The difference in spine specimen dual-energy X-ray absorptiometry bone mineral density between in situ and in vitro scans.

BACKGROUND CONTEXT: Human cadaveric specimens are commonly used to evaluate bone-implant interface strength in osteoporotic spine fixation. Dual-energy X-ray absorptiometry (DXA) scans are usually carried out on explanted spine specimens to measure bone mineral density (BMD) before in vitro biomechanical studies are carried out. PURPOSE: The purposes of this study were to verify and quantify the difference in DXA BMD between unexplanted (in situ) and explanted (in vitro) scans and to develop and validate a correction factor (CF) between in vitro and in situ DXA BMD. STUDY DESIGN: This is a retrospective analysis of past DXA scans of explanted specimens and a repeated measure scan rescan study of in situ and in vitro spine specimens. METHODS: Dual-energy X-ray absorptiometry scans were previously carried out on 106 male and 83 female lumbar specimens. Using multiple regressions, the correlation functions between Z score, BMD, and age were determined for male and female groups. The CF was developed based on difference in BMD between mean in vitro and population data. Next, in situ DXA scans were carried out on the lumbar spine of four full human cadavers, and subsequently, in vitro scans were repeated after explantation. The CF was applied to these in vitro scan data and the resulting corrected BMD compared with in situ scan values. RESULTS: The specimens had significantly lower Z score than population mean. The mean Z score was -0.7+/-1.4 (p<.001) for male and -0.3+/-1.3 (p=.03) for female specimens. The difference between in situ and in vitro scans was quantified to be 0.06 g/cm(2) for male specimens and to be a function of age (6.80 Age(-0.5)-3.76 Age(-0.365)) for female specimens. In vitro BMD was 96+/-11% of in situ BMD and was significantly different (p=.04). Corrected BMD after application of CF was 97+/-11% of in situ BMD and was not significantly different (p=.13). CONCLUSIONS: In vitro BMD scan on explanted specimens measured lower DXA values than in situ BMD scans on full cadavers. A CF when used resulted in more accurate measure of the in situ BMD.

Bone-mounted miniature robotic guidance for pedicle screw and translaminar facet screw placement: part 2--Evaluation of system accuracy.

OBJECTIVE: To evaluate the accuracy of a novel bone-mounted miniature robotic system for percutaneous placement of pedicle and translaminar facet screws. METHODS: Thirty-five spinal levels in 10 cadavers were instrumented. Each cadaver's entire torso was scanned before the procedure. Surgeons planned optimal entry points and trajectories for screws on reconstructed three-dimensional virtual x-rays of each vertebra. Either a clamp or a minimally invasive external frame was attached to the bony anatomy. Anteroposterior and lateral fluoroscopic images using targeting devices were obtained and automatically registered with the virtual x-rays of each vertebra generated from the computed tomographic scan obtained before the procedure. A miniature robot was mounted onto the clamp and external frame and the system controlled the robot's motions to align the cannulated drill guide along the planned trajectory. A drill bit was introduced through the cannulated guide and a hole was drilled through the cortex. Then, K-wires were introduced and advanced through the same cannulated guide and left inside the cadaver. The cadavers were scanned with computed tomography after the procedure and the system's accuracy was evaluated in three planes, comparing K-wire positions with the preoperative plan. A total of fifty-five procedures were evaluated. RESULTS: Twenty-nine of 32 K-wires and all four screws were placed with less than 1.5 mm of deviation; average deviation was 0.87 +/- 0.63 mm (range, 0-1.7 mm) from the preoperative plan in this group. Sixteen of 19 K-wires were placed with less than 1.5 mm of deviation. There was one broken and one bent K-wire. Another K-wire was misplaced because of collision with the previously placed wire on the contralateral side of the same vertebra because of a mistake in planning, resulting in a 6.5-mm deviation. When this case was excluded, average deviation was 0.82 +/- 0.65 mm (range, 0-1.5 mm). CONCLUSION: These results verify the system's accuracy and support its use for minimally invasive spine surgery in selected patients.

Bone-mounted miniature robotic guidance for pedicle screw and translaminar facet screw placement: Part I--Technical development and a test case result.

