Pullout Strength Of Pedicle Screws Research Articles

Patient-specific mechanical analysis of pedicle screw insertion in simulated osteoporotic spinal bone models derived from medical images.

Biomechanical study. To investigate the mechanical characteristics of bone models created from medical images. Recent advancements in three-dimensional (3D) printing technology have affected its application in surgery. However, a notable gap exists in the analyses of how patient's dimorphism and variations in vertebral body anatomy influence the maximum insertional torque (MIT) and pullout strength (POS) of pedicle screws (PS) in osteoporotic vertebral bone models derived from medical images. Male and female patients with computed tomography data were selected. Dimensions of the first thoracic (T1), fourth lumbar (L4), and fifth lumbar (L5) vertebrae were measured, and bone models consisting of the cancellous and cortical bones made from polyurethane foam were created. PS with diameters of 4.5 mm, 5.5 mm, and 6.5 mm were used. T1 PS were 25 mm long, and L4 and L5 PS were 40 mm long. The bone models were secured with cement, and the MIT was measured using a calibrated torque wrench. After MIT testing, the PS head was attached to the machine's crosshead. POS was then calculated at a crosshead speed of 5 mm/min until failure. The L4 and L5 were notably larger in female bone models, whereas the T1 vertebra was larger in male bone models. Consequently, the MIT and POS for L4 and L5 were higher in female bone models across all PS diameters than in male bone models. Conversely, the MIT for T1 was higher in male bone models across all PS; however, no significant differences were observed in the POS values for T1 between sexes. The mechanical properties of the proposed bone models can vary based on the vertebral structure and size. For accurate 3D surgical and mechanical simulations in the creation of custom-made medical devices, bone models must be constructed from patientspecific medical images.

Forcefully engaging rods into tulips with gap discrepancy leading to pedicle screw loosening—a biomechanical analysis using long porcine spine segments

BACKGROUND CONTEXTLong-segment pedicle screw instrumentation is widely used to treat complex spinal disorders. Rods are routinely precontoured to maximize assistance on the correcting side of the deformity, but there often exists a residual gap discrepancy between the precontoured rods and screw tulips. No previous research has investigated the diminished pullout strength of the most proximal or distal pedicle screw resulting from a mismatched rod in long-segment pedicle screw instrumentation. PURPOSEThe present study aimed to investigate the decreased pullout force of pedicle screws affected by the gap discrepancy when forcefully engaging a mismatched rod into a tulip in a normal-density porcine spine. STUDY DESIGNThe pedicle screw fixation strength under axial pullout force was compared among three different gap discrepancies between rods and tulips using long porcine spine segments. METHODSTwelve porcine lumbar vertebrae (L3–L6) were implanted with pedicle screws and rods. Screws on one side had no gap between the tulip and rod (0-mm group), while the most proximal screw on the other side had an intentional gap of 3 mm (3-mm group) or 6 mm (6-mm group). Three hours after forcefully engaging the rod into the tulips at room temperature, the set screws in all specimens were loosened, and each specimen was dissected into individual vertebrae for subsequent pullout testing. RESULTSThe control group exhibited significantly greater pullout strength (1987.68 ± 126.80 N) than the groups from different rod-tulip configurations (p<.05), with significantly greater strength in the 3-mm group (945.62 ± 97.43 N) than the 6-mm group (655.30 ± 194.49 N) (p<.05). Only 47.6% and 33.0% of the pullout strength was retained in the 3-mm and 6-mm groups, respectively, compared to the control group. CONCLUSIONSGap discrepancies between rods and tulips can significantly reduce pedicle screw pullout strength, with a correlation between decreased strength and increased gaps. Surgeons should avoid forcefully engaging mismatched rods and consider well-fitted contoured rods in spinal surgery to minimize the risk of screw loosening. CLINICAL SIGNIFICANCEThe gap discrepancy between rod and tulip significantly affected pullout strength, with greater gaps leading to reduced strength. Forcefully engaging mismatched rods into tulips in degenerative spinal surgery should be avoided to minimize the risk of early screw pullout.

