Biomechanical Effects of Multi-segment Fixation on Lumbar Spine and Sacroiliac Joints: A Finite Element Analysis

Abstract

Objective: Spine fixation surgery affects the biomechanical environment in the sacroiliac joint (SIJ), which may lead to the SIJ pain or degeneration after surgery. The purpose of this study is to determine the impact of the number and position of fixed segments on the SIJs and provide references for surgeons to plan fixation levels and enhance surgical outcomes.

Methods: The intact lumbar-pelvis finite element (FE) models and 11 fixation FE models with different number and position of fixed segments were developed based on CT images. A 400N follower load and 10° range of motion (ROM) of the spine were applied to the superior endplate of L1 to simulate the flexion, extension, bending and torsion motion after surgery. The peak stress on the SIJs, lumbar intervertebral discs, screws and rods were calculated to evaluate the biomechanical effects of fixation procedures.

Results: With the lowermost instrumented vertebra (LIV) of L5 or S1, the peak stress on SIJs increased with the number of fixed segments increasing. The flexion motion led to the greater von Mises stress on SIJ compared with other load conditions. Compared with the intact model, peak stress on all fixed intervertebral discs was reduced in the models with less than three fixed segments, and it increased in the models with more than three fixed segments. The stress on the SIJ was extremely high in the models with all segments from L1 to L5 fixed, including L1-L5, L1-S1 and L1-S2 fixation models. The stress on the segment adjacent to the fixed segments was significant higher compared to that in the intact model. The peak stress on rods and screws also increased with the number of fixed segments increasing in the flexion, extension and bending motion, and the bending and flexion motions led to the greater von Mises stress on SIJs.

Conclusion: Short-term fixation (≤2 segments) did not increase the stress on the SIJs significantly, while long-term segment fixation (≥4 segments) led to greater stress on the SIJs especially when all the L1-L5 segments were fixed. Unfixed lumbar segments compensated the ROM loss of the fixed segments, and the preservation of lumbar spine mobility would reduce the risks of SIJ degeneration.

Keywords

Finite element analysis / Fixation / Lumbar spine / Sacroiliac joint / Stress

References

[1] Rashbaum RF, Ohnmeiss DD, Lindley EM, Kitchel SH, Patel VV. Sacroiliac joint pain and its treatment. J Spinal Disord Tech. 2016; 29(2): 42–48.

[2] Sembrano JN, Polly DW. How often is low back pain not coming from the back? Spine (Phila Pa 1976). 2009; 34(1): 27–32.

[3] Adhia DB, Milosavljevic S, Tumilty S, Bussey MD. Innominate movement patterns, rotation trends and range of motion in individuals with low back pain of sacroiliac joint origin. Man Ther. 2016; 21: 100–108.

[4] Gusfa D, Bashir DA, Saffarian MR. Diagnosing and Managing Sacroiliac Joint Pain. Am J Phys Med Rehabil. 2021; 100(4): e40–e42.

[5] Cher D, Polly D, Berven S. Sacroiliac joint pain: burden of disease. Med Devices Evid Res. 2014; 7(1): 73–81.

[6] Casaroli G, Bassani T, Brayda-Bruno M, Luca A, Galbusera F. What do we know about the biomechanics of the sacroiliac joint and of sacropelvic fixation? A literature review. Med Eng Phys. 2020; 76: 1–12.

[7] Slipman CW, Shin CH, Patel RK, Isaac Z, Huston CW, Lipetz JS, et al. Etiologies of failed back surgery syndrome. Pain Med. 2002; 3(3): 200–214. discussion 214–7.

[8] Waguespack A, Schofferman J, Slosar P, Reynolds J. Etiology of long-term failures of lumbar spine surgery. Pain Med. 2002; 3(1): 18–22.

[9] Katz V, Schofferman J, Reynolds J. The sacroiliac joint: a potential cause of pain after lumbar fusion to the sacrum. J Spinal Disord Tech. 2003; 16(1): 96–99.

[10] Frymoyer JW, Hanley E, Howe J, Kuhlmann D, Matteri R. Disc excision and spine fusion in the management of lumbar disc disease. Spine. 1978; 3: 1–6.

[11] Maigne JY, Planchon CA. Sacroiliac joint pain after lumbar fusion. A study with anesthetic blocks. Eur Spine J. 2005; 14(7): 654–658.

[12] Depalma MJ, Ketchum JM, Saullo TR. Etiology of chronic low Back pain in patients having undergone lumbar fusion. Pain Med. 2011; 12(5): 732–739.

