Primary stability of pedicle screws depends on the screw positioning and alignment

Background contextThere is no universal consensus regarding the biomechanical aspects and relevance on the primary stability of misplaced pedicle screws.PurposeThe study is aimed to the determination of the correlation between axial pullout forces of pedicle screws with the possible screw misplacement, including mild and severe cortical violations.MethodsEighty-eight monoaxial pedicle screws were implanted into 44 porcine lumbar vertebral bodies, paying attention on trying to obtain a wide range of placement accuracy. After screw implantation, all specimens underwent a spiral computed tomography scan, and the screw placements were graded following the scales of Laine et al. and Abul Kasim et al. Axial pullout tests were then performed on a servohydraulic material testing system.ResultsDecreasing pullout forces were determined for screws implanted with increasing cortical violation. A smaller influence of cortical violations in the medial direction with respect to the lateral direction was observed. Screws implanted with a large cortical violation and misplacement in the craniocaudal direction were found to be significantly less stable than screws having comparable cortical violation but in a centered sagittal position.ConclusionsThese results provide adjunctive criteria to evaluate more accurately the fate of a spine instrumentation. Particular care should be placed in the screw evaluation regarding the craniocaudal positioning and alignment.