The Role of Spinal Instrumentation in Augmenting Lumbar Posterolateral Fusion

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Abstract
Using a sheep model, clinically practical posterolateral intertransverse process fusion was successfully achieved and biomechanically tested to determine the load-sharing environment provided by spinal instrumentation and posterolateral fusion mass following solid arthrodesis. To quantify the in vivo load-sharing capacity of spinal instrumentation on augmenting the posterolateral intertransverse fusion. The hypothesis was that transpedicular screw fixation maintains the biomechanical contribution to the posterolateral fusion stability even after successful arthrodesis because of its providing anterior and middle column support. Although many previous studies have documented the biological and biomechanical advantages of posterolateral fusion, it is known that posterolateral fusion without spinal instrumentation allowed significant remaining motion at the fused segment even after the solid arthrodesis. Whether spinal instrumentation, especially transpedicular screw fixation, augments in vivo posterolateral fusion stability after solid arthrodesis has not been previously investigated. Radiographic, macroscopic, and biomechanical analyses of a posterolateral intertransverse process fusion model were performed on 18 sheep at 4 months postoperatively. The load-sharing contribution of the spinal instrumentation was calculated based on the stability with or without spinal instrumentation tested in five loading modalities. Histomorphometry of the vertebral body spanned by spinal instrumentation provided the information regarding the biological effect of the load-sharing capacity of spinal instrumentation on bone remodelling. All sheep who received posterolateral intertransverse process fusion demonstrated successful solid arthrodesis and high biomechanical quality of the posterolateral fusion mass when compared to previous posterolateral fusion models. The significant difference in stiffness between fixation and subsequent fixation removal was observed in flexion, despite maintaining high lateral bending stiffness equivalent to the fixation (with instrumentation) level. This significant load-sharing contribution of spinal instrumentation detected in flexion corresponded to 27% when compared to the fixation level. The qualitative and quantitative bone histology showed 64% of the volumetric density of bone in the fixation group when compared to that of the sham group as well as narrow trabeculae and reduced connection of trabeculae. The continuance in support offered by transpedicular screw fixation was assured in vivo after the solid posterolateral intertransverse process fusion. This was clearly demonstrated under eccentric loads in a sagittal plane, suggesting that transpedicular screw fixation was able to provide anterior and middle column support and resist eccentric loads.