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Biomechanical comparison of unilateral and bilateral pedicle screws fixation for

oblique lumbar inter-body fusion surgery – a finite element analysis

Guofang Fang, MD, Yunzhi Lin, MD, Jiachang Wu, Wengang Cui, MD, Shihao Zhang,
MD, Lili Guo, MD, Hongxun Sang, MD, Wenghua Huang, MD

PII: S1878-8750(20)31218-3
DOI: https://doi.org/10.1016/j.wneu.2020.05.245
Reference: WNEU 15181

To appear in: World Neurosurgery

Received Date: 9 January 2020

Revised Date: 8 May 2020
Accepted Date: 9 May 2020

Please cite this article as: Fang G, Lin Y, Wu J, Cui W, Zhang S, Guo L, Sang H, Huang W,
Biomechanical comparison of unilateral and bilateral pedicle screws fixation for oblique lumbar inter-
body fusion surgery – a finite element analysis, World Neurosurgery (2020), doi: https://doi.org/10.1016/
j.wneu.2020.05.245.

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Biomechanical comparison of unilateral and bilateral pedicle screws fixation for
oblique lumbar inter-body fusion surgery – a finite element analysis

1.Guofang Fang, MD

Department of Orthopaedics, Shenzhen Hospital of Southern Medical University,

fanguofan@163.com

2. Yunzhi Lin, MD

Department of Orthopaedics, Shenzhen Hospital of Southern Medical University,

linyunzhi0@126.com

3. Jiachang Wu

Department of Orthopaedics, Shenzhen Hospital of Southern Medical University,

wujiachang1982@163.com

4. Wengang Cui, MD

Department of Orthopaedics, Shenzhen Hospital of Southern Medical University,

zhejunc@aliyun.com

5. Shihao Zhang, MD

Department of Orthopaedics, Shenzhen Hospital of Southern Medical University,

zhshihao@xinlang.com .

6. Lili Guo, MD
Department of Orthopaedics, Shenzhen Hospital of Southern Medical University,

1014586009@qq.com

7.Hongxun Sang, MD

Department of Orthopaedics, Shenzhen Hospital of Southern Medical University,

hxsang@fmmu.edu.cn

8.Wenghua Huang, MD

Department of anatomy, Southern Medical University,

13822232749@139.com
Dr. Fang Guofang and Yunzhi Lin Contributed to this work equally. This article corresponded to Dr.
Sang Hongxun.
Biomechanical comparison of stand-alone and bilateral pedicle screw fixation for oblique
lumbar interbody fusion surgery – a finite element analysis

Abstract

Background: The most common complication of oblique lumbar interbody fusion (OLIF) is endplate
fracture/subsidence. The mechanics of endplate fracture in OLIF surgery are still unclear. The aim of this study was
to evaluate the biomechanical stability in patients undergoing OLIF surgery with stand-alone (SA) methods and
bilateral pedicle screw fixation (BPSF).
Methods: A finite element model of the L1-L5 spinal unit was established and validated. Based on the validated
model technique, L4-L5 functional surgical models corresponding to the SA and BPSF methods were created.
Simulations employing the models were performed to investigate OLIF surgery. A 500 N compression force was
applied to the superior surface of the model to represent the upper body weight, and a 7.5 Nm moment was applied
to simulate the six movement directions of the lumbar spinal model: flexion/extension, right/left lateral bending and
right/left axial rotation. Finite element (FE) models were developed to compare the biomechanics of the SA and
BPSF groups.
Results: Compared to the range of motion (ROM) of the intact lumbar model, that of the SA model was decreased
by 79.6% in flexion, 54.5% in extension, 57.2% in lateral bending, and 50.0% in axial rotation, and the BPSF model
was decreased by 86.7% in flexion, 77.3% in extension, 76.2% in lateral bending, and 75.0% in axial rotation.
Compared to the BPSF model, the maximum stresses of the L4 inferior endplate (IEP) and L5 superior endplate
(SEP) were greatly increased in the SA model; the L4 IEP stress was increased to 49.7 MPa in extension, and the L5
SEP stress was increased to 47.7 MPa in flexion, which were close to the yield stress of the lamellar bone (60 MPa).
Conclusions: OLIF surgery with BPSF could reduce the maximum stresses on the endplate, which may reduce the
incidence of cage subsidence. OLIF surgery with the SA method produced more stress than BPSF, especially in
extension and flexion motion, which may be a potential risk factor for cage subsidence.
Keywords: OLIF; Pedicle screw fixation; Spinal fusion; Finite element analysis

