SPECIFIC TECHNIQUES

ROD CANTILEVER TECHNIQUES

Sharad Rajpal, M.D.
Department of Neurological Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin

CANTILEVER BEAM FIXATION techniques have a broad application in spine surgery, including the treatment of thoracolumbar spinal deformities. There are traditionally three cantilever beam xation types described: xed moment arm, nonxed moment arm, and applied moment arm. In practice, however, most constructs are applied in a hybrid fashion. The basic tenets of cantilever beam xation are provided in this article.
KEY WORDS: Cantilever, Deformity correction, Pedicle screws, Technique
Neurosurgery 63:A157A162, 2008
DOI: 10.1227/01.NEU.0000325767.45588.A2

Daniel K. Resnick, M.D.

Department of Neurological Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin Reprint requests: Daniel K. Resnick, M.D., Department of Neurological Surgery, University of Wisconsin Hospitals and Clinics, CSC K4/834, 600 Highland Avenue, Madison, WI 53792. Email: resnick@neurosurg.wisc.edu Received, May 20, 2007. Accepted, May 14, 2008.

www.neurosurgery-online.com

antilever beam xation techniques have a role in reconstruction of the spine after destabilization by traumatic, neoplastic, infectious, and degenerative spinal pathology. Such techniques are therefore pervasive in spinal surgery. Other articles in this supplement will address the classication and indications for surgery for a variety of spinal deformities. We will concentrate on the biomechanical characteristics and clinical relevance of rod cantilever techniques and their application to spinal deformities in general.

The principle of moments was derived from Archimedes appreciation of the operating principle of the lever. The concept of the moment arm, the characteristic distance between the IAR and applied force, is key to the operation of a lever and most devices capable of generating mechanical advantage. The bending moment (M) is a quantity that represents the relationship of the magnitude of a force vector (F) applied to a lever arm at a distance (d) from the axis of rotation. This relationship can be displayed according to the following equation: MFd The bending moment can thus be likened to the torque applied by a circular force (26). Bending moments increase in magnitude as the distance increases between the location of the applied force and the axis of rotation, or pivot point (Fig. 1). A cantilever is defined as any projecting structure, such as a beam or pedicle screw, that is fixed at one end but carries a load either along its length or at the opposite end (Fig. 2). The concept of a cantilever beam xation system refers to a short-segment xation technique that typically is conned to a single level above and below a pathological spinal segment. Pedicle or vertebral body screws can act as the cantilever beam in a spine construct but must withstand deformation under the various loads of the spinal column. The vertical rod or plate segment then acts to transmit the load back through another cantilever beam to the spinal column (Fig. 3). There are three cantilever beam fixation types: fixed moment arm, nonfixed moment arm, and applied moment arm. Fixed and applied moment arm cantilever beam constructs provide rigid or constrained xa-

FUNDAMENTAL PRINCIPLES
The spine is constantly under the inuence of external forces, such as gravity, acceleration and deceleration, and internal forces applied by muscles and ligaments, that induce compression, distraction, rotation, and translation. Forces characterized by a magnitude and direction in three-dimensional space are dened as vectors. The axis of rotation is dened as the axis around which an object rotates. The instantaneous axis of rotation (IAR) is the axis around which the spine tends to rotate or bend in response to applied forces. According to White and Panjabi (31), the IAR can be ascertained on the basis of the axes of rotation for the vertebral bodies individually or as a motion segment (1). In the normal spine, the IAR typically is located near the compressible disc spaces between vertebral segments. The location of the IAR at any given moment, on the other hand, is dynamic as the spine changes shape in response to various internal and external forces, the IAR for each spinal segment shifts location (25, 29).
ABBREVIATIONS: IAR, instantaneous axis of rotation

NEUROSURGERY

VOLUME 63 | NUMBER 3 | SEPTEMBER 2008 SUPPLEMENT | A157

RAJPAL AND RESNICK

FIGURE 1. Drawing showing that bending moment (M) is equivalent to the product of a force vector (F) applied at a distance (d) from the axis of rotation (instantaneous axis of rotation [IAR] in the spine). (Modified from, Zubay G, Dickman CA, Sonntag VKH, Crawford NR: Basic principles of spinal internal xation, in Winn HR (ed): Youmans Neurosurgical Surgery. Philadelphia, Elsevier, 2004, ed 5, pp 45864598 [34].)

tion; nonxed moment arm cantilever beam constructs provide dynamic, semiconstrained, or semirigid xation (2).

