What is the best way to optimize thoracic kyphosis correction? A micro-CT and biomechanical analysis of pedicle morphology and screw failure

STUDY DESIGN.: A human cadaveric biomechanical analysis. OBJECTIVE.: The purpose of this study was to evaluate the bone density/trabecular width of the thoracic pedicle and correlate that with its resistance against compressive loading used during correction maneuvers in the thoracic spine (i.e., cantilever bending). SUMMARY OF BACKGROUND DATA.: As surgeons perform cantilever correction maneuvers in the spine, it is common to have pedicle screws pullout or displace while placing corrective forces on the construct. Currently, surgeons either compress against the cephalad aspect of the pedicle or vice versa. We set out to establish which aspect of the pedicle was the most dense and to determine the optimal direction for screw compression during kyphosis/deformity correction. METHODS.: Fifteen fresh-frozen cadaveric vertebrae (n = 15) were examined by micro-computed tomography to determine percent bone volume/total volume (%BV/TV) within the cephalad and caudad aspects of the pedicle. Specimens were sectioned in the sagittal plane. Pedicles were instrumented according to the straightforward trajectory on both sides. Specimens were then mounted and loading to failure was performed perpendicular to the screw axis (either the cephalad or the caudad aspect of the pedicle). RESULTS.: Mean failure when loading against the caudad aspect of the pedicle was statistically, significantly greater (454.5 ± 241.3 N vs. 334.79 1 ± 158.435 N) than for the cephalad pedicle (P < 0.001). In concordance with failure data, more trabecular and cortical bones were observed within the caudad half of the pedicle compared with the cephalad half (P < 0.001). CONCLUSION.: Our results suggest that the caudad half of the pedicle is denser and withstands higher forces compared with the cephalad aspect. In turn, the incidence of intraoperative screw loosening and/or pedicle fracture may be reduced if the compressive forces (cantilever bending during deformity correction) placed upon the construct are applied against the caudad portion of the pedicle.