Endplate volumetric bone mineral density measured by quantitative computed tomography as a novel predictive measure of severe cage subsidence after standalone lateral lumbar fusion

Okano, Ichiro; Jones, Conor; Salzmann, Stephan N.; Reisener, Marie–Jacqueline; Sax, Oliver C.; Rentenberger, Colleen; Shue, Jennifer; Carrino, John A.; Sama, Andrew A.; Cammisa, Frank P.; Girardi, Federico P.; Hughes, Alexander P.

doi:10.1007/s00586-020-06348-0

Cited by 41 publications

(24 citation statements)

References 23 publications

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“…45,50 This pathological change may be an even more important cause of cage subsidence in contrast to the damage to BEPs. 36,37 By contrast, although stress concentration can also be observed in BEP, considering the maximum stress was still less than the yield stress of BEP (110 Mpa), 19,38 the risk of BPE fracture may be increased slightly not (Figure 7).…”

Section: Discussionmentioning

confidence: 96%

“…Additionally, maximum stress on the BEP and subendplate cancellous bone (cancellous bone within 5mm of the BEP, SCB) was also recorded to evaluate the risk of cage subsidence. 36,37 The evident variation tendency of this indicator can be observed with the insertional screw position's change. Specifically, when the screw position is close to the surgical segment (shifting down of screw on the cranial side and shifting up of screw on the caudal side), stress concentration occurs in these bony structures (Figure 4).…”

Section: Mechanical Effects Of Insertional Screw Position's Changesmentioning

confidence: 95%

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Biomechanical Effects of Pedicle Screw Positioning on the Surgical Segment in Models After Oblique Lumbar Interbody Fusion: An in-silico Study

Xu¹,

Huang²,

Cai³

et al. 2022

IJGM

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Background: Bilateral pedicle screw (BPS) is the "gold standard" of fixation methods for patients with lumbar interbody fusion. Biomechanical deterioration initially triggers complications in the surgical segment. Studies proved that BPS positions and trajectory changes affect the local biomechanical environment. However, no study illustrates the biomechanical effect of insertional screw positions' change on the surgical segment. Methods: Oblique lumbar interbody fusion (OLIF) with different BPS insertional positions has been simulated in a well-validated lumbo-sacral model. Fixation stability and stress responses on the surgical segment were evaluated under identical loading conditions. Results: There is no clear variation tendency for the risk of BPS failure and the change of strain energy density of the grafted bone. However, shifting the insertional screw position close to the surgical segment will increase the range of motions (ROM) in the surgical segment and lead to stress concentration of bony structures, especially in the caudal side of the surgical segment. Conclusion: Adjusting the insertional position of BPS close to the surgical segment in OLIF models will lead to stress concentration of bony structures and surgical segmental instability. Therefore, reducing BPS's fixation length was not recommended, which may increase the risk of segmental instability, non-union, and cage subsidence.

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Section: Discussionmentioning

confidence: 96%

Section: Mechanical Effects Of Insertional Screw Position's Changesmentioning

confidence: 95%

Biomechanical Effects of Pedicle Screw Positioning on the Surgical Segment in Models After Oblique Lumbar Interbody Fusion: An in-silico Study

Xu¹,

Huang²,

Cai³

et al. 2022

IJGM

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“…The BMD of the endplate region was highly reliable and more predictive of vertebral fracture and cage subsidence [18]. Modic changes and endplate sclerosis with higher HU values are potential predictors for preventing cage subsidence, making the endplate with MCs or sclerosis a potentially suitable condition that can be submitted to SA OLIF [19].…”

Section: Discussionmentioning

confidence: 99%

Hounsfield unit value on CT as a predictor of cage subsidence following stand-alone oblique lumbar interbody fusion for the treatment of degenerative lumbar diseases

