Screw loosening is a common complication in spinal fixation using pedicle screws which may lead to loss of correction and revision surgery. The mechanisms of pedicle screw loosening are not well understood. The purpose of this study was to compare the pedicle screw pullout force and stiffness subsequent or not to multidirectional cyclic bending load (toggling). Pedicle screws inserted into porcine lumbar vertebrae underwent toggling in craniocaudal (CC), mediolateral (ML) directions, and no toggling (NT) before pullout. This study suggests that toggling and in particular CC toggling should be included in biomechanical evaluation of pedicle screw fixation strength.

References

References
1.
Vaccaro
,
A. R.
,
Kim
,
D. H.
,
Brodke
,
D. S.
,
Harris
,
M.
,
Chapman
,
J.
,
Schildhauer
,
T.
,
Routt
,
M. C.
, and
Sasso
,
R. C.
,
2003
, “
Diagnosis and Management of Thoracolumbar Spine Fractures
,”
Instr. Course Lect.
,
53
, pp.
359
373
.
2.
Sanderson
,
P.
,
Fraser
,
R. D.
,
Hall
,
D. J.
,
Cain
,
C. M. J.
,
Osti
,
O. L.
, and
Potter
,
G.
,
1999
, “
Short Segment Fixation of Thoracolumbar Burst Fractures Without Fusion
,”
Eur. Spine J.
,
8
(
6
), pp.
495
500
.
3.
Cheung
,
W. Y.
,
Lenke
,
L. G.
, and
Luk
,
K. D.
,
2010
, “
Prediction of Scoliosis Correction With Thoracic Segmental Pedicle Screw Constructs Using Fulcrum Bending Radiographs
,”
Spine
,
35
(
5
), pp.
557
561
.
4.
Dickman
,
C. A.
,
Fessler
,
R. G.
,
MacMillan
,
M.
, and
Haid
,
R. W.
,
1992
, “
Transpedicular Screw-Rod Fixation of the Lumbar Spine: Operative Technique and Outcome in 104 Cases
,”
J. Neurosurg.
,
77
(
6
), pp.
860
870
.
5.
Esses
,
S. I.
,
Sachs
,
B. L.
, and
Dreyzin
,
V.
,
1993
, “
Complications Associated With the Technique of Pedicle Screw Fixation. A Selected Survey of ABS Members
,”
Spine
,
18
(
15
), pp.
2231
2238
.
6.
Sanden
,
B.
,
Olerud
,
C.
,
Petren-Mallmin
,
M.
,
Johansson
,
C.
, and
Larsson
,
S.
,
2004
, “
The Significance of Radiolucent Zones Surrounding Pedicle Screws, Definition of Screw Loosening in Spinal Instrumentation
,”
J. Bone Jt. Surg., Br
.,
86
(
3
), pp.
457
461
.
7.
Katonis
,
P.
,
Christoforakis
,
J.
,
Aligizakis
,
A. C.
,
Papadopoulos
,
C.
,
Sapkas
,
G.
, and
Hadjipavlou
,
A.
,
2003
, “
Complications and Problems Related to Pedicle Screw Fixation of the Spine
,”
Clin. Orthop. Relat. Res.
,
411
, pp.
86
94
.
8.
Sandén
,
B.
,
Olerud
,
C.
,
Petren-Mallmin
,
M.
, and
Larsson
,
S.
,
2002
, “
Hydroxyapatite Coating Improves Fixation of Pedicle Screws. A Clinical Study
,”
J. Bone Jt. Surg., Br
.,
84
(
3
), pp.
387
391
.
9.
Kwok
,
A. W. L.
,
Finkelstein
,
J. A.
,
Woodside
,
T.
,
Hearn
,
T. C.
, and
Hu
,
R. W.
,
1996
, “
Insertional Torque and Pull-Out Strengths of Conical and Cylindrical Pedicle Screws in Cadaveric Bone
,”
Spine
,
21
(
21
), pp.
2429
2434
.
10.
Cook
,
S. D.
,
Salkeld
,
S. L.
,
Stanley
,
T.
,
Faciane
,
A.
, and
Miller
,
S. D.
,
2004
, “
Biomechanical Study of Pedicle Screw Fixation in Severely Osteoporotic Bone
,”
Spine J.
,
4
(
4
), pp.
402
408
.
11.
Cook
,
S. D.
,
Barbera
,
J.
,
Rubi
,
M.
,
Salkeld
,
S. L.
, and
Whitecloud
,
T. S.
, III
,
2001
, “
Lumbosacral Fixation Using Expandable Pedicle Screws: An Alternative in Reoperation and Osteoporosis
,”
Spine J.
,
1
(
2
), pp.
109
114
.
12.
Mehta
,
H.
,
Santos
,
E.
,
Ledonio
,
C.
,
Sembrano
,
J.
,
Ellingson
,
A.
,
Pare
,
P.
,
Murrell
,
B.
, and
Nuckley
,
D. J.
,
2012
, “
Biomechanical Analysis of Pedicle Screw Thread Differential Design in an Osteoporotic Cadaver Model
,”
Clin. Biomech.
