
- University of Florida, FL, USA
- Spinal Health International, 511 Putter Lane, Longboat Key, FL, USA
| | - Danè Dabirrahmani
- Orthopaedic Biomechanics Group, Department of Biomedical Science, Faculty of Medicine and Health Science, Macquarie University, NSW, Australia
| | - Richard Appleyard
- Orthopaedic Biomechanics Group, Department of Biomedical Science, Faculty of Medicine and Health Science, Macquarie University, NSW, Australia
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Schmoelz W, Keiler A. Intervertebrale Cages aus biomechanischer Sicht. DER ORTHOPADE 2015; 44:132-7. [DOI: 10.1007/s00132-014-3071-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Lykissas MG, Aichmair A, Hughes AP, Sama AA, Lebl DR, Taher F, Du JY, Cammisa FP, Girardi FP. Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J 2014; 14:749-58. [PMID: 24012428 DOI: 10.1016/j.spinee.2013.06.066] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 05/16/2013] [Accepted: 06/24/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lateral lumbar interbody fusion (LLIF) has become an increasingly common minimally invasive procedure for selective degenerative deformity correction, reduction of low-grade spondylolisthesis, and indirect foraminal decompression. Concerns remain about the safety of the transpsoas approach to the spine due to proximity of the lumbosacral plexus. PURPOSE To address risk factors for iatrogenic nerve injury in a large cohort of patients undergoing LLIF. STUDY DESIGN Retrospective analysis of 919 LLIF procedures to identify risk factors for lumbosacral plexus injuries. METHODS The medical charts of patients who underwent transpsoas interbody fusion with or without supplemental posterior fusion for degenerative spinal conditions over a 6-year period were retrospectively reviewed. Patients with prior lumbar spine surgery or follow-up of less than 6 months were excluded. Factors that may affect the neurologic outcome were investigated in a subset of patients who underwent stand-alone LLIF. RESULTS Four hundred fifty-one patients (males/females: 179/272) met the inclusion criteria and were followed for a mean of 15 months (range, 6-53 months). Average age at the time of surgery was 63 years (range, 24-90 years). Average body mass index was 29 kg/m(2) (range, 17-65 kg/m(2)). A total of 919 levels were treated (mean, 2 levels per patient). Immediately after surgery, 38.5% of the patients reported anterior thigh/groin pain, whereas sensory and motor deficits were recorded in 38% and 23.9% of the patients, respectively. At the last follow-up, 4.8% of the patients reported anterior thigh/groin pain, whereas sensory and motor deficits were recorded in 24.1% and 17.3% of the patients, respectively. When patients with neural deficits present before surgery were excluded, persistent surgery-related sensory and motor deficits were identified in 9.3% and 3.2% of the patients, respectively. Among 87 patients with minimum follow-up of 18 months, persistent surgery-related sensory and motor deficits were recorded in 9.6% and 2.3% of the patients, respectively. Among patients with stand-alone LLIF, the level treated was identified as a risk factor for postoperative lumbosacral plexus injury. The use of recombinant human bone morphogenetic protein 2 was associated with persistent motor deficits. CONCLUSIONS Although LLIF is associated with an increased prevalence of anterior thigh/groin pain as well as motor and sensory deficits immediately after surgery, our results support that pain and neurologic deficits decrease over time. The level treated appears to be a risk factor for lumbosacral plexus injury.
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Affiliation(s)
- Marios G Lykissas
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th St, New York, NY 10021, USA.
| | - Alexander Aichmair
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th St, New York, NY 10021, USA
| | - Alexander P Hughes
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th St, New York, NY 10021, USA
| | - Andrew A Sama
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th St, New York, NY 10021, USA
| | - Darren R Lebl
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th St, New York, NY 10021, USA
| | - Fadi Taher
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th St, New York, NY 10021, USA
| | - Jerry Y Du
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th St, New York, NY 10021, USA
| | - Frank P Cammisa
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th St, New York, NY 10021, USA
| | - Federico P Girardi
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th St, New York, NY 10021, USA
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Schöllhorn B, Bürki A, Stahl C, Howard J, Forterre F. Comparison of the biomechanical properties of a ventral cervical intervertebral anchored fusion device with locking plate fixation applied to cadaveric canine cervical spines. Vet Surg 2013; 42:825-31. [PMID: 24033669 DOI: 10.1111/j.1532-950x.2013.12044.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 04/01/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate fixation properties of a new intervertebral anchored fusion device and compare these with ventral locking plate fixation. STUDY DESIGN In vitro biomechanical evaluation. ANIMALS Cadaveric canine C4-C7 cervical spines (n = 9). METHODS Cervical spines were nondestructively loaded with pure moments in a nonconstraining testing apparatus to induce flexion/extension while angular motion was measured. Range of motion (ROM) and neutral zone (NZ) were calculated for (1) intact specimens, (2) specimens after discectomy and fixation with a purpose-built intervertebral fusion cage with integrated ventral fixation, and (3) after removal of the device and fixation with a ventral locking plate. RESULTS Both fixation techniques resulted in a decrease in ROM and NZ (P < .001) compared with the intact segments. There were no significant differences between the anchored spacer and locking plate fixation. CONCLUSION An anchored spacer appears to provide similar biomechanical stability to that of locking plate fixation.
