Straight-forward versus anatomic trajectory technique of thoracic pedicle screw fixation: A biomechanical analysis

Study Design. A biomechanical study on cadaveric thoracic vertebrae using pullout strength, insertional torque, and bone mineral density to determine the optimal sagittal trajectory of thoracic pedicle screws. Objective. To perform a biomechanical study on cadaveric thoracic vertebrae using insertion torque, pullout strength, and bone mineral density to determine the optimal biomechanical sagittal trajectory for placement thoracic pedicle screws. We compared the straight-forward (paralleling the vertebral endplate) with anatomic trajectory (directed along the true anatomic axis of the pedicle). Methods. Thirty cadaveric thoracic vertebrae were harvested and evaluated with dual-energy x-ray adsorptiometry to assess bone mineral density. Matched, fixed-head pedicle screws were then randomly assigned by side and placed using the straight-forward or anatomic technique under fluoroscopic visualization while recording the maximum insertin torque. Pullout strength testing was then performed. Results. The maximum insertion torque for the straight-forward technique was 2.58+/-0.14 (SE) in pounds, whereas the anatomic technique averaged 1.86+/-0.14 (SE) in pounds (P=0.0005). The maximum insertional torque at the neurocentral junction for the straight-forward technique averaged 1.89+/-0.17 (SE) in-lbs. (73% of maximum insertional torque), whereas the anatomic trajectory averaged 1.39+/-0.11 (SE) in pounds (75% of maximum insertional torque) (P=0.007). The average pullout strength using a straight-forward trajectory was 611+/-50 (SE) N compared to the anatomic trajectory, which averaged 481+/-54 (SE) N (P=0.034). The pullout strength correlated with mean bone mineral density for both the straight-forward (r=0.461, P=0.027) and anatomic (r=0.598, P=0.004) techniques. Conclusions. The straight-forward technique results in a 39% increase in maximum insertional torque and a 27% increase in pullout strength compared to the anatomic technique. The maximum insertional torque at the neurocentral junction resulted in a 36% increase using the straight-forward technique versus the anatomic trajectory. Bone mineral density directly correlated with pullout strength for both techniques.