The use of a transition rod may prevent proximal junctional kyphosis in the thoracic spine after scoliosis surgery: A finite element analysis

Study Design. Finite element analysis. Objective. Via finite element analysis: (1) to demonstrate the abnormal forces present at the top of a scoliosis construct, (2) to demonstrate the importance of an intact interspinous and supraspinous ligament (ISL/SSL) complex, and (3) to evaluate a transition rod (a rod that has a short taper to a smaller diameter at one end) as an implant solution to diminish these pathomechanics, regardless of the integrity of the ISL/SSL complex. Summary of Background Data. The pathophysiology of increased nucleus pressure and increased angular displacement may contribute to proximal junctional kyphosis. Furthermore, high implant stress can be demonstrated at the upper end of the construct, possibly leading to the risk of implant failure. Methods. A finite element model was constructed to simulate a thoracic spinal fusion. The model was altered to remove the ISL/SSL complex at the level above the construct. Then, the model was altered again by extending the construct one level superior with a transition rod. The angular displacement, the maximum pressure in the nucleus, and stress within the implant were extracted from computational results under 2 conditions: load control and displacement control. The testing was performed with both titanium and stainless steel implants. Results. Pressure in the nucleus and angular displacement are all increased when the ISL/SSL complex is removed immediately above the instrumented levels, whereas the screw pullout force and maximum stress within the screw are decreased. The nucleus pressure increases by more than 50%. The angular displacement increases by 19% to 26%. This absence of the ISL/SSL complex simulates the clinical scenario that occurs when these structures are iatrogenically detached. Abnormal mechanics can be restored to normal level by extending the construct rostral one level with a transition rod. Furthermore, the elevated nucleus pressure and angular displacement noted even when the ISL/SSL complex is intact can be avoided with the use of a transition rod. Under the same bending moment (3 Nm), the nucleus pressure at the level immediately cephalad is up to 23% lower than the pressure in a standard construct. The angular displacement is 18% to 19% less than the standard construct. The maximum implant stress is also decreased by as much as 60%. Conclusion. Finite element modeling suggests that the pathomechanics at the proximal end of a scoliosis construct may be diminished by preserving the ISL/SSL complex and possibly completely eliminated with the use of rods with a diameter transition at the most proximal level.