Biomechanical limitations of partial pediculectomy in endoscopic spine surgery

Abstract

BACKGROUND CONTEXTTransforaminal endoscopic decompression is an emerging minimally invasive surgical technique in spine surgery. The biomechanical effects and limitations of resections associated with this technique are scarce. PURPOSEThe objective of this study was to analyze the effects of three different extents of reduction at the craniomedial pedicle (10%, 25%, and 50%) and to compare them with the intact native side. In addition, the influence of bone quality on the resistance of the pedicle after reduction was investigated. STUDY DESIGNBiomechanical cadaveric study. METHODSThirty lumbar vertebrae originating from six fresh frozen cadavers were tested under uniaxial compression load in a ramp-to-failure test: (1) the reduced pedicle on one side, and (2) the native pedicle on the other side. Of the 30 lumbar vertebrae, ten were assigned to each reduction group (10%, 25%, and 50%). RESULTSOn the intact side, the median axial compression force to failure was 593 N (442.4–785.8). A reduction of the pedicle by 10% of the cross-sectional area resulted in a decrease of the axial load resistance by 4% to 66% compared to the intact opposite side (p=.046). The median compression force to failure was 381.89 N (range: 336–662.1). A reduction by 25% resulted in a decrease of 7% to 71% (p=.001). The median compression force to failure was 333 N (265.1–397.3). A reduction by 50% resulted in a decrease of 39% to 90% (p<.001). The median compression force to failure was 200.9 N (192.3–283.9). At 10% pedicle reduction, the Hounsfield units (HU) value and the absolute force required to generate a pedicle fracture showed significant correlations (ρ=.872; p=.001). At 25%, a positive correlation between the two variables could still be identified (ρ=.603; p=.065). At 50%, no correlation was found (ρ=-.122; p=.738). CONCLUSIONResection of the inner, upper part of the pedicle significantly reduces the axial resistance force of the pedicle until a fracture occurs. CLINICAL SIGNIFICANCEThe extent of pedicle reduction itself plays only a limited role: once the cortical bone in the pedicle region is compromised, significant loss of resistance to loading must be anticipated.