Research Papers

The Effects of Bone Microstructure on Subsidence Risk for ALIF, LLIF, PLIF, and TLIF Spine Cages

[+] Author and Article Information
Vivek Palepu, Michael Molyneaux-Francis

U.S. Food and Drug Administration,
Center for Devices and Radiological Health,
Office of Science and Engineering Laboratories,
Division of Applied Mechanics,
Silver Spring, MD 20993

Melvin D. Helgeson

Walter Reed National Military Medical Center,
Department of Orthopaedics,
Bethesda, MD 20889

Srinidhi Nagaraja

U.S. Food and Drug Administration,
Center for Devices and Radiological Health,
Office of Science and Engineering Laboratories,
Division of Applied Mechanics,
10903 New Hampshire Avenue,
Building 62, Room 2210,
Silver Spring, MD 20993
e-mail: srin78@gmail.com

1Corresponding author.

Manuscript received April 11, 2018; final manuscript received November 15, 2018; published online January 18, 2019. Assoc. Editor: Brian D. Stemper.This material is declared a work of the U.S. Government and is not subject to copyright protection in the United States. Approved for public release; distribution is unlimited.

J Biomech Eng 141(3), 031002 (Jan 18, 2019) (8 pages) Paper No: BIO-18-1178; doi: 10.1115/1.4042181 History: Received April 11, 2018; Revised November 15, 2018

Several approaches (anterior, posterior, lateral, and transforaminal) are used in lumbar fusion surgery. However, it is unclear whether one of these approaches has the greatest subsidence risk as published clinical rates of cage subsidence vary widely (7–70%). Specifically, there is limited data on how a patient's endplate morphometry and trabecular bone quality influences cage subsidence risk. Therefore, this study compared subsidence (stiffness, maximum force, and work) between anterior (ALIF), lateral (LLIF), posterior (PLIF), and transforaminal (TLIF) lumbar interbody fusion cage designs to understand the impact of endplate and trabecular bone quality on subsidence. Forty-eight lumbar vertebrae were imaged with micro-ct to assess trabecular microarchitecture. micro-ct images of each vertebra were then imported into image processing software to measure endplate thickness (ET) and maximum endplate concavity depth (ECD). Generic ALIF, LLIF, PLIF, and TLIF cages made of polyether ether ketone were implanted on the superior endplates of all vertebrae and subsidence testing was performed. The results indicated that TLIF cages had significantly lower (p < 0.01) subsidence stiffness and maximum subsidence force compared to ALIF and LLIF cages. For all cage groups, trabecular bone volume fraction was better correlated with maximum subsidence force compared to ET and concavity depth. These findings highlight the importance of cage design (e.g., surface area), placement on the endplate, and trabecular bone quality on subsidence. These results may help surgeons during cage selection for lumbar fusion procedures to mitigate adverse events such as cage subsidence.

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Fig. 1

Midcoronal slice of vertebral endplate depicting (a) ET obtained by averaging measurements at five different points on the superior endplate inside apophyseal ring and (b) maximum ECD obtained by measuring largest vertical distance (white arrow) between the line joining highest points on the apophyseal ring and the lowest point on endplate surface

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Fig. 2

Top-view illustration of (a) PLIF, (b) TLIF, (c) LLIF, and (d) ALIF cages placed on their respective superior lumbar vertebral endplates

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Fig. 3

Experimental setup for the mechanical testing of interbody fusion cage

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Fig. 4

Representative plot of load–displacement obtained after subsidence testing of interbody cages. Stiffness, maximum force, and work to maximum force calculations are shown in the plot.

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Fig. 5

Mean and standard deviation comparisons of (a) subsidence stiffness, (b) max subsidence force, and (c) work done to maximum force for interbody fusion cages used in ALIF, LLIF, TLIF, and PLIF approaches. † symbol indicates significant difference between the two compared groups (p ≤ 0.05).

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Fig. 6

Linear regression analysis between maximum subsidence force and trabecular bone volume fraction (R2 =46–69%, p ≤ 0.05) for (a) ALIF, (b) LLIF, (c) PLIF, and (d) TLIF interbody fusion cages

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Fig. 7

Comparisons between male and female specimens for mechanical testing parameters such as (a) subsidence stiffness, (b) maximum subsidence force, and (c) work done to maximum subsidence force for ALIF, LLIF, TLIF, and PLIF cages. * symbol indicates that males were significantly greater than females for respective cage groups (*p ≤ 0.05).



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