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BMC Musculoskeletal Disorders
Published in: BMC Musculoskeletal Disorders 1/2015

Open Access 01-12-2015 | Research article

Biomechanical comparison of a novel transoral atlantoaxial anchored cage with established fixation technique - a finite element analysis

Authors: Bao-cheng Zhang, Hai-bo Liu, Xian-hua Cai, Zhi-hua Wang, Feng Xu, Hui Kang, Ran Ding, Xiao-qing Luo

Published in: BMC Musculoskeletal Disorders | Issue 1/2015

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Abstract

Background

The transoral atlantoaxial reduction plate (TARP) fixation has been introduced to achieve reduction, decompression, fixation and fusion of C1–C2 through a transoral-only approach. However, it may also be associated with potential disadvantages, including dysphagia and load shielding of the bone graft. To prevent potential disadvantages related to TARP fixation, a novel transoral atlantoaxial fusion cage with integrated plate (Cage + Plate) device for stabilization of the C1-C2 segment is designed. The aims of the present study were to compare the biomechanical differences between Cage + Plate device and Cage + TARP device for the treatment of basilar invagination (BI) with irreducible atlantoaxial dislocation (IAAD).

Methods

A detailed, nonlinear finite element model (FEM) of the intact upper cervical spine had been developed and validated. Then a FEM of an unstable BI model treated with Cage + Plate fixation, was compared to that with Cage + TARP fixation. All models were subjected to vertical load with pure moments in flexion, extension, lateral bending and axial rotation. Range of motion (ROM) of C1-C2 segment and maximum von Mises Stress of the C2 endplate and bone graft were quantified for the two devices.

Results

Both devices significantly reduced ROM compared with the intact state. In comparison with the Cage + Plate model, the Cage + TARP model reduced the ROM by 82.5 %, 46.2 %, 10.0 % and 74.3 % in flexion, extension, lateral bending, and axial rotation. The Cage + Plate model showed a higher increase stresses on C2 endplate and bone graft than the Cage + TARP model in all motions.

