JOURNAL ARTICLE

Primary stiffness of a modified transforaminal lumbar interbody fusion cage with integrated screw fixation: cadaveric biomechanical study

Alexander Keiler, Werner Schmoelz, Stefanie Erhart, Kanna Gnanalingham
Spine 2014 August 1, 39 (17): E994-E1000
24875958

STUDY DESIGN: In vitro biomechanical study using human fresh-frozen vertebrae.

OBJECTIVE: To investigate the influence of the additional screw fixation on the stability of a noncommercially available prototype transforaminal lumbar interbody fusion (TLIF) cage, when used as a stand-alone fusion device and in combination with pedicle screws (PSs).

SUMMARY OF BACKGROUND DATA: Generally interbody fusion cages are supplemented by additional fixation devices such as PS. However, such posterior instrumented techniques are associated with additional soft-tissue trauma and potentially increased complication rate. To limit such drawbacks, a conventional posterior TLIF cage was modified to allow supplemental screw fixation to the adjacent vertebral bodies, to increase initial stiffness and possibly allow as a stand-alone posterior interbody cage.

METHODS: Six monosegmental lumbar spine segments were loaded in a spine simulator with pure bending moments of 7.5 Nm in lateral bending, flexion/extension, and axial rotation. The following paradigms were tested: intact spines; a destabilized spine (i.e., after discectomy and unilateral facetectomy); and the modified TLIF cage with (i.e., fixed TLIF cage) and without (i.e., TLIF cage) integrated screw fixation as a stand-alone model and with and without additional posterior fixation with bilateral PS. The range of motion (RoM) was recorded by a 3-dimensional motion analysis system.

RESULTS: The TLIF cage with integrated screw fixation had minimal additional stabilizing effect in all motion planes with or without supplemental PS fixation. Moreover, compared with the intact spines, the stand-alone TLIF cage with and without integrated screw fixation did not reduce the RoM in any of the 3 motion planes. Comparison of the TLIF cage with integrated screw fixation to the TLIF cage supplemented with PS showed a significantly greater RoM in all testing conditions (P < 0.05).

CONCLUSION: In several testing paradigms, the prototype TLIF cage with the integrated screw fixation had limited effect in reducing RoM and providing stability. The PS was the main contributor in reducing RoM in the destabilized spine and remains the current "gold standard" in posterolateral spinal fixation.

LEVEL OF EVIDENCE: N/A.

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