0
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.

FIGURES IN THIS ARTICLE
<>
Copyright © 2019 by ASME
Your Session has timed out. Please sign back in to continue.

References

Cowan, J. A., Jr , Dimick, J. B. , Wainess, R. , Upchurch, G. R., Jr , Chandler, W. F. , and La Marca, F. , 2006, “ Changes in Utilization of Spinal Fusion in the United States,” Neurosurgery, 59(1), pp. 15–20. [CrossRef] [PubMed]
Schizas, C. , Kulik, G. , and Kosmopoulos, V. , 2010, “ Disc Degeneration: Current Surgical Options,” Eur. Cell Mater., 20, pp. 306–315. [CrossRef] [PubMed]
Weiss, A. , and Elixhauser, A. , 2004, “ Trends in Operating Room Procedures in U.S. Hospitals, 2001–2011,” Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, Rockville, MD, Statistical Brief No. 171. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb171-Operating-Room-Procedure-Trends.pdf
Rajaraman, V. , Vingan, R. , Roth, P. , Heary, R. F. , Conklin, L. , and Jacobs, G. B. , 1999, “ Visceral and Vascular Complications Resulting From Anterior Lumbar Interbody Fusion,” J. Neurosurg., 91(1), pp. 60–64. [PubMed]
Baker, J. K. , Reardon, P. R. , Reardon, M. J. , and Heggeness, M. H. , 1993, “ Vascular Injury in Anterior Lumbar Surgery,” Spine, 18(15), pp. 2227–2230. [CrossRef] [PubMed]
Sasso, R. C. , Burkus, J. K. , and LeHuec, J.-C. , 2003, “ Retrograde Ejaculation After Anterior Lumbar Interbody Fusion: Transperitoneal Versus Retroperitoneal Exposure,” Spine, 28(10), pp. 1023–1026. [PubMed]
Marchi, L. , Abdala, N. , Oliveira, L. , Amaral, R. , Coutinho, E. , and Pimenta, L. , 2013, “ Radiographic and Clinical Evaluation of Cage Subsidence After Stand-Alone Lateral Interbody Fusion,” J. Neurosurg., 19(1), pp. 110–118.
Villavicencio, A. T. , Burneikiene, S. , Bulsara, K. R. , and Thramann, J. J. , 2006, “ Perioperative Complications in Transforaminal Lumbar Interbody Fusion Versus Anterior–Posterior Reconstruction for Lumbar Disc Degeneration and Instability,” Clin. Spine Surg., 19(2), pp. 92–97.
Scaduto, A. A. , Gamradt, S. C. , Warren, D. Y. , Huang, J. , Delamarter, R. B. , and Wang, J. C. , 2003, “ Perioperative Complications of Threaded Cylindrical Lumbar Interbody Fusion Devices: Anterior Versus Posterior Approach,” Clin. Spine Surg., 16(6), pp. 502–507.
Daffner, S. D. , and Wang, J. C. , 2010, “ Migrated XLIF Cage: Case Report and Discussion of Surgical Technique,” Orthopedics, 33(7), pp. 1–8. https://www.healio.com/orthopedics/journals/ortho/2010-7-33-7/%7Ba037bb9c-a7bb-45e4-8931-baf2763d4105%7D/migrated-xlif-cage-case-report-and-discussion-of-surgical-technique
Chen, L. , Yang, H. , and Tang, T. , 2005, “ Cage Migration in Spondylolisthesis Treated With Posterior Lumbar Interbody Fusion Using BAK Cages,” Spine, 30(19), pp. 2171–2175. [CrossRef] [PubMed]
Le, T. V. , Baaj, A. A. , Dakwar, E. , Burkett, C. J. , Murray, G. , Smith, D. A. , and Uribe, J. S. , 2012, “ Subsidence of Polyetheretherketone Intervertebral Cages in Minimally Invasive Lateral Retroperitoneal Transpsoas Lumbar Interbody Fusion,” Spine, 37(14), pp. 1268–1273. [CrossRef] [PubMed]
Choi, J. Y. , and Sung, K. H. , 2006, “ Subsidence After Anterior Lumbar Interbody Fusion Using Paired Stand-Alone Rectangular Cages,” Eur. Spine J., 15(1), pp. 16–22. [CrossRef] [PubMed]
Tokuhashi, Y. , Ajiro, Y. , and Umezawa, N. , 2009, “ Subsidence of Metal Interbody Cage After Posterior Lumbar Interbody Fusion With Pedicle Screw Fixation,” Orthopedics, 32(4), pp. 259–264. https://www.healio.com/orthopedics/spine/journals/ortho/2010-4-33-4/%7Bb1591b68-a29c-4c85-bc73-a4d014af893f%7D/subsidence-of-metal-interbody-cage-after-posterior-lumbar-interbody-fusion-with-pedicle-screw-fixation
Beutler, W. J. , and Peppelman, W. C. , 2003, “ Anterior Lumbar Fusion With Paired BAK Standard and paired BAK Proximity Cages: Subsidence Incidence, Subsidence Factors, and Clinical Outcome,” Spine J., 3(4), pp. 289–293. [CrossRef] [PubMed]
Behrbalk, E. , Uri, O. , Parks, R. M. , Musson, R. , Soh, R. C. C. , and Boszczyk, B. M. , 2013, “ Fusion and Subsidence Rate of Stand Alone Anterior Lumbar Interbody Fusion Using PEEK Cage With Recombinant Human Bone Morphogenetic Protein-2,” Eur. Spine J., 22(12), pp. 2869–2875. [CrossRef] [PubMed]
Joseph, J. R. , Smith, B. W. , La Marca, F. , and Park, P. , 2015, “ Comparison of Complication Rates of Minimally Invasive Transforaminal Lumbar Interbody Fusion and Lateral Lumbar Interbody Fusion: A Systematic Review of the Literature,” Neurosurg. Focus, 39(4), p. E4. [CrossRef] [PubMed]