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Affiliation(s)
- Bernhard Schöllhorn
- Department of Small Animal Surgery, Vetsuisse Faculty of Berne, Berne, Switzerland
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Hsu CC. Shape optimization for the subsidence resistance of an interbody device using simulation-based genetic algorithms and experimental validation. J Orthop Res 2013; 31:1158-63. [PMID: 23335363 DOI: 10.1002/jor.22317] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 12/28/2012] [Indexed: 02/04/2023]
Abstract
Subsidence of interbody devices into the vertebral body might result in serious clinical problems, especially when the devices are not well designed and analyzed. Recently, some novel designs were proposed to reduce the risk of subsidence, but those designs are based on the researcher's experience. The purpose of this study was to discover the interbody device design with excellent subsidence resistance by changing the device's shape. The three-dimensional nonlinear finite element models, which consisted of the interbody device and vertebral body, were created first. Then, the simulation-based genetic algorithm, which combined the finite element model and the searching algorithm, was developed by using ANSYS® Parametric Design Language. Finally, the numerical results were carefully validated with the use of biomechanical tests. The optimum shape design obtained in this study looks like a flower with many petals and it has excellent subsidence resistance when compared with the other designs provided by the past studies. The results of the present study could help surgeons to understand the subsidence resistance of interbody devices in terms of their shapes and has directly provided the design rationales to engineers.
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Affiliation(s)
- Ching-Chi Hsu
- Graduate Institute of Applied Science and Technology, National Taiwan University of Science and Technology, Taipei 10607, Taiwan, ROC.
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Liang B, Ding Z, Liu T, Kang L, Zai W, Sha M, Zhang X. Design and biomechanical properties of a new reconstruction device for treating thoracolumbar burst fractures. Orthopedics 2012; 35:e1785-91. [PMID: 23218637 DOI: 10.3928/01477447-20121120-25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Implants currently used for reconstruction of a burst vertebral body are associated with complications, including subsidence, nonunion, and substantial intraoperative blood loss. A new reconstruction device, the U-Cage (Double Engine Medical Material Ltd, Xiamen, Fujian, China), was designed to minimize complications.Six intact adult cadaver thoracolumbar (T11-L3) spines were collected and scanned by dual-energy X-ray absorptiometry (DEXA). The stiffness of the burst spine was subsequently compared with its previous intact state during flexion/extension, lateral bending, and rotation, and then subjected to a cyclic test to predict cage subsidence and device loosening. Axial load was applied continuously until failure to test the peak load that the specimen could withstand during the cyclic test. The correlation of bone mineral density and peak load was also analyzed. The instrumented specimens were found to be equivalent to intact bone in all directions (P>.05), with the exception of left rotation (P<.05). All specimens could withstand the cyclic test, and no subsidence or loosening of the device was detected. Average peak load for the instrumented specimens was 4137.5 N, which correlated with the average bone mineral density (r=0.915; P=.011).Thoracolumbar burst fractures instrumented with a U-Cage and anterolateral D-rod fixation achieved a stiffness similar to that of intact spines. This procedure may avoid the subsidence of the cage in vivo and serve as a better option for treating thoracolumbar burst fractures.
