Pullout analysis of a lumbar plate with varying screw orientations: experimental and computational analyses.

STUDY DESIGN: Experimental and finite element analysis of anterior lumbar interbody fixation (ALIF) plate pullout. OBJECTIVE: The objective of this study was to determine the effect of screw angle and orientation on ALIF plate pullout strength. SUMMARY OF BACKGROUND DATA: It has been thought that angling the screws in an ALIF plate leads to better fixation strength; however, a few studies are published on this question, which produced conflicting results. METHODS: Using custom guides, screws were configured in 9 different orientations to affix ALIF plates to polyurethane foam blocks. Pullout tests were performed at a rate of 1 mm/min. In addition, finite element analyses were performed on a 2-dimensional screw-block model to gain insight into the internal stress during pullout. RESULTS: The pullout load was the greatest, with screws positioned 12° outward sagittaly and 6° inward coronally (936 ± 72 N). This orientation was statistically greater than the orientation with the lowest pullout load (812 ± 45 N, P < 0.05); however, no group was statistically different than placing the screws straight in (868 ± 86 N, P > 0.05). Finite elements analysis showed some gain in pullout strength at 12° followed by some loss at greater angles. As the screw insertion angle increased, stress levels elevated within the block even in the regions away from the screw. CONCLUSION: Significant difference was found between certain screw-angle configurations; however, when compared with simply placing the screws straight in, the difference was never more than 8%. This implies that there is greater freedom in the angle and placement of screws than previously thought. Our results show that there is little change in fixation strength when placing the screw in a different direction.

Pullout of a lumbar plate with varying screw lengths.

BACKGROUND: Screw length pertains to stability in various orthopedic fixation devices. There is little or no information on the relationship between plate pullout strength and screw length in anterior lumbar interbody fusion (ALIF) plate constructs in the literature. Such a description may prove useful, especially in the treatment of osteoporotic patients where maximizing construct stability is of utmost importance. Our purpose is to describe the influence of screw length on ALIF plate stability in severely and mildly osteoporotic bone foam models. METHODS: Testing was performed on polyurethane foam blocks with densities of 0.08 g/cm(3) and 0.16 g/cm(3). Four-screw, single-level ALIF plate constructs were secured to the polyurethane foam blocks by use of sets of self-tapping cancellous bone screws that were 20, 24, 28, 32, and 36 mm in length and 6.0 mm in diameter. Plates were pulled out at 1 mm/min to failure, as defined by consistently decreasing load despite increasing displacement. RESULTS: Pullout loads in 0.08-g/cm(3) foam for 20-, 24-, 28-, 32-, and 36-mm screws averaged 303, 388, 479, 586, and 708 N, respectively, increasing at a mean of 25.2 N/mm. In 0.16-g/cm(3) foam, pullout loads for 20-, 24-, 28-, 32-, and 36-mm screws averaged 1004, 1335, 1569, 1907, and 2162 N, respectively, increasing at a mean of 72.2 N/mm. CONCLUSIONS: The use of longer screws in ALIF plate installation is expected to increase construct stability. Stabilization from screw length in osteoporotic patients, however, is limited.

Multilevel magnetic resonance imaging analysis of multifidus-longissimus cleavage planes in the lumbar spine and potential clinical applications to Wiltse's paraspinal approach.

STUDY DESIGN: Retrospective magnetic resonance imaging (MRI)-based study. OBJECTIVE: Our goal was to develop Wiltse's paraspinal surgical approach by determining the precise anatomic locations of the intermuscular cleavage planes formed by the multifidus and longissimus muscles. The primary objective was to measure the distances between the midline and the intermuscular planes, bilaterally, on MRI scans at each of the five disc levels between L1 and S1. Secondary objectives included identifying the existence of any correlations between patient demographics and the measured outcomes. SUMMARY OF BACKGROUND DATA: In 1968, Wiltse described an approach to the spine using the natural cleavage plane of the multifidus and longissimus muscles as an entry to the posterior spinal elements. The small direct incisions lessened bleeding, tissue violation, and muscle retraction, which popularized Wiltse's approach among surgeons. A detailed description of the locations of the intermuscular cleavage planes at each lumbar disc level, however, is not available. METHODS: MRI scans of 200 patients taken during routine care (2007-2009) were retrospectively reviewed to gather measurements of the distances from the intermuscular cleavage planes to the midline, bilaterally, at each disc level from L1 to S1. Age, sex, and BMI (body mass index) were obtained to determine correlations. RESULTS: Mean measurements significantly differed between all disc levels. At L5-S1, the mean distance was 37.8 mm; at L4-L5, 28.4 mm; at L3-L4, 16.2 mm; at L2-L3, 10.4 mm; and at L1-L2, 7.9 mm. The mean female distances were significantly greater than males (2 mm) on both sides of L5-S1 only. No correlation was discovered between BMI, age, height (N = 50), or weight (N = 50) with respect to measured distances. CONCLUSION: In the absence of any significant clinical correlation between patient demographics and the entry site in Wiltse's approach, the spine surgeon may use distances described in this paper to apply to a broad base of spine patients regardless of BMI, sex, or age.

Novel indication for posterior dynamic stabilization: Correction of disc tilt after lumbar total disc replacement.

BACKGROUND: The increase in total disc replacement procedures performed over the last 5 years has increased the occurrence of patients presenting with postoperative iatrogenic deformity requiring revision surgery. Proposed salvage treatments include device retrieval followed by anterior lumbar interbody fusion or posterior fusion. We propose a novel approach for the correction of disc tilt after total disc replacement using a posterior dynamic stabilization system. METHODS: Pedicle screws can be inserted either in an open manner or percutaneously by standard techniques under fluoroscopy. The collapsed side is expanded, and the convex side is compressed. Universal spacers are placed bilaterally, with the spacer on the collapsed side being taller by 6 mm. Cords are threaded through the spacers and pulled into place with the tensioning instrument. Extra tension is applied to the convex side, and the wound is closed by standard techniques. RESULTS: Three patients presenting with tilted total disc replacement devices underwent corrective surgery with posterior dynamic stabilization. Radiographs confirmed correction of deformity in all cases. CONCLUSIONS/LEVEL OF EVIDENCE: This technical note presents a novel indication for posterior dynamic stabilization and describes its surgical application to the correction of disc tilt after total disc replacement. This is level V evidence.