Abstract
Preventing subsidence of intervertebral cages in posterior lumbar interbody fusion (PLIF) requires understanding its mechanism, which is yet to be done. We aimed to describe the mechanism of intervertebral cage subsidence by using finite element analysis through simulation of the osteoporotic vertebral bodies of an elderly woman. The data from computed tomography scans of L2-L5 vertebrae in a 72-year-old woman with osteoporosis were used to create 2 FE models: one not simulating implant placement (LS-INT) and one simulating L3/4 PLIF using polyetheretherketone (PEEK) cages (LS-PEEK). Loads and moments simulating the living body were applied to these models, and the following analyses were performed: 1) Drucker-Prager equivalent stress distribution at the cage contact surfaces; 2) the distribution of damage elements in L2-L5 during incremental loading; and 3) the distribution of equivalent plastic strain at the cage contact surfaces. In analysis 1, the Drucker-Prager equivalent stress on the L3 and L4 vertebral endplates was greater for LS-PEEK than for LS-INT under all loading conditions and tended to be particularly concentrated at the contact surfaces. In analysis 2, compared with LS-INT, LS-PEEK showed more damage elements along the bone around the cages in the L3 vertebral body posterior to the cage contact surfaces, followed by the area of the L4 vertebral body posterior to the cage contact surfaces. In analysis 3, in the L3 inferior surface in LS-PEEK the distribution of equivalent plastic strain was visualized as gradually expanding along the cages from the area posterior to the cages to the area anterior to them with increased loading. These analyses suggested that in PLIF for osteoporotic vertebral bodies, the localized stress concentration generated by the use of PEEK cages may cause accumulation of microscopic damage in the fragile osteoporotic vertebral bodies around the cages, which may result in cage subsidence.
Highlights
Since the 1990s, intervertebral cages have been generally used to provide stability in posterior lumbar interbody fusion (PLIF) until synostosis of the bone graft occurs [1,2,3,4,5]
Most previous studies of PLIF using Finite element analysis (FEA) have not taken into account the strength of osteoporotic bone in the elderly, and FEA analysis of PLIF in a model simulating vertebral bodies of normal bone strength for young people found almost no fractures [14], with the damage elements localized at the part of the bone around the cage
The digital imaging and communications in medicine (DICOM) data obtained from computed tomography (CT) scans of her lumbar spine were imported into the Mechanical Finder (MF)
Summary
Since the 1990s, intervertebral cages have been generally used to provide stability in posterior lumbar interbody fusion (PLIF) until synostosis of the bone graft occurs [1,2,3,4,5]. A number of studies have reported that cage subsidence may compromise clinical outcomes in the osteoporotic vertebral bodies of elderly patients, who are frequently treated with PLIF [6]. Most previous studies of PLIF using FEA have not taken into account the strength of osteoporotic bone in the elderly, and FEA analysis of PLIF in a model simulating vertebral bodies of normal bone strength for young people found almost no fractures [14], with the damage elements localized at the part of the bone around the cage. In order to understand the FEA of PLIF, it is important to consider osteoporosis and to take into account the mechanism of subsidence, with a special focus on the bone around the cages
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