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Affiliation(s)
- Bowei Liang
- Department of Orthopedics, the 175th Hospital of PLA Affiliated Dongnan Hospital of Xiamen University, 269 Zhanghua Zhong Rd, Zhangzhou, Fujian, 363000, China
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de Beer N, Scheffer C. Reducing subsidence risk by using rapid manufactured patient-specific intervertebral disc implants. Spine J 2012; 12:1060-6. [PMID: 23103407 DOI: 10.1016/j.spinee.2012.10.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 12/13/2011] [Accepted: 10/01/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Intervertebral disc implant size, shape, and position during total disc replacement have been shown to affect the risk of implant subsidence or vertebral fracture. Rapid manufacturing has been successfully applied to produce patient-specific implants for craniomaxillofacial, dental, hip, and knee requirements, but very little has been published on its application for spinal implants. PURPOSE This research was undertaken to investigate the improved load distribution and stiffness that can be achieved when using implants with matching bone interface geometry as opposed to implants with flat end plate geometries. STUDY DESIGN The study design comprises a biomechanical investigation and comparison of compressive loads applied to cadaveric vertebrae when using two different end plate designs. METHODS Four spines from male cadavers (ages 45-65 years, average 52 years), which had a total of n=88 vertebrae (C3-L5), were considered during this study. Bone mineral density scans on each spine revealed only one to be eligible for this study. Twenty remaining vertebrae (C3-L3) were potted and subjected to nondestructive compression tests followed by destructive compression tests. Custom-made nonfunctional implants were designed for this experiment. Ten implants were designed with matching end plate-to-bone interface geometry, whereas the other 10 were designed with flat end plates. Testing did not incorporate the use of a keel in either design type. I-Scan pressure sensors (Tekscan, Inc., MA, USA) were used during the nondestructive tests to assess the load distribution and percentage surface contact. RESULTS Average percent contact area measured during nondestructive tests was 45.27% and 10.49% for conformal and flat implants, respectively-a difference that is statistically significant (p<.001). A higher percent contact area was especially observed for cervical vertebrae because of their pronounced end plate concavity. During destructive compression tests, conformal implants achieved higher failure loads than flat implants. Conformal implants also performed significantly better when stiffness values were compared (p<.0001). CONCLUSIONS One of the main expected benefits from customizing the end plate geometry of disc implants is the reduced risk and potential for subsidence into the vertebral bone end plate. Subsidence depends in part on the stiffness of the implant-bone construct, and with a 137% increase in stiffness, the results of this study show that there are indeed significant potential benefits that can be achieved through the use of customization during the design and manufacture of intervertebral disc implants.
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Affiliation(s)
- Neal de Beer
- Department of Industrial Engineering, Stellenbosch University, Private Bag X1, Matieland 7602, South Africa.
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Abstract
STUDY DESIGN An in vitro biomechanical study investigating interbody device subsidence measures in synthetic vertebrae, polyurethane foam blocks, and human cadaveric vertebrae. OBJECTIVE To compare subsidence measures of bone surrogates with human vertebrae for interbody devices varying in size/placement. SUMMARY OF BACKGROUND DATA Bone surrogates are alternatives when human cadaveric vertebrae are unavailable. Synthetic vertebrae modeling cortices, endplates, and cancellous bone have been developed as an alternative to polyurethane foam blocks for testing interbody device subsidence. METHODS Indentors placed on the endplates of synthetic vertebrae, foam blocks, and human vertebrae were subjected to uniaxial compression. Subsidence, measured with custom-made extensometers, was evaluated for an indentor seated either centrally or peripherally on the endplate. Failure force and indentation stiffness were determined from force-displacement curves. RESULTS Subsidence measures in human vertebrae varied with indentor placement: failure forces were higher and indentors subsided less with peripheral placement. Subsidence measures in foam blocks were insensitive to indentor size/placement; they were similar to human vertebrae for centrally placed but not for peripherally placed indentors. Although subsidence measures in synthetic vertebrae were sensitive to indentor size/placement, failure force and indentation stiffness were overestimated, and subsidence underestimated, for both centrally placed and peripherally placed indentors. CONCLUSION The synthetic endplate correctly represented the human endplate geometry, and thus, failure force, stiffness, and subsidence in synthetic vertebrae were sensitive to indentor size/placement. However, the endplate was overly strong and thus synthetic vertebrae did not accurately model indentor subsidence in human cadaveric vertebrae. Foam blocks captured subsidence measures more accurately than synthetic vertebrae for centrally placed indentors, but because of their uniform density were not sufficiently robust to capture changes generated from different indentor sizes/placements. The current bone surrogates are not accurate enough in terms of material property distribution to completely model subsidence in human cadaveric vertebrae.
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Au AG, Aiyangar AK, Anderson PA, Ploeg HL. Replicating interbody device subsidence with lumbar vertebrae surrogates. Proc Inst Mech Eng H 2011; 225:972-85. [DOI: 10.1177/0954411911415198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Bone surrogates are proposed alternatives to human cadaveric vertebrae for assessing interbody device subsidence. A synthetic vertebra with representations of cortices, endplates and cancellous bone was recently developed as an alternative surrogate to polyurethane foam blocks. The ability of the two surrogates to replicate subsidence has not been fully assessed, and was evaluated by indenting them with ring-shaped indenters and comparing their performance with human cadaveric vertebrae using qualitative characteristics and indentation metrics. The sensitivity of each surrogate to a centrally or peripherally placed indenter was of particular interest. Many indentation characteristics of the foam blocks were similar to those of human cadaveric vertebrae, except their insensitivity to centrally and peripherally placed indenters, owing to their homogeneous mechanical properties. This is distinctly different from the cadaveric vertebrae, where a peripherally placed indenter indented significantly less than a centrally placed indenter, because of endplates. By contrast, the synthetic vertebra was sensitive to peripherally placed indenters owing to its bi-material composition, including a thickened peripheral endplate. However, an overly strong synthetic endplate resulted in unrepresentative indentation shape and depth. Both surrogates produced similar results to human cadaveric vertebrae in certain respects, but neither is accurate enough in terms of material property distribution to model subsidence completely in human cadaveric vertebrae.