CANTILEVER BEAM FIXATION TYPES

Fixed Moment Arm
The traditional example of a xed moment arm cantilever beam xation construct involves the placement of screws rigidly connected to a system of longitudinal rods or plates. Although the ultimate rigidity of the construct depends upon the mechanical properties of the instrumentation, the instrumentation assembly, and the screw design, xed moment arm cantilever systems are capable of resisting both bending and axial loading. Because the construct is load bearing, significant stresses are applied to the implant at FIGURE 2. Drawing showing the screw-rod or screw-plate that cantilevered loads are typiinterface. Not surprisingly, cally forces (F) applied perpendiYoganandan et al. (32) have cular to the long axis of the screw. M moment arm, and l demonstrated proximal screw length of the lever arm. (From, fracture in the face of excess Hollowell JP, Yoganandan N, stress. To minimize the possiBenzel EC: Spinal implant attribbility of screw failure by utes: cantilever beam xation, in means of screw fracture, the Benzel EC (ed): Spine Surgery: largest screw diameter that is Techniques, Complication permitted by the local bony Avoidance, and Management. anatomy should be used (3). Philadelphia, Elsevier, 2005, ed 2, McCormack et al. (23) further pp 14181429 [17].) described the increased in-

cidence of failure of shortsegment cantilever beam constructs in patients with thoracolumbar burst fractures who did not have adequate ventral load bearing support. A technique for preventing failure of the cantilever construct and pedicle screws is through load sharing via ventral reconstruction with autograft, allograft, or synthetic cages (1, 11, 12, 21). Load sharing is crucial in cantilevered beam constructs not only because it can help reduce device failure, but because loading of the graft can promote bone healing. When considering ventral reconstruction, one key eleFIGURE 3. Drawing of canment for successful interbody tilever beam construct with shortstrut graft includes incorposegment pedicle screws demonrating a sufficient cross secstrating load transmission. F tional area to provide resistapplied force, and P compresance to subsidence into the sive load. (From, Hollowell JP, Yo g a n a n d a n N , B e n z e l E C : vertebral body under axial Spinal implant attributes: canloads (16). The optimal tilever beam fixation, in Benzel choice of materials and techEC (ed): Spine Surgery: nique for interbody reconTechniques, Complication struction should be evaluated Avoidance, and Management. on a case-by-case basis but Philadelphia, Elsevier, 2005, ed 2, may include allograft pp 14181429 [17].) (fibula, tibia, femur, patella, humerus), autograft (ribs, bula, iliac crest), or synthetic or metallic cages lled with bone graft or bone graft substitute.

Nonxed Moment Arm

Nonxed moment arm cantilever beam constructs are different from fixed moment arm cantilever beam constructs because they lack a rigidly xed beam and do not effectively support an axial load without additional construct assistance (e.g., addition of a ventral graft). In nonfixed moment arm constructs, screws have the tendency to toggle because they are not rigidly attached to the plate or rod (even though they may extend directly through it). In contrast to the proximal screw fracture found in fixed moment arm cantilever beam constructs, the failure pattern in nonxed moment arm cantilever beam constructs is typically screw pull-out as a result of degradation of the bone-implant interface seen in this type of construct (13, 15). Bone quality, screw-bone interface, screw major diameter (width of the screw shaft with the threads), depth, and conguration (triangulation) of screw placement are some important factors that contribute to screw pull-out strength (2, 28). Nonfixed moment arm constructs are typi-

