Perspectives

Commentary on:
Adjustment of Suboptimally Placed Lumbar
Pedicle Screws Decreases Pullout Strength
and Alters Biomechanics of the Construct:
A Pilot Cadaveric Study
by Wadhwa et al. World Neurosurg 2014
http://dx.doi.org/10.1016/j.wneu.2014.04.065

Ehud Mendel, M.D.

Professor, Department of Neurosurgery
The James Comprehensive Cancer Center and
The Ohio State University Medical Center

The First Shot is Your Best Shot! Detrimental Biomechanical Effects of Revising
Suboptimally Placed Pedicle Screws
Tobias A. Mattei1 and Ehud Mendel2

everal factors affect the ultimate pullout strength of a

pedicle screw. Features inherent to the screw design (its
formatconical or cylindrical, its thread width and pitch
length, as well as its outer and inner diameter, just to mention a
few) have a strong influence upon the distribution of forces on
the metal/bone interface and, therefore, upon the overall pullout
strength of the screw (Figure 1). As a general rule, a larger outer
diameter (the most important factor), a smaller inner diameter,
and a shorter pitch interval, by increasing the total contact area
between the bone and the screw, improve its overall pullout
strength (4). However, it has already been demonstrated that in
osteoporotic patients a screw with larger diameter may not
necessarily increase its ultimate pullout strength, and may even
result in increased rates of pedicle fractures, as the outer cortex
of osteoporotic pedicles has been shown to be significantly
thinner than those of normal vertebrae (8).
Besides the intrinsic morphologic characteristics of the screw, it
has also been demonstrated that the trajectory of the pedicle
screw has also a strong influence upon its ultimate pullout
strength. The ideal trajectory of a pedicle screw in the thoracolumbar spine has been classically described as converging
from its entry point, passing completely inside the pedicle, and
reaching at least the anterior third of the vertebral body, as it has
already been shown that an 80% penetration yields a screw that
is approximately 32.5% stronger than one with a 50% penetration (9). In the sagittal plane, the ideal screw should be located in
the superior third of the vertebral body, with a trajectory parallel
to the superior endplate. For thoracic screws, 2 different

Key words
Biomechanics
- Lumbar pedicle screw
- Pullout strength
-

trajectories in the sagittal plane have been described: the

anatomical one, initially popularized by Ruf and Harms (12), in
which the screw follows the natural angle of the pedicle, and the
straightforward trajectory, popularized by Suk et al. (15), in
which the screw is inserted parallel to the superior endplate. In
comparison with the anatomic technique, biomechanical studies
have shown that the straightforward technique leads to a 27%
increase in the total pullout strength of the screw (10).
In addition to these classic trajectories, alternative ones have also
been advocated (Figure 2), such as the in-out-in thoracic pedicle
screw (an alternative extrapedicular trajectory that can be used in
small thoracic pedicles) (2), and the lateral cortical screws (which
have been recently developed as means for enhancing the total
pullout strength of lumbar pedicle screws in osteoporotic patients). Biomechanical studies have suggested that such lateral
cortical bone trajectory is able to proportionate a 30% increase in
the screws pullout strength relative to traditional pedicle screws
(13), whereas in vivo studies have demonstrated that the insertional torque of lateral cortical bone screws may be up to 1.7
times greater (11).
In relation to the biomechanical effects of misplaced screws, a
biomechanical study has demonstrated that, in comparison with
well-placed pedicle screws (i.e., those with no cortical perforation), laterally misplaced screws had 21% less mean pullout
strength (3). Interestingly, medially misplaced screws had 8%
greater mean pullout strength than well-placed screws (an increase caused by the perforation of medial cortex by the screw).

Department of Neurosurgery - Brain & Spine Center/InvisionHealth, Buffalo,

New York, USA; 2Department of Neurological Surgery, The James
Comprehensive Cancer Center and The Wexner Medical Center at the Ohio State University,
Columbus, Ohio, USA
1

To whom correspondence should be addressed: Tobias A. Mattei, M.D.

[E-mail: tobiasmattei@gmail.com]
Citation: World Neurosurg. (2014).
http://dx.doi.org/10.1016/j.wneu.2014.06.030

WORLD NEUROSURGERY - [-]: ---, MONTH 2014

www.WORLDNEUROSURGERY.org

PERSPECTIVES

Figure 1. Schematic drawing illustrating the most important features of a

pedicle screw design that influence its overall pullout strength. Reprinted
with permission from Amaritsakul Y, Chao CK, Lin J: Multiobjective
optimization design of spinal pedicle screws using neural networks and
genetic algorithm: mathematical models and mechanical validation.
Comput Math Methods Med 2013;2013:462875.

