Skip to main content

Primary stability of anterior lumbar stabilization: interdependence of implant type and endplate retention or removal

European Spine Journal volume 15, pages 807–818 (2006)Cite this article

Abstract

This is a comparative in vitro biomechanical study of the primary stability of an anterior lumbar interbody stabilization. The objective was to compare the stability of a interbody stabilizing titanium cage with and without the retention of the bordering vertebral endplates, as well as to compare the titanium cage with a tricalcium phosphate block when the endplates are removed. An adequate blood supply is critical for interbody fusion, which suggests surgical treatment of the bordering endplates. On the other hand, primary stability is improved by the retention of the endplates. Furthermore, bone substitute materials are finding more frequent use due to complications associated with autologous bone grafts. Ten bovine lumbar spine motion segments (average age 6 months) were investigated. Pure bending loadings as well as eccentric axial compression loadings were applied. A titanium cage and tricalcium phosphate block, were tested in conjunction with an anterior augmentation (MACS). Range of motion, neutral zone (NZ) and bending stiffness were measured under pure bending to 10 Nm, and bending stiffness under axial loads of up to 1500 N. Range of motion of both implants in flexion-extension was significantly smaller than physiologic (cage without endplates 4.3°, cage with 2.8°, block without 3.4°, and physiologic 6.6°, all p<0.001). The cage with endplates and the block without endplates were both significantly stiffer than physiologic in all directions except left lateral bending. The block without endplates and the cage with endplates were both stiffer than the cage without endplates. The results suggest that the use of the bone substitute block provides better stability than the cage when the endplates are removed.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

References

  1. An HS, Lim TH, You JW, Hong JH, Eck J, McGrady L (1995) Biomechanical evaluation of anterior thoracolumbar spinal instrumentation. Spine 20:1979–1983

    PubMed  Google Scholar 

  2. Bader RJ, Steinhauser E, Rechl H, Mittelmeier W, Bertagnoli R, Gradinger R (2002) Mechanische untersuchungen von lumbalen interkorporellen Fusionsimplantaten. Orthopäde 31:459–465

    PubMed  Google Scholar 

  3. Banwart JC, Asher MA, Hassanein RS (1995) Iliac crest bone graft harvest donor site morbidity. A statistical evaluation. Spine 20:1055–1060

    PubMed  Google Scholar 

  4. Beisse R, Potulski M, Beger J, Bühren V (2002) Entwicklung und klinischer Einsatz einer thorakoskopisch implantierbaren Rahmenplatte zur Behandlung thorakolumbaler Frakturen und Instabilitäten. Orthopäde 31:413–422

    PubMed  Google Scholar 

  5. Boden SD, Martin GJ Jr, Morone MA, Ugbo JL, Moskovitz PA (1999) Posterolateral lumbar intertransverse process spine arthrodesis with recombinant human bone morphogenetic protein 2/hydroxyapatite–tricalcium phosphate after laminectomy in the nonhuman primate. Spine 24:1179–1185

    Article  PubMed  Google Scholar 

  6. Brantigan JW, McAfee PC, Cunningham BW, Wang H, Orbegoso CM (1994) Interbody lumbar fusion using a carbon fiber cage implant versus allograft bone. An investigational study in the Spanish goat. Spine 19:1436–1444

    PubMed  Google Scholar 

  7. Brodke DS, Dick JC, Kunz DN, McCabe R, Zdeblick TA (1997) Posterior lumbar interbody fusion. A biomechanical comparison, including a new threaded cage. Spine 22:26–31

    Article  PubMed  Google Scholar 

  8. Closkey RF, Parsons JR, Lee CK, Blacksin MF, Zimmerman MC (1993) Mechanics of interbody spinal fusion. Analysis of critical bone graft area. Spine 18:1011–1015

    PubMed  Google Scholar 

  9. Cook SD, Dalton JE, Tan EH, Tejeiro WV, Young MJ, Whitecloud TS (1994) In vivo evaluation of anterior cervical fusions with hydroxylapatite graft material. Spine 19:1856–1866

