Clinical Biomechanics 53 (2018) 72–78

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Clinical Biomechanics
journal homepage: www.elsevier.com/locate/clinbiomech

Does pedicle screw fixation of the subaxial cervical spine provide adequate T
stabilization in a multilevel vertebral body fracture model? An in vitro
biomechanical study
⁎
John Duffa, Mir M. Hussainb, Noelle Klockeb, Jonathan A. Harrisb, , Soumya S. Yandamurib,
Lukas Bobinskia, Roy T. Daniela, Brandon S. Bucklenb
a
Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
b
Musculoskeletal Education and Research Center (MERC), A Division of Globus Medical, Inc., Audubon, PA, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Cervical vertebral body fractures generally are treated through an anterior-posterior approach.
Cervical Cervical pedicle screws offer an alternative to circumferential fixation. This biomechanical study quantifies
Pedicle screw whether cervical pedicle screws alone can restore the stability of a three-column vertebral body fracture, making
Lateral mass screw standard 360° reconstruction unnecessary.
Multilevel fracture
Methods: Range of motion (2.0 Nm) in flexion-extension, lateral bending, and axial rotation was tested on 10
Biomechanical
cadaveric specimens (five/group) at C2–T1 with a spine kinematics simulator. Specimens were tested for flex-
Anterior column support
ibility of intact when a fatigue protocol with instrumentation was used to evaluate construct longevity. For a
C4–6 fracture, spines were instrumented with 360° reconstruction (corpectomy spacer + plate + lateral mass
screws) (Group 1) or cervical pedicle screw reconstruction (C3 and C7 only) (Group 2).
Findings: Results are expressed as percentage of intact (100%). In Group 1, 360° reconstruction resulted in
decreased motion during flexion-extension, lateral bending, and axial rotation, to 21.5%, 14.1%, and 48.6%,
respectively, following 18,000 cycles of flexion-extension testing. In Group 2, cervical pedicle screw re-
construction led to reduced motion after cyclic flexion-extension testing, to 38.4%, 12.3%, and 51.1% during
flexion-extension, lateral bending, and axial rotation, respectively.
Interpretation: The 360° stabilization procedure provided the greatest initial stability. Cervical pedicle screw
reconstruction resulted in less change in motion following cyclic loading with less variation from specimen to
specimen, possibly caused by loosening of the shorter lateral mass screws. Cervical pedicle screw stabilization
may be a viable alternative to 360° reconstruction for restoring multilevel vertebral body fracture.

1. Introduction
Posterior cervical spine instrumentation is commonly used to treat
regional spinal instability resulting from trauma, tumor, infection, or
degenerative disease. Lateral mass screw placement remains a “gold
standard” for posterior cervical instrumentation, with excellent results
reported (Grob and Magerl, 1987; Jeanneret et al., 1991; Roy-Camille
and Saillant, 1972). However, use of lateral mass screws is precluded at
a vertebral level with a facet fracture, and this approach provides
limited stabilization in patients with poor bone quality, including those
with severe osteoporosis. Placement of cervical pedicle screws (CPS)
offers an alternative to standard lateral mass screw fixation (Abumi
et al., 1994; Abumi and Kaneda, 1997; Hasegawa et al., 2008; Jeanneret
et al., 1994; Reinhold et al., 2007; Richter et al., 2000). Use of CPS has
not been widely adopted despite very low reported complication rates,
because of associated technical difficulty and perceived risk of nerve
root or vertebral artery (VA) injury (Abumi et al., 2000; Richter et al.,
2004). However, CPS placement is a procedure of interest, as it affords
distinct advantages over standard lateral mass screw placement
(Dunlap et al., 2010; Johnston et al., 2006; Jones et al., 1997; Kowalski
et al., 2000). The pullout strength of a CPS is approximately twice to
quadruple that of a lateral mass screw (Ito et al., 2014; Jones et al.,
1997). Moreover, three-column fixation can be realized through a
single posterior approach and may involve instrumentation at the level

⁎
Corresponding author at: Musculoskeletal Education and Research Center (MERC), A Division of Globus Medical, Inc., 2560 General Armistead Avenue, Audubon, PA 19403, USA.
E-mail addresses: johnmichael.duff@gmail.com (J. Duff), mhussain@globusmedical.com (M.M. Hussain), nklocke@globusmedical.com (N. Klocke),
jharris@globusmedical.com (J.A. Harris), syandamuri@gmail.com (S.S. Yandamuri), lukasbobinski@yahoo.com (L. Bobinski), roy.daniel@chuv.ch (R.T. Daniel),
bbucklen@globusmedical.com (B.S. Bucklen).

