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Thoracolumbar Instrumentation Options: Biomechanical Implications.

Saurabh Rawall1, Luke A Hiatt, Steven Theiss

  • 1From the Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Alabama (Rawall and Hiatt); Department of Orthopaedic Surgery, John D. Sherrill Chair of Orthopaedic Surgery, University of Birmingham at Alabama, Birmingham, Alabama (Theiss); Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Alabama (Rajaram).

The Journal of the American Academy of Orthopaedic Surgeons
|April 15, 2026
PubMed
Summary
This summary is machine-generated.

This review details practical spine instrumentation techniques, focusing on optimizing pedicle screw fixation in osteoporotic bone and preventing proximal junctional kyphosis for better surgical outcomes.

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Area of Science:

  • Spine Surgery
  • Orthopedic Implants
  • Spinal Instrumentation

Background:

  • Pedicle screws and rods are fundamental in spine instrumentation.
  • Contemporary practice requires optimizing fixation, especially in osteoporotic bone.
  • Preventing proximal junctional kyphosis is a critical implant-related consideration.

Purpose of the Study:

  • To provide practical guidance on contemporary spine instrumentation.
  • To discuss strategies for optimizing pedicle screw fixation in challenging spinal conditions.
  • To address implant-related factors influencing proximal junctional kyphosis.

Main Methods:

  • Review of imaging for screw selection (length, diameter).
  • Analysis of screw design features (conical inner diameter, V-shaped thread, dual-core, dual-thread).
  • Evaluation of placement techniques (undertapping, convergent trajectory) and screw types (polyaxial, uniaxial, monoaxial, cortical bone trajectory).
  • Assessment of augmentation techniques for osteoporotic spine (cement, HA-coated, expandable screws).
  • Comparison of rod materials (titanium, cobalt-chromium) and techniques (precontoured, multiple rods).
  • Strategies for preventing proximal junctional kyphosis ('soft landing', vertebroplasty).

Main Results:

  • Cross-sectional imaging aids in selecting optimal pedicle screws.
  • Specific screw designs (conical, dual-thread) offer superior pullout strength and biomechanical stability.
  • Undertapping and convergent trajectories are recommended for pedicle screw placement.
  • Various screw types show comparable clinical results; alternative fixation methods exist.
  • Cement augmentation is reliable for osteoporotic spine; other methods are available.
  • Titanium and cobalt-chromium rods perform similarly; precontoured and multiple rods are recommended.
  • 'Soft landing' techniques and vertebroplasty can prevent proximal junctional kyphosis.

Conclusions:

  • Optimized pedicle screw selection and placement techniques enhance spinal fixation.
  • Augmentation strategies and specific implant designs are crucial for managing osteoporotic spine.
  • Careful rod selection and "soft landing" techniques mitigate proximal junctional kyphosis risk.