Effects of pelvic fixation strategies and multi-rod constructs on biomechanics of the proximal junction in long thoracolumbar posterior instrumented fusions: a finite-element analysis

Abstract

Abstract Purpose To assess the effect of various pelvic fixation techniques and number of rods on biomechanics of the proximal junction of long thoracolumbar posterior instrumented fusions. Methods A validated spinopelvic finite-element (FE) model was instrumented with L5–S1 ALIF and one of the following 9 posterior instrumentation configurations: (A) one traditional iliac screw bilaterally (“2 Iliac/2 Rods”); (B) T10 to S1 (“Sacral Only”); (C) unilateral traditional iliac screw (“1 Iliac/2 Rods”); (D) one traditional iliac screw bilaterally with one midline accessory rod (“2 Iliac/3 rods”); (E) S2AI screws connected directly to the midline rods (“2 S2AI/2 Rods”); and two traditional iliac screws bilaterally with two lateral accessory rods connected to the main rods at varying locations (F1: T10–11, F2: T11–12, F3: T12–L1, F4: L1–2) (“4 Iliac/4 Rods”). Range of motions (ROM) at T10–S1 and T9–T10 were recorded and compared between models. The T9–T10 intradiscal pressures and stresses of the T9–10 disc’s annulus in addition to the von Mises stresses of the T9 and T10 vertebral bodies were recorded and compared. Results For T10–S1 ROM, 4 iliac/4 rods had lowest ROM in flexion and extension, while 2 S2AI/2 rods showed lowest ROM in rotation. Constructs with 3 or 4 rods had lower stresses on the primary rods compared to 2-rod constructs. At the proximal adjacent disc (T9–10), 4 iliac/4 rods showed lowest ROM, lowest intradiscal pressures, and lowest annular stress in all directions (most pronounced in flexion–extension). Under flexion and extension, 4 iliac/4 rods also showed the lowest von Mises stresses on the T10 vertebral body but the highest stresses on the T9 vertebral body. Conclusions Dual iliac screws with 4 rods across the lumbosacral junction and extending to the thoracolumbar junction demonstrated the lowest T10–S1 ROM, the lowest adjacent segment disc (T9–T10) ROM, intradiscal pressures, and annular stresses, and the lowest UIV stresses, albeit with the highest UIV + 1 stresses. Additional studies are needed to confirm whether these biomechanical findings dictate clinical outcomes and effect rates of proximal junctional kyphosis and failure.