Zhou

Yuan

Liu

et al. 2021

BMC Musculoskelet Disord

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Background To investigate the correlation between vertebral Hounsfield unit (HU) values and cage subsidence in patients treated with stand-alone (SA) OLIF. Methods A retrospective review of collected data was performed on 76 patients who underwent SA OLIF. We utilized the HU value for lumbar bone mineral density (BMD) obtained on preoperative CT. The vertebral HU values of patients with subsidence were compared to those without subsidence. The correlation between cage subsidence and clinical score was investigated. Results Sixteen patients (21.1%) had at least radiographic evidence of interbody cage subsidence. The average cage subsidence was 2.5 ± 1.3 mm (range 0.9-4.8 mm). There were no significant differences in sex, BMI, preoperative diagnoses, or fused level (p > 0.05); however, there were significant differences between the cage subsidence group and the nonsubsidence group in age, average of the lowest T-score, and average HU value, including for the L1 vertebrae, L1-L4 horizontal plane, and L1-L4 sagittal plane (p < 0.05). The average HU value of the L1-L4 horizontal plane showed a more predictable AUC of 0.909 (95% CI, 0.834–0.984; P < 0.001) compared with the average of the lowest T-score following an AUC of 0.791 (95% CI, 0.674–0.909; P < 0.001). Based on logistic regression analysis, the average HU value of the L1-L4 horizontal plane (OR, 0.912; 95% CI, 0.861–0.966; P = 0.002) was an independent factor influencing cage subsidence. Conclusions Patients with lower average HU values of the lumbar vertebrae are at a much higher risk of developing cage subsidence after SA OLIF. Measurement of preoperative HU values on preexisting CT scans could be rapid, simple and feasible.

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“…41 Clinically-significant implant subsidence occurs in about 10% of cases, 42 precipitating spinal instability and recurrence of neuro-compressive symptoms, 34,35 particularly among older individuals with spinal osteoporosis. 43,44 Historically, a diagnosis of definitive osteoporosis has often been considered a contraindication to spinal fusion due to weak vertebral bone stock. 45,46 It is therefore impossible to exclude all at-risk patients from spinal surgery.…”

Section: Interbody Fusion In the Presence Of Osteoporosismentioning

confidence: 99%

Improving the Management of Patients with Osteoporosis Undergoing Spinal Fusion: The Need for a Bone Mineral Density-Matched Interbody Cage

Falowski¹,

Koga²,

Northcutt³

et al. 2021

ORR

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With an increasingly aging population globally, a confluence has emerged between the rising prevalence of degenerative spinal disease and osteoporosis. Fusion of the anterior spinal column remains the mainstay surgical intervention for many spinal degenerative disorders. However, decreased vertebral bone mineral density (BMD), quantitatively measured by dual x-ray absorptiometry (DXA), complicates treatment with surgical interbody fusion as weak underlying bone stock increases the risk of post-operative implant-related adverse events, including cage subsidence. There is a necessity for developing cages with advanced structural designs that incorporate bioengineering and architectural principles to tailor the interbody fusion device directly to the patient’s BMD status. Specifically, lattice-designed cages that mimic the web-like structure of native cancellous bone have demonstrated excellent resistance to post-operative subsidence. This article provides an introductory profile of a spinal interbody implant designed intentionally to simulate the lattice structure of human cancellous bone, with a similar modulus of elasticity, and specialized to match a patient’s bone status across the BMD continuum. The implant incorporates an open pore design where the degree of pore compactness directly corresponds to the patient’s DXA-defined BMD status, including patients with osteoporosis.

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Endplate volumetric bone mineral density measured by quantitative computed tomography as a novel predictive measure of severe cage subsidence after standalone lateral lumbar fusion

Cited by 41 publications

References 23 publications

Biomechanical Effects of Pedicle Screw Positioning on the Surgical Segment in Models After Oblique Lumbar Interbody Fusion: An in-silico Study

Biomechanical Effects of Pedicle Screw Positioning on the Surgical Segment in Models After Oblique Lumbar Interbody Fusion: An in-silico Study

Hounsfield unit value on CT as a predictor of cage subsidence following stand-alone oblique lumbar interbody fusion for the treatment of degenerative lumbar diseases

Improving the Management of Patients with Osteoporosis Undergoing Spinal Fusion: The Need for a Bone Mineral Density-Matched Interbody Cage

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