Use of Nonlinear Finite Element Analysis of Bone Density to Investigate the Biomechanical Effect in the Bone around Intervertebral Cages in Posterior Lumbar Interbody Fusion
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.
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Korovessis, P., Repantis, T., Baikousis, A. and Iliopoulos, P. (2012) Posterolateral versus Circumferential Instrumented Fusion for Monosegmental Lumbar Degenerative Disc Disease using an Expandable Cage. European Journal of Orthopaedic Surgery & Traumatology, 22, 639-645. https://doi.org/10.1007/s00590-011-0890-y
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Brantigan, J.W. and Steffee, A.D. (1993) A Carbon Fiber Implant to Aid Interbody Lumbar Fusion: Two-Year Clinical Results in the First 26 Patients. Spine, 18, 2106-2117. https://doi.org/10.1097/00007632-199310001-00030
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Matge, G. (2002) Cervical Cages Fusion with 5 Different Implants: 250 Cases. Acta Neurochirurgica, 144, 539-549. https://doi.org/10.1007/s00701-002-0939-0
Steffen, T., Tsantrizos, A., Fruth, I. and Aebi, M. (2000) Cages: Designs and Concepts. European Spine Journal, 9, S89-S94. https://doi.org/10.1007/PL00010027
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Hou, Y. and Yuan, W. (2012) Influences of Disc Degeneration and Bone Mineral Density on the Structural Properties of Lumbar End Plates. The Spine Journal, 12, 249-256. https://doi.org/10.1016/j.spinee.2012.01.021
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Wang, Z., Fu, S., Wu, Z.X., Zhang, Y. and Lei, W. (2013) Ti2448 Pedicle Screw System Augmentation for Posterior Lumbar Interbody Fusion. Spine, 38, 2008-2015. https://doi.org/10.1097/BRS.0b013e3182a76fec
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Vadapalli, S., Sairyo, K., Goel, V.K., Robon, M., Biyani, A., Khandha, A. and Ebraheim, N.A. (2006) Biomechanical Rationale for Using Polyetheretherketone (PEEK) Spacers for Lumbar Interbody Fusion—A Finite Element Study. Spine, 31, E992-E998. https://doi.org/10.1097/01.brs.0000250177.84168.ba
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Xiao, Z., Wang, L., Gong, H. and Zhu, D. (2012) Biomechanical Evaluation of Three Surgical Scenarios of Posterior Lumbar Interbody Fusion by Finite Element Analysis. Biomed Eng Online, 11, 31. https://doi.org/10.1186/1475-925X-11-31
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Liu, X., Ma, J., Park, P., Huang, X., Xie, N. and Ye, X. (2017) Biomechanical Comparison of Multilevel Lateral Interbody Fusion with and without Supplementary Instrumentation: A Three-Dimensional Finite Element Study. BMC Musculoskeletal Disorders, 18, 63. https://doi.org/10.1186/s12891-017-1387-6
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Alapan, Y., Demir, C., Kaner, T., Guclu, R. and Inceoglu, S. (2013) Instantaneous Center of Rotation Behavior of the Lumbar Spine with Ligament Failure. Journal of Neurosurgery: Spine, 18, 617-626. https://doi.org/10.3171/2013.3.SPINE12923
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Mazlan, M.H., Todo, M., Takano, H. and Yonezawa, I. (2016) Effect of Cage Insertion Orientation on Stress Profiles and Subsidence Phenomenon in Posterior Lumbar Interbody Fusion. Journal of Medical and Bioengineering, 5, 93-97.
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Matsuura, Y., Giambini, H., Ogawa, Y., Fang, Z., Thoreson, A.R., Yaszemski, M.J., Lu, L. and An, K.N. (2014) Specimen-Specific Nonlinear Finite Element Modeling to Predict Vertebrae Fracture Loads after Vertebroplasty. Spine, 39, E1291-E1296. https://doi.org/10.1097/BRS.0000000000000540
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Keyak, J.H., Meagher, J.M., Skinner, H.B. and Mote, C.D. (1990) Automated Three-Dimensional Finite Element Modelling of Bone: A New Method. Journal of Biomedical Engineering, 12, 389-397.