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Affiliation(s)
- A G Au
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - A K Aiyangar
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - P A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - H-L Ploeg
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Augmentation improves human cadaveric vertebral body compression mechanics for lumbar total disc replacement. Spine (Phila Pa 1976) 2010; 35:E325-31. [PMID: 20375770 PMCID: PMC3413267 DOI: 10.1097/brs.0b013e3181cf7055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cadaveric biomechanical study. OBJECTIVE To quantify the effects of vertebral body augmentation on biomechanics under axial compression by a total disc replacement (TDR) implant. SUMMARY OF BACKGROUND DATA TDR is a surgical alternative to lumbar spinal fusion to treat degenerative disc disease. Osteoporosis in the adjacent vertebrae to the interposed TDR may lead to implant subsidence or vertebral body fracture. Vertebral augmentation is used to treat osteoporotic compression fracture. This study sought to evaluate whether vertebral augmentation improves biomechanics under TDR axial loading. METHODS Forty-five L1-L5 lumbar vertebral body segments with intact posterior elements were used. Peripheral quantitative computed tomography scans were performed to determine bone density, and specimens were block-randomized by bone density into augmentation and control groups. A semiconstrained keeled lumbar disc replacement device was implanted, providing 50% endplate coverage. Vertebral augmentation of 17.6% +/- 0.9% vertebral volume fill with Cortoss was performed on the augmentation group. All segments underwent axial compression at a rate of 0.2 mm/s to 6 mm. RESULTS The load-displacement response for all specimens was nonlinear. Subfailure mechanical properties with augmentation were significantly different from control; in all cases, the augmented group was 2 times higher than control. At failure, the maximum load and stiffness with augmentation was not significantly different from control. The maximum apparent stress and modulus with augmentation were 2 times and 1.3 times greater than control, respectively. The subfailure stress and apparent modulus with augmentation were moderately correlated with bone density whereas the control subfailure properties were not. The augmented maximum stress was not correlated with bone density, whereas the control was weakly correlated. The maximum apparent modulus was moderately correlated with bone density for both the augmented and the control groups. CONCLUSION Augmentation improved the mechanical properties of the lumbar vertebral body for compression by a TDR implant.
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The effect of implant size and device keel on vertebral compression properties in lumbar total disc replacement. Spine J 2010; 10:333-40. [PMID: 20362251 DOI: 10.1016/j.spinee.2010.01.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 01/13/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Vertebral end plate support is necessary for successful lumbar total disc replacement (TDR) surgery. Failure to achieve anterior column support as a result of lumbar TDR device undersizing could lead to implant subsidence and fracture. PURPOSE The purpose of the study was to examine the compressive biomechanical behavior of the vertebral end plate with varying sizes of disc replacement implants. STUDY DESIGN The study design comprises a biomechanical investigation using a human cadaveric lumbar spine model. METHODS Fifty-six vertebrae with intact posterior elements were prepared from 13 fresh frozen lumbar spines. Peripheral quantitative computed tomography was performed to assess regional bone density. Vertebrae were potted and subjected to nondestructive compression testing with a small, medium, and large custom-made implants with the footplate geometry of the ProDisc-L TDR (Synthes Spine, West Chester, PA, USA) system and having no keel. Failure testing was performed using the ProDisc-L implant with an intact keel. Pressure sensor film was used to assess contact pressure and distribution. RESULTS There was a linear correlation between percent coverage of the end plate and implant-end plate stiffness (p=.0001) and an inverse correlation with displacement (p=.01). The difference in implant-end plate stiffness between small-medium, medium-large, and small-large implants was 10.5% (p=.03), 10.2% (p=.02), and 19.6% (p<.0001), respectively. Failure analysis revealed similar trends for implant sizing, but only bone density was found to significantly correlate with failure properties (r=0.76, p<.0001). There was a significant reduction in implant-end plate stiffness of 18% when the keel was intact compared to without the keel (range 6-27%, p=.0008). Pressure film analysis revealed that the implant was loaded peripherally and did not have central contact during nondestructive loading. There was a trend toward greater contact pressure with the small implant when compared with the medium implant (p=.06) and the large implant (p=.06). CONCLUSIONS Although larger implants reduce end plate displacement, increase apparent implant-end plate stiffness, increase the implant-end plate contact area, and decrease the peak contact pressures, low bone density reduces failure properties. The keel introduces a reduction in stiffness to the implant-end plate interface, the clinical significance of which is currently unknown.
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