Preventing Distal Pullout of Posterior Spine Instrumentation in Thoracic Hyperkyphosis: A Biomechanical Analysis

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Study Design

An in vitro biomechanical study.


Compare the mechanical behavior of 5 different constructs used to terminate dual-rod posterior spinal instrumentation in resisting forward flexion moment.

Summary of Background Data

Failure of the distal fixation construct can be a significant problem for patients undergoing surgical treatment for thoracic hyperkyphosis. We hypothesize that augmenting distal pedicle screws with infralaminar hooks or sublaminar cables significantly increases the strength and stiffness of these constructs.


Thirty-seven thoracolumbar (T12 to L2) calf spines were implanted with 5 configurations of distal constructs: (1) infralaminar hooks, (2) sublaminar cables, (3) pedicle screws, (4) pedicle screws+infralaminar hooks, and (5) pedicle screws+sublaminar cables. Progressive bending moment was applied to each construct until failure. The mode of failure was noted and the construct's stiffness and failure load determined from the load-displacement curves.


Bone density and vertebral dimensions were equivalent among the groups (F=0.1 to 0.9, P>0.05). One-way analysis of covariance (adjusted for differences in density and vertebral dimension) demonstrated that all of the screw-constructs (screw, screw+hook, and screw+cable) exhibited significantly higher stiffness and ultimate failure loads compared with either sublaminar hook or cable alone (P<0.05). The screw+hook constructs (109±11 Nm/mm) were significantly stiffer than either screws alone (88±17 Nm/mm) or screw+cable (98±13 Nm/mm) constructs, P<0.05. Screw+cable construct exhibited significantly higher failure load (1336±328 N) compared with screw constructs (1102±256 N, P<0.05), whereas not statistically different from the screw+hook construct (1220±75 N). The cable and hook constructs failed by laminar fracture, screw construct failed in uniaxial shear (pullout), whereas the screws+(hooks or wires) failed by fracture of caudal vertebral body.


Posterior dual rod constructs fixed distally using pedicle screws were stiffer and stronger in resisting forward flexion compared with cables or hooks alone. Augmenting these screws with either infralaminar hooks or sublaminar cables provided additional resistance to failure.

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