1. Introduction

Lumbar interbody fusion has become a popular technique for treating lumbar degenerative disc disease (DDD).
Anterior lumbar interbody fusion provides direct access to the disc but also carries the risk of injury to the iliac
vessels, peritoneal content, and ureteral and nervous systems. Mayer [1] described a minimally invasive anterior
approach to the lumbar spine through retroperitoneal access for the L2-L3 to L4-L5 discs and achieved solid anterior
fusion for all patients with minimal blood loss and no evidence of technique-related complications.
OLIF was introduced in 2012 by Silvestre [2]. A 4-6 cm skin incision, centered on the spinal segment to expose this
area, is made in the lateral abdominal region, and the external oblique, internal oblique, and transverse abdominal
muscles are dissected. The retroperitoneal space is accessed by blunt dissection, and the peritoneal content is
mobilized anteriorly. The psoas muscle is identified and reclined posteriorly, the sympathetic chain and the ureter are
mobilized anteriorly, and a retractor is placed to expose the disc. Discectomy is performed, and the OLIF cage is
clearly and safely inserted through this access.
The stand-alone (SA) procedure is associated with a low risk of posttreatment trauma or bleeding and offers good
stability and quick recovery. However, complications associated with this technique have been frequently reported
[3-6]. Abe investigated 155 patients who underwent OLIF surgery, and 75 complications were reported (incidence
rate, 48.3%). The most common complication was endplate fracture/subsidence (18.7%) [7]. Zeng ZY [8] reviewed
235 patients who underwent OLIF surgery and found 22 cases of endplate damage. The mechanics of endplate
fracture in OLIF surgery are still unclear. Avoiding such complications could be a major factor in the decision to use
this procedure. OLIF surgery with bilateral pedicle screw fixation (BPSF) may be an alternative solution to reduce
the complication [8]. Whether OLIF surgery with BPSF could provide sufficient stability and reduce complications
is still unknown. The aim of this study was to evaluate the biomechanical stability in patients undergoing OLIF
surgery with SA and BPSF, and to explore the mechanics of endplate fracture in OLIF surgery.
Finite element analysis (FEA) of lumbar biomechanics has become popular in the recent decades as a complement to
the cadaver test [9,10]. FE models of cages and the spine have been used for the evaluation of surgery feasibility and
the design of instruments. The purpose of this study was to evaluate stability and safety of OLIF surgery with a SA
procedure and BPSF.

2. Materials and methods

2.1 Development of an intact lumbar FE model

An L1-L5 three-dimensional lumbar model was created using Mimics 20.0 software (Materialise, Leuven, Belgium).
The data were obtained from the demo file in Mimics 20.0. The lumbar intervertebral discs, endplates, and facets
were created according to the contour of the adjacent vertebral body. The material properties of the cortical bone,
cancellous bone, facets and endplates were defined as isotropic, homogeneous and linear elastic materials. Cortical
bone and bony endplates were offset from the cancellous bone surface with a thickness of 1 mm, while cartilaginous
endplates had a thickness of 0.8 mm. Facet joints were modeled on the bony surfaces in the contact areas with a
thickness of 0.2 mm. The tangential behavior during contact was considered frictionless, and normal behavior was
defined by a penalty algorithm. The nucleus and annulus fibrosus were modeled using the hyper elastic material law.
Similar to reinforced concrete, the annulus fibrosus was composed of matrix and collagen fibers. The orientations of
the collagen fibers were 30 or 150 degrees at the bottom level of the intervertebral disc, and the stiffness of the fibers
was gradually increased from inside to outside. Seven major ligaments, including the anterior longitudinal ligament,
posterior longitudinal ligament, flava ligament, facet capsular ligament, intertransverse ligament, interspinous
ligament and supra-spinous ligament, were modeled by axial connectors (Figure 1). The mechanical properties of
the model were also adopted from the literature (Table 1) [10]. All degrees of freedom at the bottom of the L5
surface were constrained.
 Figure 1. The models of intact lumbar model