Lee, N. , Kim, K. N. , Yi, S. , Ha, Y. , Shin, D. A. , and Kim, K. S. , 2017, “ Comparison of Outcomes of Anterior, Posterior, and Transforaminal Lumbar Interbody Fusion Surgery at a Single Lumbar Level With Degenerative Spinal Disease,” World Neurosurg., 101, pp. 216–226. [CrossRef] [PubMed]
Kim, M.-C. , Chung, H.-T. , Cho, J.-L. , Kim, D.-J. , and Chung, N.-S. , 2013, “ Subsidence of Polyetheretherketone Cage After Minimally Invasive Transforaminal Lumbar Interbody Fusion,” Clin. Spine Surg., 26(2), pp. 87–92.
Lim, J. K. , and Kim, S. M. , 2013, “ Radiographic Results of Minimally Invasive (MIS) Lumbar Interbody Fusion (LIF) Compared With Conventional Lumbar Interbody Fusion,” Korean J. Spine, 10(2), pp. 65–71. [CrossRef] [PubMed]
Hildebrand, T. , Laib, A. , Müller, R. , Dequeker, J. , and Rüegsegger, P. , 1999, “ Direct Three‐Dimensional Morphometric Analysis of Human Cancellous Bone: Microstructural Data From Spine, Femur, Iliac Crest, and Calcaneus,” J. Bone Miner. Res., 14(7), pp. 1167–1174. [CrossRef] [PubMed]
Hildebrand, T. , and Rüegsegger, P. , 1997, “ A New Method for the Model‐Independent Assessment of Thickness in Three‐Dimensional Images,” J. Microsc., 185(1), pp. 67–75. [CrossRef]
Guyer, R. D. , Auer, B. P. , Zigler, J. E. , Ohnmeiss, D. D. , and Blumenthal, S. L. , 2009, “ Relationship Between Endplate Morphology and Clinical Outcome of Single-Level Lumbar Disc Arthroplasty,” Spine J. Meet. Abstr., 9(10), p.114S. https://journals.lww.com/spinejournalabstracts/Fulltext/2009/11001/RELATIONSHIP_BETWEEN_ENDPLATE_MORPHOLOGY_AND.46.aspx
Briski, D. C. , Goel, V. K. , Waddell, B. S. , Serhan, H. , Kodigudla, M. K. , Palepu, V. , Agarwal, A. K. , and Zavatsky, J. M. , 2017, “ Does Spanning a Lateral Lumbar Interbody Cage Across the Vertebral Ring Apophysis Increase Loads Required for Failure and Mitigate Endplate Violation,” Spine, 42(20), pp. E1158–E1164. [CrossRef] [PubMed]
Steffen, T. , Tsantrizos, A. , and Aebi, M. , 2000, “ Effect of Implant Design and Endplate Preparation on the Compressive Strength of Interbody Fusion Constructs,” Spine, 25(9), pp. 1077–1084. [CrossRef] [PubMed]
Perilli, E. , Briggs, A. M. , Kantor, S. , Codrington, J. , Wark, J. D. , Parkinson, I. H. , and Fazzalari, N. L. , 2012, “ Failure Strength of Human Vertebrae: Prediction Using Bone Mineral Density Measured by DXA and Bone Volume by Micro-CT,” Bone, 50(6), pp. 1416–1425. [CrossRef] [PubMed]
Lakshmanan, P. , Purushothaman, B. , Dvorak, V. , Schratt, W. , Thambiraj, S. , and Boszczyk, B. M. , 2012, “ Sagittal Endplate Morphology of the Lower Lumbar Spine,” Eur. Spine J., 21(Suppl. 2), pp. 160–164. [CrossRef]
Eswaran, S. K. , Gupta, A. , Adams, M. F. , and Keaveny, T. M. , 2006, “ Cortical and Trabecular Load Sharing in the Human Vertebral Body,” J. Bone Miner. Res., 21(2), pp. 307–314. [CrossRef] [PubMed]
Hulme, P. , Boyd, S. , and Ferguson, S. J. , 2007, “ Regional Variation in Vertebral Bone Morphology and Its Contribution to Vertebral Fracture Strength,” Bone, 41(6), pp. 946–957. [CrossRef] [PubMed]
Schmidt, H. , Kettler, A. , Heuer, F. , Simon, U. , Claes, L. , and Wilke, H.-J. , 2007, “ Intradiscal Pressure, Shear Strain, and Fiber Strain in the Intervertebral Disc Under Combined Loading,” Spine, 32(7), pp. 748–755. [CrossRef] [PubMed]

Figures

Grahic Jump Location
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).

Grahic Jump Location
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.

Grahic Jump Location
Fig. 3

Experimental setup for the mechanical testing of interbody fusion cage

Grahic Jump Location
Fig. 2

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

Grahic Jump Location
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

Grahic Jump Location
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

Grahic Jump Location
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).

Tables

Errata

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging and repositioning the boxes below.

Related Journal Articles
Related eBook Content
Topic Collections

Sorry! You do not have access to this content. For assistance or to subscribe, please contact us:

  • TELEPHONE: 1-800-843-2763 (Toll-free in the USA)
  • EMAIL: asmedigitalcollection@asme.org
Sign In