The Spine Journal 11 (2011) 324–330

Technical Report

Biomechanical effects of anterior, posterior, and combined

anterior-posterior instrumentation techniques on the stability
of a multilevel cervical corpectomy construct: a finite element
model analysis
Mozammil Hussain, PhDa,*, Ahmad Nassr, MDb, Raghu N. Natarajan, PhDc,d,
Howard S. An, MDc, Gunnar B.J. Andersson, MD, PhDc
a
Division of Research, Logan University, 1851 Schoettler Rd, Chesterfield, MO 63017, USA
b
Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
c
Department of Orthopedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
d
Department of Bioengineering, University of Illinois at Chicago, Chicago, 851 S Morgan St, IL 60607, USA
Received 22 July 2010; revised 10 December 2010; accepted 10 February 2011

Abstract BACKGROUND CONTEXT: Multilevel corpectomy, with or without anterior instrumentation,

has been associated with both graft and anterior screw-plate complications. The addition of poste-
rior instrumentation after anterior fixation has been shown to increase the overall stiffness of fused
segments and decrease the likelihood of instrumentation failure. Little biomechanical information
exists for providing guidance in the selection of an appropriate instrumentation technique after
a multilevel cervical corpectomy. Clinical studies have also been inconclusive in choosing an op-
timum fixation strategy.
PURPOSE: To test the hypothesis that combined anterior-posterior fixation would lower the
stresses on the bone-screw interfaces observed after an isolated anterior fixation and on the
graft–end plate interfaces observed after an isolated posterior fixation.
STUDY DESIGN: A finite element (FE) analysis of a C4–C7 corpectomy fusion with three dif-
ferent fixation techniques: anterior, posterior, and combined anterior-posterior.
METHODS: A previously validated three-dimensional FE model of an intact C3–T1 segment was
used. From this intact model, three additional instrumentation models were constructed using an-
terior (rigid screw-plate), posterior (rigid screw-rod), and combined anterior-posterior fixation tech-
niques following a C4–C7 corpectomy fusion. Construct stability at the cephalad and caudal levels
of the corpectomy was assessed.
RESULTS: Biomechanical comparisons between these instrumentation techniques show the least
amount of construct motion in the combined anterior-posterior instrumentation model. The use of
both anterior and posterior fixation shields the graft–end plate and screw-bone interfaces from peak
stresses as compared with an isolated anterior or an isolated posterior fixation, thereby supporting
the hypothesis of this study.
CONCLUSIONS: A combined fixation technique should be balanced against increased operating
room time and surgery costs because of dual anterior and posterior fixation and the increased risk of
long anterior plating, such as dysphasia, plate or screw dislodgement, or migration. Our study sug-
gests that the use of posterior fixation, whether alone or in combination with anterior fixation, infers

FDA device/drug status: not applicable.
Author disclosures: HSA (royalties, U&I, Inc.; stock ownership, in-
cluding options and warrants, Articular Engineering LLC; consulting,
DePuy Spine, Inc., Zimmer Spine, Inc., Life Spine, Inc., Baxter, Inc.;
speaking/teaching arrangements, Rush University Medical Center; board
of directors, Articular Engineering LLC; scientific advisory board, Pioneer,
Inc., Spinal Kinetics, Inc.; other office, International society for the Study
of the Lumber Spine; endowments, Rush University Medical Center;
grants, NIH; fellowship support, DePuy Spine, Inc., Synthes, Inc.).
* Corresponding author. Division of Research, Logan University, 1851
Schoettler Rd, Chesterfield, MO 63017, USA. Tel.: (636) 230-1955; fax:
(636) 207-2417.
E-mail address: mozammil.hussain@logan.edu (M. Hussain)