OBJECTIVE: To introduce a new miniature robot (SpineAssist; MAZOR Surgical Technologies, Caesarea, Israel) that has been developed and tested as a surgical assistant for accurate percutaneous placement of pedicle screws and translaminar facet screws. METHODS: Virtual projections in three planes-axial, lateral, and anteroposterior-are reconstructed for each vertebra from a preoperative computed tomographic (CT) scan. On a specially designed graphic user interface with proprietary software, the surgeon plans the trajectory of the screws. Intraoperative fluoroscopic x-rays with targeting devices are then matched with the CT-based virtual images, as well as the surgeon's plan. A clamp is attached to the spinous process or a minimally invasive frame (Hover-T frame; MAZOR Surgical Technologies) is mounted to the iliac crest and one spinous process. The miniature robot is then attached to the clamp and/or frame. On the basis of combined CT scan and fluoroscopic data, the robot aligns itself to the desired entry point and trajectory, as dictated by the surgeon's preoperative plan. RESULTS: A test case in a cadaver lumbar spine was performed in which four screws and two rods were inserted, using a minimally invasive technique, combining the SpineAssist system and Hover-T frame in conjunction with the PathFinder system (Spinal Concept Inc., Austin, TX). The discrepancy between the planned and actual screw trajectories was measured by means of postprocedural CT scan. Overall, the four screws were implanted with an average deviation of 1.02 +/- 0.56 mm (range, 0-1.5 mm) from the surgeon's plan. CONCLUSION: These preliminary results confirm the system's accuracy and support its use in minimally invasive spine surgery applications.

Biomechanical evaluation of the ventral and lateral surface shear strain distributions in central compared with dorsolateral placement of cages for lumbar interbody fusion.

OBJECT: The purpose of this study was to measure and compare the ventral and lateral surface strain distributions and stiffness for two types of interbody cage placement: 1) central placement for anterior lumbar interbody fusion (ALIF); and 2) dorsolateral placement for extraforaminal lumbar interbody fusion (ELIF). METHODS: Two functional spine units were obtained for testing in each of 13 cadaveric spines, yielding 26 segments (three of which were not used because of bone abnormalities). Bilateral strain gauges were mounted adjacent to the endplate on the lateral and ventral walls of each vertebral body in the 23 motion segments. Each segment was cyclically tested in compression, flexion, and extension in the following conditions: while intact, postdiscectomy, and instrumented with interbody fusion cages placed using both insertion techniques. No significant differences were observed between ALIF and ELIF in compressive stiffness, bending stiffness in flexion and extension (p > or = 0.1), ventral and lateral strain distribution during the intact tests (p > or = 0.24), and during the flexion tests after fusion (p > or = 0.22). In compression, higher ventral and lower lateral strain was observed in the ALIF than in the ELIF group (ventral, p = 0.05; lateral, p = 0.04), and in extension, higher ventral (p = 0.01) and higher lateral strain (p = 0.002) was observed in the ELIF than in the ALIF group. CONCLUSIONS: Preservation of the ventral anulus and dorsolateral placement of the interbody cages during ELIF allow alternate load transfer pathways through the dorsolateral vertebral wall and ventral anulus that are not observed following ALIF. These may be associated with a lower incidence of subsidence and a higher rate of fusion due to a more concentrated application of bone healing-enhancing compression forces during the fusion and healing process.

Vertebroplasty and kyphoplasty: filler materials.

Over 700,000 osteoporotic compression fractures occur each year in the United States, twice the number of hip fractures. These vertebral fractures, most of which occur in the elderly, represent significant personal and societal burdens. Percutaneous vertebroplasty (PVP) is a minimally invasive method that involves the percutaneous injection of polymethylmethacrylate (PMMA) into a collapsed vertebral body to stabilize the vertebra. Kyphoplasty is an advanced minimally invasive technique with a number of potential advantages over PVP, including lower risk of cement extravasation and better restoration of vertebral body height and spinal biomechanics. The filling materials used for both these techniques require good biocompatibility, good biomechanical strength and stiffness, and good radiopacity for the fluoroscopy guided procedures. New filler materials (synthetic bone substitutes, e.g., composite resin materials, calcium phosphate or calcium sulfate cements) in addition to new PMMA formulations are now available for clinical use. In this review paper, we will focus on the issues and characteristics of these filler materials as they pertain to vertebral augmentation procedures.

Histological evaluation of biopsies obtained from vertebral compression fractures: unsuspected myeloma and osteomalacia.