Conclusions

Our results indicate that the novel Cage + Plate device may provide lower biomechanical stability than the Cage + TARP device in flexion, extension, and axial rotation, however, it may reduce stress shielding of the bone graft for successful fusion and minimize the risk of postoperative dysphagia. Clinical trials are now required to validate the reproducibility and advantages of our findings using this anchored cage for the treatment of BI with IAAD.
Literature
1.
Goel A. Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation. J Neurosurg Spine. 2004;1:281–6.CrossRefPubMed
2.
Goel A. Progressive basilar invagination after transoral odontoidectomy: treatment by atlantoaxial facet distraction and craniovertebral realignment. Spine. 2005;30:E551–5.CrossRefPubMed
3.
Bhagra A, Stead LG. Basilar invagination, a rare condition mimicking posterior circulation stroke. Neurocrit Care. 2006;5:213–4.CrossRefPubMed
4.
Yang J, Ma X, Xia H, Wu Z, Ai F, Yin Q. Transoral anterior revision surgeries for basilar invagination with irreducible atlantoaxial dislocation after posterior decompression: a retrospective study of 30 cases. Eur Spine J. 2014;23:1099–108.CrossRefPubMed
5.
Goel A, Shah A, Rajan S. Vertical mobile and reducible atlantoaxial dislocation. Clinical article J Neurosurg Spine. 2009;11:9–14.CrossRefPubMed
6.
Wang C, Yan M, Zhou HT, Wang SL, Dang GT. Open reduction of irreducible atlantoaxial dislocation by transoral anterior atlantoaxial release and posterior internal fixation. Spine. 2006;31:E306–13.CrossRefPubMed
7.
Ai FZ, Yin QS, Xu DC, Xia H, Wu ZH, Mai XH. Transoral atlantoaxial reduction plate internal fixation with transoral transpedicular or articular mass screw of C2 for the treatment of irreducible atlantoaxial dislocation: two case reports. Spine (Phila Pa 1976). 2011;36:E556–62.CrossRef
8.
Xia H, Yin Q, Ai F, Ma X, Wang J, Wu Z, et al. Treatment of basilar invagination with atlantoaxial dislocation: atlantoaxial joint distraction and fixation with transoral atlantoaxial reduction plate (TARP) without odontoidectomy. Eur Spine J. 2014;23:1648–55.CrossRefPubMed
9.
Li X, Ai F, Xia H, Wu Z, Ma X, Yin Q. Radiographic and clinical assessment on the accuracy and complications of C1 anterior lateral mass and C2 anterior pedicle screw placement in the TARP-III procedure: a study of 106 patients. Eur Spine J. 2014;23:1712–9.CrossRefPubMed
10.
Yoshizumi T, Murata H, Ikenishi Y, Sato M, Takase H, Tateishi K, et al. Occipitocervical fusion with relief of odontoid invagination: atlantoaxial distraction method using cylindrical titanium cage for basilar invagination-case report. Neurosurg Rev. 2014;37:519–24. 524–525.CrossRefPubMed
11.
Kasliwal M, Kasliwal M, O’Toole J. Integrated intervertebral device for anterior cervical fusion: An initial experience. J Craniovert Jun Spine. 2012;3:52–7.CrossRef
12.
Cai X, Liu Z, Yu Y, Zhang M, Huang W. Evaluation of biomechanical properties of anterior atlantoaxial transarticular locking plate system using three-dimensional finite element analysis. Eur Spine J. 2013;22:2686–94.CrossRefPubMedPubMedCentral
13.
Puttlitz CM, Goel VK, Clark CR, Traynelis VC, Scifert JL, Grosland NM. Biomechanical rationale for the pathology of rheumatoid arthritis in the craniovertebral junction. Spine (Phila Pa 1976). 2000;25:1607–16.CrossRef
14.
Brolin K, Halldin P. Development of a finite element model of the upper cervical spine and a parameter study of ligament characteristics. Spine (Phila Pa 1976). 2004;29:376–85.CrossRef
15.
Zhang H, Bai J. Development and validation of a finite element model of the occipito-atlantoaxial complex under physiologic loads. Spine (Phila Pa 1976). 2007;32:968–74.CrossRef
16.
Puttlitz CM, Goel VK, Traynelis VC, Clark CR. A finite element investigation of upper cervical instrumentation. Spine (Phila Pa 1976). 2001;26:2449–55.CrossRef
17.
Cai X, Yu Y, Liu Z, Zhang M, Huang W. Three-dimensional finite element analysis of occipitocervical fixation using an anterior occiput-to-axis locking plate system: a pilot study. Spine J. 2014;14:1399–409.CrossRefPubMed
18.
Wang J, Xia H, Yin Q. Classification and its clinical significance of basilar invagination. Chinese journal of spine and spinal cord. 2011;21:290–4.
19.
Padua MRA, Yeom JS, Lee SY, Lee SM, Kim H, Chang B, et al. Fluoroscopically guided anterior atlantoaxial transarticular screws: a feasibility and trajectory study using CT-based simulation software. Spine J. 2013;13:1455–63.CrossRefPubMed
20.
21.
Wu Z, Zheng Y, Yin Q, Ma X, Yin Y. Anterior pedicle screw fixation of C2: an anatomic analysis of axis morphology and simulated surgical fixation. Eur Spine J. 2014;23:356–61.CrossRefPubMed
22.
Cheung KM, Mak KC, Luk KD. Anterior approach to cervical spine. Spine (Phila Pa 1976). 2012;37:E297–302.CrossRef
23.
Polikeit A, Ferguson SJ, Nolte LP, Orr TE. Factors influencing stresses in the lumbar spine after the insertion of intervertebral cages: finite element analysis. Eur Spine J. 2003;12:413–20.CrossRefPubMed
24.
Panjabi M, Dvorak J, Duranceau J, Yamamoto I, Gerber M, Rauschning W, et al. Three-dimensional movements of the upper cervical spine. Spine. 1988;13:726–30.CrossRefPubMed
25.
Panjabi M, Dvorak J, Crisco JR, Oda T, Hilibrand A, Grob D. Flexion, extension, and lateral bending of the upper cervical spine in response to alar ligament transections. J Spinal Disord. 1991;4:157–67.CrossRefPubMed
26.
Panjabi M, Dvorak J, Crisco JR, Oda T, Wang P, Grob D. Effects of alar ligament transection on upper cervical spine rotation. J Orthop Res. 1991;9:584–93.CrossRefPubMed
