Biomechanical insights into anterolateral vertebral screw fixation in osteoporotic spines: a comparative study of fixation methods and positions using porcine vertebrae

Objective: Combining oblique lumbar interbody fusion (OLIF) with posterior pedicle screw fixation (PPSF) has been proposed to reduce cage subsidence, especially in osteoporotic spines. Recently, anterolateral screw-rod fixation has gained interest as it allows direct pathology observation and avoids a posterior approach. However, controversies exist between anterolateral screw fixation systems and traditional PPSF due to variations in osteoporotic vertebral mineral density, screw fixation positions, and fixation methods (bicortical vs. unicortical). This study aimed to investigate the biomechanical impact of fixation position and method in osteoporotic spine.

Methods: Seventy-two fresh‑frozen porcine vertebrae (L1-6) were decalcified using 0.5 M EDTA and divided into two groups based on fixation method: bicortical or unicortical. Six groups for each method were created according to the screw position in the lateral vertebral body, with six specimens in each group: anterior, central, and posterior in the middle body and para-endplate regions. Correlations among screw position, fixation method and axial pullout strength were analyzed.

Results: A 4-week decalcification process, bone mineral density in the porcine vertebrae decreased to approximately 48% (p < 0.05) of the original value, categorizing them as osteoporotic. Bicortical fixation showed significantly greater pullout forces than unicortical fixation, with differences ranging from 82 to 273%. Notably, central or posterior screws outperformed anterior screws in pullout strength.

Conclusion: Bicortical fixation exhibited significantly greater pullout forces than unicortical fixation. We suggest positioning screws in the central or posterior region of the middle body with bicortical fixation in osteoporotic vertebrae.