title: Does superior-segment facet violation or laminectomy destabilize the adjacent level in lumbar transpedicular fixation? An in vitro human cadaveric assessment.
abstract: METHODS
  This is an in vitro biomechanical study.
  
  
  OBJECTIVE
  The current investigation was performed to evaluate adjacent level kinematic change following unilateral and bilateral facet violation and laminectomy following 1-, 2-, and 3-level reconstruction.
  
  
  BACKGROUND
  The incidence of superior-segment facet violation with lumbar transpedicular fixation has been reported as high as 35%; however, its contribution to biomechanical instability at the supradjacent level is unknown. In addition, superior-segment laminectomy has been implicated as a risk factor for the development of adjacent level disease. The authors assess the acute biomechanical effects of proximal facet violation and subsequent laminectomy in an instrumented posterior fusion model in 10 cadaveric specimens.
  
  
  METHODS
  Biomechanical testing was performed on 10 human cadaveric spines under axial rotation (AR), flexion-extension (FE), and lateral bending (LB) loading. After intact analysis, pedicle screws were inserted from L5-S1 and testing repeated with: (1) preserved L4-L5 facets, (2) unilateral facet breach, (3) bilateral breach, and (4) L5 laminectomy. Following biomechanical analysis, instrumentation was extended to L4, then L3 and biomechanical testing repeated. Full range of motion (ROM) at the proximal adjacent levels were recorded and normalized to intact (100%).
  
  
  RESULTS
  Supradjacent level ROM was increased for all groups under all loading methods relative to intact (P < 0.05). However, AR testing revealed progressive instability at the adjacent level in groups 3 and 4, relative to group 1, following 1-, 2- and 3-level fixation (P < 0.05). During FE, supradjacent level ROM was significantly increased for group 4 specimens compared with group 1 after L5-S1 fixation (P < 0.05), and was greater than all other groups for L3-S1 constructs (P < 0.05). Interestingly, under lateral bending, facet joint destabilization did not change adjacent segment ROM.
  
  
  CONCLUSIONS
  There were significant changes in proximal level ROM immediately after posterior stabilization. However, an additional increase in supradjacent segment ROM was recorded during AR after bilateral facet breach.Subsequent complete laminectomy at the uppermostfixation level further destabilized the supradjacent segment in FE and AR. Therefore, meticulous preservation of the cephalad-most segment facet joints-is paramount to ensure stability.
authors.affiliation: Neurosurgery Service, Walter Reed Army Medical Center, Washington, DC 20307, USA. mtcardoso@comcast.net
authors.forename: Mario J
authors.initials: MJ
authors.lastname: Cardoso
authors.forename: Anton E
authors.initials: AE
authors.lastname: Dmitriev
authors.forename: Melvin
authors.initials: M
authors.lastname: Helgeson
authors.forename: Ronald A
authors.initials: RA
authors.lastname: Lehman
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Kuklo
authors.forename: Michael K
authors.initials: MK
authors.lastname: Rosner
mesh_terms: D000328:Adult; D001696:Biomechanical Phenomena; D002102:Cadaver; D006801:Humans; D016268:Internal Fixators / Q000592:standards; D007796:Laminectomy / Q000295:instrumentation* / Q000379:methods / Q000592:standards; D008159:Lumbar Vertebrae / Q000473:pathology* / Q000601:surgery*; D013123:Spinal Fusion / Q000295:instrumentation / Q000379:methods / Q000592:standards