27.
Barsa P, Suchomel P. Factors affecting sagittal malalignment due to cage subsidence in standalone cage assisted anterior cervical fusion. Eur Spine J. 2007;16:1395–400.CrossRefPubMedPubMedCentral
28.
Dong Y, Hong MX, Jianyi L, Lin MY. Quantitative anatomy of the lateral mass of the atlas. Spine (Phila Pa 1976). 2003;28:860–3.
29.
Cattrysse E, Provyn S, Gagey O, Kool P, Clarys JP, Van Roy P. In vitro three dimensional morphometry of the lateral atlantoaxial articular surfaces. Spine (Phila Pa 1976). 2008;33:1503–8.CrossRef
30.
Li S, Ni B, Xie N, Wang M, Guo X, Zhang F, et al. Biomechanical evaluation of an atlantoaxial lateral mass fusion cage with C1-C2 pedicle fixation. Spine (Phila Pa 1976). 2010;35:E624–32.CrossRef
31.
Nadim Y, Sabry F, Xu R, Ebraheim N. Computed tomography in the determination of transarticular C1-C2 screw length. Orthopedics. 2000;23:373–5.PubMed
32.
Passias PG, Wang S, Zhao D, Wang S, Kozanek M, Wang C. The Reversibility of Swan Neck Deformity in Chronic Atlantoaxial Dislocations. Spine. 2013;38:E379–85.CrossRefPubMed
33.
Guo Q, Ni B, Yang J, Liu K, Sun Z, Zhou F, et al. Relation between alignments of upper and subaxial cervical spine: a radiological study. Arch Orthop Trauma Surg. 2011;131:857–62.CrossRefPubMed
34.
Yoshida G, Kamiya M, Yoshihara H, Kanemura T, Kato F, Yukawa Y, et al. Subaxial sagittal alignment and adjacent-segment degeneration after atlantoaxial fixation performed using C-1 lateral mass and C-2 pedicle screws or transarticular screws. J Neurosurg Spine. 2010;13:443–50.CrossRefPubMed
35.
Izeki M, Neo M, Takemoto M, Fujibayashi S, Ito H, Nagai K, et al. The O-C2 angle established at occipito-cervical fusion dictates the patient’s destiny in terms of postoperative dyspnea and/or dysphagia. Eur Spine J. 2014;23:328–36.CrossRefPubMed
36.
Miyata M, Neo M, Fujibayashi S, Ito H, Takemoto M, Nakamura T. O-C2 angle as a predictor of dyspnea and/or dysphagia after occipitocervical fusion. Spine (Phila Pa 1976). 2009;34:184–8.CrossRef
37.
Jian FZ, Chen Z, Wrede KH, Samii M, Ling F. Direct posterior reduction and fixation for the treatment of basilar invagination with atlantoaxial dislocation. Neurosurgery. 2010;66:678–87.CrossRefPubMed
38.
Daniel RT, Muzumdar A, Ingalhalikar A, Moldavsky M, Khalil S. Biomechanical Stability of a Posterior-Alone Fixation Technique After Craniovertebral Junction Realignment. World Neurosurg. 2012;77:357–61.CrossRefPubMed
39.
Njoku IJ, Alimi M, Leng LZ, Shin BJ, James AR, Bhangoo S, et al. Anterior cervical discectomy and fusion with a zero-profile integrated plate and spacer device: a clinical and radiological study. J Neurosurg Spine. 2014;21:529–37.CrossRefPubMed
40.
Barbagallo GM, Romano D, Certo F, Milone P, Albanese V. Zero-P: a new zero-profile cage-plate device for single and multilevel ACDF. A single institution series with four years maximum follow-up and review of the literature on zero-profile devices. Eur Spine J. 2013;22(6):S868–78.CrossRefPubMed
41.
Qi M, Chen H, Liu Y, Zhang Y, Liang L, Yuan W. The use of a zero-profile device compared with an anterior plate and cage in the treatment of patients with symptomatic cervical spondylosis: A preliminary clinical investigation. Bone Joint J. 2013;95-B:543–7.CrossRefPubMed
42.
Majid K, Chinthakunta S, Muzumdar A, Khalil S. A comparative biomechanical study of a novel integrated plate spacer for stabilization of cervical spine: An in vitro human cadaveric model. Clin Biomech (Bristol, Avon). 2012;27:532–6.CrossRef
43.
Clavenna AL, Beutler WJ, Gudipally M, Moldavsky M, Khalil S. The biomechanical stability of a novel spacer with integrated plate in contiguous two-level and three-level ACDF models: an in vitro cadaveric study. Spine J. 2012;12:157–63.CrossRefPubMed
44.
Reis MT, Reyes PM, Crawford NR. Biomechanical Assessment of Anchored Cervical Interbody Cages: Comparison of 2-screw and 4-screw Designs. Neurosurgery. 2014;10(3):412–7.CrossRefPubMed
45.
Hakalo J, Pezowicz C, Wronski J, Bedzinski R, Kasprowicz M. The process of subsidence after cervical stabilizations by cage alone, cage with plate and plate-cage. A biomechanical comparative study. Neurol Neurochir Pol. 2007;41:411–6.PubMed
46.
Kao T, Wu C, Chou Y, Chen H, Chen W, Tsou H. Risk factors for subsidence in anterior cervical fusion with stand-alone polyetheretherketone (PEEK) cages: a review of 82 cases and 182 levels. Arch Orthop Trauma Surg. 2014;134:1343–51.CrossRefPubMedPubMedCentral
47.
Ordway NR, Lu Y, Zhang X, Cheng C, Fang H, Fayyazi AH. Correlation of cervical endplate strength with CT measured subchondral bone density. Eur Spine J. 2007;16:2104–9.CrossRefPubMedPubMedCentral
48.
Li Y, Wu Z, Li X, Guo Z, Wu S, Zhang Y, et al. A polycaprolactone-tricalcium phosphate composite scaffold as an autograft-free spinal fusion cage in a sheep model. Biomaterials. 2014;35:5647–59.CrossRefPubMed
49.
Kandziora F, Schollmeier G, Scholz M, Schaefer J, Scholz A, Schmidmaier G, et al. Influence of cage design on interbody fusion in a sheep cervical spine model. J Neurosurg. 2002;96:321–32.PubMed
Metadata
Title
Biomechanical comparison of a novel transoral atlantoaxial anchored cage with established fixation technique - a finite element analysis
Authors
Bao-cheng Zhang
Hai-bo Liu
Xian-hua Cai
Zhi-hua Wang
Feng Xu
Hui Kang
Ran Ding
Xiao-qing Luo
Publication date
01-12-2015
Publisher
BioMed Central
Published in
BMC Musculoskeletal Disorders / Issue 1/2015
Electronic ISSN: 1471-2474
DOI
https://doi.org/10.1186/s12891-015-0662-7

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