Biomechanical comparison of a two-level Maverick disc replacement with a hybrid one-level disc replacement and one-level anterior lumbar interbody fusion

Abstract

Background context Multilevel lumbar disc disease (MLDD) is a common finding in many patients. Surgical solutions for MLDD include fusion or disc replacement. The hybrid model, combining fusion and disc replacement, is a potential alternative for patients who require surgical intervention at both L5–S1 and L4–L5. The indications for this hybrid model could be posterior element insufficiency, severe facet pathology, calcified ligamentum flavum, and subarticular disease confirming spinal stenosis at L5–S1 level, or previous fusion surgery at L5–S1 and new symptomatic pathology at L4–L5. Biomechanical data of the hybrid model with the Maverick disc and anterior fusion are not available in the literature. Purpose To compare the biomechanical properties of a two-level Maverick disc replacement at L4–L5, L5–S1, and a hybrid model consisting of an L4–L5 Maverick disc replacement with an L5–S1 anterior lumbar interbody fusion using multidirectional flexibility test. Study design An in vitro human cadaveric biomechanical study. Methods Six fresh human cadaveric lumbar specimens (L4–S1) were subjected to unconstrained load in axial torsion (AT), lateral bending (LB), flexion (F), extension (E), and flexion-extension (FE) using multidirectional flexibility test. Four surgical treatments—intact, one-level Maverick at L5–S1, two-level Maverick between L4 and S1, and the hybrid model (anterior fusion at L5–S1 and Maverick at L4–L5) were tested in sequential order. The range of motion of each treatment was calculated. Results The Maverick disc replacement slightly reduced intact motion in AT and LB at both levels. The total FE motion was similar to the intact motion. However, the E motion is significantly increased (approximately 50% higher) and F motion is significantly decreased (30%–50% lower). The anterior fusion using a cage and anterior plate significantly reduced spinal motion compared with the condition (p<.05). No significant differences were found between two-level Maverick disc prosthesis and the hybrid model in terms of all motion types at L4–L5 level (p>.05). Conclusion The Maverick disc preserved total motion but altered the motion pattern of the intact condition. This result is similar to unconstrained devices such as Charité. The motion at L4–L5 of the hybrid model is similar to that of two-level Maverick disc replacement. The fusion procedure using an anterior plate significantly reduced intact motion. Clinical studies are recommended to validate the efficacy of the hybrid model.