https://doi.org/10.1016/j.clinbiomech.2018.02.009
Received 28 April 2016; Accepted 12 February 2018
0268-0033/ © 2018 Elsevier Ltd. All rights reserved.
J. Duff et al. Clinical Biomechanics 53 (2018) 72–78

of an articular fracture.
Multilevel cervical vertebral body fracture (VBF) from trauma or
other pathology generally is treated by anterior reconstruction, often
supplemented by posterior stabilization (Memtsoudis et al., 2011).
However, because multilevel anterior instrumentation introduces the
potential for significant morbidity, it may be preferable to consider
treating patients with multilevel cervical VBF through a single posterior
approach with CPS placement. Although such reconstruction is plau-
sible, the basic biomechanics of a CPS construct have not been ex-
plored, and the effectiveness of CPS placement in restoring three-
column stability after disruption has not been examined.
This study looks at biomechanical aspects of two possible surgical
solutions for multilevel anterior cervical VBF. Investigators compared
the relative stability of a posteriorly placed CPS construct alone versus
360° reconstruction (with anterior cage/plate and posterior lateral mass
screw construct) before and after a simulated period of repetitive
bending (cyclic loading). Researchers hypothesized that CPS fixation,
which should maintain adequate anterior column support through in-
creased screw length, may be comparable with more invasive front-
back reconstruction. A clinical case of multilevel VBF, which could have
been treated by either of these surgical techniques, is presented later to
describe the CPS technique as used in clinical practice.

2. Methods

2.1. Specimen preparation

Ten fresh-frozen cadaveric cervical spines (two groups of five spe-

cimens) at C2–T1 were used in this study. The medical history of each
donor was reviewed along with radiographic images to exclude speci-
mens with spinal trauma, malignancy, deformity, or fracture that would
otherwise affect the outcome of the test. Specimens were then carefully
dissected, leaving only ligaments, vertebral bodies, and intervertebral
discs of desired segments. Specimens were fixed at the C2 body proxi-
mally and at the T1 body distally, using a 1:1 mixture of Bondo® Auto
Body Filler (Bondo/MarHyde Corp., Atlanta, GA, USA) and fiberglass
resin (Home Solutions™ All Purpose; Bondo/MarHyde Corp.). All spe-
cimens were double-wrapped in plastic bags and were stored at −20 °C.
2.2. Fracture model and surgical reconstruction
Specimens were randomly assigned to one of two groups. To si-
mulate multilevel VBF, each specimen was placed in a custom fixture
and loaded cranially with 5 kg to simulate the mass of the head (Fig. 1).
A 3.5 mm burr tip (5100-1 TPS Console, Stryker®, Kalamazoo, MI, USA)
was used to disrupt the anterior and middle columns until collapse of
the C4, C5, and C6 vertebrae, determined by visual inspection. Anterior
and posterior longitudinal ligaments were preserved at these levels.
After fracture creation, half of the spines were stabilized by 360° re-
construction following corpectomy of C4 through C6 with removal of
the anterior longitudinal ligament and preservation of the posterior
longitudinal ligament. Reconstruction was performed with an expand-
able polyether ether ketone (PEEK) cage (XPAND®; Globus Medical,
Inc., Audubon, PA, USA) at C3–7. An anterior plate (PROVIDENCE®;
Globus Medical, Inc.) was placed at C3–7 to restore the anterior tension
band. This was followed by posterior unicortical lateral mass screw
placement (4 × 14-mm screws; ELLIPSE®; Globus Medical, Inc.) at each
level. It is worth noting that lateral mass screws were placed at C7, as
each specimen was deemed to have adequately sized lateral masses at
this level, although pedicle screws are often used at C7 in clinical
practice (Group 1). The other half of the spines were instrumented with
unicortical terminal point CPS (4 × 28-mm screws) at C3 and C7 but
with no intermediate point fixation anchors (Group 2). All in-
strumentation was performed under fluoroscopic guidance. A ball tip
probe was used to confirm intact circumferential bone corridors with no
breaches along screw trajectories.
Fig. 1. Custom fixture used to simulate multilevel VBF.
Specimens in Group 1 had a mean age of 60.8 (standard deviation
[SD] 10.7) years (two female, three male), and in Group 2, 65.2 (SD
5.8) years (three female, two male). All screws in both groups were
inserted with unicortical purchase, as is common in clinical practice. An
illustration of these groups is provided in Fig. 2.
2.3. Multidirectional and dynamic cyclic fatigue testing
Each specimen was thawed overnight and then was tested intact to
establish baseline values. Specimens were tested for flexibility before
and after a cyclic loading protocol, which was conducted to evaluate
the longevity of instrumentation.
Researchers measured flexibility both before and after cyclic
loading using a custom-built six-degrees-of-freedom (6DOF) testing
apparatus used to simulate physiological loads, as used in selected
previous studies (Hallager et al., 2016; Kim et al., 2017; Majid et al.,
2012; Wu et al., 2017). The cranial (C2) and caudal (T1) portion of the
specimen was affixed via rectangular metal tubing container to a 6DOF
motor gimbal assembly which applied a pure, unconstrained rotational
moment independently about the x-, y-, and z-axis corresponding to
flexion-extension, axial rotation, and lateral bending. The gimbal as-
sembly is attached to the test platform which includes linear air-bearing
guide rails (x- and z-axis) and pneumatic-controlled linear actuator (y-
axis) enabling pure, unconstrained translation. A load control protocol
with servomotors will apply a pure moment, caudally, at a rate of 1.5°/

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J. Duff et al. Clinical Biomechanics 53 (2018) 72–78

Fig. 2. Schematic of fixation for Group 1 (360°) and Group 2 (CPS).

