In Vitro Biomechanical and Fluoroscopic Study of a Continuously Expandable Interbody Spacer Concerning Its Role in Insertion Force and Segmental Kinematics

Joel Torretti,Jonathan Andrew Harris,Brandon Seth Bucklen,Mark Moldavsky,Saif El Din Khalil 대한척추외과학회 2018 Asian Spine Journal Vol.12 No.4

Study Design: In vitro cadaveric study. Purpose: To compare biomechanical performance, trial and implant insertion, and disc distraction during implant placement, when two interbody devices, an in situ continuously expandable spacer (CES) and a traditional static spacer (SS), were used for transforaminal lumbar interbody fusion. Overview of Literature: Severe degenerative disc diseases necessitate surgical management via large spacers to increase the disc space for implants. Next-generation interbody devices that expand in situ minimize insertion forces, optimize fit between vertebral endplates, and limit nerve root retraction. However, the literature lacks characterization of insertion forces as well as details on other parameters of expandable and static spacers. Methods: Ten cadaveric segments (L5–S1) were divided into two groups (n=5) and implanted with either CES or SS. Each specimen experienced unconstrained pure moment of ±6 Nm in flexion–extension, lateral bending, and axial rotation to assess the contribution of CES and SS implants in biomechanical performance. Radiographic analysis was performed during trial and implant insertion to measure distraction during spacer insertion at the posterior, central, and anterior disc regions. Pressure sensors measured the force of trial and implant insertion. Results: Biomechanical analysis showed no significant differences between CES and SS in all planes of motion. A total 2.6±0.9 strikes were required for expandable spacer trials insertion and 2.6±0.5 strikes for CES insertion. A total of 8.4±3.8 strikes were required to insert SS trials and 4.2±1.6 strikes for SS insertion. The total force per surgery was 330 N for CES and 635 N for SS. Fluoroscopic analysis revealed a significant reduction in distraction during implant insertion at the posterior and anterior disc regions (CES, 0.58 and 0.14 mm; SS, 1.04 and 0.78 mm, respectively). Conclusions: Results from the three study arms reveal the potential use of expandable spacers. During implant insertion, CESs provided similar stability, required less insertion force, and significantly reduced over-distraction of the annulus compared with SS.

An In Vitro Biomechanical Analysis of Contralateral Sacroiliac Joint Motion Following Unilateral Sacroiliac Stabilization with and without Lumbosacral Fixation

Cho Woojin,Wang Wenhai,Lim Hyun Jin,Bucklen Brandon S. 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.1

Study Design: Cadaveric biomechanics study.Purpose: This study investigated the effects of unilateral sacroiliac joint (SIJ) fixation for fusion with/without L5–S1 fixation on contralateral SIJ range of motion (ROM).Overview of Literature: SIJ fusion raises concerns that unilateral SIJ stabilization for fusion may increase contralateral SIJ mobility, leading to accelerated SIJ degeneration. Also, prior lumbosacral fixation may lead to accelerated SIJ degeneration, due to adjacent level effects. SIJ fixation biomechanics have been evaluated, showing a reduced-ROM, but SIJ fixation effects on contralateral nonfixated SIJ remain unknown.Methods: Seven human lumbopelvic spines were used, each affixed to six-degrees-of-freedom testing apparatus; 8.5-Nm pure unconstrained bending moments applied in flexion-extension, lateral bending, and axial rotation. The ROM of left and right SIJ was measured using a motion analysis system. Each specimen tested as (1) intact, (2) injury (left), (3) L5–S1 fixation, (4) unilateral stabilization (left), (5) unilateral stabilization+L5–S1 fixation, (6) bilateral stabilization, and (7) bilateral stabilization+L5–S1 fixation. Both left-sided iliosacral and posterior ligaments were cut for injury condition to model SIJ instability before surgery.Results: There were no statistical differences between fixated and contralateral nonfixated SIJ ROM following unilateral stabilization with/without L5–S1 fixation for all loading directions (<i>p</i>>0.930). Injured condition and L5–S1 fixation provided the largest motion increases across both joints; no significant differences were recorded between SIJs in any loading direction (<i>p</i>>0.850). Unilateral and bilateral stabilization with/without L5–S1 fixation reduced ROM compared with the injured condition for both SIJs, with bilateral stabilization providing maximum stability.Conclusions: In the cadaveric model, unilateral SIJ stabilization with/without lumbosacral fixation did not lead to significant contralateral SIJ hypermobility; long-term changes and <i>in vivo</i> response may differ.