1529-9430/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.spinee.2011.02.008
 M. Hussain et al. / The Spine Journal 11 (2011) 324–330
comparable stability. Further studies are warranted to identify whether the current findings are con-
sistent with other biomechanical studies. Ó 2011 Elsevier Inc. All rights reserved.
Keywords: Cervical finite element corpectomy model; Anterior rigid screw-plate and posterior rigid screw-rod; Range of
motion; Graft–end plate stresses; Bone-screw stresses
Introduction
Multilevel corpectomy is a predictable and frequently
used technique for decompressing the spinal cord in pa-
tients with cervical spondylosis and myelopathy [1]. Fu-
sions both with and without anterior instrumentation have
reported graft settling, migration, and screw-plate compli-
cations, including failure and displacement. On the other
hand, posterior lateral mass screw-rod systems have been
shown to maintain the sagittal alignment of the cervical
spine [2]. Good clinical and radiological results have been
shown in patients who underwent posterior cervical decom-
pression and fusion with instrumentation [3]. Although pos-
terior fixation appears to have advantages over multilevel
anterior fixation, many clinical scenarios exist that still re-
quire multilevel anterior corpectomy to achieve optimal de-
compression and realignment of a neutral to kyphotic spine.
The addition of posterior instrumentation after anterior
screw-plate fixation has been shown to increase the overall
stiffness of fused segments and decrease the likelihood of
graft failure, migration, and screw pullout [4].
The use of combined anterior-posterior fixation has been
debated extensively. The most commonly cited fusion con-
struct complications resulting in poor outcomes still include
graft subsidence and screw loosening and pullout [5–7].
Little biomechanical information exists for providing guid-
ance in the selection of appropriate instrumentation tech-
nique (anterior, posterior, or combined anterior-posterior)
after a multilevel cervical corpectomy and strut grafting.
Clinical studies have also been inconclusive in choosing
an optimum fixation strategy after a multilevel corpectomy
[8,9]. In addition to immediate construct stability, which
biomechanical factors help influence, better fusion rates
with minimum chances of screw loosening are also poorly
understood.
It may be difficult to address the described biomechani-
cal issues using either in vivo or in vitro methods. Although
experimental studies have investigated different instrumen-
tation techniques after cervical corpectomies, the limita-
tions of these studies have not allowed for the evaluation
of stresses at the graft–end plate or bone-screw interfaces
[4,10–14]. Also, sacrificing some of the spinal structures
to simplify the experimental procedure, and the presence
of degeneration at most of the spinal segments, make the
cadaveric study data less accurate. To overcome some of
these shortcomings, the present study used a finite element
(FE) model of the cervical spine to understand the construct
stability. Another reason to use FE technique is because of
its power to analyze the overall spinal behavior by changing
one or more parameters of interest.
325
The objective of the present study is to compare the
range of motion, end plate stresses, bone graft stresses,
and bone-screw stresses for a C4–C7 corpectomy fusion
model following three different fixation techniques (an-
terior, posterior, and combined anterior-posterior). It is
hypothesized that an isolated anterior fixation model
would increase the stresses on the bone-screw interfaces,
whereas an isolated posterior fixation model would in-
crease the stresses on the graft–end plate interfaces.
Combined anterior-posterior fixation would lower the
stresses on the bone-screw interfaces observed after an
isolated anterior fixation and on the graft–end plate inter-
faces observed after an isolated posterior fixation.
Materials and methods
A previously validated three-dimensional FE model of
a healthy, intact C3–T1 segment was used [15]. This was
created using data from a computed tomography of a healthy
38-year-old female. The model components included the fol-
lowing: cortical bone, cancellous bone, end plates, annulus
fibrosus, nucleus pulposus, articular facets, anterior
longitudinal ligaments, posterior longitudinal ligaments, in-
terspinous ligaments, ligamentum flava, and capsular liga-
ments. The insertion points and areas of the ligaments were
closely matched with data from existing literature [16,17].
Anisotropy imparted by fibers in the anterior and posterior
annulus regions was simulated by varying regional tissue
elasticity. To simulate anterior interwoven (high-strength)
and posterior vertically straight (low-strength) fibers [18],
one-tenth of the anterior and posterior annulus regions were
modeled with elastic modulus that was 10% higher and 10%
lower than the lateral annulus, respectively.
From the intact C3–T1 model, a two-level corpectomy
was performed by removing the C5 and C6 vertebral bod-
ies and adjoining intervertebral discs. Anterior longitudi-
nal ligaments and posterior longitudinal ligaments for
the C4–C5, C5–C6, and C6–C7 motion segments were
also removed. A strut bone graft rigidly fused with the
end plates was chosen such that it occupied 50% areas
of the opposing C4 inferior and C7 superior end plates
[19,20]. Preparation of end plates for decompression was
not performed because minimal surface preparation of
end plates causes a loss in its integrity [21] and a failure
at lower loads [22]. From this corpectomy model, three
additional instrumentation models were constructed using
anterior, posterior, and combined anterior-posterior fixa-
tion techniques. The anterior instrumentation model was
created by using an anterior titanium plate (height552.12
326 M. Hussain et al. / The Spine Journal 11 (2011) 324–330
mm, width513.12 mm, thickness52.30 mm) with a rigid
screw trajectory, from C4 to C7. Two screws at each of the
cephalad and caudal ends of the anterior plate were placed
parallel to the end plates. The posterior instrumentation
model was created by using two posterior rods, on each
of the right and left sides, rigidly attached to segmental
screws placed in the lateral masses of C4 to C7. Screws
were placed in the posterior lateral mass according to
the technique described by An et al. [23]. The combined
anterior-posterior instrumentation model (Fig. 1) was cre-
ated by adding posterior instrumentation to the anterior in-
strumentation model. The screws for both the anterior and
lateral mass fixation were unicortical titanium screws, 16
mm in length, with an outer diameter of 3.5 mm and an
inner diameter of 2.5 mm (mean diameter of 3.0 mm).
The diameter of the posterior titanium rod was 3.0 mm.
The material properties for the FE models were taken from
the literature (Table).
Moment loads of 1.5 Nm were created by applying ap-
propriate equal and opposite point loads on the C3 superior
surface. The T1 inferior surface was fixed along three
Fig. 1. Two-level corpectomy model with combined anterior screw-plate and posterior screw-rod instrumentations.
perpendicular planes. An axial compressive preload of
73.6 N [24] was simulated before moment load application.
The compressive preload was simulated using two isotropic
truss elements connecting the midlateral sides of the verte-
bral bodies to mimic a follower load technique [25]. Con-
struct stability at the cephalad and caudal levels of the
corpectomy was assessed by recording the biomechanical
responses of the three instrumentation models in terms of
range of motion, end plate stresses, bone graft stresses,
and bone-screw stresses. An assumption of rigid fusion be-
tween end plates and bone graft was taken into account
while measuring compressive stresses. Bone-screw stresses
were calculated using Von Mises stresses in the vertebral
bone near the screws. The analysis was performed using
the commercially available FE code ADINA (ADINA R &
D Inc., Watertown, MA, USA).
Results
No major differences were observed in total construct
motion with the various fixation techniques (Fig. 2). When
 M. Hussain et al. / The Spine Journal 11 (2011) 324–330 327