Table 1 Assigned Material Properties for the Finite Element Models

Tissues Modulus (MPa) Poisson’s Element type Thickness

ratio
Cortical bone 12000 0.3 Shell 1mm
Cancellous bone 100 0.2 Solid /
Bony endplate 12000 0.3 Shell 0.8mm
Facet 35 0.4 Shell 0.2mm
Annular ground substance c1 = 0.18, c2 = 0.045 / Solid /
Nucleus pulposus c1 = 0.12, c2 = 0.03 / Solid /
Annular collagen fiber 450 0.3 Surface /
PEEK (polyetheretherketone) 3700 0.3 Solid /
Titanium (Ti-6Al-4V) 110000 0.3 Solid /

2.2 Development of the OLIF FE model

An OLIF cage (10 mm in height, 55 mm in length, 18mm in width ,5-degree sagittal angle) was assembled based on
the L4-L5 functional spinal unit (FSU) model (Figure 2) to simulate the SA model. Four pedicle screws (6.5 mm in
diameter and 45 mm in length) and two rods (5.5 mm in diameter and 45 mm in length) were assembled on both
sides of the SA model to simulate the BPSF model (Figure 2). The properties were the same as those of the intact
lumbar model. The bottom of the L5 vertebral body was fully constrained. The mechanical properties were the same
as those of the intact model.

Figure 2. The models of OLIF with SA, BPSF

(A:SA geometric model B:SA FE model C: BPSF geometric model D: BPSF FE model)

2.3 Model validation

A mesh sensitivity test was used to verify the new lumbar FE model. Three lumbar models were created by mesh
resolution with element sizes of 1 mm, 1.5 mm and 2 mm (Figure 3). Ayturk and Puttlitz [11] reported that axial
rotation was the movement most sensitive to the mesh resolution in the FE model and that the ROM was not found
to be an indicator of mesh convergence. Thus, the three mesh resolutions used in this study were tested under the
same axial rotation with a moment of 7.5 Nm. The von Mises stress was used as a criterion to judge the mesh
convergence. The bottom surface of L5 was constrained for all degrees of freedom. A pure moment of 7.5 Nm was
applied to the superior surface of L1. The maximum von Mises stresses of different tissues in the models were
calculated. When the difference between the predicted results of the two mesh resolutions was less than 5%, the
mesh was considered convergent [12].
 Figure 3. Three mesh solutions for the whole lumbar models.

(Mesh 1: Element size 1mm; Mesh 2: Element size 1.5mm; Mesh 2: Element size 2mm)

The ROM of L4-L5 in the FE model under pure moment loading conditions (2.5, 5, and 7.5 Nm) in
flexion/extension, left/right lateral bending, and left/right axial rotation and the intervertebral disc pressure (IDP) of
the L4-L5 discs in this study were tested with pure compressive forces of 300 and 1000 N, which were compared
with in vitro experimental data (Brinckmann & Grootenboer 1991) [13]. The ROM of L4-L5 in the FE model under
a 500 N axial load and a moment load of 7.5 Nm were tested and compared with in vivo experimental results
(Dreischarf et al. 2014) [14].

2.4 Finite element analysis

The load process consisted of two steps. In the first step, a 500 N compression force was applied to the superior
surface of the model to represent the upper body weight. In the second step, a moment of 7.5 Nm was applied to the
surface of the model to test the six movement directions of the lumbar spinal model: flexion/extension, right/left
lateral bending and right/left axial rotation. The biomechanics of the SA and BPSF groups were compared to
evaluate the risk of cage subsidence.