A158 | VOLUME 63 | NUMBER 3 | SEPTEMBER 2008 SUPPLEMENT

www.neurosurgery-online.com

ROD CANTILEVER TECHNIQUES

cally more appropriate when some elements of the spine are available to help with axial load resistance and resistance to translation. In practice, most constructs are applied in a hybrid fashion, with the instrumentation playing several roles depending on the particular stresses applied. For example, in the subaxial cervical spine, nonxed moment arm screw-plate systems may be very effective in limiting translational motion because of the shape of the lateral mass and orientation of the cervical facet joints. In this case, the construct more closely represents a tension band than a cantilever beam. Surgical technique and preload play a role in the stresses placed upon a construct. When a xed cantilever beam construct is initially placed in a neutral mode with no compression, distraction, rotation, or translational forces, the construct will be forced to bear load (potentially shielding an interbody graft) once the spine is brought upright into an erect posture (2). Preloading of the ventral graft through compression may help avoid this phenomenon.

three-dimensional thoracolumbar deformities in all three planes. To add to the complexity, there is often coupling between intervertebral motion segments. Coupling is dened as motion in one axis that is accompanied by motion along another axis (e.g., lateral bending in the lumbar spine with axial rotation). Thoracolumbar deformities therefore may also include a rotational component. In addition to the planes of deformity, the length and location of the deformity can be variable and must be gauged so that the stabilizing construct provides an adequate bending moment to the spine and does not cause unnecessary deformity progression by terminating at an apical segment or near a transition zone (26).

APPLICATIONS TO SPINE SURGERY

The most straightforward application of the rod cantilever technique involves the placement of screws into the vertebral bodies spanning a single disc space. The most practical application for deformity correction surgery, however, is the use of cantilever beam xation in a multisegmental fashion (13). As noted previously, ideal construct systems include load sharing between the vertebral bodies and instrumentation. The use of interbody strut grafts helps with load sharing in cases of large defects between vertebral bodies, a technique more commonly found in traumatic thoracolumbar fractures and tumors. In thoracolumbar deformities, however, abnormal angulation of the spine results in atypical biomechanics and migration of the IAR from its usual position in the neutral spine. Thus, cantilever beam construct systems provide an excellent means by which these deformities can be fused with correction or in situ to halt progression. Thoracic and lumbar xation systems, although biomechanically similar to those used in the cervical spine, are subject to greater stresses than those used in the cervical spine. The ideal rod cantilever beam system includes segmental screw xation within the vertebral bodies between the extreme neutral vertebrae rigidly afxed to longitudinal rods or plates. Fixed, nonxed, and applied moment arm cantilever beam constructs in the thoracolumbar spine can be applied from either the ventral or dorsal position. Ventral applications include a true ventral, intermediate, or lateral position (17). Although the specific position used is restricted only by the anatomic constraints of the surgical approach chosen, deformity reduction techniques in the thoracic and lumbar spine are most commonly applied from the lateral and posterior approaches. With the application of ventral constructs, large forces can be applied to the spine to achieve coronal or sagittal plane correction via compression, distraction, or derotation. Ventral constructs often include interbody struts to reduce the extent of bending moment borne by the instrumentation. This load sharing between the implant and construct may reduce instrumentation failure. Dorsal pedicle screw constructs have been shown to offer biomechanical advantages over standard hook-rod constructs because they have a greater stiffness and pullout strength, allowing greater corrective forces to be applied to the spine during deformity correction (7, 20, 30, 33). Bess et al. (4) com-

Applied Moment Arm

The application of compression, distraction, or rotational forces using the cantilevered implant to reduce deformity is termed applied moment arm cantilever beam xation. In these constructs, the plate or rod is attached to the pedicle screws and forces are applied to the screws after attachment to the plate or rod in order to manipulate the spinal elements. Signicant and complex forces may be applied during both insertion and loading (24). Excessive load application can lead to instrumentation failure. Instrumentation stress and the potential for instrumentation failure can be reduced somewhat by the incorporation of additional points of xation so that there is distribution of the corrective forces (34). Applied moment arm cantilever beam constructs are used because they offer the ability to alter the alignment of the spine using short-segment xation, a technique which may be highly desirable in deformity correction (9, 18). Compressing across the heads of pedicle screws to reduce the posterior gap created during osteotomy procedures is an example of the use of an applied moment arm cantilever beam construct.

