title: Flexion failure of posterior cervical lateral mass screws. Influence of insertion technique and position.
abstract: METHODS
  The strength of posterior cervical lateral mass fixation was evaluated in a cadaver model for two techniques of screw insertion.
  
  
  OBJECTIVE
  To compare the flexion failure strengths of posterior cervical plate fixation for two techniques of screw placement at the superior and inferior screw hole positions, and to evaluate the effect of bone mineral density on fixation strength.
  
  
  BACKGROUND
  Biomechanical analyses of various screw insertion techniques for posterior cervical lateral mass fixation have never evaluated the effect of screw position along the plate.
  
  
  METHODS
  Individual C3-C6 segments of 24 human cadaveric cervical spines were used. The spinous process and lamina were removed to simulate a postlaminectomy situation. Vertebral body bone mineral density for each specimen was determined by dual-energy radiograph absorption scanning. In each lateral mass, a bicortical 3.5-mm screw was placed using either the Magerl or Roy-Camille insertion technique through an end hole of a titanium bone plate. For "superior" screws, the plate was directed caudally; for "inferior" screws, the plate was directed cranially. Screw violation of the surrounding facet joint was noted. An increasing flexion moment was applied by loading the plate 4 cm from the screw head at a rate of 10 cm/min using a servohydraulic testing machine until screw failure.
  
  
  RESULTS
  For the superior screw hole position, the Magerl screw sustained a significantly higher average moment to failure (190.2 Ncm) than the Roy-Camille screw (138.7 Ncm; P < 0.05). For the inferior screw hole position, there was no significant difference in flexion failure strength between the two techniques (Magerl screws, 287.7 Ncm; Roy-Camille screws, 308.2 Ncm). For each insertion technique, inferior screws were nearly twice as strong as superior screws (P < 0.01). Violation of the inferior articular process occurred with 53% of Roy-Camille screws and with none of the Magerl screws. Lateral mass fracture on screw insertion occurred with 6% of the Roy-Camille screws and with 7% of the Magerl screws. Significant correlation between screw path length and load to failure was found only at the superior screw hole position. Correlation with vertebral body bone mineral density was significant at both positions.
  
  
  CONCLUSIONS
  The Magerl technique has advantages over the Roy-Camille technique for placing the end screws when performing posterior cervical lateral mass plate fixation, providing greater strength superiorly and not violating unfused facet joints inferiorly. Evaluation of bone mineral density by dual-energy radiographic absorption scanning is predictive of failure strength for both test modes.
authors.affiliation: Department of Orthopaedic Surgery, Hospital for Joint Diseases Orthopaedic Institute, New York, New York, USA.
authors.forename: J
authors.initials: J
authors.lastname: Choueka
authors.forename: J M
authors.initials: JM
authors.lastname: Spivak
authors.forename: F J
authors.initials: FJ
authors.lastname: Kummer
authors.forename: T
authors.initials: T
authors.lastname: Steger
mesh_terms: D001696:Biomechanical Phenomena; D001860:Bone Plates; D001863:Bone Screws; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D011859:Radiography; D012044:Regression Analysis