STUDY DESIGN: A histological evaluation of biopsies obtained from presumed osteoporotic vertebral compression fractures (VCF) to confirm possible osteomalacia after tetracycline labeling. OBJECTIVE: To describe the results of a series of biopsies obtained at the time of vertebral augmentation in presumed osteoporotic VCF, with special reference to the presence of unmineralized bone (osteomalacia) and occult or unconfirmed plasma cell dyscrasia. SUMMARY OF BACKGROUND DATA: Vertebral augmentation is now widely performed as a method to treat osteoporotic or osteolytic VCF. However, the influence of underlying pathology on the effect of treatment is unclear. METHODS: As of October 2003, 178 biopsies were obtained from 142 patients with VCF during 246 kyphoplasty procedures. There were 110 one-level, 28 two-level, and 4 three-level biopsies. Patients included 41 men and 101 women, with an average age of 72 years (range 40-90). The patients consented to this procedure, and 25 received tetracycline (1g/day, in 2 doses separated by 6 days). Vertebral body biopsies were taken using a trephine just before the kyphoplasty procedure. The biopsies were fixed, embedded, and stained with toluidine blue and hematoxylin eosin, and were viewed with transmitted light. Unstained sections were viewed under fluorescent light to detect tetracycline labels. RESULTS: The 178 biopsy levels included: T4 (3), T5 (1), T6 (4), T7 (13), T8 (12), T9 (8), T10 (11), T11 (17), T12 (28), L1 (25), L2 (14), L3 (13), L4 (17), and L5 (12). All specimens showed fragmented bone with variable amounts of unmineralized bone (osteoid), suggesting bone remodeling and/or fracture healing. Woven bone and cartilaginous tissue were often present, representing fracture callus formation. The biopsies obtained from 30 patients (21%), including 4 who received tetracycline, showed significantly increased osteoid, suggesting either increased bone remodeling activity or mineralization defect (osteomalacia). One sample from these 4 patients who received tetracycline showed no tetracycline labels, essentially diagnostic of osteomalacia. The biopsies also provided definitive diagnoses for one case of unsuspected and 3 cases of unconfirmed plasma cell dyscrasia. CONCLUSIONS: The majority of biopsies from this series of patients revealed findings consistent with various stages of fracture healing. Osteoid seams were increased in 30 patients, representing either increased bone remodeling or osteomalacia. More cases with tetracycline labeling will help elucidate the true incidence of osteomalacia in this population. As we confirmed 4 cases of plasma cell dyscrasia, we advocate a biopsy during each first-time vertebral augmentation procedure.

Biomechanical changes after the augmentation of experimental osteoporotic vertebral compression fractures in the cadaveric thoracic spine.

BACKGROUND CONTEXT: Osteoporotic compression fractures are an important public health concern, leading to significant morbidity, mortality and economic burden. Cement augmentation procedures used to treat these fractures alter the biomechanics of the fractured segment, which could promote adjacent failure. However, if alignment is improved or restored, there will be less risk of adjacent failure. PURPOSE: To determine the effects of load (compression/flexion), adjacent vertebral location (superior/inferior) and augmentation on vertebral segment stiffness and adjacent vertebral strain in the upper and lower thoracic spine. STUDY DESIGN: Human cadaveric thoracic spine segments were tested under load control before and after the creation of experimentally augmented vertebral compression fractures. METHODS: Six T1-T5 and six T8-T12 segments were obtained from eight thoracic spines with known bone mineral density (BMD). Rosette strain gauges were applied to T2, T4, T9 and T11 to measure strain adjacent to the experimental fracture sites T3 and T10. Two compression fractures were created in succession, the first in flexion preceded by a weakening defect in T3 and T10 and the second created in an adjacent vertebra in compression without prior weakening. The first fracture was reduced with the inflatable bone tamp (IBT) and augmented with cement. Compression and flexion tests were performed before and after the first fracture while measuring vertebral cortical shear strain on T2, T4, T9 and T11 and stiffness of the entire segment. Strain and stiffness were compared by using a repeated measures analysis using adjacent vertebral location (superior/inferior), augmentation and load (compression/flexion) as factors. RESULTS: The mean BMD was 0.61+/-0.11 g/cm(2) (T1-T5) and 0.78+/-0.07 g/cm(2) (T8-T12). Stiffness in compression and flexion increased with load (p<.05, and p>.27, respectively). Augmentation reduced compressive and bending stiffness (p=.23, and p=.19, respectively), whereas the adjacent vertebral strain increased (p>.11). The adjacent strain in flexion was much greater than in compression (p<.03). Cement augmentation caused greater amounts of inferior than superior adjacent strain (p>.19). The applied moment at first fracture was 2.98+/-1.28 Nm (T1-T5) and 8.44+/-1.02 Nm (T8-T12). The compressive load at second fracture was 1122+/-993 N (T1-T5) and 2906+/-1008 N (T8-T12). Adjacent vertebral strain during the second compression and flexion tests exceeded that during the first compression and flexion tests (p=.11). Adjacent vertebral strain at second fracture exceeded that at first fracture (p=.007) and was greater on the superior adjacent vertebra than the inferior (p=.47). CONCLUSION: With axial compressive loads, the addition of flexion increases fracture risk. Cement augmentation of a fractured vertebral segment reduces stiffness while increasing both the superior and inferior adjacent cortical strain. This increment in strain that is greatest on the inferior adjacent vertebra effectively redistributes loads from the superior adjacent vertebra to the inferior adjacent vertebra, sparing the superior adjacent vertebra from failure.

