Comparison of the strengths of lumbosacral fixation achieved with techniques using one and two triangulated sacral screws

Abstract

Study Design. The strength of sacral screw fixation achieved with techniques using one sacral screw and two triangulated sacral screws with Chopin block was tested on 10 fresh human sacrum specimens. Objectives. To compare the stiffness and the failure strength of single sacral screw fixation and those of two divergent triangulated sacral screw fixation under different loading conditions. Summary of Background Data. Weak sacral screw fixation is the major cause of failure in instrumented lumbosacral fusion. Although previous studies have evaluated the strength of anteromedially and anterolaterally inserted sacral screws, the strength of two divergent triangulated sacral screws has not been evaluated biomechanically. It is assumed that increasing the number of sacral screws and using a triangulated insertion technique may increase the strength of purchase for lumbosacral fixation. Methods. Ten fresh human sacrum specimens were used in this study. Six specimens were from donors less than 30 years of age (younger group), and the other four were from donors more than 60 years of age (aged group). The specimens were assigned randomly to either one side with one S1 pedicle screw inserted anteromedially or to the other side with two screws directed anteromedially and anterolaterally. All specimens were tested with an Instron material testing machine (Instron Limited, High Wycombe, England). The average stiffness under compression, tension, and torsion were calculated from the average slopes of the load deformation curves. The failure load was applied for the final testing. Results. The results showed significant differences in stiffness between fixation with one screw and fixation with two divergent triangulated screws. With one S1 pedicle screw fixation, the average stiffness was 203 N/mm for compression, 147 N/mm for tension, and 2 Nm/°for torsion. With two-screw fixation, the average stiffness increased to 255 N/mm (126%), 185 N/mm (126%) and 2.4 Nm/°(120%), respectively. The average failure strength under tension loads was found to be 1450 N in the younger specimens and was reduced to 980 N in the aged specimens. Conclusion. This study showed that fixation with two divergent triangulated screws to the sacrum was significantly stronger than one-screw fixation for lumbosacral fusion. The strength of fixation seems to have a negative correlation with aging.