3. Results

3.1 Mesh sensitivity test

Mesh 1, Mesh 2 and Mesh 3 included 973,883, 558,484, and 321,451 elements, respectively. The calculation times
required for the three meshes using the same computer were 78 minutes, 46 minutes and 16 minutes. The differences
in von Mises stress between Mesh 1 and Mesh 3 and between Mesh 2 and Mesh 3 are displayed in Table 2. The
differences among most tissues in mesh 1, mesh 2 and mesh 3 were less than 5% (Table 2).

Table 2 Mesh sensitivity analysis

Maximum Mises Mesh1 Mesh2(percentage Mesh3(percentage

stresses difference between difference between
Mesh1 and Mesh2) Mesh1 and Mesh3)

Cortical bone (MPa) 4.54 4.43(2%) 4.49(1%)

Cancellous bone 0.18 0.18(0%) 0.17(5%)

(MPa)

Nucleus (KPa) 8.01 7.96 (1%) 7.80(3%)

Facet (KPa) 1.23 1.28(4%) 1.14(7%)

3.2 Model validation

3.2.1 Pure moment

For the ROM, the IRA values of the L4/5 segment in the whole lumbar model were recorded in flexion/extension,
right/left lateral bending, and right/left axial rotation and compared with the in vitro experimental data reported by
Panjabi et al. (1994) [15]. As shown in Figure 4 we found that the IRA values of this study were consistent with the
results of Panjabi`s study.

Figure 4. Comparison of the IRA in L4/5 segment between the whole lumbar model and experimental data (panjabi
et al.1994) under pure moment of flexion/extension, left/right lateral bending, and left/right axial rotation
3.2.2 Pure compression

The maximum IDP values of the L4/5 segment in this study were 0.42 and 1.15 MPa under compressive forces of
300 and 1000 N, respectively, which were within the range of the existing experimental data (Brinckmann &
Grootenboer 1991) [13].

Figure 5. Comparison of IDP in l4-l5 level between the whole lumbar model and vitro experimental data
(Brinckmann & grootenboer 1991)

3.2.3 Combined compression

Under 500 N axial load and a moment load of 7.5 Nm, the ROM values of the L4/5 segment in the whole lumbar FE
model were 7.0 degrees in flexion, 2.2 degrees in extension, 4.2 degrees in lateral bending and 1.2 degrees in axial
rotation, which were within the mean and standard deviation range of the values reported by Dreischarf et al. 2014.
Figure 6. Comparison of IRA in L4/5 between the whole lumbar model and Dreischarf`s data under 500 N axial
load and 7.5NM moment loading of flexion/extension, left/right lateral bending, and left/right axial rotation.

3.3 ROM and displacement in the OLIF model

Compared to the ROM of the intact lumbar model, the SA model values were decreased by 79.6% in flexion, 54.5%
in extension, 57.2% in lateral bending, and 50.0% in axial rotation, and the BPSF model values were decreased by
86.7% in flexion, 77.3% in extension, 76.2% in lateral bending, and 75.0% in axial rotation (Figure 7). These results
showed that the OLIF procedure with BPSF could considerably reduce the ROM of the fusion segment. However,
OLIF with the SA procedure could not effectively reduce the extension, lateral bending and axial rotation motion
(less than 60%).

Figure 7. ROM of OLIF with SA and BPSF

3.4 Stress in the models

Compared to the BPSF model, the maximum stresses of L4 IEP and L5 SEP were significantly increased in the SA
model; the L4 IEP max stress was increased to 49.7 MPa in extension, and the L5 SEP max stress was increased to
47.7 MPa in flexion (Figure 8, Figure 9, Figure 10 and Figure 11). In the BPSF model, L4 IEP max stress was 11.25
MPa in extension and L5 SEP max stress was 28.89MPa in flexion (Figure 9, Figure 11). The L4 IEP of the SA
model produced 339% greater stress than the BPSF model in the extension moment, and the L5 SEP of the SA
model produced 64% greater stress than the BPSF model in the flexion moment. These results indicated that OLIF
with SA was associated with a higher risk of endplate fracture in the flexion and extension motions than OLIF with
BPSF. OLIF with BPSF could greatly decrease the von Mises stress of the endplate, which may reduce the risk of
endplate fracture.
 Figure8. The maximum von Mises stress of L4 IEP in all models