Pullout strength of different pedicle screws after primary and revision insertion: an in vitro study on polyurethane foam

BackgroundSurgeons are routinely required to remove loose or failed pedicle screws and insert a new screw in their place. However, inserting a new screw into an existing hole may compromise the holding capacity of the pedicle screw. The purpose of this study is to evaluate the pullout strength of pedicle screws with different thread designs after the primary insertion and revision surgery in a synthetic bone model.MethodsFour pedicle screws with different thread designs (single-lead-thread (SLT) screw, dual-lead-thread (DLT) screw, mixed-single-lead-thread (MSLT) screw, and proximal-unthreaded-dual-thread (PUDL) screw) were inserted into pre-drilled, untapped holes (ø 4.2 mm, length 35 mm) in Sawbone blocks of density 20 pcf. In the first sequence, a 6.0 mm screw was inserted into the predrilled foam block and the primary pullout strength of the screw was measured according to ASTM F543. In the second sequence, a 6.0 mm screw was inserted and removed, and then either a 6.5 mm screw of the same design or a different screw design was inserted into the same hole and the pullout strength recorded.ResultsIn the first sequence, the mean pullout strength of the MSLT screw was significantly (p < 0.05) greater than all other screw designs. In the second sequence, when the MSLT screw was the primary screw, using a larger MSLT screw (6.5 mm) as the revision screw did not lead to a higher pullout strength than if a 6.0 mm diameter PUDL screw was used for the revision. Using a larger DLT screw (6.5 mm) as the revision screw resulted in a significantly (p < 0.05) greater pullout strength than a 6.0 mm STL, DLT, MSLT, or PUDL screw.ConclusionsOur results indicate that employing classic oversizing of the same screw design is a safe choice for maintaining screw purchase in the bone after revision. In cases where oversizing with the same screw design is not practical, opting for a PUDL screw with the same original diameter can provide enough purchase in the bone to maintain stability.

Bone density optimized pedicle screw insertion.

Background: Spinal fusion is the most common surgical treatment for the management of degenerative spinal disease. However, complications such as screw loosening lead to painful pseudoarthrosis, and are a common reason for revision. Optimization of screw trajectories to increase implant resistance to mechanical loading is essential. A recent optimization method has shown potential for determining optimal screw position and size based on areas of high bone elastic modulus (E-modulus). Aim: The aim of this biomechanical study was to verify the optimization algorithm for pedicle screw placement in a cadaveric study and to quantify the effect of optimization. The pull-out strength of pedicle screws with an optimized trajectory was compared to that of a traditional trajectory. Methods: Twenty-five lumbar vertebrae were instrumented with pedicle screws (on one side, the pedicle screws were inserted in the traditional way, on the other side, the screws were inserted using an optimized trajectory). Results: An improvement in pull-out strength and pull-out strain energy of the optimized screw trajectory compared to the traditional screw trajectory was only observed for E-modulus values greater than 3500MPacm3. For values of 3500MPacm3 or less, optimization showed no clear benefit. The median screw length of the optimized pedicle screws was significantly smaller than the median screw length of the traditionally inserted pedicle screws, p < 0.001. Discussion: Optimization of the pedicle screw trajectory is feasible, but seems to apply only to vertebrae with very high E-modulus values. This is likely because screw trajectory optimization resulted in a reduction in screw length and therefore a reduction in the implant-bone interface. Future efforts to predict the optimal pedicle screw trajectory should include screw length as a critical component of potential stability.

Percutaneous Juxtapedicular Cement Salvage of Failed Spinal Instrumentation? Institutional Experience and Cadaveric Biomechanical Study.

