title: Transverse process hooks at upper instrumented vertebra provide more gradual motion transition than pedicle screws.
abstract: METHODS
  Biomechanical study in a porcine model.
  
  
  OBJECTIVE
  To determine whether transverse process hooks (TPHs) placed at the proximal end of a long posterior spinal fusion construct provide a more gradual transition to normal motion of the adjacent cephalad motion segment compared with an all pedicle screw (APS) construct.
  
  
  BACKGROUND
  Proximal junctional kyphosis after instrumentation with long posterior spinal constructs has been increasingly associated with incidence of adjacent segment pathologies. Clinical studies have suggested that proximal anchor type may affect the incidence of proximal junctional kyphosis.
  
  
  METHODS
  Biomechanical tests were conducted on porcine thoracic spines before and after implantation of a long spinal fusion construct. In all specimens, dual long rods (Co-Cr) were implanted posteriorly using pedicle screws at T7-T15. Upper instrumented vertebra, T6, received either TPHs (n = 7) or pedicle screws (APSs) (n = 6). Each specimen was tested in flexion-extension then lateral bending. Moments were applied, and vertebral displacements were recorded. Range of motion (ROM) and stiffness (K) were determined for each motion segment. Differences between TPH and APS at the transition were determined using t tests.
  
  
  RESULTS
  In flexion-extension, ROM at the most proximal instrumented motion segment was 9% of control for APS versus 21% of control for TPH. Difference between APS and TPH at UIV was 0.5° (P < 0.008). Stiffness of TPH at T6-T7 was significantly lower than APS in FE (P < 0.003). For APS, the greatest mean ROM occurred at the first uninstrumented segment, whereas TPH maintained the pattern of monotonic increases in mean ROM from distal to proximal.
  
  
  CONCLUSIONS
  TPHs at the upper instrumented vertebra provided a more gradual transition to normal motion compared with pedicle screws in long posterior spinal fusion constructs. TPH at the upper instrumented vertebra may be postulated to decrease the incidence of postoperative proximal junctional kyphosis compared with APS.
  
  
  METHODS
  N/A.
authors.affiliation: *Department of Orthopaedics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; and †University of Cincinnati, Cincinnati, OH.
authors.forename: Dinesh P
authors.initials: DP
authors.lastname: Thawrani
authors.forename: David L
authors.initials: DL
authors.lastname: Glos
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Coombs
authors.forename: Donita I
authors.initials: DI
authors.lastname: Bylski-Austrow
authors.forename: Peter F
authors.initials: PF
authors.lastname: Sturm
mesh_terms: D000818:Animals; D001696:Biomechanical Phenomena / Q000502:physiology; D065289:Pedicle Screws; D016059:Range of Motion, Articular / Q000502:physiology*; D013123:Spinal Fusion / Q000295:instrumentation*; D013552:Swine; D013904:Thoracic Vertebrae / Q000601:surgery*