Rod Attachment Induces Significant Strain in Lumbosacral Fixation.

STUDY DESIGN This was a laboratory investigation. OBJECTIVE Rod attachment can induce significant pedicle screw-and-rod pre-strain that may predispose the instrumentation to failure. This study investigated how in vitro L5-S1 rod strain and S1 screw strain during rod-screw attachment (pre-strain) compared with strains recorded during pure-moment bending (test-strain). SUMMARY OF BACKGROUND DATA The lumbosacral junction is highly vulnerable to construct failure due to rod fatigue fracture, sacral screw pull-out, and screw fatigue fracture. MATERIALS AND METHODS Twelve cadaveric specimens were instrumented with L2-ilium pedicle screws and rod. Strain gauges on contoured rods and sacral screws recorded strains during sequential rod-to-screw tightening (pre-strains). The same instrumented constructs were immediately tested in a 6-degree-of-freedom apparatus under continuous loading to 7.5 Nm in multidirectional bending while recording instrumentation test-strains. Rod and screw pre-strains and test-strains were compared using 1-way repeated-measures analysis of variance followed by Holm-Šidák paired analysis (significant at P<0.05). RESULTS The mean first (171±192 µE) and second (322±269 µE) rod attachment pre-strains were comparable to mean test-strains during flexion (265±109 µE) and extension (315±125 µE, P≥0.13). The mean rod attachment pre-strain was significantly greater than mean test-strains during bidirectional lateral bending (40±32 µE ipsilateral and 39±32 µE contralateral, P<0.001) and axial rotation (72±60 µE ipsilateral and 60±57 µE contralateral, P<0.001). The mean first and second sacral screw pre-strains during rod attachment (1.03±0.66 and 1.39±1.00 Nm, respectively) did not differ significantly (P=0.41); however, the mean sacral screw pre-strain during final (second) rod attachment was significantly greater than screw test-strains during all directions of movement (≤0.81 Nm, P≤0.03). CONCLUSIONS Instrumentation pre-strains imposed during in vitro rod-screw attachment of seemingly well-contoured rods in L2-ilium fixation are comparable to, and at times greater than, strains experienced during in vitro bending. Spine surgeons should be aware of the biomechanical consequences of rod contouring and attachment on construct vulnerability.