s, to a maximum moment of ± 2.5 Nm. Each test construct experienced

three load-unload cycles in FE, LB, and AR. Data was collected on the
third cycle to allow for the viscoelasticity of the tissue. Plexiglass strips
with three markers were placed at C3 and C7 vertebral bodies. With
these markers, relative range of motion (ROM) for all test groups was
assessed using Optotrak Certus® (Northern Digital Inc., Waterloo, ON,
Canada).
To create cyclic loading, an MTS® 858 mini bionix servo-hydraulic
machine (MTS Systems Corporation, Eden Prairie, MN, USA) was used
to simulate long-term stability in flexion-extension. Each specimen was
affixed to custom pots that were allowed to freely rotate about a pin
seated in fixtures secured at the load cell and actuator (Fig. 3). The
linear, axial motion of the actuator produced a force, and a moment was
calculated using the distance between the center of the pot and the axle.
A load-control protocol was used to apply ± 1.5 Nm at 0.75 Hz for
18,000 cycles, to simulate approximately eight weeks of maximum
bending (minor bends were ignored to obtain the worst-case scenario)
(Hedman et al., 1991). To avoid potential dehydration of the specimen
during cyclic loading, testing was performed under time constraints of
20 h, as reported by Wilke et al. (1998), so that biomechanical prop-
erties would not be affected. Specimens were wrapped in gauze and
were soaked in saline solution every 20 min throughout testing, as has
been described (Kettler et al., 2000; Wilke et al., 1998).
The two stabilization methods were compared and evaluated in
terms of ROM. Stability of the tested constructs was assessed through
measurement of peak-to-peak range of motion reported across the fix-
ated level (C3–7) and normalized to the intact condition per specimen
(intact = 100%). During ROM and cyclic fatigue, specimens were vi-
sually inspected for complications such as rod or screw fracture, screw
loosening in bone, or further induced vertebral fracture.

2.4. Case illustration

A single case was performed to assess the feasibility of bilateral

cervical pedicle screws. After experiencing severe cervical trauma from
a skiing accident, a 15-year-old male presented with central cord syn-
drome with sacral sparing and bilateral distal motor deficit in the upper
limbs (American Spinal Injury Association [ASIA] class C).
2.5. Data analysis
Statistical analysis was performed using one-factor repeated-mea-
sures analysis of variance (ANOVA) to isolate significant (alpha = 0.05)
Fig. 3. Simulated in vivo cyclic fatigue test setup.
differences in motion (normalized to the intact condition) between
experimental constructs. Two-way ANOVA was used to compare mo-
tion of independent, between-groups (test groups 1 and 2) and depen-
dent, within-groups (tested constructs). Post hoc testing was performed
using Tukey's test with IBM SPSS® Statistics (SPSS® v22, IBM Corp.,
Armonk, NY, USA).

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Table 1 Table 4
360° group raw C3–C7 motion, ° (AVG ± SD). CPS group normalized C3–C7 motion, % (AVG ± SD).

Mode Intact Initial Post-fatigue Mode Intact Initial Post-fatigue

FE 23.3° (SD 10.4°) 1.8° (SD 2.0°) 5.0° (SD 5.0°) FE 100% 34.2% (SD 11.6%) 38.4% (SD 10.5%)
LB 8.3° (SD 4.2°) 0.7° (SD 0.5°) 1.0° (SD 0.8°) LB 100% 12.8% (SD 5.8%) 12.3% (SD 3.5%)
AR 21.6° (SD 9.2°) 7.6° (SD 5.8°) 9.4° (SD 9.4°) AR 100% 54.7% (SD 26.7%) 51.1% (SD 23.8%)

360° = corpectomy (C4–C6) with lateral mass screws (C3–C7). CPS = cervical pedicle screws.

Table 2
360° group normalized C3–C7 motion, % (AVG ± SD).

Mode Intact Initial Post-fatigue

FE 100% 8.0% (SD 7.7%) 21.5% (SD 18.9%)

LB 100% 9.2% (SD 9.4%) 14.1% (SD 13.9%)
AR 100% 38.0% (SD 30.3%) 48.6% (SD 53.6%)

360° = corpectomy (C4–C6) with lateral mass screws (C3–C7).