Instrumented spinal fusion constructs sometimes fail because of fatigue loading, frequently necessitating open revision surgery. Favorable outcomes after percutaneous juxtapedicular cement salvage (perc-cement salvage) of failing instrumentation have been described; however, this approach is not widely known among spine surgeons, and its biomechanical properties have not been evaluated. We report our institutional experience with perc-cement salvage and investigate the relative biomechanical strength of this technique as compared with 3 other common open revision techniques. A retrospective chart review of patients who underwent perc-cement salvage was conducted. Biomechanical characterization of revision techniques was performed in a cadaveric model of critical pedicle screw failure. Three revision cohorts involved removal and replacement of hardware: (1) screw upsizing, (2) vertebroplasty, and (3) fenestrated screw with cement augmentation. These were compared with a cohort with perc-cement salvage performed using a juxtapedicular trajectory with the failed primary screw remaining engaged in the vertebral body. Ten patients underwent perc-cement salvage from 2018 to 2022 to address screw haloing and/or endplate fracture threatening construct integrity. Pain palliation was reported by 8/10 patients. Open revision surgery was required in 4/10 patients, an average of 8.9 months after the salvage procedure (range 6.2-14.7 months). Only one revision was due to progressive hardware dislodgement. The remainder avoided open revision surgery through an average of 1.9 years of follow-up. In the cadaveric study, there were no significant differences in pedicle screw pullout strength among any of the revision cohorts. Perc-cement salvage of failing instrumentation is reasonably efficacious. The technique is biomechanically noninferior to other revision strategies that require open surgery for removal and replacement of hardware. Open revision surgery may be avoided by perc-cement salvage in select cases.

Postfusion effect on pullout strength of pedicle screws with expandablepeek shell and conventional screws.

The pullout performance of various pedicle screws after artificial fusion process was investigated in this study. Normal, cannulated (cemented), novel expandable and normal (cemented) pedicle screws were tested. Polyurethane foams (Grade 10 and Grade 40) produced by casting method were used as test materials. The instrumentation of pedicle screws has been carried out with production of foams, simultaneously. For cemented pedicle screws, 3D models were prepared with respect to the anteriosuperior and oblique radiographs by using PMMA before casting procedure. Pullout tests were performed in an Instron 3369 testing device. Load versus displacement graph was recorded and the ultimate force was defined as the pullout strength sustained before failure of screw. As expected, the pullout strengths of pedicle screws in postfusion are higher than before fusion. Pullout strengths increased significantly by artificial fusion in Grade 10 foams compared to Grade 40 foams. Additionally, while the pullout strengths of normal, cannulated and novel expandable pedicle screws increased by artificial fusion, cemented normal pedicle screws had lower pullout values than before fusion in Grade 40 foams. When the cemented normal pedicle screws are excluded, other screws have almost similar pullout strength level. On the other hand, the pedicle screws have different increasing behaviour also, there is no correlation between each other. As a result, the novel expandable pedicle screws can be used instead of normal and cannulated ones due to their performances in non-cemented usage.

Predicting pullout strength of pedicle screws in broken bones from X-ray images

Pedicle screw fixation is one of the most common procedures used in spinal fusion surgery. The screw loosening is a major concern, which may be caused by broken pedicles. In vitro pullout tests or insertion torque are the main approaches for assessing the stability of the screw; however, direct evidence was lacking for clinical human spines. Here, we aim to provide a model that can predict the pullout strengths of pedicle screws in various pedicle conditions from X-ray images. A weighted embedded bone volume (EBV) model is proposed for pullout strengths prediction by considering the bone heterogeneity and confinement of the screw. We showed that the pullout strength is proportional to the EBV for homogeneous bone and the weighted EBV for layered composite bone. The proposed weighted EBV model is validated with in vitro Sawbones® pullout experiments. The results show that the model has better accuracy than the simple EBV model, with a coefficient of determination of 0.94. The proposed weighted EBV model can help assess the stability of a pedicle screw in a broken pedicle by simply examining 2D X-ray images.

