Insufficient stability of pedicle screws in osteoporotic vertebrae: biomechanical correlation of bone mineral density and pedicle screw fixation strength

Purpose: Loosening of pedicle screws is one major complication of posterior spinal stabilisation, especially in the patients with osteoporosis. Augmentation of pedicle screws with cement or lengthening of the instrumentation is widely used to improve implant stability in these patients. However, it is still unclear from which value of bone mineral density (BMD) the stability of pedicle screws is insufficient and an additional stabilisation should be performed. The aim of this study was to investigate the correlation of bone mineral density and pedicle screw fatigue strength as well as to define a threshold value for BMD below which an additional stabilisation is recommended. Methods: Twenty-one human T12 vertebral bodies were collected from donors between 19 and 96 years of age and the BMD was measured using quantitative computed tomography. Each vertebral body was instrumented with one pedicle screw and mounted in a servo-hydraulic testing machine. Fatigue testing was performed by implementing a cranio-caudal sinusoidal, cyclic (0.5 Hz) load with stepwise increasing peak force. Results: A significant correlation between BMD and cycles to failure (r = 0.862, r2 = 0.743, p < 0.001) as well as for the linearly related fatigue load was found. Specimens with BMD below 80 mg/cm3 only reached 45% of the cycles to failure and only 60% of the fatigue load compared to the specimens with adequate bone quality (BMD > 120 mg/cm3). Conclusions: There is a close correlation between BMD and pedicle screw stability. If the BMD of the thoracolumbar spine is less than 80 mg/cm3, stability of pedicle screws might be insufficient and an additional stabilisation should be considered.

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Insufficient stability of pedicle screws in osteoporotic vertebrae: biomechanical correlation of bone mineral density and pedicle screw fixation strength