3. Results

3.1. Multidirectional and dynamic cyclic fatigue results

3.1.1. Range-of-motion
A summary of raw and normalized ROM values for 360° re-
construction (Tables 1–2), raw and normalized ROM values for CPS
reconstruction (Tables 3–4), and normalized ROM comparisons before
and following cyclic loading with significant relationships (Fig. 4) are
presented.
Group 1 (360°) intact specimens have average intact motion values
of 23.3° (SD 10.4°) of FE, 8.3° (SD 4.2°) of LB, and 21.6° (SD 9.2°) of AR.
After 360° reconstruction, motion was significantly reduced to 1.8° (SD
2.0°) FE, 0.7° (SD 0.5°) LB, and 7.6° (SD 5.8°) AR. This represents a
decrease in motion to 8.0%, 9.2%, and 38.0% during FE, LB, and AR,
respectively, of intact. After cyclic loading testing, motion was in-
creased in all modes to 5.0° (SD 5.0°) FE, 1.0° (SD 0.8°) LB, and 9.4° (SD
9.4°) AR, representing an increase in ROM relative to intact of 21.5%,
14.1%, and 48.6% in FE, LB, and AR, respectively. Anteroposterior
reconstruction significantly reduced motion relative to intact, both
before and after dynamic cyclic fatigue, across all motion planes (all
P < 0.05); only in FE did motion significantly increase following cyclic
fatigue (P < 0.05) (Fig. 4). Group 1 included two specimens with C7
screw loosening, observed visually during ROM testing following si-
mulated in vivo cyclic fatigue. Of the two, one specimen had loosening
of three screws (two anterior plate screws and left lateral mass screw),
while the other had loosening of four screws (two anterior plate screws
and both lateral mass screws).
Group 2 (CPS) intact specimens have average intact motion values
of 21.6° (SD 9.1°) FE, 9.4° (SD 3.9°) LB, and 33.3° (SD 12.2°) AR. After
CPS reconstruction, motion was decreased to 7.5° (SD 3.4°) FE, 1.1° (SD
0.5°) LB, and 19.0° (SD 9.9°) AR. This represents a decrease in motion
relative of intact to 34.2%, 12.8%, and 54.7% during FE, LB, and AR,
respectively. After cyclic loading testing, motion did not change much;
8.0° (SD 2.9°) FE, 1.2° (SD 0.7°) LB, and 16.9° (SD 8.1°) AR, representing
an increase in ROM relative to intact of 38.4%, 12.3%, and 51.1% in FE,
LB, and AR, respectively. Anteroposterior reconstruction significantly
Table 3
CPS group raw C3–C7 motion, ° (AVG ± SD).
Mode Intact Initial Post-fatigue
FE 21.6° (SD 9.1°) 7.5° (SD 3.4°) 8.0° (SD 2.9°)
LB 9.4° (SD 3.9°) 1.1° (SD 0.5°) 1.2° (SD 0.7°)
AR 33.3° (SD 12.2°) 19.9° (SD 9.2°) 16.9° (SD 8.1°)
CPS = cervical pedicle screws.
Fig. 4. Graph showing normalized range of motion for Group 1 and Group 2 with fixation
before and after (post cycling) wear simulation. * shows statistical significance versus
intact and injured; † represents statistical differences versus Group 1 fixation before cyclic
loading.
reduced motion relative to intact, both before and after dynamic cyclic
fatigue, across all motion planes (all P < 0.05); no significant differ-
ences in motion between pre- and post-fatigue were observed (all
P > 0.05) (Fig. 4). Lastly, in Group 2, screw loosening of a single right
pedicle at C7 was observed in one specimen following simulated in vivo
cyclic testing.
3.2. Case illustration results
Computed tomography (CT) scan showed a fracture split of the
vertebral body of C4 and C5 with kyphosis and fracture of the facet of
left C5 (Fig. 5A–C). Magnetic resonance imaging (MRI) confirmed high
cord signal and posterior ligamentous injury (Fig. 5D). The patient
underwent stabilization through image-guided pedicle screw placement
at C3 and C6 bilaterally with correction of kyphosis. The postoperative
course was uneventful, and the patient was discharged home after two
weeks. Follow-up at two years showed fusion of the fractures (Figs. 6–7)
as well as posterior fusion. X-rays confirmed proper lordosis alignment
of the cervical spine. The patient had normal findings on neurologic
examination, and his daily and sporting activities were not restricted.
4. Discussion
This study was conducted to explore the stability of two different
surgical reconstruction options for treatment of multilevel, multi-
column cervical fracture. Range-of-motion baseline values indicate that
Group 1 (three-level corpectomy spacer + plate + lateral mass screws)
was stiffer than Group 2 (terminal pedicle screws at C3 and C7 with no
anterior reconstruction) in FE. After cyclic loading (see Fig. 4), these
effects were somewhat neutralized, as the initially greater stiffness in
Group 1 was further reduced by cyclic loading in terms of percentage to
intact than was stiffness in Group 2—ultimately resulting in near
equivalence among groups. In FE, however, Group 1 remained ~15%
stronger than Group 2, even after cyclic loading. It remains to be seen
whether the 15% difference in construct strength would have been
completely eliminated if cyclic loading had continued.
Lateral bending and AR were similar in both groups before and after

