BACKGROUND CONTEXT In lumbar spine motion preservation, either two-level motion preservation or motion preservation device adjacent to fusion (hybrid construct), are alternatives to two-level fusion when treating a symptomatic segment next to a level that has only mild radiographic changes. By preserving motion, this strategy may theoretically protect the adjacent mobile segments. PURPOSE This work investigated the protective effect on L3-L4 of a L4-S1 hybrid construct and a L4-S1 two-level total joint replacement (TJR). STUDY DESIGN/SETTING Biomechanical cadaveric study. OUTCOME MEASURES Segmental motion. METHODS Segmental motion data were collected in human cadaveric spine specimens (T10-S1, N=8, 56±5 years) during simulation of standing flexion and the transition from standing to sitting. To determine the protective effect, we determined the change in motion at L3-L4 during activities of daily living when the segment was adjacent to a hybrid L4-S1 construct (a motion-preserving total joint replacement (TJR) at L4-L5 with fusion at L5-S1) and a two-level TJR (L4-S1). Change was calculated using displacement-control analysis. L3-L4 motion before surgery was the reference value. RESULTS Forward flexion while standing: mean L3-L4 motion with an L4-S1 hybrid construct was a tenth of a degree less than intact L3-L4 motion (Hybrid 4.8° (1.6°) vs 4.9° (1.2°), p>0.05; data is mean (standard deviation)). Adjacent to an L4-S1 TJR, the average L3-L4 motion was 1.2 degrees less than intact. This reduction in L3-L4 motion over intact was statistically significant (L4-S1 TJR 3.7° (1.2°), p=0.006). Transition from standing to sitting: L3-L4 motion for the same reduction in sacral slope (or comparable sitting posture) was not significantly different from intact with hybrid and 2-level motion preservation constructs (Intact 3.8°(1.2°), hybrid 4.0°(1.3°), L4-S1 TJR, 2.7°(1.1°), p>0.05). On average, L3-L4 motion was 0.2 degrees higher with the L4-S1 hybrid construct and 1.1 degrees lower with the two-level L4-S1 TJR. CONCLUSIONS The hybrid and two-level total joint replacement constructs did not exhibit the increased proximal segment motion during forward bending and sitting activities that may lead to junctional breakdown over time. Preserving motion using a hybrid construct or two-level total joint replacement may be an alternative surgical option to improve patient comfort and function during activities of daily living while potentially decreasing the need for adjacent level surgery. FDA DEVICE/DRUG STATUS MOTUS (Investigational/Not Approved) In lumbar spine motion preservation, either two-level motion preservation or motion preservation device adjacent to fusion (hybrid construct), are alternatives to two-level fusion when treating a symptomatic segment next to a level that has only mild radiographic changes. By preserving motion, this strategy may theoretically protect the adjacent mobile segments. This work investigated the protective effect on L3-L4 of a L4-S1 hybrid construct and a L4-S1 two-level total joint replacement (TJR). Biomechanical cadaveric study. Segmental motion. Segmental motion data were collected in human cadaveric spine specimens (T10-S1, N=8, 56±5 years) during simulation of standing flexion and the transition from standing to sitting. To determine the protective effect, we determined the change in motion at L3-L4 during activities of daily living when the segment was adjacent to a hybrid L4-S1 construct (a motion-preserving total joint replacement (TJR) at L4-L5 with fusion at L5-S1) and a two-level TJR (L4-S1). Change was calculated using displacement-control analysis. L3-L4 motion before surgery was the reference value. Forward flexion while standing: mean L3-L4 motion with an L4-S1 hybrid construct was a tenth of a degree less than intact L3-L4 motion (Hybrid 4.8° (1.6°) vs 4.9° (1.2°), p>0.05; data is mean (standard deviation)). Adjacent to an L4-S1 TJR, the average L3-L4 motion was 1.2 degrees less than intact. This reduction in L3-L4 motion over intact was statistically significant (L4-S1 TJR 3.7° (1.2°), p=0.006). Transition from standing to sitting: L3-L4 motion for the same reduction in sacral slope (or comparable sitting posture) was not significantly different from intact with hybrid and 2-level motion preservation constructs (Intact 3.8°(1.2°), hybrid 4.0°(1.3°), L4-S1 TJR, 2.7°(1.1°), p>0.05). On average, L3-L4 motion was 0.2 degrees higher with the L4-S1 hybrid construct and 1.1 degrees lower with the two-level L4-S1 TJR. The hybrid and two-level total joint replacement constructs did not exhibit the increased proximal segment motion during forward bending and sitting activities that may lead to junctional breakdown over time. Preserving motion using a hybrid construct or two-level total joint replacement may be an alternative surgical option to improve patient comfort and function during activities of daily living while potentially decreasing the need for adjacent level surgery.
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