title: Prevention of vertebral body-splitting fractures after multilevel ProDisc-L implantation.
abstract: BACKGROUND
  Prior studies of multilevel ProDisc-L (PD-L) implants (Synthes Spine, Inc., West Chester, Pennsylvania) using the standard US technique have used conventional radiography postoperatively. We found vertebral body-splitting fractures (VB-SFs) in interposed vertebral bodies after 5 sequential multilevel PD-L device implantations using the standard US technique. These were identified with postoperative computed tomography (CT) but were not visible on plain radiographs. In an additional patient, we found that a stress-relieving, pilot holes-only technique did not prevent VB-SFs. The 5 patients operated on with the standard technique composed the background series against which we compared the incidence of VB-SFs in patients operated on with a modification of the standard US technique-a combination of stress-relieving pilot holes, removal of cortex in the chisel path, and a fenestrated chisel (PH/CR/FC)-intended to reduce the incidence of VB-SFs in multilevel PD-L constructs.
  
  
  METHODS
  Patients receiving multilevel PD-L implants at 2 sites-1 in the United States and the other in Germany-were operated on with the PH/CR/FC technique and their postoperative CT scans evaluated for the presence of VB-SFs. The frequency of VB-SFs in these patients was compared with that of the 5 patients from the background series who were operated on by the standard US technique. The groups' mean sex, age, body mass index, and vertebral body height, as well as average spinal T score, were also compared.
  
  
  RESULTS
  No fractures were found in 13 interposed vertebral bodies in 11 patients operated on with the PH/CR/FC technique, as compared with 4 VB-SFs and 1 anterior keel cut-to-anterior keel cut fracture in 5 interposed vertebral bodies in 5 patients operated on with the US technique (P ≤ .001). Although the sample sizes were small, this difference in fracture rate was not associated with sex, age, body mass index, or average spinal T score. At up to 13 months of follow-up of patients in the background series, we found that VB-SFs tend not to bridge with bone, instead forming sclerotic margins.
  
  
  CONCLUSIONS
  The PH/CR/FC technique studied reduced the incidence of VB-SF in multilevel PD-L implants. Because previously published multilevel studies did not use postoperative CT scans and because VB-SFs are not visible on conventional radiography, the incidence of VB-SFs in multilevel PD-L applications may be higher than previously reported. Our findings may contribute to prevention of complications in total disc replacement.
authors.affiliation: Department of Neurosurgery, Gundersen Lutheran Health System, La Crosse, WI.
authors.forename: Humbert G
authors.initials: HG
authors.lastname: Sullivan
authors.affiliation: Department of Radiology, Gundersen Lutheran Health System, La Crosse, WI.
authors.forename: Rudolf
authors.initials: R
authors.lastname: Bertagnoli
authors.affiliation: Spine Center, St Elizabeth Klinikum, Straubing, Germany.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Nigogosyan
authors.affiliation: Department of Medical Research, Gundersen Lutheran Medical Foundation, La Crosse, WI.
authors.forename: Nicholas R
authors.initials: NR
authors.lastname: Ladwig
authors.affiliation: Department of Medical Research, Gundersen Lutheran Medical Foundation, La Crosse, WI.
authors.forename: Hayley L
authors.initials: HL
authors.lastname: Born
authors.affiliation: Department of Neurosurgery, Gundersen Lutheran Health System, La Crosse, WI.
authors.forename: Molly M
authors.initials: MM
authors.lastname: Cerniglia
authors.affiliation: Department of Radiology, Gundersen Lutheran Health System, La Crosse, WI.
authors.forename: Hartmann
authors.initials: H
authors.lastname: Habbicht
authors.affiliation: Department of Medical Research, Gundersen Lutheran Medical Foundation, La Crosse, WI.
authors.forename: Michelle A
authors.initials: MA
authors.lastname: Mathiason
authors.affiliation: Department of Medical Research, Gundersen Lutheran Medical Foundation, La Crosse, WI.
authors.forename: Vicki L
authors.initials: VL
authors.lastname: McHugh
keywords: Complications; Fracture; Lumbar disc arthroplasty; ProDisc-L; Total disc replacement; Vertebral body