Minimizing Pedicle Screw Pullout Risks A Detailed Biomechanical Analysis of Screw Design and Placement

Study Design: Detailed biomechanical analysis of the anchorage performance provided by different pedicle screw designs and placement strategies under pullout loading. Objective: To biomechanically characterize the specific effects of surgeon-specific pedicle screw design parameters on anchorage performance using a finite element model. Summary of Background Data: Pedicle screw fixation is commonly used in the treatment of spinal pathologies. However, there is little consensus on the selection of an optimal screw type, size, and insertion trajectory depending on vertebra dimension and shape. Methods: Different screw diameters and lengths, threads, and insertion trajectories were computationally tested using a design of experiment approach. A detailed finite element model of an L3 vertebra was created including elastoplastic bone properties and contact interactions with the screws. Loads and boundary conditions were applied to the screws to simulate axial pullout tests. Force-displacement responses and internal stresses were analyzed to determine the specific effects of each parameter. Results: The design of experiment analysis revealed significant effects (P<0.01) for all tested principal parameters along with the interactions between diameter and trajectory. Screw diameter had the greatest impact on anchorage performance. The best insertion trajectory to resist pullout involved placing the screw threads closer to the pedicle walls using the straightforward insertion technique, which showed the importance of the cortical layer grip. The simulated cylindrical single-lead thread screws presented better biomechanical anchorage than the conical dual-lead thread screws in axial loading conditions. Conclusions: The model made it possible to quantitatively measure the effects of both screw design characteristics and surgical choices, enabling to recommend strategies to improve single pedicle screw performance under axial loading.