Screw loosening is a common complication in spinal fixation using pedicle screws which may lead to loss of correction and revision surgery. The mechanisms of pedicle screw loosening are not well understood. The purpose of this study was to compare the pedicle screw pullout force and stiffness subsequent or not to multidirectional cyclic bending load (toggling). Pedicle screws inserted into porcine lumbar vertebrae underwent toggling in craniocaudal (CC), mediolateral (ML) directions, and no toggling (NT) before pullout. This study suggests that toggling and in particular CC toggling should be included in biomechanical evaluation of pedicle screw fixation strength.
Issue Section:
Research Papers
Keywords:
Biomechanics
References
1.
Vaccaro
, A. R.
, Kim
, D. H.
, Brodke
, D. S.
, Harris
, M.
, Chapman
, J.
, Schildhauer
, T.
, Routt
, M. C.
, and Sasso
, R. C.
, 2003
, “Diagnosis and Management of Thoracolumbar Spine Fractures
,” Instr. Course Lect.
, 53
, pp. 359
–373
.2.
Sanderson
, P.
, Fraser
, R. D.
, Hall
, D. J.
, Cain
, C. M. J.
, Osti
, O. L.
, and Potter
, G.
, 1999
, “Short Segment Fixation of Thoracolumbar Burst Fractures Without Fusion
,” Eur. Spine J.
, 8
(6
), pp. 495
–500
.3.
Cheung
, W. Y.
, Lenke
, L. G.
, and Luk
, K. D.
, 2010
, “Prediction of Scoliosis Correction With Thoracic Segmental Pedicle Screw Constructs Using Fulcrum Bending Radiographs
,” Spine
, 35
(5
), pp. 557
–561
.4.
Dickman
, C. A.
, Fessler
, R. G.
, MacMillan
, M.
, and Haid
, R. W.
, 1992
, “Transpedicular Screw-Rod Fixation of the Lumbar Spine: Operative Technique and Outcome in 104 Cases
,” J. Neurosurg.
, 77
(6
), pp. 860
–870
.5.
Esses
, S. I.
, Sachs
, B. L.
, and Dreyzin
, V.
, 1993
, “Complications Associated With the Technique of Pedicle Screw Fixation. A Selected Survey of ABS Members
,” Spine
, 18
(15
), pp. 2231
–2238
.6.
Sanden
, B.
, Olerud
, C.
, Petren-Mallmin
, M.
, Johansson
, C.
, and Larsson
, S.
, 2004
, “The Significance of Radiolucent Zones Surrounding Pedicle Screws, Definition of Screw Loosening in Spinal Instrumentation
,” J. Bone Jt. Surg., Br
., 86
(3
), pp. 457
–461
.7.
Katonis
, P.
, Christoforakis
, J.
, Aligizakis
, A. C.
, Papadopoulos
, C.
, Sapkas
, G.
, and Hadjipavlou
, A.
, 2003
, “Complications and Problems Related to Pedicle Screw Fixation of the Spine
,” Clin. Orthop. Relat. Res.
, 411
, pp. 86
–94
.8.
Sandén
, B.
, Olerud
, C.
, Petren-Mallmin
, M.
, and Larsson
, S.
, 2002
, “Hydroxyapatite Coating Improves Fixation of Pedicle Screws. A Clinical Study
,” J. Bone Jt. Surg., Br
., 84
(3
), pp. 387
–391
.9.
Kwok
, A. W. L.
, Finkelstein
, J. A.
, Woodside
, T.
, Hearn
, T. C.
, and Hu
, R. W.
, 1996
, “Insertional Torque and Pull-Out Strengths of Conical and Cylindrical Pedicle Screws in Cadaveric Bone
,” Spine
, 21
(21
), pp. 2429
–2434
.10.
Cook
, S. D.
, Salkeld
, S. L.
, Stanley
, T.
, Faciane
, A.
, and Miller
, S. D.
, 2004
, “Biomechanical Study of Pedicle Screw Fixation in Severely Osteoporotic Bone
,” Spine J.
, 4
(4
), pp. 402
–408
.11.
Cook
, S. D.
, Barbera
, J.
, Rubi
, M.
, Salkeld
, S. L.
, and Whitecloud
, T. S.
, III, 2001
, “Lumbosacral Fixation Using Expandable Pedicle Screws: An Alternative in Reoperation and Osteoporosis
,” Spine J.
, 1
(2
), pp. 109
–114
.12.
Mehta
, H.
, Santos
, E.
, Ledonio
, C.
, Sembrano
, J.
, Ellingson
, A.
, Pare
, P.
, Murrell
, B.
, and Nuckley
, D. J.