Insertional torque and pullout strength of pedicle screws versus titanium suture Anchors: Towards development of a novel proximal junctional kyphosis prevention technique

Proximal junctional kyphosis (PJK) is a common and devastating complication after spinal deformity surgery with a high need for revision surgery. PJK often leads to poor patient outcomes and large societal costs, which has led to the development of multiple prophylactic methods which have yet to eliminate PJK. A novel method for PJK prevention includes placing suture anchors, rather than pedicle screws, above the spinal construct to function as a tether. This biomechanical investigation examined the insertional torque and pullout strength of pedicle screws compared to suture anchors on 6 cadaveric vertebrae (12 pedicles). The mean insertional torque was 0.802 ± 0.477 N*m for pedicle screws and 0.368 ± 0.310 N*m for suture anchors (p = 0.047). The mean pullout strength was 973.16 ± 202.03 N for pedicle screws and 206.94 ± 181.78 N for suture anchors (p < 0.01). This study demonstrated that suture anchors had both less insertional torque and pullout strength compared to pedicle screws and may provide a more physiologic stress taper at the upper instrumented vertebrae of long-segment spinal constructs to help prevent proximal junctional kyphosis or catastrophic proximal junctional failure. Further research is needed to examine the biomechanics of this in long-segment constructs as well as in vivo performance of suture anchors as proximal junctional kyphosis prophylaxis.

Pullout strength of pedicle screws using cadaveric vertebrae with or without artificial demineralization

OBJECTIVESTo evaluate the differences in the pullout strength and displacement of pedicle screws in cadaveric thoracolumbar vertebrae with or without artificial demineralization. METHODSFive human lumbar and five thoracic vertebrae from one cadaver were divided into two hemivertebrae. The left-side specimens were included in the simulated osteopenic model group and the right-side bones in a control group. In the model group, we immersed each specimen in HCl (1 N) solution for 40 minutes. We measured bone mineral density (BMD) using dual-energy X-ray absorptiometry and quantitative computerized tomography. We inserted polyaxial pedicle screws into the 20 pedicles of the cadaveric lumbar and thoracic spine after measuring the BMD of the 2 hemivertebrae of each specimen. We measured the pullout strength and displacement of the screws before failure in each specimen using an Instron system. RESULTSThe average pullout strength of the simulated osteopenic model group was 76% that of the control group. In the control and model groups, the pullout strength was 1678.87±358.96 N and 1283.83±341.97 N, respectively, and the displacement was 2.07±0.34 mm and 2.65±0.50 mm, respectively (p<.05). We detected positive correlations between pullout strength and BMD in the control group and observed a negative correlation between displacement and BMD in the model group. CONCLUSIONSBy providing an anatomically symmetric counterpart, the human cadaveric model with or without demineralization can be used as a test bed for pullout tests of the spine. In the simulated osteopenic model group, pullout strength was significantly decreased compared with the untreated control group. CLINICAL SIGNIFICANCEDecreased bone mineral density may significantly reduce the pullout strength of a pedicle screw, even though the range is osteopenic rather than osoteoporotic.

The effect of denosumab on pedicle screw fixation: a prospective 2-year longitudinal study using finite element analysis

BackgroundPedicle screw loosening is a major complication following spinal fixation associated with osteoporosis in elderly. However, denosumab is a promising treatment in patients with osteoporosis. The effect of denosumab on pedicle screw fixation is unknown. Therefore, we investigated whether denosumab treatment improves pedicle screw fixation in elderly patients with osteoporosis.MethodsThis was a 2-year prospective open-label study. From February 2015 to January 2016, we included 21 patients with postmenopausal osteoporosis who received initial denosumab treatment. At baseline, 12 months, and 24 months, we measured volumetric bone mineral density (BMD) using quantitative computed tomography (QCT) and performed CT-based finite element analysis (FEA). Finite element models of L4 vertebrae were created to analyze the bone strength and screw fixation.ResultsBMD increased with denosumab treatment. FEA revealed that both pullout strength of pedicle screws and compression force of the vertebra increased significantly at 12 and 24 months following denosumab treatment. Notably, pullout strength showed a stronger correlation with three-dimensional volumetric BMD around pedicle screw placement assessed by QCT (r = 0.83, at 24 months) than with two-dimensional areal BMD assessed by dual energy X-ray absorptiometry (r = 0.35, at 24 months).ConclusionTo our knowledge, this is the first study to reveal that denosumab treatment achieved strong pedicle screw fixation with an increase in BMD around the screw assessed by QCT and FEA; therefore, denosumab could be useful for osteoporosis treatment during spinal surgery in elderly patients with osteoporosis.

