A Finite Element Analysis of the Effects of Different Internal Fixation Strategies and Cage Implantation Methods on the Biomechanics of the Lumbar Spine

Objective: Providing the biomechanical evidences to the surgeons on the internal fixation strategy and Cage implantation method in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) by the finite element analysis (FEA).Methods: Firstly, based on the common MIS-TLIF surgical methods, three surgical models with different internal fixation strategies and Cage implantation methods were established. The surgical models simulated the physiological activities of the lumbar spine to evaluate the range of motion (ROM) of lumbar spine, the peak stress and the overall stress of the internal fixation system and Cage.Results: The results of the study show that the ROM of the surgical model has decreased significantly under all working conditions, and the decrease range is between 71.07-97.53%. The peak stress of the internal fixation system range was 48.56 to 100.09 MPa in Model-A, 58.10 to 136.05 MPa in Model-B, and 83.26 to 189.81 MPa in Model-C. Especially in the three working conditions of left lateral bending (LLB), left rotation (LR), and right rotation (RR), the peak stress of the internal fixation system of Model-C is 1.80 , 2.07, 1.79 times of Model-A and 2.05 , 1.64, 2.28 times of Model-B. The peak stress of Model-C Cage is significantly lower than Model-A and Model-B under all working conditions.Conclusion: Although the strategy of unilateral pedicle screw + lamina articular process screw + Cage horizontal implantation has the least Cage stress, there is a higher risk of internal fixation fail. Comprehensive evaluation, the surgical strategy of bilateral pedicle screw + Cage horizontal implantation has the best performance, and has the potential to become the standard implantation strategy of MIS-TLIF.