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J. Duff et al.
Fig. 5. Admission computed tomography scan (CT) of A) lateral view, B) anterior-posterior view, and C) axial view shows C5 and C6 anterior and posterior fractures. Alignment is slightly
kyphotic. D) Preoperative magnetic resonance imaging (MRI) confirms high cord signal and ligamentous disruption.
cyclic testing. This shows the efficacy of CPS stabilization versus 360°
reconstruction in these axes of motion. Moreover, AR was least affected
after fixation. Theoretically, an added cross connector may have af-
fected these results, as the addition of cross connectors to rigid rod
constructs has been shown to significantly reduce AR (Majid et al.,
2011).
Comparisons of ROM following cyclic loading remain difficult due
to the specificity of the operative constructs tested and lack of a defined
standard, like the ASTM F1717, for simulating fatigue with cadaveric
specimens. Hedman et al. (1991) outlines intervertebral disc prosthesis
design considerations and estimates the average person makes 125,000
“significant bends” in flexion-extension each year (Hedman et al.,
1991). Tissue exposure and desiccation limits cyclic fatigue to roughly
18,000 cycles – at 0.75 Hz, testing requires 6.25 h to complete. Despite
this limitation, 18,000 cycles simulates approximately 7.5 weeks of
significant bends. Clinically, graft-derived cell differentiation and initial
integration of the interbody bone graft is observed within the first two
weeks post-operatively (Gould et al., 2000). Therefore, simulating
18,000 cycles, implemented in the present study and previously by Luo
et al. (2015), provides clinically relevant information as the patient
theoretically begins to heal (Luo et al., 2015).
Researchers have shown that screw purchase is relative to screw
diameter and screw length (Brantley et al., 1994; Cook et al., 2004). Use
of much longer pedicle screws in Group 2 as compared with shorter
lateral mass screws in Group 1 contributed to enhanced construct sta-
bility. Several studies have confirmed the superior pullout strength of
cervical pedicle screws compared with lateral mass screws (Barnes
et al., 2009; Benke et al., 2011; Dunlap et al., 2010; Kothe et al., 2004;
Kretzer et al., 2010; Ma et al., 2009; Nassos et al., 2009; Regan et al.,
Fig. 6. X-rays of A) anterior-posterior view, B) flexion, and C) extension one year postoperatively.
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Clinical Biomechanics 53 (2018) 72–78
2013; Savage et al., 2011; Xu et al., 2010). Findings suggest that three-
column cervical reconstruction may be achieved through a posterior-
only approach with placement of longer pedicle screws. Use of inter-
mediate fixation points should further increase construct stability but
was not evaluated in the current study. As posterior fusion rates of the
cervical spine are generally high, anterior approaches may be re-
dundant (Burkhardt et al., 2013; Chen et al., 2013; Frenkel et al., 2013;
Wang et al., 2015). Use of cervical pedicle screws is technically diffi-
cult, but the difficulty may be overcome by image-guided screw pla-
cement, as in the presented case illustration (Bolger et al., 1999; Bolger
and Wigfield, 2000; Ishikawa et al., 2010; Ling et al., 2013; Mezger
et al., 2013; Richter et al., 2000; Santos et al., 2012; Scheufler et al.,
2011a, 2011b).
Results of the current study are promising with regard to insertion
of cervical pedicle screws through a posterior approach for three-
column cervical reconstruction. Although the authors cannot defini-
tively state that enhanced stability was due to screw length and pla-
cement across the pedicle, study results appear to corroborate re-
sistance of cervical pedicle screws to loosening. It remains unclear at
what point enhanced initial stability of 360° fixation techniques per-
formed in a laboratory setting is nullified by gradual screw loosening.
Inherent limitations of this study are common to human cadaveric
studies. First, captured motion data does not account for patient factors
such as bone healing. Furthermore, removal of soft tissue and the ab-
sence of physiologic loading of the weight of the head may have had a
negative impact on screw loosening. Anatomic differences between
specimens could have affected results; however, all motion data was
normalized to intact to limit this influence. Lack of availability and high
cost of specimens procured limited sample sizes for this study and
J. Duff et al.
Fig. 7. Computed tomography (CT) scans of A) anterior-posterior, B) axial, and C) lateral views two years postoperatively show excellently maintained lordosis and fully healed vertebral
body fractures.
quantification of bone mineral density (BMD). The small sample size
did not compromise the study within the context of cadaveric bio-
mechanical literature, which typically reports use of 3 to 8 specimens