[13] Ackerman SJ, Polly DW, Knight T, Schneider K, Holt T, Cummings J. Comparison of the costs of nonoperative care to minimally invasive surgery for sacroiliac joint disruption and degenerative sacroiliitis in a United States medicare population: potential economic implications of a new minimally-invasive technology. Clin Outcomes Res. 2013; 5(1): 575–587.

[14] Harrop JS, Youssef JA, Maltenfort M, Vorwald P, Jabbour P, Bono CM, et al. Lumbar adjacent segment degeneration and disease after arthrodesis and total disc arthroplasty. Spine (Phila Pa 1976). 2008; 33(15): 1701–1707.

[15] Saavedra-Pozo FM, Deusdara RAM, Benzel EC. Adjacent segment disease perspective and review of the literature. Ochsner J. 2014; 14(1): 78–83.

[16] Chen CS, Cheng CK, Liu CL, Lo WH. Stress analysis of the disc adjacent to interbody fusion in lumbar spine. Med Eng Phys. 2001; 23: 485–493.

[17] Dekutoski MB, Schendel MJ, Ogilvie JW, Olsewski JM, Wallace LJ, Lewis JL. Comparison of in vivo and in vitro adjacent segment motion after lumbar fusion. Spine. 1994; 19: 1745–1751.

[18] Esses SI, Doherty BJ, Crawford MJ, Dreyzin V. Kinematic evaluation of lumbar fusion techniques. Spine. 1996; 21: 676–684.

[19] Ivanov AA, Kiapour A, Ebraheim NA, Goel V. Lumbar fusion leads to increases in angular motion and stress across sacroiliac joint: a finite element study. Spine (Phila Pa 1976). 2009; 34(5): 162–169.

[20] Soriano-Baron H, Lindsey DP, Rodriguez-Martinez N, Reyes PM, Newcomb A, Yerby SA, et al. The effect of implant placement on sacroiliac joint range of motion: posterior versus transarticular. Spine (Phila Pa 1976). 2015; 40(9): E525–E530.

[21] Zhao Y, Zhang S, Sun T, Wang D, Lian W, Tan J, et al. Mechanical comparison between lengthened and short sacroiliac screws in sacral fracture fixation: a finite element analysis. Orthop Traumatol Surg Res. 2013; 99(5): 601–606.

[22] Mushlin HM, Shea P, Brooks DM, Hayward GM, Ferrick BJ, Olexa J, et al. The effect of sacroiliac fusion and pelvic fixation on rod strain in thoracolumbar fusion constructs: a biomechanical investigation. Spine (Phila Pa 1976). 2021; 46(14): E769–E775.

[23] Wu T, Ren X, Cui Y, Cheng X, Peng S, Hou Z, et al. Biomechanical study of three kinds of internal fixation for the treatment of sacroiliac joint disruption using biomechanical test and finite element analysis. J Orthop Surg Res. 2018; 13(1): 1–8.

[24] Zhao G, Wang H, Wang L, et al. The biomechanical effects of different bag-carrying styles on lumbar spine and paraspinal muscles: a combined musculoskeletal and finite element study. Orthop Surg. 2023; 15(1): 315–327.

[25] Wu Y, Wang Y, Wu J, Guan J, Mao N, Lu C, et al. Study of double-level degeneration of lower lumbar spines by finite element model. World Neurosurg. 2016; 86: 294–299.

[26] Xu Z, Li Y, Zhang S, Liao L, Wu K, Feng Z, et al. A finite element analysis of sacroiliac joint displacements and ligament strains in response to three manipulations. BMC Musculoskelet Disord. 2020; 21(1): 1–10.

[27] Wang H, Wan Y, Liu X, Ren B, Xia Y, Liu Z. The biomechanical effects of Ti versus PEEK used in the PLIF surgery on lumbar spine: a finite element analysis. Comput Methods Biomech Biomed Engin. 2021; 24(10): 1115–1124.

[28] Zheng J, Feng X, Xiang J, Liu F, Leung FKL, Chen B. S2-alar-iliac screw and S1 pedicle screw fixation for the treatment of non-osteoporotic sacral fractures: a finite element study. J Orthop Surg Res. 2021; 16(1): 1–10.

[29] Denozière G, Ku DN. Biomechanical comparison between fusion of two vertebrae and implantation of an artificial intervertebral disc. J Biomech. 2006; 39(4): 766–775.

[30] Ambati DV, Wright EK, Lehman RA, Kang DG, Wagner SC, Dmitriev AE. Bilateral pedicle screw fixation provides superior biomechanical stability in transforaminal lumbar interbody fusion: a finite element study. Spine J. 2015; 15(8): 1812–1822.