THEORETICAL ADVANTAGES
The purposes of deformity correction surgery include symptom relief, curvature correction, prevention of deformity progression, restoration of balance, and cosmetic improvement. With internal xation techniques, the goal is successful bony fusion. Although several internal xation techniques exist, the indication and type of construct depend upon the location, length, severity, and cause of the deformity, as well as the skeletal maturity of the patient. Spinal deformities of the thoracolumbar spine present unique anatomic challenges to the surgeon: larger vertebral bodies, rib cage, and a spinal transition zone. Although deformities are theoretically categorized into coronal, sagittal, or axial plane deformities, the complex interaction of external and internal forces applied to a biological spine often produces

NEUROSURGERY

VOLUME 63 | NUMBER 3 | SEPTEMBER 2008 SUPPLEMENT | A159

RAJPAL AND RESNICK

FIGURE 4. Drawing of possible modes of application of dorsal cantilever beam xation types. A xed moment arm cantilever beam construct can be applied in a distraction, neutral, or compression mode (A). A nonxed moment arm cantilever beam construct can be effectively applied only in a neutral mode (B). An applied moment arm cantilever beam construct may be used to apply axial forces (distraction or compression) or bending moments (extension or exion) (C). Arrows represent applied force vectors. (From, Benzel EC: Biomechanics of Spine Stabilization. New York, Thieme, 2001, pp 155170, 189200, 239275, 357373 [2].)

FIGURE 5. Drawing showing that sagittal plane applied moment arm cantilever beam forces may be applied with either exion (A) or extension (B) bending moments. Curved arrows represent bending moments, and straight arrows depict forces. (From, Benzel EC: Biomechanics of Spine Stabilization. New York, Thieme, 2001, pp 155170, 189200, 239275, 357373 [2].)

pared radiographical and clinical outcomes of adult spinal deformity patients treated with thoracic pedicle screws versus thoracic hook constructs. They found improved main thoracic curve correction in coronal deformities with the pedicle screw constructs compared with hook constructs (24.8 degrees versus 13.8 degrees; P 0.05) despite the fact that the patients treated with pedicle screw constructs had a more rigid and larger preoperative curve. They also found greater thoracolumbar kyphosis correction in sagittal plane deformities with thoracic pedicle screw constructs, as compared with thoracic hook constructs (12.1 degrees versus 2.5 degrees; P 0.05). Dorsal cantilever beam fixation constructs can be applied in several modalities (Fig. 4). Fixed moment arm cantilever constructs can be applied in distraction, neutral, or compression mode. Nonxed moment arm cantilever beam constructs are typically applied in neutral mode, whereas the applied moment arm cantilever beam construct can be applied in distraction, neutral, compression, exion, and extension (17). The decision on which construct system is best to apply depends on the pathology. In situations of thoracolumbar deformities, there are typically enough spinal components to resist axial loading, in which case any of the cantilever beam constructs (rigid or nonrigid) are appropriate. There are some advantages to screw-plate constructs over screw-rod constructs, including the ability of the plate to hold bone grafts against the dorsal fusion bed and therefore promote bony fusion (8, 19). Although bicortical lateral mass screw xation has not been shown to provide any biomechanical advantage over unicortical lateral mass screws in the cervical spine, the use of bicortical transverse process screws in the thoracic spine has been shown to provide some biomechanical advantages when pedicle screw xation is not feasible (14, 27). Although controversy exists over the need to include xation at every spinal segment versus only selected segments in dorsal cantilever beam constructs spanning multiple spinal segments,

