Skip to main content
Top
Published in: European Spine Journal 11/2017

01-11-2017 | Original Article

Insufficient stability of pedicle screws in osteoporotic vertebrae: biomechanical correlation of bone mineral density and pedicle screw fixation strength

Authors: Lukas Weiser, Gerd Huber, Kay Sellenschloh, Lennart Viezens, Klaus Püschel, Michael M. Morlock, Wolfgang Lehmann

Published in: European Spine Journal | Issue 11/2017

Login to get access

Abstract

Purpose

Loosening of pedicle screws is one major complication of posterior spinal stabilisation, especially in the patients with osteoporosis. Augmentation of pedicle screws with cement or lengthening of the instrumentation is widely used to improve implant stability in these patients. However, it is still unclear from which value of bone mineral density (BMD) the stability of pedicle screws is insufficient and an additional stabilisation should be performed. The aim of this study was to investigate the correlation of bone mineral density and pedicle screw fatigue strength as well as to define a threshold value for BMD below which an additional stabilisation is recommended.

Methods

Twenty-one human T12 vertebral bodies were collected from donors between 19 and 96 years of age and the BMD was measured using quantitative computed tomography. Each vertebral body was instrumented with one pedicle screw and mounted in a servo-hydraulic testing machine. Fatigue testing was performed by implementing a cranio-caudal sinusoidal, cyclic (0.5 Hz) load with stepwise increasing peak force.

Results

A significant correlation between BMD and cycles to failure (r = 0.862, r 2 = 0.743, p < 0.001) as well as for the linearly related fatigue load was found. Specimens with BMD below 80 mg/cm3 only reached 45% of the cycles to failure and only 60% of the fatigue load compared to the specimens with adequate bone quality (BMD > 120 mg/cm3).