    PubMed  Google Scholar 

  10. Cotterill PC, Kostuik JP, D’Angelo G, Fernie GR, Maki BE (1986) An anatomical comparison of the human and bovine thoracolumbar spine. J Orthop Res 4:298–303

    Article  PubMed  Google Scholar 

  11. Emery SE, Fuller DA, Stevenson S (1996) Ceramic anterior spinal fusion. Biologic and biomechanical comparison in a canine model. Spine 21:2713–2719

    Article  PubMed  Google Scholar 

  12. Eysel P (2000) Biomechanical principles of ventral and dorsal instrumentation correction in scoliosis. Biomechanische Korrekturprinzipien ventraler und dorsaler Instrumentationen bei Skoliosen. Orthopade 29:507–517

    Article  PubMed  Google Scholar 

  13. Eysel P, Furderer S, Rompe JD, Zollner J (2000) Initial instability of different cages for fusion of the cervical spine. Zentralbl Neurochir 61:171–176

    Article  PubMed  Google Scholar 

  14. Fuller DA, Stevenson S, Emery SE (1996) The effects of internal fixation on calcium carbonate. Ceramic anterior spinal fusion in dogs. Spine 21:2131–2136

    Article  PubMed  Google Scholar 

  15. Fürderer S, Schöllhuber F, Rompe JD, Eysel P (2002) Einfluss von Design und Implantationstechnik auf das Risiko der progredienten Sinterung verschiedener HWS-Cages. Orthopäde 31:466–471

    PubMed  Google Scholar 

  16. Gauthier O, Bouler JM, Aguado E, Pilet P, Daculsi G (1998) Macroporous biphasic calcium phosphate ceramics: influence of macropore diameter and macroporosity percentage on bone ingrowth. Biomaterials 19:133–139

    Article  PubMed  Google Scholar 

  17. Glazer PA, Colliou O, Klisch SM, Bradfore DS, Bueff HU, Lotz JC (1997) Biomechanical analysis of multilevel fixation methods in the lumbar spine. Spine 22:171–182

    Article  PubMed  Google Scholar 

  18. Grant JP, Oxland TR, Dvorak MF (2001) Mapping the structural properties of the lumbosacral vertebral endplates. Spine 26:889–896

    Article  PubMed  Google Scholar 

  19. Grupp TM, Beisse R, Potulski M, Marnay T, Beger J, Blömer W (2002) Mechanische Testung der Implantateigenschaften eines thorakoskopisch implantierbaren ventralen Wirbelsäulenistabilisierungssystems. Orthopäde 31:406–412

    PubMed  Google Scholar 

  20. Gunther KP, Scharf HP, Pesch HJ, Puhl W (1998) Integration properties of bone substitute materials. Experimental studies on animals. Einwachsverhalten von Knochenersatzstoffen. Tierexperimentelle Untersuchung. Orthopade 27:105–117

    Article  PubMed  Google Scholar 

  21. Hasegawa K, Abe M, Washio T, Hara T (2001) An experimental study on the interface strength between titanium mesh cage and vertebra in reference to vertebral bone mineral density. Spine 26:957–963

    Article  PubMed  Google Scholar 

  22. Heller JG, Zdeblick T, Kunz DA, McCabe R, Cooke ME (1993) Spinal instrumentation for metastatic disease: in vitro biomechanical analysis. J Spinal Disord 6:17–22

    PubMed  Google Scholar 

  23. Hollowell JP, Vollmer DG, Wilson CR, Pintar FA, Yoganandan N (1996) Biomechanical analysis of thoracolumbar interbody constructs. How important is the endplate? Spine 21:1032–1036

    Article  PubMed  Google Scholar 

  24. Holte DC, O’Brien JP, Renton P (1994) Anterior lumbar fusion using a hybrid interbody graft. A preliminary radiographic report. Eur Spine J 3:32–38