Distribution of anterior cortical shear strain after a thoracic wedge compression fracture.

BACKGROUND CONTEXT: Vertebral compression fractures (VCFs) are a common clinical problem and may follow trauma or be pathological. Osteoporosis increases susceptibility to fracture by reducing bone mass and weakening bone architecture. Approximately 2.5 million osteoporotic fractures occur worldwide annually, usually involving the vertebrae, wrist and hip. In the United States 700,000 VCFs occur annually, causing significant morbidity, mortality and economic burden. An initial VCF often leads to subsequent VCFs. The strain distribution along the anterior cortex, the major load-bearing pathway in flexion, may be predictive of impending VCF. Regions of high strain distribution are likely to experience secondary fracture. PURPOSE: To investigate the distribution of anterior cortical strain at, above and below an experimentally created index VCF to determine the vertebral body at risk of secondary fracture. STUDY DESIGN: In vitro experimental study using cadaveric thoracic spinal segments. METHODS: Seventeen thoracic spines underwent dual-energy X-ray absorptiometry (DEXA) to assess bone mineral density and were divided into T1-T3 (Subsegment 1), T4-T6 (Subsegment 2), T7-T9 (Subsegment 3) and T10-T12 (Subsegment 4). Rectangular rosette strain gauges were applied to the anterior cortices of the vertebrae of each subsegment (vertebrae in each specimen were denoted V1-superior, V2-intermediate and V3-inferior). V1 and V3 were partially embedded into polyester resin blocks, which were used to mount the specimens in a materials testing machine. Nondestructive predefect testing was performed in compression at 125 N and 250 N, followed by flexion at 1.25 Nm and 2.5 Nm. To ensure fracture reproducibility, V2 of each specimen had a trabecular defect created to a volume of 21.3+/-4.4% of the V2 centrum. Postdefect nondestructive compression and flexion were then performed in a manner similar to the predefect tests, followed by destructive testing in flexion. Anterior cortical shear strain on V1, V2 and V3, applied moments and applied flexion angle were all measured and analyzed. RESULTS: A VCF occurred in 55 of the 59 subsegments. Fifty-one VCF (93%) were seen in V2 and 4 VCF (7%) were seen in V1. After the creation of the trabecular defect, the shear strain on V2 increased, but a comparison of the postdefect with the predefect nondestructive tests showed no significant differences. The pre- and postdefect shear strain distribution in compression and flexion was V1strain>V3strain>V2strain. Shear strain at failure was highest on V2, and in all subsegments there were significant differences between V2 and V3 (p<.05). In all subsegments there were no significant differences between V2 and V1 (p>.05) at failure with the exception of Subsegment 1 where V2 and V1 were significantly different (p<.05). The predominant strain pattern at failure was (V2strain>V1strain>V3strain V2strain>>V3strain). Using shear strain as the codeterminant of peak moment with bending stiffness and applied angle at failure, the strain on V1 was the greatest predictor (p=.0084; R2=0.78). These findings suggest that the events leading to a secondary fracture probably start before the index VCF occurs and continue with loading beyond the index VCF. CONCLUSION: Anterior cortical strain is concentrated at the apex of a thoracic kyphotic curve. The vertebral body immediately above the index VCF has the next highest amount of strain and therefore the highest risk of secondary fracture.