per group (Cook et al., 2004; Kruger et al., 2012; Mundis et al., 2015;
Ordway et al., 2013; Santoni et al., 2013; Yeager et al., 2015a; Yeager
et al., 2015b). Use of a larger sample size may reduce the likelihood of
type I and type II error, thereby increasing statistical power of motion
analyses. To account for BMD variability, specimens were separated
into the two test groups at random. Lastly, limitations to study design
include the “surgery” provided for Group 1 was a destabilizing proce-
dure that was followed by a restabilizing procedure, as opposed to a
pure stabilizing procedure, which was performed for Group 2. How-
ever, this difference simulates clinical practice in reflecting treatment
options for the initial injury.
5. Conclusions
Multilevel anterior cervical fractures are devastating injuries that
generally are treated by corpectomy, interbody cage, and anterior plate,
followed by posterior fixation with lateral mass screws. Cervical pedicle
screw reconstruction may simplify surgery and provide adequate sta-
bilization for bone fusion, with acceptable risk to neurovascular struc-
tures. Pedicle screws provide better screw purchase and the need for
fewer fixation points. Immediate range of motion, range of motion after
fixation before cyclic loading, and range of motion after cyclic loading
were measured. Although 360° reconstruction was more stable before
and after testing, pedicle screws provided more consistent stability after
cyclic loading. Cervical pedicle screw constructs may be adequate for
three-column reconstruction and may be a viable alternative to 360°
reconstruction for this challenging clinical problem.
Author conflict of interest and funding statement
JD, RTD, and LB have no financial relationships to disclose. MMH,
NK, JAH, SSY, and BSB are salaried employees of the Musculoskeletal
Education and Research Center (MERC), A Division of Globus Medical,
Inc. Funding for this biomechanical study was provided by the
Musculoskeletal Education and Research Foundation (MERC), A
Division of Globus Medical, Inc. MERC provided all equipment and
testing apparatus such as the six-degrees-of-freedom spine motion si-
mulator. MERC employees performed all aspects of data analysis and
data collection. All authors reviewed and approved the final manuscript
for submission.
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Clinical Biomechanics 53 (2018) 72–78
Acknowledgments
The authors would like to acknowledge editorial assistance pro-
vided by Ms. Dolores Matthews, MEd, ELS, in preparation of the
manuscript.
References
Abumi, K., Kaneda, K., 1997. Pedicle screw fixation for nontraumatic lesions of the cer-
vical spine. Spine 22, 1853–1863.
Abumi, K., Itoh, H., Taneichi, H., Kaneda, K., 1994. Transpedicular screw fixation for
traumatic lesions of the middle and lower cervical spine: description of the techni-
ques and preliminary report. Clin. Spine Surg. 7, 19–28.
Abumi, K., Shono, Y., Ito, M., Taneichi, H., Kotani, Y., Kaneda, K., 2000. Complications of
pedicle screw fixation in reconstructive surgery of the cervical spine. Spine 25,
962–969.
Barnes, A.H., Eguizabal, J.A., Acosta Jr., F.L., Lotz, J.C., Buckley, J.M., Ames, C.P., 2009.
Biomechanical pullout strength and stability of the cervical artificial pedicle screw.
Spine 34, E16–20.
Benke, M.T., O'Brien, J.R., Turner, A.W., Yu, W.D., 2011. Biomechanical comparison of
transpedicular versus intralaminar C2 fixation in C2–C6 subaxial constructs. Spine
36, E33–37.
Bolger, C., Wigfield, C., 2000. Image-guided surgery: applications to the cervical and
thoracic spine and a review of the first 120 procedures. J. Neurosurg. 92, 175–180.
Bolger, C., Wigfield, C., Melkent, T., Smith, K., 1999. Frameless stereotaxy and anterior
cervical surgery. Comput. Aided Surg. 4, 322–327.
Brantley, A.G., Mayfield, J.K., Koeneman, J.B., Clark, K.R., 1994. The effects of pedicle
screw fit. An in vitro study. Spine 19, 1752–1758.
Burkhardt, J.K., Mannion, A.F., Marbacher, S., Dolp, P.A., Fekete, T.F., Jeszenszky, D.,
Porchet, F., 2013. A comparative effectiveness study of patient-rated and radio-
graphic outcome after 2 types of decompression with fusion for spondylotic myelo-
pathy: anterior cervical discectomy versus corpectomy. Neurosurg. Focus. 35, E4.
Chen, F., He, W., Mahaney, K., Noeller, J., Mhanna, N., Viljoen, S., Torner, J., Hitchon, P.,
2013. Alternative grafts in anterior cervical fusion. Clin. Neurol. Neurosurg. 115,
2049–2055.
Cook, S.D., Salkeld, S.L., Stanley, T., Faciane, A., Miller, S.D., 2004. Biomechanical study
of pedicle screw fixation in severely osteoporotic bone. Spine J. 4, 402–408. http://
dx.doi.org/10.1016/j.spinee.2003.11.010.
Dunlap, B.J., Karaikovic, E.E., Park, H.S., Sokolowski, M.J., Zhang, L.Q., 2010. Load
sharing properties of cervical pedicle screw-rod constructs versus lateral mass screw-
rod constructs. Eur. Spine J. 19, 803–808.
Frenkel, M.B., Cahill, K.S., Javahary, R.J., Zacur, G., Green, B.A., Levi, A.D., 2013. Fusion