Airball screws (defined as those that passed through the pedicle

but completely missed the vertebral body) had only 66% of the
mean pullout strength of well-placed screws. Proper medialization (triangulation) of pedicle screws is another factor that has
been shown to play a major role in the final strength of the
construct. It has already been shown, for example, that the
convergence of pedicle screws by 30 in the coronal plane can
increase their axial pullout strength by 28.6% in comparison with
screws placed in a parallel fashion (1).
Apart from the aforementioned intentional variations in the trajectory of pedicle screws, the vast majority of surgeons strive
hard for an ideal trajectory of pedicle screws, sometimes even
combining intraoperative navigation and fluoroscopy. Nevertheless, most spine surgeons would agree that a screw without a
cortical breach (even if it presents a nonsatisfactory mediolateral
or craniocaudal trajectory, or, if it is too short) is acceptable,
although it may not be ideal.
The study of Wadhwa et al. brings new data to answer a very
important question that is frequently faced by spine surgeons in
the intraoperative scenario. What is the best course of action
when intraoperative imaging methods (either fluoroscopy or
intraoperative computed tomography/O-arm
Surgical Imaging
System; Medtronic, Minneapolis, Minnesota, USA) suggest that
a pedicle screw may not be perfectly positioned? A significant
proportion of the spine surgeons (especially in the United States,
where lawsuits and the associated medicolegal implications of
surgical errors may have a catastrophic impact upon the surgeons career) would have a very low threshold for simply
revising the screw, without necessarily evaluating the biomechanical consequences of such attitude.
The results of Wadhwa et al. study calls into question the legitimacy of such rather automatic and apparently harmless surgical
step. According to the presented data, in patients with lower

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Figure 2. (A) Anatomical (AN) and straightforward (SF) trajectories for

thoracic pedicle screws. (B) Extrapedicular in-out-in trajectory for
thoracic pedicle screws. Representative radiographs showing pedicle
screws inserted through the traditional trajectory (C) and the alternative
lateral cortical bone trajectory (D). Note that, although shorter, the lateral
cortical trajectory has been shown to yield a much greater pullout strength
because of the close contact of the screw threads with the cortex of the
medial wall of the pedicle as well as with the cortex of the lateral wall of
the vertebral body. (C and D). Reprinted with permission from: Santoni BG,
Hynes RA, McGilvray KC, Rodriguez-Canessa G, Lyons AS, Henson MA,
Womack WJ, Puttlitz CM: Cortical bone trajectory for lumbar pedicle
screws. Spine J 9:366-373, 2009.

bone mineral density - i.e. either osteoporotic (T-score < 2.5) or

osteopenic patients (T-score between 1 and 2.5), revising a
pedicle screw initially inserted in a nonparallel fashion to the
superior endplate leads to a significant reduction (approximately
30%) in the overall pullout strength of the screw as well as to a
significant decrease in the axial rotation and flexion/extension
stiffness of the final construct. In other words, revising pedicle
screws in patients with low bone quality may have a clinically
meaningful detrimental effect in terms of the overall biomechanical strength of the final construct. The results of such study
are in accordance with a previous similar biomechanical study in
which the authors demonstrated a significant reduction in the
insertional torque and final pullout strength of screws after the
performance of multiple pilot-holes for screw insertion (5).
It could be said that, based on such data, an extra dose of caution
is recommended when deciding whether to revise a screw that
seems to be completely inside the pedicle but not in that ideal
book chapter-position. An interesting solution would be to
strongly rely on other methods of confirming the absence of

WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.06.030

PERSPECTIVES

cortical violation. If the surgeon is absolutely confident through

ball-tip palpation that there is no cortical breaches (although the
sensitivity of such maneuver has been severely questioned by
recent studies) (6), and the neurophysiological monitoring confirms the absence of pedicle violation (evoked electromyography
stimulation thresholds >11 mA have been shown to yield a
97.5% negative predictive value) (14), it could be argued that the
most adequate attitude in such situation (and probably the
hardest one for a typical neurosurgeon moved by an unrelentless
perfectionist strive) would be to silence the hurted ego and
accept the imperfect radiological result.
Some limitations of the study under discussion should be highlighted. The small number of specimens (6 cadavers) is a major
drawback, which may lead some readers to question the scientific strength of the obtained results. Additionally, because all
cadaveric specimens had decreased bone mineral density, the
conclusions of this study cannot be generalized to the overall
population with normal bone quality. Finally, only lumbar pedicle
screws (actually only the L4/L5 level) were studied.
In summary, the beautifully designed study by Wadhwa et al.
provides novel data to the important discussion that affects the
daily intraoperative routine of every spine surgeon and that is
centered at the question: At what cost should radiographic
perfection be pursued? A very reasonable answer would be:
As long as it does not compromise the overall biomechanical
strength of the construct. After all, worse than having a postoperative radiograph of a non-ideal screw recurrently coming
back to our almost obsessive-compulsive and perfectionist mind

