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Biomechanical Stability of Lateral Interbody Implants and Supplemental Fixation in a Cadaveric Degenerative Spondylolisthesis Model

Fogel, Guy R., MD*; Turner, Alexander W. L., PhD; Dooley, Zachary A., MS; Cornwall, G. Bryan, PhD

doi: 10.1097/BRS.0000000000000485

Study Design. In vitro cadaveric biomechanical study of lateral interbody cages and supplemental fixation in a degenerative spondylolisthesis (DS) model.

Objective. To investigate changes in shear and flexion-extension stability of lateral interbody fusion constructs.

Summary of Background Data. Instability associated with DS may increase postoperative treatment complications. Several groups have investigated DS in cadaveric spines. Extreme lateral interbody fusion (XLIF) cages with supplemental fixation have not previously been examined using a DS model.

Methods. Seven human cadaveric L4–L5 motion segments were evaluated using flexion-extension moments to ±7.5 N·m and anterior-posterior (A-P) shear loading of 150 N with a static axial compressive load of 300 N. Conditions were: (1) intact segment, (2) DS simulation with facet resection and lateral discectomy, (3) standalone XLIF cage, (4) XLIF cage with (1) lateral plate, (2) lateral plate and unilateral pedicle screws contralateral to the plate (PS), (3) unilateral PS, (4) bilateral PS, (5) spinous process plate, and (6) lateral plate and spinous process plate. Flexion-extension range of motion (ROM) data were compared between conditions and with results from a previous study without DS simulation. A-P shear displacements were compared between conditions.

Results. Flexion-extension ROM after DS destabilization increased significantly by 181% of intact ROM. With the XLIF cage alone, ROM decreased to 77% of intact. All conditions were less stable than corresponding conditions with intact posterior elements except those including the spinous process plate. Under shear loading, A-P displacement with the XLIF cage alone increased by 2.2 times intact. Bilateral PS provided the largest reduction of A-P displacement, whereas the spinous process plate alone provided the least.

Conclusion. This is the first in vitro shear load testing of XLIF cages with supplemental fixation in a cadaveric DS model. The variability in sagittal plane construct stability, including significantly increased flexion-extension ROM found with most fixation conditions including bilateral PS may explain some clinical treatment complications in DS with residual instability.

Level of Evidence: N/A

A cadaveric degenerative spondylolisthesis model demonstrated increased instability in flexion-extension range of motion and anterior-posterior shear displacement with lateral interbody cages and various supplemental fixations. This instability associated with some fixation options may explain clinical complications of degenerative spondylolisthesis fusion.

*Spinepainbegone, San Antonio, TX; and

NuVasive Inc., San Diego, CA.

Address correspondence and reprint requests to Guy R. Fogel, MD, Spinepainbegone, 8042 Wurzbach Rd, Ste 350, San Antonio, TX 78229; E-mail:

Acknowledgment date: August 8, 2013. First revision date: December 16, 2013. Second revision date: March 2, 2014. Third revision date: April 21, 2014. Acceptance date: May 21, 2014.

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

This manuscript includes unlabeled/investigational uses of the products/devices listed below and the status of these is disclosed in the manuscript: the CoRoent XL interbody cage is only FDA-cleared for use with supplemental fixation. It is not indicated for standalone use.

Material support was provided by NuVasive Inc.

Relevant financial activities outside the submitted work: employment, stock/stock options, and travel/accommodations/meeting expenses.

© 2014 by Lippincott Williams & Wilkins