Biomechanical effects of anterior, posterior, and combined anterior-posterior instrumentation techniques on the stability of a multilevel cervical corpectomy construct: a finite element model analysis

BACKGROUND CONTEXT: Multilevel corpectomy, with or without anterior instrumentation, has been associated with both graft and anterior screw-plate complications. The addition of posterior instrumentation after anterior fixation has been shown to increase the overall stiffness of fused segments and decrease the likelihood of instrumentation failure. Little biomechanical information exists for providing guidance in the selection of an appropriate instrumentation technique after a multilevel cervical corpectomy. Clinical studies have also been inconclusive in choosing an optimum fixation strategy. PURPOSE: To test the hypothesis that combined anterior-posterior fixation would lower the stresses on the bone-screw interfaces observed after an isolated anterior fixation and on the graft-end plate interfaces observed after an isolated posterior fixation. STUDY DESIGN: A finite element (FE) analysis of a C4-C7 corpectomy fusion with three different fixation techniques: anterior, posterior, and combined anterior-posterior. METHODS: A previously validated three-dimensional FE model of an intact C3-T1 segment was used. From this intact model, three additional instrumentation models were constructed using anterior (rigid screw-plate), posterior (rigid screw-rod), and combined anterior-posterior fixation techniques following a C4-C7 corpectomy fusion. Construct stability at the cephalad and caudal levels of the corpectomy was assessed. RESULTS: Biomechanical comparisons between these instrumentation techniques show the least amount of construct motion in the combined anterior-posterior instrumentation model. The use of both anterior and posterior fixation shields the graft-end plate and screw-bone interfaces from peak stresses as compared with an isolated anterior or an isolated posterior fixation, thereby supporting the hypothesis of this study. CONCLUSIONS: A combined fixation technique should be balanced against increased operating room time and surgery costs because of dual anterior and posterior fixation and the increased risk of long anterior plating, such as dysphasia, plate or screw dislodgement, or migration. Our study suggests that the use of posterior fixation, whether alone or in combination with anterior fixation, infers comparable stability. Further studies are warranted to identify whether the current findings are consistent with other biomechanical studies. (C) 2011 Elsevier Inc. All rights reserved.