Effect of the Total Facet Arthroplasty System After Complete Laminectomy-facetectomy on the Biomechanics of Implanted and Adjacent Segments

Background Context: Lumbar fusion is traditionally used to restore stability after wide surgical decompression for spinal stenosis. The Total Facet Arthroplasty System (TFAS) is a motion-restoring implant suggested as an alternative to rigid fixation after complete facetectomy.

Purpose: To investigate the effect of TFAS on the kinematics of the implanted and adjacent lumbar segments.

Study Design: Biomechanical in vitro study.

Methods: Nine human lumbar spines (L1 to sacrum) were tested in flexion-extension (+8 to -6Nm), lateral bending (+/-6Nm), and axial rotation (+/-5Nm). Flexion-extension was tested under 400 N follower preload. Specimens were tested intact, after complete L3 laminectomy with L3-L4 facetectomy, after L3-L4 pedicle screw fixation, and after L3-L4 TFAS implantation. Range of motion (ROM) was assessed in all tested directions. Neutral zone and stiffness in flexion and extension were calculated to assess quality of motion.

Results: Complete laminectomy-facetectomy increased L3-L4 ROM compared with intact in flexion-extension (8.7+/-2.0 degrees to 12.2+/-3.2 degrees, p<.05) lateral bending (9.0+/-2.5 degrees to 12.6+/-3.2 degrees, p=.09), and axial rotation (3.8+/-2.7 degrees to 7.8+/-4.5 degrees p<.05). Pedicle screw fixation decreased ROM compared with intact, resulting in 1.7+/-0.5 degrees flexion-extension (p<.05), 3.3+/-1.4 degrees lateral bending (p<.05), and 1.8+/-0.6 degrees axial rotation (p=.09). TFAS restored intact ROM (p>.05) resulting in 7.9+/-2.1 degrees flexion-extension, 10.1+/-3.0 degrees lateral bending, and 4.7+/-1.6 degrees axial rotation. Fusion significantly increased the normalized ROM at all remaining lumbar segments, whereas TFAS implantation resulted in near-normal distribution of normalized ROM at the implanted and remaining lumbar segments. Flexion and extension stiffness in the high-flexibility zone decreased after facetectomy (p<.05) and increased after simulated fusion (p<.05). TFAS restored quality of motion parameters (load-displacement curves) to intact (p>.05). The quality of motion parameters for the whole lumbar spine mimicked L3-L4 segmental results.

Conclusions: TFAS restored range and quality of motion at the operated segment to intact values and restored near-normal motion at the adjacent segments.