, 2012
, “Biomechanical Analysis of Pedicle Screw Thread Differential Design in an Osteoporotic Cadaver Model
,” Clin. Biomech.
, 27
(3
), pp. 234
–240
.13.
Pfeiffer
, M.
, Gilbertson
, L. G.
, Goel
, V. K.
, Griss
, P.
, Keller
, J. C.
, Ryken
, T. C.
, and Hoffman
, H. E.
, 1996
, “Effect of Specimen Fixation Method on Pullout Tests of Pedicle Screws
,” Spine
, 21
(9
), pp. 1037
–1044
.14.
Abshire
, B. B.
, McLain
, R. F.
, Valdevit
, A.
, and Kambic
, H. E.
, 2001
, “Characteristics of Pullout Failure in Conical and Cylindrical Pedicle Screws After Full Insertion and Back-Out
,” Spine J.
, 1
(6
), pp. 408
–414
.15.
Halvorson
, T. L.
, Kelley
, L. A.
, Thomas
, K. A.
, Whitecloud
, T. S.
, III, and Cook
, S. D.
, 1994
, “Effects of Bone Mineral Density on Pedicle Screw Fixation
,” Spine
, 19
(21
), pp. 2415
–2420
.16.
Soshi
, S.
, Shiba
, R.
, Kondo
, H.
, and Murota
, K.
, 1991
, “An Experimental Study on Transpedicular Screw Fixation in Relation to Osteoporosis of the Lumbar Spine
,” Spine
, 16
(11
), pp. 1335
–1341
.17.
Wittenberg
, R. H.
, Lee
, K. S.
, Shea
, M.
, White
, A. A.
, III, and Hayes
, W. C.
, 1993
, “Effect of Screw Diameter, Insertion Technique, and Bone Cement Augmentation of Pedicular Screw Fixation Strength
,” Clin. Orthop. Relat. Res.
, 296
, pp. 278
–287
.18.
Brantley
, A. G.
, Mayfield
, J. K.
, Koeneman
, J. B.
, and Clark
, K. R.
, 1994
, “The Effects of Pedicle Screw Fit: An In Vitro Study
,” Spine
, 19
(15
), pp. 1752
–1758
.19.
Hirano
, T.
, Hasegawa
, K.
, Takahashi
, H. E.
, Uchiyama
, S.
, Hara
, T.
, Washio
, T.
, Sugiura
, T.
, Yokaichiya
, M.
, and Ikeda
, M.
, 1997
, “Structural Characteristics of the Pedicle and Its Role in Screw Stability
,” Spine
, 22
(21
), pp. 2504
–2510
.20.
Kumano
, K.
, Hirabayashi
, S.
, Ogawa
, Y.
, and Aota
, Y.
, 1994
, “Pedicle Screws and Bone Mineral Density
,” Spine
, 19
(10
), pp. 1157
–1161
.21.
Kim
, Y.-Y.
, Choi
, W.-S.
, and Rhyu
, K.-W.
, 2012
, “Assessment of Pedicle Screw Pullout Strength Based on Various Screw Designs and Bone Densities—An Ex Vivo Biomechanical Study
,” Spine J.
, 12
(2
), pp. 164
–168
.22.
Hashemi
, A.
, Bednar
, D.
, and Ziada
, S.
, 2009
, “Pullout Strength of Pedicle Screws Augmented With Particulate Calcium Phosphate: An Experimental Study
,” Spine J.
, 9
(5
), pp. 404
–410
.23.
Patel
, P. S. D.
, Shepherd
, D. E. T.
, and Hukins
, D. W. L.
, 2010
, “The Effect of Screw Insertion Angle and Thread Type on the Pullout Strength of Bone Screws in Normal and Osteoporotic Cancellous Bone Models
,” Med. Eng. Phys.
, 32
(8
), pp. 822
–828
.24.
McLain
, R. F.
, McKinley
, T. O.
, Yerby
, S. A.
, Smith
, T. S.
, and Sarigul-Klijn
, N.
, 1997
, “The Effect of Bone Quality on Pedicle Screw Loading in Axial Instability: A Synthetic Model
,” Spine
, 22
(13
), pp. 1454
–1460
.25.
Paik
, H.
, Dmitriev
, A. E.
, Lehman
, R. A.
, Gaume
, R. E.
, Ambati
, D. V.
, Kang
, D. G.
, and Lenke
, L. G.
, 2012
, “The Biomechanical Effect of Pedicle Screw Hubbing on Pullout Resistance in the Thoracic Spine
,” Spine J.
, 12
(5
), pp. 417
–424
.26.
Johnston
, T. L.
, Karaikovic
, E. E.
, Lautenschlager
, E. P.
, and Marcu
, D.
