Research Article: Does Semi-Rigid Instrumentation Using Both Flexion and Extension Dampening Spacers Truly Provide an Intermediate Level of Stabilization?

Date Published: April 11, 2013

Publisher: Hindawi Publishing Corporation

Author(s): Dilip Sengupta, Brandon Bucklen, Aditya Ingalhalikar, Aditya Muzumdar, Saif Khalil.

http://doi.org/10.1155/2013/738252

Abstract

Conventional posterior dynamic stabilization devices demonstrated a tendency towards highly rigid stabilization approximating that of titanium rods in flexion. In extension, they excessively offload the index segment, making the device as the sole load-bearing structure, with concerns of device failure. The goal of this study was to compare the kinematics and intradiscal pressure of monosegmental stabilization utilizing a new device that incorporates both a flexion and extension dampening spacer to that of rigid internal fixation and a conventional posterior dynamic stabilization device. The hypothesis was the new device would minimize the overloading of adjacent levels compared to rigid and conventional devices which can only bend but not stretch. The biomechanics were compared following injury in a human cadaveric lumbosacral spine under simulated physiological loading conditions. The stabilization with the new posterior dynamic stabilization device significantly reduced motion uniformly in all loading directions, but less so than rigid fixation. The evaluation of adjacent level motion and pressure showed some benefit of the new device when compared to rigid fixation. Posterior dynamic stabilization designs which both bend and stretch showed improved kinematic and load-sharing properties when compared to rigid fixation and when indirectly compared to existing conventional devices without a bumper.

Partial Text

Fusion using rigid pedicle screw-rod instrumentation is a conventional surgical treatment for mechanical back pain due to disc degeneration when nonoperative treatment has failed. In spite of this standard, it is associated with implant-related failures such as screw breakage or loosening. Screw breakage or loosening have been reported in the literature to range from 1% to 11.2% of the screws inserted [1–7]. It has been shown to be affected by a number of factors such as screw design, the number of levels fused, anterior column load-sharing, bone density, the presence of pseudoarthrosis, and its use in burst fractures [3, 4, 8–10]. While in multilevel fusion, bone density and burst fracture applications are more related to patient pathology and indications; all other factors are more dependent on implant design and biomechanics. Anterior column load-sharing is negatively affected by the absence of interbody support and higher stiffness of posterior fixation devices [3, 11]. Adjacent segment degeneration (ASD) has also been recognized as a potential long-term complication of rigidly instrumented fusion [12–17]. While there is some debate surrounding the causality of the disease (whether it is mechanical factors or a natural degenerative progression), a review of 271 articles found a higher rate of symptomatic ASD in 12%–18% of patients fused with rigid transpedicular instrumentation. In spite of these disadvantages, it is proven that implant rigidity is required to achieve successful fusion.

Conventional rigid fusion in the surgical treatment for chronic low back pain has some negative side effects such as the potential for adjacent segment degeneration and screw loosening. The concept of semi-rigid or dynamic stabilization has evolved to possibly prevent such degeneration, if it is not a function of natural disease progression, mainly through the reduction of stress at the adjacent segments. Soft-stabilization devices were developed to permit load-sharing with the anterior column to accomplish solid fusion and, at the same time, provide a softer posterior implant stiffness. Consequently, semi-rigid instrumentation is expected to lower screw breakage associated with transmission of forces through posterior instrumentation as opposed to through the anterior column. While there is some disparity between the potential uses of PDS systems (whether they are for reducing adjacent level degeneration or for promoting fusion through load-sharing), the ubiquitousness of such systems cannot be ignored. Their prevalence currently has more to do with dissatisfaction with conventional fusion than a proven efficacy. This study attempts to characterize the biomechanical efficacy of a select system. The clinical efficacy has yet to be determined. It remains to be seen if “soft fusion” can be achieved and if, in the presence of boney ingrowth with weaker mechanical properties, adjacent level effects can be ameliorated.

The semi-rigid fixation/dynamic stabilization device investigated in this study, which utilized posteriorly placed flexion and extension dampening materials, was able to reduce the motion (P < 0.05) at the surgical level in all modes, and the reduction in motion was significantly less in comparison to rigid internal fixation. The adjacent levels were off-loaded by the dynamic stabilization device, in terms of both motion and intradiscal pressure, though the effect was often insignificant. The new dynamic device provides more uniform reduction of motion at the surgical level in all directions, especially in flexion, as well as permits more uniform load-sharing when compared to conventional systems like Dynesys. The disc, which is a uniform load-bearing structure of homogeneous material properties, may, likewise, benefit from a device with uniform rigidity.   Source: http://doi.org/10.1155/2013/738252

 

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