European Spine Journal

, Volume 22, Issue 1, pp 46–53 | Cite as

Comparison of revision strategies for failed C2-posterior cervical pedicle screws: a biomechanical study

  • Michael Mayer
  • Juliane Zenner
  • Robert Bogner
  • Wolfgang Hitzl
  • Markus Figl
  • Arvind von Keudell
  • Daniel Stephan
  • Rainer Penzkofer
  • Peter Augat
  • Gundobert Korn
  • Herbert Resch
  • Heiko Koller
Original Article


Study purpose

With increasing usage within challenging biomechanical constructs, failures of C2 posterior cervical pedicle screws (C2-pCPSs) will occur. The purpose of the study was therefore to investigate the biomechanical characteristics of two revision techniques after the failure of C2-pCPSs.

Materials and methods

Twelve human C2 vertebrae were tested in vitro in a biomechanical study to compare two strategies for revision screws after failure of C2-pCPSs. C2 pedicles were instrumented using unicortical 3.5-mm CPS bilaterally (Synapse/Synthes, Switzerland). Insertion accuracy was verified by fluoroscopy. C2 vertebrae were potted and fixed in an electromechanical testing machine with the screw axis coaxial to the pullout direction. Pullout testing was conducted with load and displacement data taken continuously. The peak load to failure was measured in newtons (N) and is reported as the pullout resistance (POR). After pullout, two revision strategies were tested in each vertebra. In Group-1, revision was performed with 4.0-mm C2-pCPSs. In Group-2, revision was performed with C2-pedicle bone-plastic combined with the use of a 4-mm C2-pCPSs. For the statistical analysis, the POR between screws was compared using absolute values (N) and the POR of the revision techniques normalized to that of the primary procedures (%).


The POR of primary 3.5-mm CPSs was 1,140.5 ± 539.6 N for Group-1 and 1,007.7 ± 362.5 N for Group-2; the difference was not significant. In the revision setting, the POR in Group-1 was 705.8 ± 449.1 N, representing a reduction of 38.1 ± 32.9 % compared with that of primary screw fixation. For Group-2, the POR was 875.3 ± 367.9 N, representing a reduction of 13.1 ± 23.4 %. A statistical analysis showed a significantly higher POR for Group-2 compared with Group-1 (p = 0.02). Although the statistics showed a significantly reduced POR for both revision strategies compared with primary fixation (p < 0.001/p = 0.001), the loss of POR (in %) in Group-1 was significantly higher compared with the loss in Group-2 (p = 0.04).


Using a larger-diameter screw combined with the application of a pedicle bone-plastic, the POR can be significantly increased compared with the use of only an increased screw diameter.


Cervical pedicle screw Failure Revision strategy Biomechanics Pedicle bone-plastic 



Corporate/industry funds were received in support of this work. Supported by a grant from Synthes/Switzerland. No personal benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Approval of Institutional Review Board: This statement confirms that the study entitled “Comparison of revision strategies for failed C2-posterior cervical pedicle screws - A biomechanical study” has been approved by the Institutional Review Board.

Conflict of interest



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Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Michael Mayer
    • 1
  • Juliane Zenner
    • 2
  • Robert Bogner
    • 1
  • Wolfgang Hitzl
    • 3
  • Markus Figl
    • 4
  • Arvind von Keudell
    • 1
  • Daniel Stephan
    • 5
    • 6
  • Rainer Penzkofer
    • 5
    • 6
  • Peter Augat
    • 5
    • 6
  • Gundobert Korn
    • 1
  • Herbert Resch
    • 1
  • Heiko Koller
    • 2
  1. 1.Department for Traumatology and Sports InjuriesParacelsus Medical UniversitySalzburgAustria
  2. 2.German Scoliosis Center Bad Wildungen, Werner-Wicker-KlinikBad WildungenGermany
  3. 3.Research Office, BiostatisticsParacelsus Medical UniversitySalzburgAustria
  4. 4.Department for TraumatologyGeneral HospitalTullnAustria
  5. 5.Institute of BiomechanicsTrauma Center MurnauMurnauGermany
  6. 6.Institute of BiomechanicsParacelsus Medical UniversitySalzburgAustria

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