intermediate screws and cross-xations have been shown to increase the stiffness of the construct (10, 17, 22). The forces applied at the screw-rod or screw-plate interface are greater with the dorsal cantilever beam system because of the longer moment arm as a result of the longer screws required to reach the vertebral body. Consequently, ventral cantilever beam construct systems are at a lower risk of instrumentation failure. As long as the screw, regardless of length, passes through the neutral axis, there is no difference in axial load-bearing capacity (17). The applied bending moment of a cantilever beam construct system can be increased by increasing the distance between the screws (moment arm) within the same segment. Lateral translational deformities can either be reduced or prevented in the thoracic and lumbar spine by toeing-in of the screws, applying rigid cross-xation of the longitudinal rods, adding levels of spinal segmental fixation, or incorporating any combination of these techniques (5). Applied moment arm cantilever beam constructs are popular for thoracolumbar deformity correction because they combine short-segment xation with powerful corrective forces to overcome the rigidity of deformities (9, 18). Chang (6) applied the cantilever bending technique to large and rigid scoliosis and found a reduced need for anterior release, fewer complications, and a greater rate of patient satisfaction. Applied moment arm cantilever beam constructs are also helpful for the reduction and xation of wedge compression and burst fractures of the thoracolumbar and lumbar regions (2). They can be applied via the application of exion or extension bending moments and can be used with or without distraction or compression or an accompanying ventral dural sac decompression and/or interbody bone graft (Fig. 5) (2). As mentioned previously, one technique for preventing failure of the cantilever construct and pedicle screws is load shar-

A160 | VOLUME 63 | NUMBER 3 | SEPTEMBER 2008 SUPPLEMENT

www.neurosurgery-online.com

ROD CANTILEVER TECHNIQUES

FIGURE 8. Patient 1. Reduction of L1 exion distraction fracture followed by long-segment xation with a rigid rod cantilever system (dorsal thoracic and lumbar pedicle screws xed rigidly to longitudinal rods). Postoperative lateral (left) and anteroposterior (right) x-rays. L, left. FIGURE 6. Drawing of an applied moment arm cantilever beam construct that uses distraction and an extension bending moment, without an interbody fusion (A). Load-bearing-to-load-sharing force application provided biomechanical and clinical advantages by allowing the implant and spine to share the load (unloading the implant). In this case, the spine is distracted (with or without extension or exion bending moment application) by the implant (B), followed by bone graft placement (C) and compression of the implant (D). Curved arrows represent bending moments, and straight arrows depict forces. (From, Benzel EC: Biomechanics of Spine Stabilization. New York, Thieme, 2001, pp 155170, 189200, 239275, 357373 [2].)

Reduction followed by long-segment xation with a rigid rod cantilever system (dorsal thoracic and lumbar pedicle screws xed rigidly to longitudinal rods) provided the ability to maintain reduction of the grossly unstable injury (Fig. 8). In this case, the involved vertebral bodies were preserved enough to allow load sharing, and therefore no additional strut or graft was required.

ing via ventral reconstruction. This technique involves ventral decompression, the placement of an interbody weightbearing bone graft, and compression of the construct onto the ventral graft and remaining intrinsic weightbearing spinal elements. This technique is termed loadbearing-to-load-sharing force application and offers biomechanical and clinical advantages (Fig. 6) (2).

Patient 2
Use of load-sharing constructs is not limited to the thoracolumbar spine. In this patient with basilar invagination, reduction (achieved with traction) was maintained with the use of an occipitocervical construct (occipital plate with bilateral C2 laminar and bilateral C3 and C4 lateral mass screws) and a rigid screw/rod system (Fig. 9). The use of rigidly attached screws allows the construct to bear some of the load of the cranium and to transfer this load to the subaxial cervical spine. FIGURE 7. Patient 1, who was involved in a motor vehicle accident with subsequent traumatic flexion-distraction fracture dislocation at L1. Computed tomographic scan showing sagittal reconstruction of CT.

