Predicting Pedicle Screw Pullout and Fatigue Performance: Comparing Lateral Dual-Energy X-Ray Absorptiometry, Anterior to Posterior Dual-Energy X-Ray Absorptiometry, and Computed Tomography Hounsfield Units

Abstract

Background: As the prevalence and associated health care costs of osteoporosis continue to rise in our aging population, there is a growing need to continue to identify methods to predict spine construct integrity accurately and cost-effectively. Dual-energy x-ray absorptiometry (DEXA) in both anterior to posterior (AP) and lateral planes, as well as computed tomography (CT) Hounsfield units (HU), have all been investigated as potential preoperative predictive tools. The purpose of this study is to determine which of the 3 bone density analysis modalities has the highest potential for predicting pedicle screw biomechanics. Methods: Lumbar spine specimens (L2, L3, and L4) from 6 fresh frozen cadavers were used for testing. AP-DEXA, lateral-DEXA, and CT images were obtained. Biomechanical testing of pedicle screws in each vertebrae was then performed including pullout strength and fatigue testing. Statistical analysis was performed. Results: Pullout strength was best predicted by CT HU, followed by AP-DEXA, then lateral-DEXA (R2 = 0.78, 0.70, and 0.40, respectively). Fatigue testing showed a significant correlation of relative rotation between HU value and AP-DEXA bone mineral density (R2 = 0.54 and R2 = 0.72, respectively), and there was a significant correlation between relative translation and HU value (R2 = 0.43). There was a poor correlation between relative rotation and lateral-DEXA (R2 = 0.13) as well as a poor correlation between relative translation and both AP- and lateral-DEXA (R2 = 0.35 and R2 = 0.02). Conclusions: CT is the only modality with a statistically significant correlation to all biomechanical parameters measured (pullout strength, relative angular rotation, and relative translation). AP-DEXA also predicts the biomechanical measures of screw pullout and relative angular rotation and is superior to lateral-DEXA. CT may provide an incremental benefit in assessing fatigue strength, but this should be weighed against the disadvantages of cost and radiation. Clinical Relevance: The results of this study can help to inform clinicians on different bone density analyses and their implications on pedicle screw failure.