,
27
(
3
), pp.
234
240
.
13.
Pfeiffer
,
M.
,
Gilbertson
,
L. G.
,
Goel
,
V. K.
,
Griss
,
P.
,
Keller
,
J. C.
,
Ryken
,
T. C.
, and
Hoffman
,
H. E.
,
1996
, “
Effect of Specimen Fixation Method on Pullout Tests of Pedicle Screws
,”
Spine
,
21
(
9
), pp.
1037
1044
.
14.
Abshire
,
B. B.
,
McLain
,
R. F.
,
Valdevit
,
A.
, and
Kambic
,
H. E.
,
2001
, “
Characteristics of Pullout Failure in Conical and Cylindrical Pedicle Screws After Full Insertion and Back-Out
,”
Spine J.
,
1
(
6
), pp.
408
414
.
15.
Halvorson
,
T. L.
,
Kelley
,
L. A.
,
Thomas
,
K. A.
,
Whitecloud
,
T. S.
, III
, and
Cook
,
S. D.
,
1994
, “
Effects of Bone Mineral Density on Pedicle Screw Fixation
,”
Spine
,
19
(
21
), pp.
2415
2420
.
16.
Soshi
,
S.
,
Shiba
,
R.
,
Kondo
,
H.
, and
Murota
,
K.
,
1991
, “
An Experimental Study on Transpedicular Screw Fixation in Relation to Osteoporosis of the Lumbar Spine
,”
Spine
,
16
(
11
), pp.
1335
1341
.
17.
Wittenberg
,
R. H.
,
Lee
,
K. S.
,
Shea
,
M.
,
White
,
A. A.
, III
, and
Hayes
,
W. C.
,
1993
, “
Effect of Screw Diameter, Insertion Technique, and Bone Cement Augmentation of Pedicular Screw Fixation Strength
,”
Clin. Orthop. Relat. Res.
,
296
, pp.
278
287
.
18.
Brantley
,
A. G.
,
Mayfield
,
J. K.
,
Koeneman
,
J. B.
, and
Clark
,
K. R.
,
1994
, “
The Effects of Pedicle Screw Fit: An In Vitro Study
,”
Spine
,
19
(
15
), pp.
1752
1758
.
19.
Hirano
,
T.
,
Hasegawa
,
K.
,
Takahashi
,
H. E.
,
Uchiyama
,
S.
,
Hara
,
T.
,
Washio
,
T.
,
Sugiura
,
T.
,
Yokaichiya
,
M.
, and
Ikeda
,
M.
,
1997
, “
Structural Characteristics of the Pedicle and Its Role in Screw Stability
,”
Spine
,
22
(
21
), pp.
2504
2510
.
20.
Kumano
,
K.
,
Hirabayashi
,
S.
,
Ogawa
,
Y.
, and
Aota
,
Y.
,
1994
, “
Pedicle Screws and Bone Mineral Density
,”
Spine
,
19
(
10
), pp.
1157
1161
.
21.
Kim
,
Y.-Y.
,
Choi
,
W.-S.
, and
Rhyu
,
K.-W.
,
2012
, “
Assessment of Pedicle Screw Pullout Strength Based on Various Screw Designs and Bone Densities—An Ex Vivo Biomechanical Study
,”
Spine J.
,
12
(
2
), pp.
164
168
.
22.
Hashemi
,
A.
,
Bednar
,
D.
, and
Ziada
,
S.
,
2009
, “
Pullout Strength of Pedicle Screws Augmented With Particulate Calcium Phosphate: An Experimental Study
,”
Spine J.
,
9
(
5
), pp.
404
410
.
23.
Patel
,
P. S. D.
,
Shepherd
,
D. E. T.
, and
Hukins
,
D. W. L.
,
2010
, “
The Effect of Screw Insertion Angle and Thread Type on the Pullout Strength of Bone Screws in Normal and Osteoporotic Cancellous Bone Models
,”
Med. Eng. Phys.
,
32
(
8
), pp.
822
828
.
24.
McLain
,
R. F.
,
McKinley
,
T. O.
,
Yerby
,
S. A.
,
Smith
,
T. S.
, and
Sarigul-Klijn
,
N.
,
1997
, “
The Effect of Bone Quality on Pedicle Screw Loading in Axial Instability: A Synthetic Model
,”
Spine
,
22
(
13
), pp.
1454
1460
.
25.
Paik
,
H.
,
Dmitriev
,
A. E.
,
Lehman
,
R. A.
,
Gaume
,
R. E.
,
Ambati
,
D. V.
,
Kang
,
D. G.
, and
Lenke
,
L. G.
,
2012
, “
The Biomechanical Effect of Pedicle Screw Hubbing on Pullout Resistance in the Thoracic Spine
,”
Spine J.
,
12
(
5
), pp.
417
424
.
26.
Johnston
,
T. L.
,
Karaikovic
,
E. E.
,
Lautenschlager
,
E. P.
, and
Marcu
,
D.
,
2006
, “
Cervical Pedicle Screws vs Lateral Mass Screws: Uniplanar Fatigue Analysis and Residual Pullout Strengths
,”
Spine J.