Figure9. Distribution of maximum stresses and strain in L4 IEP in extension motion

Figure10. The maximum von Mises stress of L5 SEP in all models

 Figure11. Distribution of maximum stresses and strain in L5 SEP in flexion

The maximum von Mises stresses of the cage were significantly decreased in the BPSF model in the flexion and
extension moments compared to the SA model. The cage in the BPSF model produced 39.6% less stress than the SA
model in the flexion moment and 84.1% less stress in the extension moment (Figure 12 and Figure 13).

Figure12. The maximum von Mises stress of cage in all models

 Figure13. Distribution of maximum stresses of cage in flexion and extension moment
(A1:SA model in flexion A2: SA model in extension B1: BPSF model in flexion B2: BPSF model in extension)

.
4. Discussion

OLIF surgery has become popular recent years. The stand-alone procedure offers patients many benefits such as a
small incision and scar, less blood loss, less pain, shorter hospitalization time, and faster recovery [2-6].
Nevertheless, the complication rates range from 3.7% to 66.7% [2-6,16-17]. Zeng ZY [8] reviewed 235 patients with
OLIF surgery and found 22 cases of endplate damage. The cage subsidence incidence in the stand-alone group was
higher than that in the OLIF combined with posterior pedicle screw fixation group [8]. Avoiding such complications
could be a major factor in the decision to use this procedure. The mechanics of endplate fracture are unclear.
In this study, the OLIF model was developed using published biomechanical assessment methods. A validated
lumbar FE lumbar model ensured the accuracy and reliability of the simulation results. With respect to morphology,
this study focused on facet and intervertebral discs, which strongly influence results [9]. Facet joints were modeled
on the bony surfaces in the contact areas with a thickness of 0.2 mm. The tangential behavior during contact was
considered frictionless, and normal behavior was defined by a penalty algorithm. The nucleus and annulus fibrosus
were modeled using the hyper elastic material law. This new method could make FEA precisely. Too much detailed
variations in morphologies required mesh-density convergence analysis [11]. In this study, we performed mesh-
density convergence analysis which was seldom performed in the pre-studies. In the mesh-density convergence
analysis , three lumbar models were created by mesh resolution with element sizes of 1 mm, 1.5 mm and 2 mm , the
differences of max stresses among most tissues in the three models were less than 5%, which meant that the mesh
was considered convergent. During model validation, the pure moment, pure compressive force and combined
loading were tested and compared with those in the literature [13-15]. The results were in good agreement with
previous studies. The FE model was successfully validated, and it was considered reliable for lumbar biomechanical
predictions.
Based on the validated lumbar model, OLIF models including SA and BPSF procedures at the level of the FSU (L4-
L5) have been developed. The simulation showed that BPSF could extensively reduce the ROM of the lumbar
segment. However, compared to the ROM of the intact lumbar model, the SA model decreased the ROM of the
lumbar segment by 54.5% in extension, 57.2% in lateral bending, and 50.0% in axial rotation, which meant that the
SA OLIF procedure could not effectively reduce the extension, lateral bending and axial rotation motion of the
lumbar segment (less than 60%).
In the SA model, under 500 N of axial load and 7.5 Nm moment loading, the maximum stress of the L4 IEP was
49.7 MPa in extension movement, and the maximum stress of the L5 SEP was 47.7 MPa in flexion movement,
which were similar to the yield stress of lamellar bone (60 MPa) [18]. This suggested that the SA OLIF procedure
may be a potential risk factor for endplate fracture and cage subsidence. The L4 IEP of the BPSF model exhibited
77.2% less stress than the SA model in extension moment, and the L5 SEP of the BPSF model showed 39.0% less
stress than the SA model in the flexion moment; therefore, BPSF could efficiently reduce the maximum stress on the
endplate. This indicated that OLIF with BPSF was safer than SA OLIF with regard to cage subsidence.
Overall, the FEA revealed that the SA procedure could not provide sufficient rigidity in OLIF surgery. The
maximum stresses of the L4 IEP and L5 SEP were greatly increased in the SA model in the flexion and extension
moment, which may be an underlying risk factor for cage subsidence. In this study, we also found that BPSF could
share the stresses of the endplate and restrict the ROM of the lumbar segment, which may be an effective method to
reduce the complication of cage subsidence. A clinical study also showed that BPSF can decrease the rate of cage
displacement [19].
In conclusion, BPSF is important for OLIF surgery. Although BPSF will increase the medical expense and may
result in other complications such as fixation failure, infection, and neurological deficits [20], compared to the
greater risk of cage subsidence, the additional risks of BPSF are lower and less destructive.
Due to the complications, decision-making between SA OLIF procedure and OLIF with BPSF procedure is very
important. From this study, SA OLIF procedure is not suitable for the patients with poor bone quality, such as
osteoporosis, because their endplates were too weak and have high risk of cage subsidence. OLIF with BPSF is the
best choice for them. For the patients with excellent bone quality, SA OLIF procedure may be a good solution. Due
to multiple risk factors for endplate fracture may exist, including endplate damage, obesity, high iliac crest, and poor
stability of lesion segments [8], the specific surgical plan is more complex in clinical experience.
Limitations