    PubMed  Google Scholar 

  25. Kanayama M, Cunningham BW, Haggerty CJ, Abumi K, Kaneda K, McAfee PC (2000) In vitro biomechanical investigation of the stability and stress-shielding effect of lumbar interbody fusionI. J Neurosurg 93 (2):259–265

    PubMed  Google Scholar 

  26. Kettler A, Dietl R, Krammer M, Lumenta CB, Claes L, Wilke HJ (2002) Dislokationstendenz, stabilisierende Wirkung und Einbruchtendenz unterschiedlicher LWS-Cages im In-virto-Experiment. Orthopäde 31:481–487

    PubMed  Google Scholar 

  27. Knop C, Lange U, Bastian L, Blauth M (2001) Biomechanical stability with a new artificial vertebral body implant. 3-dimensional movement analysis of instrumented human vertebral segments. Biomechanische Stabilität mit einem neuen Wirbelkörperersatzimplantat. Unfallchirurg 104:984–997

    Article  PubMed  Google Scholar 

  28. Knop C, Lange U, Bastian L, Oeser M, Blauth M (2001) Comparative biomechanical compression trials with a new vertebral prosthetic implant. Vergleichende biomechanische Kompressionsversuche mit einem neuen Wirbelkörperersatzimplantat. Unfallchirurg 104:25–33

    Article  PubMed  Google Scholar 

  29. Kozak JA, Heilman AE, O’Brien JP (1994) Anterior lumbar fusion options. Technique and graft materials. Clin Orthop 300:45–51

    PubMed  Google Scholar 

  30. Lee SW, Lim TH, You JW, An HS (2000) Biomechanical effect of anterior grafting devices on the rotational stability of spinal constructs. J Spinal Disord 13:150–155

    Article  PubMed  Google Scholar 

  31. Lim TH, Kwon H, Jeon CH, Kim JG, Sokolowski M, Natarajan R, An HS, Andersson GB (2001) Effect of endplate conditions and bone mineral density on the compressive strength of the graft-endplate interface in anterior cervical spine fusion. Spine 26:951–956

    Article  PubMed  Google Scholar 

  32. Mittelmeier H, Mittelmeier W, Gleitz M (1998) Pyrost, a spongious, mineral bone substitute. Experimental bases and 13-year clinical experience in over 1000 cases. Mineralisches, spongiöses Knochenersatzmaterial Pyrost. Experimentelle Grundlagen und 13 Jahre klinische Erfahrung bei über 1000 Fällen. Orthopade 27:126–135

    Article  PubMed  Google Scholar 

  33. Morlock M, Strandborg J, Sellenschloh K, Nassutt R, Püschel K, Eggers C (2002) Vergleich unterschiedlicher Wirbelkörperersatzsysteme hinsichtlich Migration und Primärstabilität bei dorsoventraler Spondylodese nach Korporektomie mit und ohne Laminektomie. Orthopäde 31:514–521

    PubMed  Google Scholar 

  34. Morone MA, Boden SD (1998) Experimental posterolateral lumbar spinal fusion with a demineralized bone matrix gel. Spine 23:159–167

    Article  PubMed  Google Scholar 

  35. Muller-Mai C, Voigt C, Hering A, Rahmanzadeh R, Gross U (2001) Madreporic hydroxyapatite granulates for filling bone defects. Madreporische Hydroxylapatitgranulate zur Füllung ossärer Defekte. Unfallchirurg 104:221–229

    Article  PubMed  Google Scholar 

  36. Oda I, Cunningham BW, Abumi K, Kaneda K, McAfee PC (1999) The stability of reconstruction methods after thoracolumbar total spondylectomy. An in vitro investigation. Spine 24:1634–1638

    Article  PubMed  Google Scholar 

  37. Oxland TR, Lund T (2000) Biomechanics of the stand-alone cages and cages in combination with posterior fixation: a literature review. Eur Spine J 9(Suppl 1):95–101

    Google Scholar 

  38. Oxland T, Panjabi MM, Southern EP (1991) An anatomic basis for spinal instability: a porcine trauma model. J Orthop Res 9:462