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Keyak, J.H., Rossi, S.A., Jones, K.A. and Skinner, H.B. (1998) Prediction of Femoral Fracture Load using Automated Finite Element Modeling. Journal of Biomechanics, 31, 125-133.
[46]
Tsuang, Y.H., Chiang, Y.F., Hung, C.Y., Wei, H.W., Huang, C.H. and Cheng, C.K. (2009) Comparison of Cage Application Modality in Posterior Lumbar Interbody Fusion with Posterior Instrumentation—A Finite Element Study. Medical Engineering & Physics, 31, 565-570.
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Kaneko, T.S., Pejcic, M.R., Tehranzadeh, J. and Keyak, J.H. (2003) Relationships between Material Properties and CT Scan Data of Cortical Bone with and without Metastatic Lesions. Medical Engineering & Physics, 25, 445-454.
[48]
Keaveny, T.M., Wachtel, E.F., Ford, C.M. and Hayes, W.C. (1994) Differences between the Tensile and Compressive Strengths of Bovine Tibial Trabecular Bone Depend on Modulus. Journal of Biomechanics, 27, 1137-1146.
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Bessho, M., Ohnishi, I., Matsuyama, J., Matsumoto, T., Imai, K. and Nakamura, K. (2007) Prediction of Strength and Strain of the Proximal Femur by a CT-Based Finite Element Method. Journal of Biomechanics, 40, 1745-1753.
[50]
Kurtz, S.M. and Devine, J.N. (2007) PEEK Biomaterials in Trauma, Orthopedic, and Spinal Implants. Biomaterials, 28, 4845-4869.
[51]
Chen, S.H., Lin, S.C., Tsai, W.C., Wang, C.W. and Chao, S.H. (2012) Biomechanical Comparison of Unilateral and Bilateral Pedicle Screws Fixation for Transforaminal Lumbar Interbody Fusion after Decompressive Surgery—A Finite Element Analysis. BMC Musculoskeletal Disorders, 16, 72. https://doi.org/10.1186/1471-2474-13-72
[52]
Oh, K.W., Lee, J.H., Lee, D.Y. and Shim, H.J. (2017) The Correlation between Cage Subsidence, Bone Mineral Density, and Clinical Results in Posterior Lumbar Interbody Fusion. Clinical Spine Surgery, 30, E683-E689.
[53]
Lang, G., Navarro-Ramirez, R., Gandevia, L., Hussain, I., Nakhla, J., Zubkov, M. and Härtl, R. (2017) Elimination of Subsidence with 26-Mm-Wide Cages in Extreme Lateral Interbody Fusion. World Neurosurgery, 104, 644-652.
[54]
Korovessis, P., Repantis, T., Baikousis, A. and Iliopoulos, P. (2012) Posterolateral versus Circumferential Instrumented Fusion for Monosegmental Lumbar Degenerative Disc Disease using an Expandable Cage. European Journal of Orthopaedic Surgery & Traumatology, 22, 639-645. https://doi.org/10.1007/s00590-011-0890-y
[55]
Lee, J.H., Lee, D.O., Lee, J.H. and Shim, H.J. (2015) Effects of Lordotic Angle of a Cage on Sagittal Alignment and Clinical Outcome in One Level Posterior Lumbar Interbody Fusion with Pedicle Screw Fixation. BioMed Research International, 2015, Article ID: 523728. https://doi.org/10.1155/2015/523728
[56]
Tawara, D., Sakamoto, J., Murakami, H., Kawahara, N., Oda, J. and Tomita, K. (2010) Mechanical Therapeutic Effects in Osteoporotic L1-Vertebrae Evaluated by Nonlinear Patient-Specific Finite Element Analysis. Journal of Biomechanical Science and Engineering, 5, 499-514. https://doi.org/10.1299/jbse.5.499