Effect of thread profile variation on pullout and bending strength of a pedicle screw

Pedicle screw is an important instrument in treatment of spinal degeneration or disease. However, the pedicle screw failure still occurs due to the screw loosening, fracture and pullout. There are few factors that affected the pedicle screw performance as reported by previous research but still lacking study related to the pedicle screw thread profile. Thus, the aim of this research is to investigate the effect of variation of thread pitch on the pullout and bending strength of pedicle screw. The research is carried out by constructing 3D pedicle screw models (model 1-6), importing the models into ANSYS, meshing and post processing analysis. The equivalent or Von-Mises stress used to compare the bending and pullout performance of the pedicle screws. Based on the obtained finite element analysis result, the single thread pedicle screw (model 3) has the optimum performance in bending while the model 4 is the optimum in pullout performance. While, for the dual threaded pedicle screw, the model 6 which has coarse thread pitch at screw tip is better than model 5 (fine thread). Thus, it can be conclude that both the single and dual threaded pedicle screw with coarse thread pitch has lower maximum equivalent stress than fine thread pitch, which is means it has better bending and pullout performance.

Toggling effect on pullout performance of pedicle screws: Review

Screw loosening in spine surgery is a clinical complication in patients with poor bone quality. Pedicle screws are subjected to bending moments and axial loads that may cause toggling during daily movements of spine. The purpose of this study was to assess the previous studies related to toggling effect on pullout performance of pedicle screws by surveying the whole literature and to provide some discussion for new studies about pullout performance of pedicle screws after toggling. The search was performed by combining terms of pedicle screw, toggling, screw loosening, fatigue, cyclic loading, and pullout. The retrieved articles dealing with determined terms and also their references were reviewed. Some of these articles were eliminated after review process. Toggling was determined to be crucial for the stabilization performance of pedicle screw because the loosening mechanism of screws was affected directly by cyclic loading. The toggling or cyclic loading affected the holding capacity of pedicle screws negatively, and the possibility of loosening or failure problem for pedicle screws increased with cyclic loading magnitude. Loading conditions, screw properties, test medium, level of spinal region, and cement usage were determined by many researchers as the most important parameters affecting the toggling performance as well as the pullout strength of pedicle screws. The pullout strength of pedicle screws generally decreased with cyclic loading. The parameters of cyclic loading were fairly important for pullout performance of pedicle screws. Screw properties and cement augmentation had critical effects on the stability of screws under cyclic loading, as well.

Pull-Out Strength Comparison Among Conventional Pedicle Screw, Cortical Infero-Superior, and Cortical Supero-Inferior Trajectories in Yorkshire Porcine Lumbar Spines: A Biomechanical Study.

Posterior instrumentation of the spine presents a challenge, especially in conditions with low bone quality. Pedicle screw insertion with cortical bone trajectory is designed to add interface between the screw and the bone through engagement between pedicles and the cortex when compared to conventional screw course. Pedicle screw insertion trajectory from cortical infero-superior and the proposed cortical supero-inferior should obtain better pull-out performance than conventional pedicle trajectory. We aim to evaluate the pull-out strength differences among conventional pedicle screw, cortical infero-superior, and cortical supero-inferior trajectories. Samples from Yorkshire porcine lumbar spine (L1-L5; n = 30) were relieved of soft tissue attachments and dried. Morphometric measurements were conducted, and the samples were randomly assigned to 3 groups. The screws were inserted into the vertebrae by drilling with the 3 trajectories: conventional, cortical infero-superior, and cortical supero-inferior. The trajectories of the screws were examined using x-rays. Pull-out tests were conducted by applying uniaxial traction in line with the screw trajectory with a translational speed of 5 mm/min. The results of the pull-out are measured in Newtons. We obtained a mean value of pull-out force in conventional trajectory of 491.72 ± 187.2 N, cortical infero-superior of 822.16 ± 295.73 N, and cortical supero-inferior of 644.14 ± 201.97 N. Cortical infero-superior and cortical supero-inferior trajectories attained 67% and 30% higher pull-out mean, respectively. Using 1-way analysis of variance and a post hoc Tukey test revealed a significant difference between cortical infero-superior and conventional trajectories (P < .01). Differing pull-out strengths between cortical infero-superior and supero-inferior trajectories showed no statistical significance. Results of our study showed a 30% higher pull-out strength in our proposed trajectory than the conventional one, although not statistically significant. The trajectory of the screws within the lumbar spine seemed to have an impact in pull-out strength. Cortical bone engagement using the novel trajectories may increase pull-out strength of pedicle screws. Level 5.