,
6
(
6
), pp.
667
672
.
27.
Zindrick
,
M. R.
,
Wiltse
,
L. L.
,
Widell
,
E. H.
,
Thomas
,
J. C.
,
Holland
,
W. R.
,
Field
,
B. T.
, and
Spencer
,
C. W.
,
1986
, “
A Biomechanical Study of Intrapeduncular Screw Fixation in the Lumbosacral Spine
,”
Clin. Orthop. Relat. Res.
,
203
, pp.
99
112
.
28.
Okuyama
,
K.
,
Sato
,
K.
,
Abe
,
E.
,
Inaba
,
H.
,
Shimada
,
Y.
, and
Murai
,
H.
,
1993
, “
Stability of Transpedicle Screwing for the Osteoporotic Spine: An In Vitro Study of the Mechanical Stability
,”
Spine
,
18
(
15
), pp.
2240
2245
.
29.
Lotz
,
J. C.
,
Hu
,
S. S.
,
Chiu
,
D. F. M.
,
Yu
,
M.
,
Colliou
,
O.
, and
Poser
,
R. D.
,
1997
, “
Carbonated Apatite Cement Augmentation of Pedicle Screw Fixation in the Lumbar Spine
,”
Spine
,
22
(
23
), pp.
2716
2723
.
30.
Zdeblick
,
T. A.
,
Kunz
,
D. N.
,
Cooke
,
M. E.
, and
McCabe
,
R.
,
1993
, “
Pedicle Screw Pullout Strength: Correlation With Insertional Torque
,”
Spine
,
18
(
12
), pp.
1673
1676
.
31.
Myers
,
B. S.
,
Belmont
,
P. J.
,
Richardson
,
W. J.
,
Yu
,
J. R.
,
Harper
,
K. D.
, and
Nightingale
,
R. W.
,
1996
, “
The Role of Imaging and In Situ Biomechanical Testing in Assessing Pedicle Screw Pull-Out Strength
,”
Spine
,
21
(
17
), pp.
1962
1968
.
32.
İnceoğlu
,
S.
,
Ehlert
,
M.
,
Akbay
,
A.
, and
McLain
,
R. F.
,
2006
, “
Axial Cyclic Behavior of the Bone–Screw Interface
,”
Med. Eng. Phys.
,
28
(
9
), pp.
888
893
.
33.
Mehmanparast
,
H. N.
,
Mac-Thiong
,
J.-M.
, and
Petit
,
Y.
,
2015
, “
In Vitro Evaluation of Pedicle Screw Loosening Mechanism: A Preliminary Study on Animal Model
,”
Scoliosis
,
10
(
Suppl 1
), p.
O25
.
34.
Aerssens
,
J.
,
Boonen
,
S.
,
Lowet
,
G.
, and
Dequeker
,
J.
,
1998
, “
Interspecies Differences in Bone Composition, Density, and Quality: Potential Implications for In Vivo Bone Research 1
,”
Endocrinology
,
139
(
2
), pp.
663
670
.
35.
Dath
,
R.
,
Ebinesan
,
A.
,
Porter
,
K.
, and
Miles
,
A.
,
2007
, “
Anatomical Measurements of Porcine Lumbar Vertebrae
,”
Clin. Biomech.
,
22
(
5
), pp.
607
613
.
36.
McLain
,
R. F.
,
Yerby
,
S. A.
, and
Moseley
,
T. A.
,
2002
, “
Comparative Morphometry of L4 Vertebrae: Comparison of Large Animal Models for the Human Lumbar Spine
,”
Spine
,
27
(
8
), pp.
E200
E206
.
37.
Aslani
,
F. J.
,
Hukins
,
D. W.
, and
Shepherd
,
D. E.
,
2012
, “
Applicability of Sheep and Pig Models for Cancellous Bone in Human Vertebral Bodies
,”
Proc. Inst. Mech. Eng., Part H
,
226
(
1
), pp.
76
78
.
38.
Zindrick
,
M. R.
,
Wiltse
,
L. L.
,
Doornik
,
A.
,
Widell
,
E. H.
,
Knight
,
G. W.
,
Patwardhan
,
A. G.
,
Thomas
,
J. C.
,
Rothman
,
S. L.
, and
Fields
,
B.
,
1987
, “
Analysis of the Morphometric Characteristics of the Thoracic and Lumbar Pedicles
,”
Spine
,
12
(
2
), pp.
160
166
.
39.
Levasseur
,
A.
,
Ploeg
,
H.-L.
, and
Petit
,
Y.
,
2012
, “
Comparison of the Influences of Structural Characteristics on Bulk Mechanical Behaviour: Experimental Study Using a Bone Surrogate
,”
Med. Biol. Eng. Comput.
,
50
(
1
), pp.
61
67
.
40.
ASTM
,
2007
, “
Standard Specification and Test Methods for Metallic Medical Bone Screws
,”
American Society for Testing and Materials
,
West Conshohocken, PA
, Standard No. F543-07.
You do not currently have access to this content.