rates in multilevel, instrumented anterior cervical fusion for degenerative disease
with and without the use of bone morphogenetic protein. J. Neurosurg. Spine 18,
269–273.
Gould, S.E., Rhee, J.M., Tay, B.-B., Otsuka, N.Y., Bradford, D.S., 2000. Cellular con-
tribution of bone graft to fusion. J. Orthop. Res. 18, 920–927.
Grob, D., Magerl, F., 1987. Dorsal spondylodesis of the cervical spine using a hooked
plate. Orthopade 16, 55–61.
Hallager, D.W., Gehrchen, M., Dahl, B., Harris, J.A., Gudipally, M., Jenkins, S., Wu, A.M.,
Bucklen, B.S., 2016. Use of supplemental short pre-contoured accessory rods and
cobalt chrome alloy posterior rods reduces primary rod strain and range of motion
across the pedicle subtraction osteotomy level: an in vitro biomechanical study. Spine
(Phila Pa 1976) 41, E388–395.
J. Duff et al.
Hasegawa, K., Hirano, T., Shimoda, H., Homma, T., Morita, O., 2008. Indications for
cervical pedicle screw instrumentation in nontraumatic lesions. Spine 33,
2284–2289.
Hedman, T.P., Kostuik, J.P., Fernie, G.R., Hellier, W.G., 1991. Design of an intervertebral
disc prosthesis. Spine (Phila Pa 1976) 16, S256–260.
Ishikawa, Y., Kanemura, T., Yoshida, G., Ito, Z., Muramoto, A., Ohno, S., 2010. Clinical
accuracy of three-dimensional fluoroscopy-based computer-assisted cervical pedicle
screw placement: a retrospective comparative study of conventional versus com-
puter-assisted cervical pedicle screw placement. J. Neurosurg. Spine 13, 606–611.
Ito, Z., Higashino, K., Kato, S., Kim, S.S., Wong, E., Yoshioka, K., Hutton, W.C., 2014.
Pedicle screws can be 4 times stronger than lateral mass screws for insertion in the
midcervical spine: a biomechanical study on strength of fixation. Clin. Spine Surg. 27
(2), 80–85 (April).
Jeanneret, B., Magerl, F., Ward, E.H., Ward, J.C., 1991. Posterior stabilization of the
cervical spine with hook plates. Spine 16, S56–63.
Jeanneret, B., Gebhard, J.S., Magerl, F., 1994. Transpedicular screw fixation of articular
mass fracture-separation: results of an anatomical study and operative technique.
Clin. Spine Surg. 7, 222–229.
Johnston, T.L., Karaikovic, E.E., Lautenschlager, E.P., Marcu, D., 2006. Cervical pedicle
screws vs. lateral mass screws: uniplanar fatigue analysis and residual pullout
strengths. Spine J. 6, 667–672.
Jones, E.L., Heller, J.G., Silcox, D.H., Hutton, W.C., 1997. Cervical pedicle screws versus
lateral mass screws. Anatomic feasibility and biomechanical comparison. Spine 22,
977–982.
Kettler, A., Wilke, H.J., Dietl, R., Krammer, M., Lumenta, C., Claes, L., 2000. Stabilizing
effect of posterior lumbar interbody fusion cages before and after cyclic loading. J.
Neurosurg. 92, 87–92.
Kim, C., Harris, J.A., Muzumdar, A., Khalil, S., Sclafani, J.A., Raiszadeh, K., Bucklen, B.S.,
2017. The effect of anterior longitudinal ligament resection on lordosis correction
during minimally invasive lateral lumbar interbody fusion: biomechanical and
radiographic feasibility of an integrated spacer/plate interbody reconstruction de-
vice. Clin. Biomech. (Bristol, Avon) 43, 102–108.
Kothe, R., Ruther, W., Schneider, E., Linke, B., 2004. Biomechanical analysis of trans-
pedicular screw fixation in the subaxial cervical spine. Spine 29, 1869–1875.
Kowalski, J.M., Ludwig, S.C., Hutton, W.C., Heller, J.G., 2000. Cervical spine pedicle
screws: a biomechanical comparison of two insertion techniques. Spine 25,
2865–2867.
Kretzer, R.M., Hu, N., Kikkawa, J., Garonzik, I.M., Jallo, G.I., Tortolani, P.J., McAfee,
P.C., Cunningham, B.W., 2010. Surgical management of two- versus three-column
injuries of the cervicothoracic junction: biomechanical comparison of translaminar
screw and pedicle screw fixation using a cadaveric model. Spine 35, E948–954.
Kruger, A., Oberkircher, L., Kratz, M., Baroud, G., Becker, S., Ruchholtz, S., 2012. Cement
interdigitation and bone-cement interface after augmenting fractured vertebrae: A
cadaveric study. Int. J. Spine Surg. 6, 115–123.
Ling, J.M., Tiruchelvarayan, R., Seow, W.T., Ng, H.B., 2013. Surgical treatment of adult
and pediatric C1/C2 subluxation with intraoperative computed tomography gui-
dance. Surg. Neurol. Int. 4, S109–117.
Luo, B., Yan, M., Huang, J., Duan, W., Huang, Z., Chen, J., Luo, Z., Zhu, Q., Li, M., 2015.
Biomechanical study of unilateral pedicle screw combined with contralateral trans-
laminar facet screw in transforaminal lumbar interbody fusion. Clin. Biomech.
(Bristol, Avon) 30, 657–661.
Ma, X.Y., Yin, Q.S., Wu, Z.H., Xia, H., Liu, J.F., Xiang, M., Zhao, W.D., Zhong, S.Z., 2009.
C1 pedicle screws versus C1 lateral mass screws: comparisons of pullout strengths and
biomechanical stabilities. Spine 34, 371–377.
Majid, K., Gudipally, M., Hussain, M., Moldavsky, M., Khalil, S., 2011. The biomechanical
effect of transverse connectors use in a pre- and postlaminectomy model of the
posterior cervical spine: an in vitro cadaveric study. Spine (Phila Pa 1976) 36,
E1694–1701.