Conclusions

There is a close correlation between BMD and pedicle screw stability. If the BMD of the thoracolumbar spine is less than 80 mg/cm3, stability of pedicle screws might be insufficient and an additional stabilisation should be considered.
Literature
1.
go back to reference Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 22:465–475. doi:10.1359/jbmr.061113 CrossRefPubMed Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 22:465–475. doi:10.​1359/​jbmr.​061113 CrossRefPubMed
3.
go back to reference Gaines RW Jr (2000) The use of pedicle-screw internal fixation for the operative treatment of spinal disorders. J Bone Jt Surg Am 82-A:1458–1476CrossRef Gaines RW Jr (2000) The use of pedicle-screw internal fixation for the operative treatment of spinal disorders. J Bone Jt Surg Am 82-A:1458–1476CrossRef
6.
go back to reference Halvorson TL, Kelley LA, Thomas KA, Whitecloud TS 3rd, Cook SD (1994) Effects of bone mineral density on pedicle screw fixation. Spine (Phila Pa 1976) 19:2415–2420CrossRef Halvorson TL, Kelley LA, Thomas KA, Whitecloud TS 3rd, Cook SD (1994) Effects of bone mineral density on pedicle screw fixation. Spine (Phila Pa 1976) 19:2415–2420CrossRef
7.
go back to reference Soshi S, Shiba R, Kondo H, Murota K (1991) An experimental study on transpedicular screw fixation in relation to osteoporosis of the lumbar spine. Spine (Phila Pa 1976) 16:1335–1341CrossRef Soshi S, Shiba R, Kondo H, Murota K (1991) An experimental study on transpedicular screw fixation in relation to osteoporosis of the lumbar spine. Spine (Phila Pa 1976) 16:1335–1341CrossRef
8.
go back to reference Hallab NJ, Cunningham BW, Jacobs JJ (2003) Spinal implant debris-induced osteolysis. Spine (Phila Pa 1976) 28:S125–S138CrossRef Hallab NJ, Cunningham BW, Jacobs JJ (2003) Spinal implant debris-induced osteolysis. Spine (Phila Pa 1976) 28:S125–S138CrossRef
10.
go back to reference Wu ZX, Gong FT, Liu L, Ma ZS, Zhang Y, Zhao X, Yang M, Lei W, Sang HX (2012) A comparative study on screw loosening in osteoporotic lumbar spine fusion between expandable and conventional pedicle screws. Arch Orthop Trauma Surg 132:471–476. doi:10.1007/s00402-011-1439-6 CrossRefPubMed Wu ZX, Gong FT, Liu L, Ma ZS, Zhang Y, Zhao X, Yang M, Lei W, Sang HX (2012) A comparative study on screw loosening in osteoporotic lumbar spine fusion between expandable and conventional pedicle screws. Arch Orthop Trauma Surg 132:471–476. doi:10.​1007/​s00402-011-1439-6 CrossRefPubMed
11.
go back to reference Paxinos O, Tsitsopoulos PP, Zindrick MR, Voronov LI, Lorenz MA, Havey RM, Patwardhan AG (2010) Evaluation of pullout strength and failure mechanism of posterior instrumentation in normal and osteopenic thoracic vertebrae. J Neurosurg Spine 13:469–476. doi:10.3171/2010.4.SPINE09764 CrossRefPubMed Paxinos O, Tsitsopoulos PP, Zindrick MR, Voronov LI, Lorenz MA, Havey RM, Patwardhan AG (2010) Evaluation of pullout strength and failure mechanism of posterior instrumentation in normal and osteopenic thoracic vertebrae. J Neurosurg Spine 13:469–476. doi:10.​3171/​2010.​4.​SPINE09764 CrossRefPubMed
12.
go back to reference El Saman A, Meier S, Sander A, Kelm A, Marzi I, Laurer H (2013) Reduced loosening rate and loss of correction following posterior stabilization with or without PMMA augmentation of pedicle screws in vertebral fractures in the elderly. Eur J Trauma Emerg Surg 39:455–460. doi:10.1007/s00068-013-0310-6 CrossRefPubMed El Saman A, Meier S, Sander A, Kelm A, Marzi I, Laurer H (2013) Reduced loosening rate and loss of correction following posterior stabilization with or without PMMA augmentation of pedicle screws in vertebral fractures in the elderly. Eur J Trauma Emerg Surg 39:455–460. doi:10.​1007/​s00068-013-0310-6 CrossRefPubMed
13.
go back to reference Coe JD, Warden KE, Herzig MA, McAfee PC (1990) Influence of bone mineral density on the fixation of thoracolumbar implants. A comparative study of transpedicular screws, laminar hooks, and spinous process wires. Spine (Phila Pa 1976) 15:902–907CrossRef Coe JD, Warden KE, Herzig MA, McAfee PC (1990) Influence of bone mineral density on the fixation of thoracolumbar implants. A comparative study of transpedicular screws, laminar hooks, and spinous process wires. Spine (Phila Pa 1976) 15:902–907CrossRef
15.
go back to reference Kueny RA, Kolb JP, Lehmann W, Puschel K, Morlock MM, Huber G (2014) Influence of the screw augmentation technique and a diameter increase on pedicle screw fixation in the osteoporotic spine: pullout versus fatigue testing. Eur Spine J 23:2196–2202. doi:10.1007/s00586-014-3476-7 CrossRefPubMed Kueny RA, Kolb JP, Lehmann W, Puschel K, Morlock MM, Huber G (2014) Influence of the screw augmentation technique and a diameter increase on pedicle screw fixation in the osteoporotic spine: pullout versus fatigue testing. Eur Spine J 23:2196–2202. doi:10.​1007/​s00586-014-3476-7 CrossRefPubMed