Evaluation of Two Novel Integrated Stand-Alone Spacer Designs Compared with Anterior and Anterior-Posterior Single-Level Lumbar Fusion Techniques: An In Vitro Biomechanical Investigation

Craig A. Kuhns,Jonathan A. Harris,Mir M. Hussain,Aditya Muzumdar,Brandon S. Bucklen,Saif Khalil 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.6

Study Design: In vitro biomechanical investigation. Purpose: To compare the biomechanics of integrated three-screw and four-screw anterior interbody spacer devices and traditional techniques for treatment of degenerative disc disease. Overview of Literature: Biomechanical literature describes investigations of operative techniques and integrated devices with four dual-stacked, diverging interbody screws; four alternating, converging screws through a polyether-ether-ketone (PEEK) spacer; and four converging screws threaded within the PEEK spacer. Conflicting reports on the stability of stand-alone devices and the influence of device design on biomechanics warrant investigation. Methods: Fourteen cadaveric lumbar spines were divided randomly into two equal groups (n=7). Each spine was tested intact, after discectomy (injured), and with PEEK interbody spacer alone (S), anterior lumbar plate and spacer (AP+S), bilateral pedicle screws and spacer (BPS+S), circumferential fixation with spacer and anterior lumbar plate supplemented with BPS, and three-screw (SA3s) or four-screw (SA4s) integrated spacers. Constructs were tested in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). Researchers performed one-way analysis of variance and independent t -testing (p ≤0.05). Results: Instrumented constructs showed significantly decreased motion compared with intact except the spacer-alone construct in FE and AR (p ≤0.05). SA3s showed significantly decreased range of motion (ROM) compared with AP+S in LB (p ≤0.05) and comparable ROM in FE and AR. The three-screw design increased stability in FE and LB with no significant differences between integrated spacers or between integrated spacers and BPS+S in all loading modes. Conclusions: Integrated spacers provided fixation statistically equivalent to traditional techniques. Comparison of three-screw and four-screw integrated anterior lumbar interbody fusion spacers revealed no significant differences, but the longer, larger-diameter interbody spacer with three-screw design increased stabilization in FE and LB; the diverging four-screw design showed marginal improvement during AR.

Biomechanical Assessment of Stabilization of Simulated Type II Odontoid Fracture with Case Study

Roy T. Daniel,Mir M. Hussain,Noelle Klocke,Soumya S. Yandamuri,Lukas Bobinski,John M. Duff,Brandon S. Bucklen 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.1

Study Design: Researchers created a proper type II dens fracture (DF) and quantified a novel current posterior fixation technique with spacers at C1–C2. A clinical case study supplements this biomechanical analysis. Purpose: Researchers explored their hypothesis that spacers combined with posterior instrumentation (PI) reduce range of motion significantly, possibly leading to better fusion outcomes. Overview of Literature: Literature shows that the atlantoaxial joint is unique in allowing segmental rotary motion, enabling head turning. With no intervertebral discs at these joints, multiple ligaments bind the axis to the skull base and to the atlas; an intact odontoid (dens) enhances stability. The most common traumatic injury at these strong ligaments is a type II odontoid fracture. Methods: Each of seven specimens (C0–C3) was tested on a custom-built six-degrees-of-freedom spine simulator with constructs of intact state, type II DF, C1–C2 PI, PI with joint capsulotomy (PIJC), PI with spacers (PIS) at C1–C2, and spacers alone (SA). A bending moment of 2.0 Nm (1.5°/sec) was applied in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). One-way analysis of variance with repeated measures was performed. Results: DF increased motion to 320%, 429%, and 120% versus intact (FE, LB, and AR, respectively). PI significantly reduced motion to 41%, 21%, and 8%. PIJC showed negligible changes from PI. PIS reduced motion to 16%, 14%, and 3%. SA decreased motion to 64%, 24%, and 54%. Reduced motion facilitated solid fusion in an 89-year-old female patient within 1 year. Conclusions: Type II odontoid fractures can lead to acute or chronic instability. Current fixation techniques use C1–C2 PI or an anterior dens screw. Addition of spacers alongside PI led to increased biomechanical rigidity over intact motion and may offer an alternative to established surgical fixation techniques.