European Spine Journal

, Volume 27, Issue 8, pp 1887–1894 | Cite as

Biomechanical investigation of lumbar hybrid stabilization in two-level posterior instrumentation

  • Aldemar Andres Hegewald
  • Sebastian Hartmann
  • Alexander Keiler
  • Kai Michael Scheufler
  • Claudius Thomé
  • Werner Schmoelz
Original Article



Hybrid stabilization with a dynamic implant has been suggested to avoid adjacent segment disease by creating a smoother transition zone from the instrumented segments to the untreated levels above. This study aims to characterize the transition zones of two-level posterior instrumentation strategies for elucidating biomechanical differences between rigid fixation and the hybrid stabilization approach with a pedicle screw-based dynamic implant.


Eight human lumbar spines (L1–5) were loaded in a spine tester with pure moments of 7.5 Nm and with a hybrid loading protocol. The range of motion (ROM) of all segments for both loading protocols was evaluated and normalized to the native ROM.


For pure moment loading, ROM of the segments cranial to both instrumentations were not affected by the type of instrumentation (p > 0.5). The dynamic instrumentation in L3–4 reduced the ROM compared to intact (p < 0.05) but allowed more motion than the rigid fixation of the same segment (p < 0.05). Under hybrid loading testing, the cranial segments (L1–2, L2–3) had a significant higher ROM for both instrumentations compared to the intact (p < 0.05). Comparing the two instrumentations with each other, the rigid fixation resulted in a higher increased ROM of L1–2 and L2–3 than hybrid stabilization.


Regardless of the implant, two-level posterior instrumentation was accompanied by a considerable amount of compensatory movement in the cranial untreated segments under the hybrid protocol. Hybrid stabilization, however, showed a significant reduction of this compensatory movement in comparison to rigid fixation. These results could support the surgical strategy of hybrid stabilization, whereas the concept of topping-off, including a healthy segment, is discouraged.


Spine biomechanics Dynamic stabilization Hybrid stabilization Lumbar fusion Topping-off Lumbar 



The laboratory costs of the study were supported by Paradigm Spine GmbH.

Compliance with ethical standards

Conflict of interest

A. A. Hegewald received speaker honorarium and worked as a clinical consultant for Paradigm Spine GmbH. All other authors declare that they have no conflict of interest. The authors have full control of all primary data and agree to allow the journal to review the data if requested.