16.
go back to reference Schulze M, Gehweiler D, Riesenbeck O, Wahnert D, Raschke MJ, Hartensuer R, Vordemvenne T (2016) Biomechanical characteristics of pedicle screws in osteoporotic vertebrae—comparing a new cadaver corpectomy model and pure pull-out testing. J Orthop Res. doi:10.1002/jor.23237 PubMed Schulze M, Gehweiler D, Riesenbeck O, Wahnert D, Raschke MJ, Hartensuer R, Vordemvenne T (2016) Biomechanical characteristics of pedicle screws in osteoporotic vertebrae—comparing a new cadaver corpectomy model and pure pull-out testing. J Orthop Res. doi:10.​1002/​jor.​23237 PubMed
17.
go back to reference Bostelmann R, Keiler A, Steiger HJ, Scholz A, Cornelius JF, Schmoelz W (2015) Effect of augmentation techniques on the failure of pedicle screws under cranio-caudal cyclic loading. Eur Spine J. doi:10.1007/s00586-015-3904-3 Bostelmann R, Keiler A, Steiger HJ, Scholz A, Cornelius JF, Schmoelz W (2015) Effect of augmentation techniques on the failure of pedicle screws under cranio-caudal cyclic loading. Eur Spine J. doi:10.​1007/​s00586-015-3904-3
18.
go back to reference Weiser L, Dreimann M, Huber G, Sellenschloh K, Puschel K, Morlock MM, Rueger JM, Lehmann W (2016) Cement augmentation versus extended dorsal instrumentation in the treatment of osteoporotic vertebral fractures: a biomechanical comparison. Bone Jt J 98-B:1099–1105. doi:10.1302/0301-620X.98B8.37413 CrossRef Weiser L, Dreimann M, Huber G, Sellenschloh K, Puschel K, Morlock MM, Rueger JM, Lehmann W (2016) Cement augmentation versus extended dorsal instrumentation in the treatment of osteoporotic vertebral fractures: a biomechanical comparison. Bone Jt J 98-B:1099–1105. doi:10.​1302/​0301-620X.​98B8.​37413 CrossRef
19.
go back to reference Wittenberg RH, Shea M, Swartz DE, Lee KS, White AA 3rd, Hayes WC (1991) Importance of bone mineral density in instrumented spine fusions. Spine (Phila Pa 1976) 16:647–652CrossRef Wittenberg RH, Shea M, Swartz DE, Lee KS, White AA 3rd, Hayes WC (1991) Importance of bone mineral density in instrumented spine fusions. Spine (Phila Pa 1976) 16:647–652CrossRef
20.
go back to reference Okuyama K, Sato K, Abe E, Inaba H, Shimada Y, Murai H (1993) Stability of transpedicle screwing for the osteoporotic spine. An in vitro study of the mechanical stability. Spine (Phila Pa 1976) 18:2240–2245CrossRef Okuyama K, Sato K, Abe E, Inaba H, Shimada Y, Murai H (1993) Stability of transpedicle screwing for the osteoporotic spine. An in vitro study of the mechanical stability. Spine (Phila Pa 1976) 18:2240–2245CrossRef
21.
go back to reference Rohlmann A, Bergmann G, Graichen F (1997) Loads on an internal spinal fixation device during walking. J Biomech 30:41–47CrossRefPubMed Rohlmann A, Bergmann G, Graichen F (1997) Loads on an internal spinal fixation device during walking. J Biomech 30:41–47CrossRefPubMed
25.
go back to reference Karius T, Deborre C, Wirtz DC, Burger C, Prescher A, Folsch A, Kabir K, Pflugmacher R, Goost H (2016) Radiofrequency-activated PMMA-augmentation through cannulated pedicle screws: a cadaver study to determine the biomechanical benefits in the osteoporotic spine. Technol Health Care. doi:10.3233/THC-161273 Karius T, Deborre C, Wirtz DC, Burger C, Prescher A, Folsch A, Kabir K, Pflugmacher R, Goost H (2016) Radiofrequency-activated PMMA-augmentation through cannulated pedicle screws: a cadaver study to determine the biomechanical benefits in the osteoporotic spine. Technol Health Care. doi:10.​3233/​THC-161273
26.
go back to reference Wilke HJ, Kaiser D, Volkheimer D, Hackenbroch C, Puschel K, Rauschmann M (2016) A pedicle screw system and a lamina hook system provide similar primary and long-term stability: a biomechanical in vitro study with quasi-static and dynamic loading conditions. Eur Spine J 25:2919–2928. doi:10.1007/s00586-016-4679-x CrossRefPubMed Wilke HJ, Kaiser D, Volkheimer D, Hackenbroch C, Puschel K, Rauschmann M (2016) A pedicle screw system and a lamina hook system provide similar primary and long-term stability: a biomechanical in vitro study with quasi-static and dynamic loading conditions. Eur Spine J 25:2919–2928. doi:10.​1007/​s00586-016-4679-x CrossRefPubMed
27.
