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Biomechanical Effects of Cage Positions and Facet Fixation on Initial Stability of the Anterior Lumbar Interbody Fusion Motion Segment

Hueng, Dueng-Yuan, MD, PhD*; Chung, Tzu-Tsao, MD*; Chuang, Wen-Hsien, PhD; Hsu, Chi-Pin, PhD; Chou, Kuan-Nien, MD*; Lin, Shang-Chih, PhD

doi: 10.1097/BRS.0000000000000336

Study Design. An in vitro biomechanical study using porcine lumbar segments as specimens.

Objective. To evaluate the effects of interbody cage support and endplate strength on the stability of instrumented segments.

Summary of Background Data. The anterior lumbar interbody fusion (ALIF) cage is widely used to restore disc height and support the anterior column. Transpedicle or posterior spinal fusion or facet screw fixation (FSF) can improve the stability of the vertebra-instrumented segments. The cage position can affect the anterior support and initial stability of the ALIF region, but there is no consistent data on its biomechanical effects on ALIF and ALIF/FSF segments.

Methods. Nine variations of 3 instrumentation modes (intact, ALIF, ALIF/FSF) and 3 cage positions (type I, anterolateral; type II, mediolateral; and type III, posteromedial) are tested under 5 lumbar motions. The range of motion and axial displacement are used as comparison indices for the different variations.

Results. The cage placement serves as support for the intervertebral loads while the posterior fixation behaves as lever to further enhance the anterior support. At the endplate-cage interfaces, the endplate strength directly affects the cage subsidence. Type III exhibits higher stability for standing due to the greater strength of the endplate in the posterior region. Otherwise, type I consistently has higher stability for all other types of motion.

Conclusion. The initial stability of the ALIF region is affected by the moment arm and the mechanical strength of the engaged endplates. Type I has greater moment arm and provides more efficient support to the instrumented segments. Endplate strength provides an ability to withstand lumbar loads and suppress the cage subsidence. Bone quality at the endplate-cage interfaces must therefore be cautiously evaluated preoperatively.

Level of Evidence: N/A

This in vitro biomechanical study is conducted to compare the construct stability of the porcine lumbar segment with anterior cages and/or facet screws. Anterolateral cage placement provides higher stability for all motions except in the standing position. Posterior fixation behaves as an effective lever to further enhance cage support.

*Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; and

Graduate Institute of Biomedical Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan.

Address correspondence and reprint requests to Shang-Chih Lin, PhD, Graduate Institute of Biomedical Engineering, National Taiwan University of Science and Technology, 43, Sec. 4, Keelung Rd., Taipei, 106, Taiwan, Republic of China; E-mail:

Acknowledgment date: September 4, 2013. Revision date: November 20, 2013. Acceptance date: January 3, 2014.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

© 2014 by Lippincott Williams & Wilkins