  1. 1.
    Sears WR, Sergides IG, Kazemi N, Smith M, White GJ, Osburg B (2011) Incidence and prevalence of surgery at segments adjacent to a previous posterior lumbar arthrodesis. Spine J 11:11–20. CrossRefPubMedGoogle Scholar
  2. 2.
    Pan A, Hai Y, Yang J, Zhou L, Chen X, Guo H (2016) Adjacent segment degeneration after lumbar spinal fusion compared with motion-preservation procedures: a meta-analysis. Eur Spine J 25:1522–1532. CrossRefPubMedGoogle Scholar
  3. 3.
    Norvell DC, Dettori JR, Skelly AC, Riew KD, Chapman JR, Anderson PA (2012) Methodology for the systematic reviews on an adjacent segment pathology. Spine 37:10–17. CrossRefGoogle Scholar
  4. 4.
    Lawrence BD, Wang J, Arnold PM, Hermsmeyer J, Norvell DC, Brodke DS (2012) Predicting the risk of adjacent segment pathology after lumbar fusion: a systematic review. Spine 37:123–132. CrossRefGoogle Scholar
  5. 5.
    He B, Yan L, Guo H, Liu T, Wang X, Hao D (2014) The difference in superior adjacent segment pathology after lumbar posterolateral fusion by using 2 different pedicle screw insertion techniques in 9-year minimum follow-up. Spine 39:1093–1098. CrossRefPubMedGoogle Scholar
  6. 6.
    Ou CY, Lee TC, Lee TH, Huang YH (2015) Impact of body mass index on adjacent segment disease after lumbar fusion for degenerative spine disease. Neurosurgery 76:396–401. CrossRefPubMedGoogle Scholar
  7. 7.
    Yamasaki K, Hoshino M, Omori K et al (2017) Risk factors of adjacent segment disease after transforaminal inter-body fusion for degenerative lumbar disease. Spine 42:E86–E92. CrossRefPubMedGoogle Scholar
  8. 8.
    Wang H, Ma L, Yang D et al (2017) Incidence and risk factors of adjacent segment disease following posterior decompression and instrumented fusion for degenerative lumbar disorders. Medicine 96:e6032. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Putzier M, Hoff E, Tohtz S, Gross C, Perka C, Strube P (2010) Dynamic stabilization adjacent to single-level fusion: part II. No clinical benefit for asymptomatic, initially degenerated adjacent segments after 6 years follow-up. Eur Spine J 19:2181–2189. CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Strube P, Tohtz S, Hoff E, Gross C, Perka C, Putzier M (2010) Dynamic stabilization adjacent to single-level fusion: part I. Biomechanical effects on lumbar spinal motion. Eur Spine J 19:2171–2180. CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Korovessis P, Repantis T, Zacharatos S, Zafiropoulos A (2009) Does Wallis implant reduce adjacent segment degeneration above lumbosacral instrumented fusion? Eur Spine J 18:830–840. CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Fleege C, Rickert M, Werner I, Rauschmann M, Arabmotlagh M (2016) Hybrid stabilization technique with spinal fusion and interlaminar device to reduce the length of fusion and to protect symptomatic adjacent segments: clinical long-term follow-up. Orthopade 45:770–779. CrossRefPubMedGoogle Scholar
  13. 13.
    Li C, Liu L, Shi JY, Yan KZ, Shen WZ, Yang ZR (2016) Clinical and biomechanical researches of polyetheretherketone (PEEK) rods for semi-rigid lumbar fusion: a systematic review. Neurosurg Rev. CrossRefPubMedGoogle Scholar
  14. 14.
    Andrieu K, Allain J, Longis PM, Steib JP, Beaurain J, Delécrin J (2017) Comparison between total disc replacement and hybrid construct at two lumbar levels with minimum follow-up of 2 years. Orthop Traumatol Surg Res 103:39–43. CrossRefPubMedGoogle Scholar
  15. 15.
    Tachibana N, Kawamura N, Kobayashi D et al (2017) Preventive effect of dynamic stabilization against adjacent segment degeneration after posterior lumbar interbody fusion. Spine 42:25–32. CrossRefPubMedGoogle Scholar
  16. 16.
    Wilke HJ, Heuer F, Schmidt H (2009) Prospective design delineation and subsequent in vitro evaluation of a new posterior dynamic stabilization system. Spine 34:255–261. CrossRefPubMedGoogle Scholar
  17. 17.
    Knop C, Lange U, Bastian L, Blauth M (2000) Three-dimensional motion analysis with Synex. Comparative biomechanical test series with a new vertebral body replacement for the thoracolumbar spine. Eur Spine J 9:472–485CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Lange T, Schmoelz W, Gosheger G et al (2017) Is a gradual reduction of stiffness on top of posterior instrumentation possible with a suitable proximal implant? A biomechanical study. Spine J. PubMedCrossRefGoogle Scholar
  19. 19.
    Wilke HJ, Wenger K, Claes L (1998) Testing criteria for spinal implants: recommendations for the standardization of in vitro stability testing of spinal implants. Eur Spine J 7:148–154CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Panjabi MM (2007) Hybrid multidirectional test method to evaluate spinal adjacent-level effects. Clin Biomech 22:257–265. CrossRefGoogle Scholar
  21. 21.
    Schmoelz W, Huber JF, Nydegger T, Claes L, Wilke HJ (2003) Dynamic stabilization of the lumbar spine and its effects on adjacent segments: an in vitro experiment. J Spinal Disord Tech 16:418–423CrossRefPubMedGoogle Scholar
  22. 22.
    Volkheimer D, Malakoutian M, Oxland TR, Wilke HJ (2015) Limitations of current in vitro test protocols for investigation of instrumented adjacent segment biomechanics: critical analysis of the literature. Eur Spine J 24:1882–1892. CrossRefPubMedGoogle Scholar
  23. 23.
    Mageswaran P, Techy F, Colbrunn RW, Bonner TF, McLain RF (2012) Hybrid dynamic stabilization: a biomechanical assessment of adjacent and supraadjacent levels of the lumbar spine. J Neurosurg Spine 17:232–242. CrossRefPubMedGoogle Scholar
  24. 24.
    Cheng BC, Gordon J, Cheng J, Welch WC (2007) Immediate biomechanical effects of lumbar posterior dynamic stabilization above a circumferential fusion. Spine 32:2551–2557. CrossRefPubMedGoogle Scholar
  25. 25.
    Malakoutian M, Street J, Wilke HJ, Stavness I, Dvorak M, Fels S, Oxland T (2016) Role of muscle damage on loading at the level adjacent to a lumbar spine fusion: a biomechanical analysis. Eur Spine J 25:2929–2937. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  1. 1.Department of NeurosurgeryHelios Ostseeklinik DampDampGermany
  2. 2.Department of NeurosurgeryUniversity Medical Center Mannheimm, Heidelberg UniversityMannheimGermany
  3. 3.Department of NeurosurgeryMedical University of InnsbruckInnsbruckAustria
  4. 4.Department of Trauma SurgeryMedical University of InnsbruckInnsbruckAustria
  5. 5.Department of NeurosurgeryKlinikum DortmundDortmundGermany

Personalised recommendations