Direct vertebral rotation significantly decreases the pullout strength of the pedicle screw: a biomechanical study in adult cadavers.

The pullout strength of the pedicle screws after direct vertebral rotation (DVR) maneuver is not known. This biomechanical study was performed to quantitatively analyze the pullout strength of a pedicle screw after DVR maneuver using human cadaveric vertebrae. Thoracic vertebral bodies from three cadavers were harvested and stripped of soft tissues. Thirty pedicles of 15 vertebrae were separated into two groups after bone mineral density measurements. Polyaxial 5.5 mm pedicle screws with appropriate length were inserted with a freehand technique for each pedicle. One Kirschner wire was inserted to the anterior part of each vertebral corpus the half depth of each corpus was embedded into PVC pipes using polyester paste. In the DVR group, each screw was pulled horizontally with 2 kg (~20 N) load over a screwdriver rigidly attached to the screw, and a DVR maneuver was simulated. The control group did not load with a DVR maneuver. Samples were placed on a universal testing machine and pullout loads were measured. The Mann-Whitney U test was utilized, and the P value <0.05 was considered as statistically significant. In the DVR group, the mean pullout strength was 183.35 N (SD ± 100.12), and in the control group, the mean pullout strength was 279.95 N (SD ± 76.26). Intergroup comparisons revealed that DVR maneuver significantly decreases the pullout strength (P = 0.012). The results of this study confirm that the pullout strength of pedicle screw significantly decreases by approximately 35% when DVR maneuver is applied.

Comparison of biomechanical properties of cervical paravertebral foramen screws, lateral mass screws and pedicle screws

Objective To investigate and compare the biomechanical strength of paravertebral foramen screws (PVFS), lateral mass screws (LMS) and pedicle screws (PS). Methods A total of 30 human cervical spine vertebrae (C3-C6) were harvested from 8 fresh-frozen cadaver specimens whose mean age was 45.3±11.2 years at death. The vertebrae were randomly divided into three groups for specific screws. For each vertebra, one side was randomly chosen for direct pullout strength test (speed 5 mm/s), and the other side for fatigue test (displacement ±1.0 mm, frequency 1 Hz, 500 cycles) and residual pullout strength test. 4.5 mm × 12 mm screws were used for PVFS, 3.5 mm × 14 mm screws for LMS, and 3.5 mm × 24 mm screws for PS. Results The direct pullout strength was 327.10±17.07 N for PVFS, 305.71 ± 11.63 N for LMS, and 635.67 ± 22.82 N for PS. The residual pullout strength was 265.62 ±18.19 N for PVFS, 192.80 ±17.10 N for LMS, and 494.89 ±41.79 N for PS. The residual pullout strength of PVFS, LMS and PS respectively, compared with the direct pullout strength, decreased by 18.8%, 36.93% and 22.15% (tPVFS=7.795, tLMS=17.267, tPS=9.349, P<0.001). The direct pullout strength of PS was higher than that of PVFS and LMS(t=34.245, t=40.741, P< 0.001), as well as PVFS was slightly higher than LMS (t=3.275, P=0.004). The residual pullout strength of PS was the highest, PVFS was the second, and LMS was the smallest (F=314.619, P<0.001). For the fatigue test, the load at the first cycle and the first time when the set position was reached of PVFS were higher than those of LMS (t=3.625, P=0.002; t=5.388, P<0.001) and PS (t=2.575, P=0.019; t=2.680, P=0.015), but there was no difference between those of LMS and PS (t=0.609, P=0.550; t=1.953, P=0.067). The load at the last cycle of PVFS and PS was higher than that of LMS (t=5.341, P<0.001; t=3.439, P=0.003), while there was no difference between PVFS and PS (t=1.606, P=0.126). Conclusion The direct pullout strength of PVFS was slightly higher than that of LMS, and the residual pullout strength was significantly higher than LMS. The property of fatigue resistance of PVFS was similar to PS and obviously better than LMS. In summary, PVFS can be used as an effective substitute for LMS and PS. Key words: Cervical vertebrae; Spinal fusion; Bone screws; Biomechanics

