Is It Safe to Back Out Pedicle Screws After Augmentation With Polymethyl Methacrylate or Calcium Phosphate Cement? A Biomechanical Study

Study Design: Biomechanical cadaveric study. Objective: To determine the torque required to remove pedicle screws augmented with polymethyl methacrylate (PMMA) or calcium phosphate cement (CPC); thus, proving the safety of back out of augmented screws in the osteopotoric model, which would be a more dangerous setting than the nonosteoporotic model. Summary of Background Data: To our knowledge, no earlier study has characterized the safety of backing out pedicle screw augmented with PMMA or CPC. Methods: Pedicle screws were inserted in 24 osteoporotic vertebrae (48 pedicles). The maximal insertion torque and pullout strength of each screw were recorded. After pullout of the pedicle screws, the vertebrae were then randomized into 2 groups of 12 (24 pedicles) each. PMMA was injected into the pedicles in the first group and CPC was injected into the second group after which the pedicle screws were inserted. The pedicle screws were inserted into the pedicle holes augmented with PMMA or CPC, respectively. Finally, all augmented screws were backed out and the maximal removal torque was recorded using a digital torque wrench. Results: Throughout the study, no incidence of pedicle or lamina fractures was observed. The average insertion torque was 0.5 +/- 0.27 and 0.45 +/- 0.29 N.m for groups 1 and 2, respectively (P = 0.724). The average pullout strength was 723.1 +/- 391.7 and 671.2 +/- 383.0N (P = 0.950). After cement augmentation, the average removal torque was 0.77 +/- 0.31 and 0.81 +/- 0.26 N.m for PMMA and CPC, respectively (P = 0.494). Conclusions: The results of this study showed that pedicle screws can be easily and safely backed out after augmentation with PMMA or CPC. The result of CPC, however, may only be valid before any bony ingrowth.