The postoperative residual annular fibrous was not constructed in the stand-alone OLIF model. The muscles were
not considered in this study, which play an important role in supporting the stability of lumbar spine. The FEA does
not provide actual clinic outcome evidence. Further clinical studies should be done in the future to verify the FEA
results.
Conclusion

The new lumbar FEA model was validated successfully and as good as pre-studies. It was reliable for lumbar
biomechanical predictions. The FEA indicated that the SA OLIF procedure may result in a greater risk of cage
subsidence and OLIF with BPSF was very important for the patients with poor bone quality. Since the FEA does not
provide actual clinic outcome evidence, further clinical studies should be done in the future to verify the FEA
results.

Declarations Ethics approval and consent to participate

This article did not involve the experiments of human and all the data came from the demo file in Mimics 20.0
software.
Consent for publication Not applicable.
Availability of data and material
The data came from the demo file in Mimics 20.0 software.
Competing interests
None.
Funding

This study was supported by Sanming Project of Medicine in Shenzhen （SZSM201612019）, Shenzhen key

laboratory of digital surgical printing project(ZDSYS201707311542415) and Southern Medical University clinical

start-up fund（LC2016ZD036）.

Authors' contributions
Dr. GF Fang and Dr. YZ Lin had full access to all the data in the study and takes responsibility for the integrity of
the data and the accuracy of the data analysis. Dr. HX Sang and WH Huang designed the study protocol. LL
Guo ,WG Cui ,JC WU and SH Zhang drafted the work.
Acknowledgments
We would like to thank Mr. Zhang for computer technique support (Guangzhou Li Suan Computer Technology Co.,
Ltd).
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Abbreviations
OLIF: oblique lumbar inter-body fusion
SA: stand-alone
BPSF: Bilateral pedicle screw fixation
UPSF:Unilateral pedicle screw fixation
ROM: Range of motion
IEP: inferior endplate
SEP: superior endplate
FE: Finite element
FSU: functional spinal unit
FEA: Finite element analysis
TLIF:transforaminal lumbar interbody fusion
IDP:intervertebral disc pressure
IRA:inter-segmental rotation angle
MPa: megapascals
Dr. GF Fang and Dr. YZ Lin had full access to all the data in the study and takes responsibility for the

integrity of the data and the accuracy of the data analysis. Dr. HX Sang and WH Huang designed the

study protocol. LL Guo, WG Cui, JC Wu and SH Zhang drafted the work.

No conflict of interest exits in the submission of this manuscript, and manuscript is approved by all
authors for publication. I would like to declare on behalf of my co-authors that the work described was
original research that has not been published previously, and not under consideration for publication
elsewhere, in whole or in part. All the authors listed have approved the manuscript that is enclosed.