Correlation between the Computed Tomography Values of the Screw Path and Pedicle Screw Pullout Strength: An Experimental Study in Porcine Vertebrae.

Study DesignBiomechanical study.PurposeTo assess the correlation between the computed tomography (CT) values of the pedicle screw path and screw pull-out strength.Overview of LiteratureThe correlation between pedicle screw pull-out strength and bone mineral density has been well established. In addition, several reports have demonstrated a correlation between bone mineral density and CT values. However, no previous biomechanical studies investigated the correlation between CT values and pedicle screw pull-out strength.MethodsSixty fresh-frozen lumbar vertebrae from 6-month-old pigs were used. Before screw insertion, the CT values of the screw path were obtained for each sample. Specimens were then randomly divided into three equal groups. Each group had one of three pedicle screws inserted: 4.0-mm LEGACY (4.0-LEG), 4.5-mm LEGACY (4.5-LEG), or 4.5-mm SOLERA (4.5-SOL) (all from Medtronic Sofamor Danek Inc., Memphis, TN, USA). Each screw had a consistent 30-mm thread length. Axial pull-out testing was performed at a rate of 1.0 mm/min. Correlations between the CT values and pedicle screw pull-out strength were evaluated using Pearson’s correlation coefficient analysis.ResultsThe correlation coefficients between the CT values of the screw path and pedicle screw pull-out strength for the 4.0-LEG, 4.5-LEG, and 4.5-SOL groups were 0.836 (p<0.001), 0.780 (p<0.001), and 0.873 (p<0.001), respectively. Greater CT values were associated with greater screw pull-out strength.ConclusionsThe CT values of the screw path were strongly positively correlated with pedicle screw pull-out strength, regardless of the screw type and diameter, suggesting that the CT values could be clinically useful for predicting pedicle screw pull-out strength.

Comparison of pullout strength of pedicle screws following revision using larger diameter screws

Pedicle screw fixation and fusion are the gold standard for the treatment of spinal instability. Screw failures such as pullout and breakages have been reported during the past several years of research and development in this field. Further, the rate of revision surgeries due to failed pedicle screws is around 2–12%. This creates unavoidable hardship to the patients. Improper screw size for revision surgery can lead to complications such as pedicle fractures, screw pullout, or reduced stability of the fusion construct. We performed pullout strength studies on five osteoporotic lumbar vertebra and a rigid polyurethane foam block to find the effect of the outer diameter of revision screws as per American Standards for Testing of Materials (ASTM) 543–07 protocol. The present study revealed that whereas the use of revision screws that were one millimeter greater in diameter than the original screws decreased the pullout strength by 79% in the foam model, the pullout strength increased by 121% when the original index screws were replaced with screws that were two millimeters greater in diameter. The effect of revision screw diameter on pullout strength was significant (p < 0.05). Cadaveric testing reveals a trend that agrees with the foam model tests.

Pullout Strength Predictor: A Machine Learning Approach.