Majid, K., Chinthakunta, S., Muzumdar, A., Khalil, S., 2012. A comparative biomechanical
study of a novel integrated plate spacer for stabilization of cervical spine: an in vitro
human cadaveric model. Clin. Biomech. (Bristol, Avon) 27, 532–536.
Memtsoudis, S.G., Vougioukas, V.I., Ma, Y., Gaber-Baylis, L.K., Girardi, F.P., 2011.
Perioperative morbidity and mortality after anterior, posterior, and anterior/
78
Clinical Biomechanics 53 (2018) 72–78
posterior spine fusion surgery. Spine 36, 1867–1877.
Mezger, U., Jendrewski, C., Bartels, M., 2013. Navigation in surgery. Langenbeck's Arch.
Surg./Deutsche Gesellschaft fur Chirurgie 398, 501–514.
Mundis, G.M., Eastlack, R.K., Moazzaz, P., Turner, A.W., Cornwall, G.B., 2015.
Contribution of Round vs. Rectangular Expandable Cage Endcaps to Spinal Stability
in a Cadaveric Corpectomy Model. Int. J. Spine Surg. 9, 53.
Nassos, J.T., Ghanayem, A.J., Sasso, R.C., Tzermiadianos, M.N., Voronov, L.I., Havey,
R.M., Rinella, A.S., Carandang, G., Patwardhan, A.G., 2009. Biomechanical evalua-
tion of segmental occipitoatlantoaxial stabilization techniques. Spine 34, 2740–2744.
Ordway, N.R., Lavelle, W.F., Brown, T., Bao, Q.B., 2013. Biomechanical assessment and
fatigue characteristics of an articulating nucleus implant. Int. J. Spine Surg. 7,
e109–e117.
Regan, C.M., Emmanuel, S., Hornik, C., Weinhold, P., Lim, M.R., 2013. Lateral mass
versus hybrid construct for cervical laminectomy and fusion. Orthopedics 36,
e484–488.
Reinhold, M., Magerl, F., Rieger, M., Blauth, M., 2007. Cervical pedicle screw placement:
feasibility and accuracy of two new insertion techniques based on morphometric
data. Eur. Spine J. 16, 47–56.
Richter, M., Amiot, L.P., Neller, S., Kluger, P., Puhl, W., 2000. Computer-assisted surgery
in posterior instrumentation of the cervical spine: an in-vitro feasibility study. Eur.
Spine J. 9 (Suppl. 1), S65–70.
Richter, M., Mattes, T., Cakir, B., 2004. Computer-assisted posterior instrumentation of
the cervical and cervico-thoracic spine. Eur. Spine J. 13, 50–59.
Roy-Camille, R., Saillant, G., 1972. Surgery of the cervical spine. 4. Osteosynthesis of the
upper cervical spine. Nouv. Press. Med. 1, 2847–2849.
Santos, E.R., Ledonio, C.G., Castro, C.A., Truong, W.H., Sembrano, J.N., 2012. The ac-
curacy of intraoperative O-arm images for the assessment of pedicle screw postion.
Spine 37, E119–125.
Santoni, B.G., Alexander 3rd, G.E., Nayak, A., Cabezas, A., Marulanda, G.A., Murtagh, R.,
Castellvi, A.E, 2013. Effects on inadvertent endplate fracture following lateral cage
placement on range of motion and indirect spine decompression in lumbar spine
fusion constructs: A cadaveric study. Int. J. Spine Surg. 7, e101–e108.
Savage, J.W., Limthongkul, W., Park, H.S., Zhang, L.Q., Karaikovic, E.E., 2011. A com-
parison of biomechanical stability and pullout strength of two C1–C2 fixation con-
structs. Spine J. 11, 654–658.
Scheufler, K.M., Franke, J., Eckardt, A., Dohmen, H., 2011a. Accuracy of image-guided
pedicle screw placement using intraoperative computed tomography-based naviga-
tion with automated referencing, part I: cervicothoracic spine. Neurosurgery 69,
782–795 (discussion 795).
Scheufler, K.M., Franke, J., Eckardt, A., Dohmen, H., 2011b. Accuracy of image-guided
pedicle screw placement using intraoperative computed tomography-based naviga-
tion with automated referencing. Part II: thoracolumbar spine. Neurosurgery 69,
1307–1316.
Wang, T.Y., Lubelski, D., Abdullah, K.G., Steinmetz, M.P., Benzel, E.C., Mroz, T.E., 2015.
Rates of anterior cervical discectomy and fusion after initial posterior cervical for-
aminotomy. Spine J. 15 (5), 971–976 (1 May).
Wilke, H.J., Jungkunz, B., Wenger, K., Claes, L.E., 1998. Spinal segment range of motion
as a function of in vitro test conditions: effects of exposure period, accumulated cy-
cles, angular-deformation rate, and moisture condition. Anat. Rec. 251, 15–19.
Wu, A.M., Harris, J.A., Hao, J.C., Jenkins, S.M., Chi, Y.L., Bucklen, B.S., 2017.
Biomechanical properties of posterior transpedicular-transdiscal oblique lumbar
screw fixation with novel trapezoidal lateral interbody spacer: an in vitro human
cadaveric model. Eur. Spine J. 26 (11), 2873–2882 (November).
Xu, R., McGirt, M.J., Sutter, E.G., Sciubba, D.M., Wolinsky, J.P., Witham, T.F., Gokaslan,
Z.L., Bydon, A., 2010. Biomechanical comparison between C-7 lateral mass and
pedicle screws in subaxial cervical constructs. Presented at the 2009 Joint Spine
Meeting. Laboratory investigation. J. Neurosurg. Spine 13, 688–694.
Yeager, M.S., Cook, D.J., Cheng, B.C., 2015a. In Vitro Comparison of Dynesys, PEEK, and
Titanium Constructs in the Lumbar Spine. Adv. Orthop., 895931.
Yeager, M.S., Dupre, D.A., Cook, D.J., Oh, M.Y., Altman, D.T., Cheng, B.C., 2015b.
Anterior lumbar interbody fusion with integrated fixation and adjunctive posterior
stabilization: A comparative biomechanical analysis. Clin. Biomech. (Bristol, Avon)
30, 769–774.