, 2006
, “Cervical Pedicle Screws vs Lateral Mass Screws: Uniplanar Fatigue Analysis and Residual Pullout Strengths
,” Spine J.
, 6
(6
), pp. 667
–672
.27.
Zindrick
, M. R.
, Wiltse
, L. L.
, Widell
, E. H.
, Thomas
, J. C.
, Holland
, W. R.
, Field
, B. T.
, and Spencer
, C. W.
, 1986
, “A Biomechanical Study of Intrapeduncular Screw Fixation in the Lumbosacral Spine
,” Clin. Orthop. Relat. Res.
, 203
, pp. 99
–112
.28.
Okuyama
, K.
, Sato
, K.
, Abe
, E.
, Inaba
, H.
, Shimada
, Y.
, and Murai
, H.
, 1993
, “Stability of Transpedicle Screwing for the Osteoporotic Spine: An In Vitro Study of the Mechanical Stability
,” Spine
, 18
(15
), pp. 2240
–2245
.29.
Lotz
, J. C.
, Hu
, S. S.
, Chiu
, D. F. M.
, Yu
, M.
, Colliou
, O.
, and Poser
, R. D.
, 1997
, “Carbonated Apatite Cement Augmentation of Pedicle Screw Fixation in the Lumbar Spine
,” Spine
, 22
(23
), pp. 2716
–2723
.30.
Zdeblick
, T. A.
, Kunz
, D. N.
, Cooke
, M. E.
, and McCabe
, R.
, 1993
, “Pedicle Screw Pullout Strength: Correlation With Insertional Torque
,” Spine
, 18
(12
), pp. 1673
–1676
.31.
Myers
, B. S.
, Belmont
, P. J.
, Richardson
, W. J.
, Yu
, J. R.
, Harper
, K. D.
, and Nightingale
, R. W.
, 1996
, “The Role of Imaging and In Situ Biomechanical Testing in Assessing Pedicle Screw Pull-Out Strength
,” Spine
, 21
(17
), pp. 1962
–1968
.32.
İnceoğlu
, S.
, Ehlert
, M.
, Akbay
, A.
, and McLain
, R. F.
, 2006
, “Axial Cyclic Behavior of the Bone–Screw Interface
,” Med. Eng. Phys.
, 28
(9
), pp. 888
–893
.33.
Mehmanparast
, H. N.
, Mac-Thiong
, J.-M.
, and Petit
, Y.
, 2015
, “In Vitro Evaluation of Pedicle Screw Loosening Mechanism: A Preliminary Study on Animal Model
,” Scoliosis
, 10
(Suppl 1
), p. O25
.34.
Aerssens
, J.
, Boonen
, S.
, Lowet
, G.
, and Dequeker
, J.
, 1998
, “Interspecies Differences in Bone Composition, Density, and Quality: Potential Implications for In Vivo Bone Research 1
,” Endocrinology
, 139
(2
), pp. 663
–670
.35.
Dath
, R.
, Ebinesan
, A.
, Porter
, K.
, and Miles
, A.
, 2007
, “Anatomical Measurements of Porcine Lumbar Vertebrae
,” Clin. Biomech.
, 22
(5
), pp. 607
–613
.36.
McLain
, R. F.
, Yerby
, S. A.
, and Moseley
, T. A.
, 2002
, “Comparative Morphometry of L4 Vertebrae: Comparison of Large Animal Models for the Human Lumbar Spine
,” Spine
, 27
(8
), pp. E200
–E206
.37.
Aslani
, F. J.
, Hukins
, D. W.
, and Shepherd
, D. E.
, 2012
, “Applicability of Sheep and Pig Models for Cancellous Bone in Human Vertebral Bodies
,” Proc. Inst. Mech. Eng., Part H
, 226
(1
), pp. 76
–78
.38.
Zindrick
, M. R.
, Wiltse
, L. L.
, Doornik
, A.
, Widell
, E. H.
, Knight
, G. W.
, Patwardhan
, A. G.
, Thomas
, J. C.
, Rothman
, S. L.
, and Fields
, B.
, 1987
, “Analysis of the Morphometric Characteristics of the Thoracic and Lumbar Pedicles
,” Spine
, 12
(2
), pp. 160
–166
.39.
Levasseur
, A.
, Ploeg
, H.-L.
, and Petit
, Y.
, 2012
, “Comparison of the Influences of Structural Characteristics on Bulk Mechanical Behaviour: Experimental Study Using a Bone Surrogate
,” Med. Biol. Eng. Comput.
, 50
(1
), pp. 61
–67
.40.
ASTM
, 2007
, “Standard Specification and Test Methods for Metallic Medical Bone Screws
,” American Society for Testing and Materials
, West Conshohocken, PA
, Standard No. F543-07.Copyright © 2015 by ASME
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