    Article  Google Scholar 

  39. Paar O, Andereya S, Staatz G, Ambacher T, Erli HJ (2001) Value of human recombinant osteogenetic proteins as bone replacement materials in lumbar spondylodesis. Results of an animal experiment study. Wertigkeit von rekombinantem humanem osteogenetischem Protein als Knochenersatzmaterial bei der lumbalen Spondylodese. Unfallchirurg 104:700–709

    Article  PubMed  Google Scholar 

  40. Panjabi MM (1988) Biomechanical evaluation of spinal fixation devices: I. A conceptual framework. Spine 13:1129–1134

    PubMed  Google Scholar 

  41. Panjabi MM (1991) Three-dimensional testing of the stability of spinal implants. Dreidimensionale Testung der Stabilität von Wirbelsäulenimplantaten. Orthopade 20:106–111

    PubMed  Google Scholar 

  42. Panjabi MM (1992) The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord 5:390–396

    PubMed  Google Scholar 

  43. Panjabi M, White AA (1990) Physical properties and functional biomechanics of the spine. In: White AA, Panjabi MM (eds) Clinical biomechanics of the spine. Lippincott, Philadelphia, pp 1–83

    Google Scholar 

  44. Panjabi MM, Krag MH, Summers D, Videman T (1985) Biomechanical time-tolerance of fresh cadaveric human spine specimens. J Orthop Res 3:292–300

    Article  PubMed  Google Scholar 

  45. Pintar FA, Maiman DJ, Hollowell JP, Yoganandan N, Droese KW, Reinartz JM, Cuddy B (1994) Fusion rate and biomechanical stiffness of hydroxylapatite versus autogenous bone grafts for anterior discectomy. An in vivo animal study. Spine 19:2524–2528

    PubMed  Google Scholar 

  46. Pitzen T, Geisler H, Matthis H, Müller-Storz H, Pedersen K, Steudel WI (2000) The influence of cancellous bone density on load-sharing in human lumbar spine in compression, a comparison between an intact and surgically altered motion segment. In: Kienapfel H, Jones D, Rüther W (eds) European orthopaedic research society, vol. 10. Annual conference. EORS; Marburg, pp 0–75

  47. Rueger JM (1998) Bone substitution materials. Current status and prospects. Knochenersatzmittel. Heutiger Stand und Ausblick. Orthopade 27:72–79

    Article  PubMed  Google Scholar 

  48. Rueger JM, Linhart W, Sommerfeldt D (1998) Biologic reactions to calcium phosphate ceramic implantations. Results of animal experiments. Biologische Reaktionen auf Kalziumphosphatkeramik-Implantationen. Tierexperimentelle Ergebnisse. Orthopade 27:89–95

    Article  PubMed  Google Scholar 

  49. Schnee CL, Freese A, Weil RJ, Marcotte PJ (1997) Analysis of harvest morbidity and radiographic outcome using autograft for anterior cervical fusion. Spine 22:2222–2227

    Article  PubMed  Google Scholar 

  50. Schneid S, Sabitzer RJ, Fuss FK, Grupp TM, Blömer W (2002) In-vitro-Stabilitätsuntersuchungen eines neuartigen Implantatsystems für den minimal-invasiven transforaminalen Zugang. Orthopäde 31:488–493

    PubMed  Google Scholar 

  51. Schultheiss M, Wilke HJ, Claes L, Kinzl L, Hartwig E (2002) MACS-TL-Polyaxialscrew XL. Orthopäde 31:397–401

    PubMed  Google Scholar 

  52. Schultheiss M, Wilke HJ, Claes L, Kinzl L, Hartwig E (2002) MACS-TL-twin-screw. Orthopäde 31:362–367

    PubMed  Google Scholar 

  53. Scifert JL, Sairyo K, Goel VK, Grobler LJ, Grosland NM, Spratt KF, Chesmel KD (1999) Stability analysis of an enhanced load sharing posterior fixation device and its equivalent conventional device in a calf spine model. Spine 24:2206–2213

