title: Is a gradual reduction of stiffness on top of posterior instrumentation possible with a suitable proximal implant? A biomechanical study.
abstract: Proximal junctional kyphosis (PJK) is a challenging complication after rigid posterior instrumentation (RI) of the spine. Several risk factors have been described in literature so far, including the rigidity of the cranial aspect of the implant.
  
  
  
  The aim of this biomechanical study was to compare different proximal implants designed to gradually reduce the stiffness between the instrumented and non-instrumented spine.
  
  
  
  This is a biomechanical study.
  
  
  
  Eight calf lumbar spines (L2-L6) underwent RI with a titanium pedicle screw rod construct at L4-L6. The proximal transition segment (L3-L4) was instrumented stepwise with different supplementary implants-spinal bands (SB), cerclage wires (CW), hybrid rods (HR), hinged pedicle screws (HPS), or lamina hooks (LH)-and compared with an all-pedicle screw construct (APS). The flexibility of each segment (L2-L6) was tested with pure moments of ±10.0 Nm in the native state and for each implant at L3-L4, and the segmental range of motion (ROM) was evaluated.
  
  
  
  On flexion and extension, the native uninstrumented L3-L4 segment showed a mean ROM of 7.3°. The CW reduced the mean ROM to 42.5%, SB to 41.1%, HR to 13.7%, HPS to 12.3%, LH to 6.8%, and APS to 12.3%. On lateral bending, the native segment L3-L4 showed a mean ROM of 15°. The CW reduced the mean ROM to 58.0%, SB to 78.0%, HR to 6.7%, HPS to 6.7%, LH to 10.0%, and APS to 3.3%. On axial rotation, the uninstrumented L3-L4 segment showed a mean ROM of 2.7°. The CW reduced the mean ROM to 55.6%, SB to 77.8%, HR to 55.6%, HPS to 55.6%, LH to 29.6%, and APS to 37.0%.
  
  
  
  Using CW or SB at the proximal transition segment of a long RI reduced rigidity by about 60% in relation to flexion and extension in that segment, whereas the other implants tested had a high degree of rigidity comparable with APS. Clinical randomized controlled trials are needed to elucidate whether this strategy might be effective for preventing PJK.
authors.affiliation: Department of Orthopedics and Tumor Orthopedics, Münster University Hospital, Albert-Schweitzer-Campus 1, 48149 Münster, Germany. Electronic address: tobias.lange@ukmuenster.de.
authors.forename: Tobias
authors.initials: T
authors.lastname: Lange
authors.affiliation: Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
authors.forename: Werner
authors.initials: W
authors.lastname: Schmoelz
authors.affiliation: Department of Orthopedics and Tumor Orthopedics, Münster University Hospital, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
authors.forename: Georg
authors.initials: G
authors.lastname: Gosheger
authors.affiliation: Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
authors.forename: Martin
authors.initials: M
authors.lastname: Eichinger
authors.affiliation: Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
authors.forename: Christian H
authors.initials: CH
authors.lastname: Heinrichs
authors.affiliation: Department of Orthopedics and Tumor Orthopedics, Münster University Hospital, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
authors.forename: Albert Schulze
authors.initials: AS
authors.lastname: Boevingloh
authors.affiliation: Department of Orthopedics and Trauma Surgery, St. Josef-Hospital, University Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.
authors.forename: Tobias L
authors.initials: TL
authors.lastname: Schulte
mesh_terms: D000818:Animals; D001696:Biomechanical Phenomena; D002417:Cattle; D008159:Lumbar Vertebrae / Q000601:surgery*; D065289:Pedicle Screws / Q000009:adverse effects*; D011183:Postoperative Complications / Q000517:prevention & control; D016059:Range of Motion, Articular; D013123:Spinal Fusion / Q000009:adverse effects / Q000379:methods*
keywords: Biomechanics; Dynamic instrumentation; Posterior instrumentation; Proximal junctional kyphosis; Spine deformity; Stiffness