go back to reference Aycan MF, Tolunay T, Demir T, Yaman ME, Usta Y (2017) Pullout performance comparison of novel expandable pedicle screw with expandable poly-ether-ether-ketone shells and cement-augmented pedicle screws. Proc Inst Mech Eng H 231:169–175. doi:10.1177/0954411916687792 CrossRefPubMed Aycan MF, Tolunay T, Demir T, Yaman ME, Usta Y (2017) Pullout performance comparison of novel expandable pedicle screw with expandable poly-ether-ether-ketone shells and cement-augmented pedicle screws. Proc Inst Mech Eng H 231:169–175. doi:10.​1177/​0954411916687792​ CrossRefPubMed
28.
go back to reference Yuan HA, Garfin SR, Dickman CA, Mardjetko SM (1994) A historical cohort study of pedicle screw fixation in thoracic, lumbar, and sacral spinal fusions. Spine (Phila Pa 1976) 19:2279S–2296SCrossRef Yuan HA, Garfin SR, Dickman CA, Mardjetko SM (1994) A historical cohort study of pedicle screw fixation in thoracic, lumbar, and sacral spinal fusions. Spine (Phila Pa 1976) 19:2279S–2296SCrossRef
29.
30.
go back to reference Choma TJ, Frevert WF, Carson WL, Waters NP, Pfeiffer FM (2011) Biomechanical analysis of pedicle screws in osteoporotic bone with bioactive cement augmentation using simulated in vivo multicomponent loading. Spine (Phila Pa 1976) 36:454–462. doi:10.1097/BRS.0b013e3181d449ec CrossRef Choma TJ, Frevert WF, Carson WL, Waters NP, Pfeiffer FM (2011) Biomechanical analysis of pedicle screws in osteoporotic bone with bioactive cement augmentation using simulated in vivo multicomponent loading. Spine (Phila Pa 1976) 36:454–462. doi:10.​1097/​BRS.​0b013e3181d449ec​ CrossRef
31.
go back to reference Kiner DW, Wybo CD, Sterba W, Yeni YN, Bartol SW, Vaidya R (2008) Biomechanical analysis of different techniques in revision spinal instrumentation: larger diameter screws versus cement augmentation. Spine (Phila Pa 1976) 33:2618–2622. doi:10.1097/BRS.0b013e3181882cac CrossRef Kiner DW, Wybo CD, Sterba W, Yeni YN, Bartol SW, Vaidya R (2008) Biomechanical analysis of different techniques in revision spinal instrumentation: larger diameter screws versus cement augmentation. Spine (Phila Pa 1976) 33:2618–2622. doi:10.​1097/​BRS.​0b013e3181882cac​ CrossRef
33.
go back to reference Bredow J, Boese CK, Werner CM, Siewe J, Lohrer L, Zarghooni K, Eysel P, Scheyerer MJ (2016) Predictive validity of preoperative CT scans and the risk of pedicle screw loosening in spinal surgery. Arch Orthop Trauma Surg 136:1063–1067. doi:10.1007/s00402-016-2487-8 CrossRefPubMed Bredow J, Boese CK, Werner CM, Siewe J, Lohrer L, Zarghooni K, Eysel P, Scheyerer MJ (2016) Predictive validity of preoperative CT scans and the risk of pedicle screw loosening in spinal surgery. Arch Orthop Trauma Surg 136:1063–1067. doi:10.​1007/​s00402-016-2487-8 CrossRefPubMed
34.
go back to reference Popp AW, Meer S, Krieg MA, Perrelet R, Hans D, Lippuner K (2016) Bone mineral density (BMD) and vertebral trabecular bone score (TBS) for the identification of elderly women at high risk for fracture: the SEMOF cohort study. Eur Spine J 25:3432–3438. doi:10.1007/s00586-015-4035-6 CrossRefPubMed Popp AW, Meer S, Krieg MA, Perrelet R, Hans D, Lippuner K (2016) Bone mineral density (BMD) and vertebral trabecular bone score (TBS) for the identification of elderly women at high risk for fracture: the SEMOF cohort study. Eur Spine J 25:3432–3438. doi:10.​1007/​s00586-015-4035-6 CrossRefPubMed
35.
go back to reference Okuyama K, Abe E, Suzuki T, Tamura Y, Chiba M, Sato K (2001) Influence of bone mineral density on pedicle screw fixation: a study of pedicle screw fixation augmenting posterior lumbar interbody fusion in elderly patients. Spine J 1:402–407CrossRefPubMed Okuyama K, Abe E, Suzuki T, Tamura Y, Chiba M, Sato K (2001) Influence of bone mineral density on pedicle screw fixation: a study of pedicle screw fixation augmenting posterior lumbar interbody fusion in elderly patients. Spine J 1:402–407CrossRefPubMed
36.
go back to reference Kumano K, Hirabayashi S, Ogawa Y, Aota Y (1994) Pedicle screws and bone mineral density. Spine (Phila Pa 1976) 19:1157–1161CrossRef Kumano K, Hirabayashi S, Ogawa Y, Aota Y (1994) Pedicle screws and bone mineral density. Spine (Phila Pa 1976) 19:1157–1161CrossRef
Metadata
Title
Insufficient stability of pedicle screws in osteoporotic vertebrae: biomechanical correlation of bone mineral density and pedicle screw fixation strength
Authors
Lukas Weiser
Gerd Huber
Kay Sellenschloh
Lennart Viezens
Klaus Püschel
Michael M. Morlock
Wolfgang Lehmann
Publication date
01-11-2017
Publisher
Springer Berlin Heidelberg
Published in
European Spine Journal / Issue 11/2017
Print ISSN: 0940-6719
Electronic ISSN: 1432-0932
DOI
https://doi.org/10.1007/s00586-017-5091-x

Other articles of this Issue 11/2017

European Spine Journal 11/2017 Go to the issue