Study DesignA biomechanical study.PurposeTo develop a predictive model for pullout strength.Overview of LiteratureSpine fusion surgeries are performed to correct joint deformities by restricting motion between two or more unstable vertebrae. The pedicle screw provides a corrective force to the unstable spinal segment and arrests motions at the unit that are being fused. To determine the hold of a screw, surgeons depend on a subjective perioperative feeling of insertion torque. The objective of the paper was to develop a machine learning based model using density of foam, insertion angle, insertion depth, and reinsertion to predict the pullout strength of pedicle screw.MethodsTo predict the pullout strength of pedicle screw, an experimental dataset of 48 data points was used as training data to construct a model based on different machine learning algorithms. A total of five algorithms were tested in the Weka environment and the performance was evaluated based on correlation coefficient and error matrix. A sensitive study of various parameters for obtaining the best combination of parameters for predicting the pullout strength was also preformed using the L9 orthogonal array of Taguchi Design of Experiments.ResultsRandom forest performed the best with a correlation coefficient of 0.96, relative absolute error of 0.28, and root relative squared error of 0.29. The difference between the experimental and predicted value for the six test cases was not significant (p >0.05).ConclusionsThis model can be used clinically for understanding the failure of pedicle screw pullout and pre-surgical planning for spine surgeon.

Comparison of the Pullout Strength of Pedicle Screws According to the Thread Design for Various Degrees of Bone Quality

Although dual-threaded pedicle screws have been developed, the advantages over single-threaded screws remain controversial. We aimed to investigate the biomechanical performance of two types of dual-threaded pedicle screw by comparing their pullout strength with that of a single-threaded screw in relation to bone quality. Four types of pedicle screw with different thread patterns were designed. Type I: single-threaded screw; Type II: double-threaded screw; Type III: dual-threaded screw; Type IV: a newly designed double dual-threaded screw. Five types of polyurethane foams simulating various degrees of bone quality were used. These were: Type A: cancellous bone; Type B: cancellous bone with cortical bone in the upper margin; Type C: osteoporotic cancellous bone; Type D: osteoporotic cancellous bone with cortical bone in the upper margin; and Type E: osteoporotic bone with cortical bone in the upper and lower margins. A comparison of the pullout strength of Type I, II, and III screws in Type A, B, C and D bone specimens was performed. Type C and E bone specimens were used for comparisons among Type I, II, and IV screws. Compared to the single-threaded screw, the dual-threaded pedicle screws exhibited higher pullout strength in normal-quality bone and significantly lower pullout strength in compromised osteoporotic bone. However, the double dual-threaded screw exhibited better pullout biomechanics in osteoporotic bone with bi-cortical bone.

Pullout Strength of Pedicle Screws Following Redirection After Lateral or Medial Wall Breach.

A cadaveric biomechanical study designed to test the pullout strength of pedicle screws. To evaluate the pullout strength of redirected pedicle screws with a larger diameter following lateral wall breach, redirected pedicle screws of the same diameter following medial wall breach, and redirected pedicle screws with a larger diameter following medial wall breach. Screw malposition is one of the main pitfalls of inserting pedicle screws. Intraoperatively a malpositioned screw is redirected and inserted along the correct axis. Forty-seven vertebrae (T9-L5) were harvested from eight fresh cadaveric spines. The 18 pedicle screws that breached the lateral wall were then removed and redirected using a pedicle screw of 1 mm larger in diameter. The 16 pedicle screws that had breached the medial wall were then removed and redirected using a pedicle screw of the same diameter. The other 13 pedicle screws that had breached the medial wall were then removed and redirected using a pedicle screw of 1 mm larger in diameter. The pullout strength was measured. Following lateral wall breach, mean pullout strength for the larger redirected screws was 46.9% greater than that of the correctly aligned screws. Following medial wall breach, mean pullout strength for the redirected screws of the same diameter was 20.6% less than that of the correctly aligned screws. Mean pullout strength for the larger pedicle screws following medial wall breach was 27.3% more than that of the correctly aligned screws. Redirected pedicle screws of larger diameter after a lateral or medial pedicle breach show recovery of pullout strength. However, the pullout strength of redirected pedicle screws of the same diameter after a medial pedicle breach is significantly less than that of correctly aligned screws. 1.