title: Biomechanical comparison of cervical spine interbody fusion cages.
abstract: METHODS
  An in vitro biomechanical study of cervical spine interbody fusion cages using a sheep model was conducted.
  
  
  OBJECTIVE
  To evaluate the biomechanical effects of cervical spine interbody fusion cages, and to compare three different cage design groups.
  
  
  BACKGROUND
  Recently, there has been a rapid increase in the use of cervical spine interbody fusion cages as an adjunct to spondylodesis. These cages can be classified into three design groups: screw, box, or cylinder designs. Although several comparative biomechanical studies of lumbar interbody fusion cages are available, biomechanical data for cervical spine constructs are lacking. Additionally, only limited data are available concerning comparative evaluation of different cage designs.
  
  
  METHODS
  In this study, 80 sheep cervical spines (C2-C5) were tested in flexion, extension, axial rotation, and lateral bending with a nondestructive stiffness method using a nonconstrained testing apparatus. Three-dimensional displacement was measured using an optical measurement system (Qualysis). Complete discectomy (C3-C4) was performed. Cervical spine interbody fusion cages were implanted according to manufacturers' information. Eight spines in each of the the following groups were tested: intact, autologous iliac bone graft, two titanium screws (Novus CTTi; Sofamor Danek, Koln, Germany), two titanium screws (BAK-C 8 mm; Sulzer Orthopedics, Baar, Switzerland), one titanium screw (BAK-C 12 mm; Sulzer Orthopedics), carbon box (Novus CSRC; Sofamor Danek), titanium box (Syncage; Synthes, Bochum, Germany), titanium mesh cylinder (Harms; DePuy Acromed, Sulzbach, Germany), titanium cylinder (MSD; Ulrich, Ulm, Germany), and titanium cylinder (Kaden; BiometMerck, Berlin, Germany). The mean apparent stiffness values were calculated from the corresponding load-displacement curves. Additionally, cage volume and volume-related stiffness was determined.
  
  
  RESULTS
  After cervical spine interbody fusion cage implantation, flexion stiffness increased, as compared with that of the intact motion segment. On the contrary, rotation stiffness decreased after implantation of a cervical spine interbody fusion cage, except for the Novus CSRC, Syncage, and Kaden-Cage. If two screws were inserted (Novus CTTi and BAK-C 8 mm), there was no significant difference in flexion stiffness between screw and cylinder design groups. If one screw was inserted (BAK-C 12 mm), flexion stiffness was higher for cylinder designs (P < 0.05). Extension and bending stiffness were always higher with cylinder designs (P < 0.05). Volume-related stiffness for flexion extension and bending was highest for the Harms cage (P < 0.05). There was no difference for rotation volume-related stiffness between Harms and Syncage.
  
  
  CONCLUSIONS
  The biomechanical results indicate that design variations in screw and cylinder design groups are of little importance. In this study, however, cages with a cylinder design were able to control extension and bending more effectively than cages with a screw design.
authors.affiliation: Unfall- und Wiederherstellungschirurgie, and the Strahlenklinik und Poliklinik Universitätsklinikum Charité der Humboldt Universität Berlin, Campus Virchow-Klinikum, Berlin, Germany. frank.kandziora@charite.de
authors.forename: F
authors.initials: F
authors.lastname: Kandziora
authors.forename: R
authors.initials: R
authors.lastname: Pflugmacher
authors.forename: J
authors.initials: J
authors.lastname: Schäfer
authors.forename: C
authors.initials: C
authors.lastname: Born
authors.forename: G
authors.initials: G
authors.lastname: Duda
authors.forename: N P
authors.initials: NP
authors.lastname: Haas
authors.forename: T
authors.initials: T
authors.lastname: Mittlmeier
mesh_terms: D000818:Animals; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000502:physiology / Q000601:surgery*; D017586:Diskectomy; D004548:Elasticity; D005260:Female; D008422:Materials Testing; D009984:Orthopedic Fixation Devices; D019736:Prostheses and Implants; D011474:Prosthesis Design; D011859:Radiography; D012756:Sheep; D013123:Spinal Fusion / Q000295:instrumentation*; D013314:Stress, Mechanical