    Article  PubMed  Google Scholar 

  54. Senter HJ, Kortyna R, Kemp WR (1989) Anterior cervical discotomy with hydroxylapatite fusion. Neurosurgery 25(1):39–43

    Article  PubMed  Google Scholar 

  55. Snedecor GW, Cochran WG (1989) Statistical methods. Iowa State University Press, Ames, Iowa

    Google Scholar 

  56. Spiegel DA, Cunningham BW, Oda I, Dormans JP, McAfee PC, Drummond DS (2000) Anterior vertebral screw strain with and without solid interspace support. Spine 25:2755–2761

    Article  PubMed  Google Scholar 

  57. Stutzle H, Hallfeldt K, Mandelkow H, Kessler S, Schweiberer L (1998) Bone regeneration stimulated by bone substitute materials. Knochenneubildung durch Knochenersatzmaterialien. Orthopade 27:118–125

    Article  PubMed  Google Scholar 

  58. Tencer AF, Hampton D, Eddy S (1995) Biomechanical properties of threaded inserts for lumbar interbody spinal fusion. Spine 20:2408–2414

    PubMed  Google Scholar 

  59. Thalgott JS, Fritts K, Giuffre JM, Timlin M (1999) Anterior interbody fusion of the cervical spine with coralline hydroxyapatite. Spine 24:1295–1299

    Article  PubMed  Google Scholar 

  60. Toth JM, An HS, Lim TH, Ran Y, Weiss NG, Lundberg WR, Xu RM, Lynch KL (1995) Evaluation of porous biphasic calcium phosphate ceramics for anterior cervical interbody fusion in a caprine model. Spine 20:2203–2210

    PubMed  Google Scholar 

  61. Vahldiek MJ, Panjabi MM (1998) Stability potential of spinal instrumentations in tumor vertebral body replacement surgery. Spine 23:543–550

    Article  PubMed  Google Scholar 

  62. Weiner BK, Fraser RD (1998) Spine update lumbar interbody cages. Spine 23:634–640

    Article  PubMed  Google Scholar 

  63. Wilke HJ, Kettler A, Wenger KH, Claes LE (1997) Anatomy of the sheep spine and its comparison to the human spine. Anat Rec 247:542–555

    Article  PubMed  Google Scholar 

  64. Wilke HJ, Krischak ST, Wenger KH, Claes LE (1997) Load-displacement properties of the thoracolumbar calf spine: experimental results and comparison to known human data. Eur Spine J 6:129–137

    Article  PubMed  Google Scholar 

  65. 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 7:148–154

    Article  PubMed  Google Scholar 

  66. Zdeblick TA, Smith GR, Warden KE, Eng MB, McAfee PC (1991) Two-point fixation of the lumbar spine. Differential stability in rotation. Spine 16:S298–S301

    PubMed  Google Scholar 

  67. Zdeblick TA, Warden KE, Zou D, McAfee PC, Abitbol JJ (1993) Anterior spinal fixators. A biomechanical in vitro study. Spine 18:513–517

    PubMed  Google Scholar 

Download references

Author information

Affiliations

  1. Department of Orthopaedics, Hannover Medical School, Anna-von-Borriesstr. 1-7, 30625, Hannover, Germany

    Christian H. Flamme, Nadine von der Heide, Caroline Heymann & Christof Hurschler

Authors
  1. Christian H. Flamme
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nadine von der Heide
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Caroline Heymann
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Christof Hurschler
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Christian H. Flamme.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Flamme, C.H., von der Heide, N., Heymann, C. et al. Primary stability of anterior lumbar stabilization: interdependence of implant type and endplate retention or removal. Eur Spine J 15, 807–818 (2006). https://doi.org/10.1007/s00586-005-0993-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-005-0993-4

Keywords

  • Biomechanical properties
  • Endplates
  • Anterior instrumentation
  • Ceramic block