ILLUSTRATIVE CASES
Patient 1
The patient was involved in a motor vehicle accident and sustained a traumatic flexiondistraction injury resulting in a fracture-dislocation at the thoracolumbar junction (L1) (Fig. 7).

FIGURE 9. Patient 2, who had basilar invagination. The patient underwent reduction and subsequently received an occipitocervical construct composed of an occipital plate, bilateral C2 laminar screws, and bilateral C3 and C4 lateral mass screws xed together with a rod system. Lateral x-ray.

CONCLUSIONS
Deformities of the thoracolumbar spine present challenges to the surgeon because of the unique and complex interaction of its anatomic and mechanical relationships. Cantilever beam xation techniques thus play an increasing role in degenerative

NEUROSURGERY

VOLUME 63 | NUMBER 3 | SEPTEMBER 2008 SUPPLEMENT | A161

RAJPAL AND RESNICK

spine correction because of the numerous styles available to the surgeon and their myriad applications.

REFERENCES
1. Abumi K, Panjabi MM, Duranceau J: Biomechanical evaluation of spinal xation devices. Part III. Stability provided by six spinal xation devices and interbody bone graft. Spine 14:12491255, 1989. 2. Benzel EC: Biomechanics of Spine Stabilization. New York, Thieme, 2001, pp 155170, 189200, 239275, 357373. 3. Benzel EC, Baldwin NG: Crossed-screw xation of the unstable thoracic and lumbar spine. J Neurosurg 82:1116, 1995. 4. Bess RS, Lenke LG, Bridwell KH, Cheh G, Mandel S, Sides B: Comparison of thoracic pedicle screw to hook instrumentation for the treatment of adult spinal deformity. Spine 32:555561, 2007. 5. Carson WL, Dufeld RC, Arendt M, Ridgely BJ, Gaines RW Jr: Internal forces and moments in transpedicular spine instrumentation. The effect of pedicle screw angle and transxationThe 4R-4bar linkage concept. Spine 15:893 901, 1990. 6. Chang KW: Cantilever bending technique for treatment of large and rigid scoliosis. Spine 28:24522458, 2003. 7. Coe JD, Warden KE, Herzig MA, McAfee PC: Inuence of bone mineral density on the fixation of thoracolumbar implants. A comparative study of transpedicular screws, laminar hooks, and spinous process wires. Spine 15:902907, 1990. 8. Cotrel Y, Dubousset J, Guillaumat M: New universal instrumentation in spinal surgery. Clin Orthop Relat Res 227:1023, 1988. 9. Dick W: The xateur interne as a versatile implant for spine surgery. Spine 12:882900, 1987. 10. Dick JC, Jones MP, Zdeblick TA, Kunz DN, Horton WC: A biomechanical comparison evaluating the use of intermediate screws and cross-linkage in lumbar pedicle xation. J Spine Disord 7:402407, 1994. 11. Dufeld RC, Carson WL, Chen LY, Voth B: Longitudinal element size effect on load sharing, internal loads, and fatigue life of tri-level spinal implant constructs. Spine 18:16951703, 1993. 12. Gaines RW Jr, Carson WL, Satterlee CC, Groh GI: Experimental evaluation of seven different spinal fracture internal xation devices using nonfailure stability testing. The load-sharing and unstable-mechanism concepts. Spine 16:902909, 1991. 13. Gurr KR, McAfee PC, Shih CM: Biomechanical analysis of anterior and posterior instrumentation systems after corpectomy. A calf-spine model. J Bone Joint Surg Am 70:11821191, 1988. 14. Heller JG, Shuster JK, Hutton WC: Pedicle and transverse process screws of the upper thoracic spine. Biomechanical comparison of loads to failure. Spine 24:654658, 1999. 15. Hollowell JP, Mueller WM, Larson SJ: Lumbar fusion with instrumentation for the treatment of degenerative spinal disordersA 10 year experience. Presented at the Rachidian Society 3rd Annual Meeting, Kona, Hawaii, 1995. 16. Hollowell JP, Vollmer DG, Wilson CR, Pintar FA, Yoganandan N: Biomechanical analysis of thoracolumbar interbody constructs. How important is the endplate? Spine 21:10321036, 1996.

