Identification of Pedicle Screw Pullout Load Paths for Osteoporotic Vertebrae

STUDY DESIGN: A biomechanical study. PURPOSE: To determine the actual load path and compare pullout strengths as a function of screw size used in revision surgeries using postmortem human subject specimens. OVERVIEW OF LITERATURE: Pedicle screw fixation has become the standard of care in the surgical management of spinal instability. However, pullout failures are widely observed in osteoporotic spines and treated by revision surgeries using a higher diameter screw, performing cement augmentation, or increasing the levels of fixation. While the peak forces to final pullout are reported, the actual load path to achieve the final force level is not available. METHODS: Six osteoporotic lumbar spines (L2–L5) were instrumented with 5.5×40 mm polyaxial screws and loaded along the axis of the screw using a material testing machine according to American Society for Testing of Materials 543-07 test protocol. Tests were again conducted by replacing them with 6.5×40 mm (group A) or 7.5×40 mm (group B) screws. Force-displacement data were grouped and load paths (mean±1 standard deviation) were compared. RESULTS: Pullout strength decreased by 36% when the size of the revision screw was increased by 1 mm, while it increased by 35% when the size of the revision screw was increased by 2 mm compared to the index screw value. While the morphologies of the load paths were similar in all cases, they differ between the two groups: the larger screw responded with generally elevated stiffer path than the smaller screw, suggesting that revision surgery using a larger screw has more purchase along the inserted body-pedicle axis. CONCLUSIONS: A larger screw enhances strength and increases biomechanical stability in revision surgeries, although the final surgical decision is made by the clinician, which includes the patient’s anatomy and associated characteristics.