REFERENCES
1. Barber JW, Boden SD, Ganey T, Hutton WC:
Biomechanical study of lumbar pedicle screws:
does convergence affect axial pullout strength?
J Spinal Disord 11:215-220, 1998.
2. Belmont PJ Jr, Klemme WR, Dhawan A,
Polly DW Jr: In vivo accuracy of thoracic pedicle
screws. Spine (Phila Pa 1976) 26:2340-2346, 2001.
3. Brasiliense LB, Theodore N, Lazaro BC, Sayed ZA,
Deniz FE, Sonntag VK, Crawford NR: Quantitative
analysis of misplaced pedicle screws in the
thoracic spine: how much pullout strength is lost?
Presented at the 2009 Joint Spine Section Meeting.
J Neurosurg Spine 12:503-508, 2010.
4. Cho W, Cho SK, Wu C: The biomechanics of
pedicle screw-based instrumentation. J Bone Joint
Surg Br 92:1061-1065, 2010.
5. Deno HL, Rosa RC, Silva P, Shimano AC,
Volpon JB, de Paula FJ, Schleicher P, Schnake K,
Kandziora F: The effect of repetitive pilot-hole use
on the insertion torque and pullout strength of
vertebral system screws. Spine (Phila Pa 1976) 34:
871-876, 2009.
6. Donohue ML, Moquin RR, Singla A, Calancie: Is
in vivo manual palpation for thoracic pedicle
screw instrumentation reliable? J Neurosurg Spine
20:492-496, 2014.

(and reminding us that, after all, we, neurosurgeons, also are

humans) is to have a patient at the door of our office with
perfectly placed pedicle screws and pseudarthrosis. The present
study provides clear evidence that, at least in the population with
decreased bone quality, striving for the optimal pullout strength
of a spine construct implies in the hard, but correct, commitment
of not revising pedicle screws displaying a nonideal ideal trajectory but that shows sufficient evidence of being still totally contained in bone. Similarly, such study suggests that, at least in the
osteoporotic/osteopenic population, revising a pedicle screw
without increasing the width of the salvage screw is highly
contraindicated.
An interesting alternative to overcome such detrimental effects of
screw revision (especially in those cases of small pedicles which
may not afford salvage pedicle screws of a larger diameter) is the
use of cement augmentation before insertion of the revised pedicle
screw. Several biomechanical studies have already demonstrated
that cement augmentation is able to significantly increase the pullout strength of pedicle screws in osteoporotic patients (with an
increase up to 5-fold with 3 ml of cement injection) (7, 16).
For neurosurgeons in-training, the take-home message of the
results of Wadhwa et al. article (which is invariably true for
almost every neurosurgical procedure) is: the first shot is your
best shot! Resilient patience during critical surgical maneuvers,
meticulous care, and obstinate strife for precision cannot be
overemphasized, as every correction (even if possible, as in the
case of spinal instrumentation) always carries along an inherent
associated cost.

7. Flsch C, Goost H, Figiel J, Paletta JR, Schultz W,

Lakemeier S: Correlation of pullout strength of
cement-augmented pedicle screws with CT-volumetric measurement of cement. Biomed Tech
(Berl) 57:473-480, 2012.
8. Hirano T, Hasegawa K, Takahashi HE,
Uchiyama S, Hara T, Washio T, Sugiura T,
Yokaichiya M, Ikeda M: Structural characteristics
of the pedicle and its role in screw stability. Spine
22:2504-2509, 1997.
9. Krag MH, Beynnon BD, Pope MH, Frymoyer JW,
Haugh LD, Weaver DL: An internal xator for
posterior application to short segments of the
thoracic, lumbar, or lumbosacral spine: design
and testing. Clin Orthop 203:75-98, 1986.
10. Lehman RA Jr, Polly DW Jr, Kuklo TR,
Cunningham B, Kirk KL, Belmont PJ Jr: Straightforward versus anatomic trajectory technique of
thoracic pedicle screw xation: a biomechanical
analysis. Spine (Phila Pa 1976) 28:2058-2065, 2003.

on further growth. Spine (Phila Pa 1976) 27:

E460-E466, 2002.
13. Santoni BG, Hynes RA, McGilvray KC, RodriguezCanessa G, Lyons AS, Henson MA, Womack WJ,
Puttlitz CM: Cortical bone trajectory for lumbar
pedicle screws. Spine J 9:366-373, 2009.
14. Shi YB, Binette M, Martin WH, Pearson JM,
Hart RA: Electrical stimulation for intraoperative
evaluation of thoracic pedicle screw placement.
Spine (Phila Pa 1976) 28:595-601, 2003.
15. Suk SI, Lee CK, Kim WJ, Chung YJ, Park YB:
Segmental pedicle screw xation in the treatment
of thoracic idiopathic scoliosis. Spine 20:
1399-1405, 1995.
16. Sven H, Yannick L, Daniel B, Paul H, Lorin B:
Inuence of screw augmentation in posterior dynamic and rigid stabilization systems in osteoporotic lumbar vertebrae: a biomechanical cadaveric
study. Spine (Phila Pa 1976) 39:E384-E389, 2014.

11. Matsukawa K, Yato Y, Kato T, Imabayashi H,

Asazuma T, Nemoto K: In vivo analysis of insertional torque during pedicle screwing using
cortical bone trajectory technique. Spine (Phila Pa
1976) 39:E240-E245, 2014.

Citation: World Neurosurg. (2014).

http://dx.doi.org/10.1016/j.wneu.2014.06.030

12. Ruf M, Harms J: Pedicle screws in 1- and 2-yearold children: technique, complications, and effect

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