17. Hollowell JP, Yoganandan N, Benzel EC: Spinal implant attributes: cantilever beam fixation, in Benzel EC (ed): Spine Surgery: Techniques, Complication Avoidance, and Management. Philadelphia, Elsevier, 2005, ed 2, pp 14181429. 18. 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 Relat Res 203:7598, 1986. 19. Kumar VG, Rea GL, Mervis LJ, McGregor JM: Cervical spondylotic myelopathy: Functional and radiographical long-term outcome after laminectomy and posterior fusion. Neurosurgery 44:771778, 1999. 20. Liljenqvist UR, Halm HF, Link TM: Pedicle screw instrumentation of the thoracic spine in idiopathic scoliosis. Spine 22:22392245, 1997. 21. Maiman DJ, Pintar F, Yoganandan N, Reinartz J: Effects of anterior vertebral grafting on the traumatized lumbar spine after pedicle screw-plate xation. Spine 18:24232430, 1993. 22. Margulies JY, Caser RS, Neuwirth MG, Margulies SD, Kummer FJ: Screw omission and the stability of posterior pedicle screw constructs for shortsegment stabilization. J Spine Disord 10:240245, 1997. 23. McCormack T, Karaikovic E, Gaines RW: The load sharing classication of spine fractures. Spine 19:17411744, 1994. 24. McLain RF, Sparling E, Benson DR: Early failure of short-segment pedicle instrumentation for thoracolumbar fractures. A preliminary report. J Bone Joint Surg Am 75:162167, 1993. 25. Rolander SD: Motion of the lumbar spine with special reference to the stabilizing effect of posterior fusion. An experimental study on autopsy specimens. Acta Orthop Scand 90:1144, 1966. 26. Schlenk RP, Kowalski RJ, Benzel EC: Biomechanics of spinal deformity. Neurosurg Focus 14:e2, 2003. 27. Seybold EA, Baker JA, Criscitiello AA, Ordway NR, Park CK, Connolly PJ: Characteristics of unicortical and bicortical lateral mass screws in the cervical spine. Spine 24:23972403, 1999. 28. Skinner R, Maybee J, Transfeldt E, Venter R, Chalmers W: Experimental pullout testing and comparison of variables in transpedicular screw xation. A biomechanical study. Spine 15:195201, 1990. 29. Smith TJ, Fernie GR: Functional biomechanics of the spine. Spine 16:1197 1203, 1991. 30. Suk SI, Lee CK, Min HJ, Cho KH, Oh JH: Comparison of Cotrel-Dubousset pedicle screws and hooks in the treatment of idiopathic scoliosis. Int Orthop 18:341346, 1994. 31. White AA, Panjabi MM: Clinical Biomechanics of the Spine. Philadelphia, Lippincott, 1990, pp 1125, ed 2. 32. Yoganandan N, Larson SJ, Pinar F, Maiman DJ, Reinartz J, Sances A Jr: Biomechanics of lumbar pedicle screw/plate xation in trauma. Neurosurgery 27:873880, 1990. 33. Zindrick MR, Wiltse LL, Widell EH, Thomas JC, Holland WR, Field BT, Spencer CW: A biomechanical study of intrapeduncular screw xation in the lumbosacral spine. Clin Orthop Relat Res 203:99112, 1986. 34. Zubay G, Dickman CA, Sonntag VKH, Crawford NR: Basic principles of spinal internal fixation, in Winn HR (ed): Youmans Neurosurgical Surgery. Philadelphia, Elsevier, 2004, ed 5, pp 45864598.

A162 | VOLUME 63 | NUMBER 3 | SEPTEMBER 2008 SUPPLEMENT

www.neurosurgery-online.com