[31] Miller JAA, Schultz AB, Andersson GBJ. Load-displacement behavior of sacroiliac joints. J Orthop Res. 1987; 5(1): 92–101.

[32] Hu P, Wu T, Wang HZ, Qi XZ, Yao J, Cheng XD, et al. Influence of different boundary conditions in finite element analysis on pelvic biomechanical load transmission. Orthop Surg. 2017; 9(1): 115–122.

[33] Eichenseer PH, Sybert DR, Cotton JR. A finite element analysis of sacroiliac joint ligaments in response to different loading conditions. Spine (Phila Pa 1976). 2011; 36(22): E1446–E1452.

[34] Hammer N, Klima S. In-silico pelvis and sacroiliac joint motion—a review on published research using numerical analyses. Clin Biomech. 2019; 61(December 2018): 95–104.

[35] Watson PJ, Dostanpor A, Fagan MJ, Dobson CA. The effect of boundary constraints on finite element modelling of the human pelvis. Med Eng Phys. 2017; 43: 48–57.

[36] Kim YH, Yao Z, Kim K, Park WM. Quantitative investigation of ligament strains during physical tests for sacroiliac joint pain using finite element analysis. Man Ther. 2014; 19(3): 235–241.

[37] Longo UG, Loppini M, Berton A, Laverde L, Maffulli N, Denaro V. Degenerative changes of the sacroiliac joint after spinal fusion: an evidence-based systematic review. Br Med Bull. 2014; 112(1): 47–56.

[38] Ha KY, Lee JS, Kim KW. Degeneration of sacroiliac joint after instrumented lumbar or lumbosacral fusion: a prospective cohort study over five-year follow-up. Spine (Phila Pa 1976). 2008; 33(11): 1192–1198.

[39] Nessim A, Cho W, Yang XA, Applebaum A, Sekerak R, Brill S, et al. Infra-adjacent segment disease after lumbar fusion. Spine (Phila Pa 1976). 2021; 46(16): E888–E892.

[40] Sturesson B, Selvik G, Udén A. Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine (Phila Pa 1976). 1989; 14(2): 162–165.

[41] Shibata Y, Shirai Y, Miyamoto M. The aging process in the sacroiliac joint: helical computed tomography analysis. J Orthop Sci. 2002; 7(1): 12–18.

[42] Chen CS, Cheng CK, Liu CL. A biomechanical comparison of posterolateral fusion and posterior fusion in the lumbar spine. J Spinal Disord Techniques. 2002; 15: 53–63.

[43] Jegede KA, Miller CP, Bible JE, Whang PG, Grauer JN. The effects of three different types of orthoses on the range of motion of the lumbar spine during 15 activities of daily living. Spine (Phila Pa 1976). 2011; 36(26): 2346–2353.

[44] Li Q, Gao Q, Wang L, Liu L, Yang H, Song Y. Comparison of long-term follow-up of n-HA PA66 cage and PEEK cage of lumbar interbody fusion in multi-level degenerative lumbar diseases: a stepwise propensity score matching analysis. Orthop Surg. 2024; 16(1): 17–28.

[45] Xin J, Wang Y, Zheng Z, Wang S, Na S, Zhang S. Treatment of intervertebral disc degeneration. Orthop Surg. 2022; 14(7): 1271–1280.

[46] Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat. 2012; 221(6): 537–567.

[47] Pan CC, Lee CH, Chen KH, Yen YC, Su KC. Comparative biomechanical analysis of unilateral, bilateral, and lateral pedicle screw implantation in oblique lumbar interbody fusion: a finite element study. Bioengineering (Basel). 2023; 10(11): 1238.

[48] Mumtaz M, Mendoza J, Vosoughi AS, Unger AS, Goel VK. A comparative biomechanical analysis of various rod configurations following anterior column realignment and pedicle subtraction osteotomy. Neurospine. 2021; 18(3): 587–596.

[49] Toyohara R, Kurosawa D, Hammer N, Werner M, Honda K, Sekiguchi Y, et al. Finite element analysis of load transition on sacroiliac joint during bipedal walking. Sci Rep. 2020; 10(1): 13683.

[50] Choi KC, Ryu KS, Lee SH, Kim YH, Lee SJ, Park CK. Biomechanical comparison of anterior lumbar interbody fusion: stand-alone interbody cage versus interbody cage with pedicle screw fixation – a finite element analysis. BMC Musculoskelet Disord. 2013; 26(14): 220.

RIGHTS & PERMISSIONS

2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.