Table
Material properties of the spinal components
Description Element type Young’s modulus (MPa) E Poisson’s ratio n References
Cortical bone 3-D solid (4 nodes) 10,000.00 0.29 [34–36]
Cancellous bone 3-D solid (4 nodes) 100.00 0.29
Posterior elements 3-D solid (4 nodes) 3,500.00 0.29
End plate 3-D solid (4 nodes) 500.00 0.40
Annulus fibrosus 3-D solid (4 nodes) 2.50 0.40
Nucleus pulposus 3-D solid (4 nodes) 1.50 0.49
Facet cartilage 3-D solid (4 nodes) 10.40 0.40 [37]
Anterior longitudinal ligament 3-D tension truss (2 nodes) 15 (3!12%), 30 (3O12%) — [24]
Posterior longitudinal ligament 3-D tension truss (2 nodes) 10 (3!12%), 20 (3O12%) —
Interspinous ligament 3-D tension truss (2 nodes) 2 (3!40%), 8 (3O40%) —
Ligamentum flavum 3-D tension truss (2 nodes) 5 (3!25%), 10 (3O25%) —
Capsular ligaments 3-D tension truss (2 nodes) 7 (3!12%), 30 (3O12%) —
Bone graft 3-D solid (4 nodes) 3,500.00 0.30 [38–40]
Anterior plate 3-D solid (4 nodes) 1,10,000.00 0.30 [41]
Anterior/posterior screws 3-D solid (4 nodes) 1,10,000.00 0.30 [41]
Posterior rods 3-D solid (4 nodes) 1,10,000.00 0.30 [41]

compared with the intact model, the range of motion of the
corpectomy models reduced by more than 95%.
Stresses in the bone graft were found to be highest with
the posterior instrumentation model, followed by the ante-
rior instrumentation model, and then the combined instru-
mentation model, except for extension, in which anterior
instrumentation model allowed the highest graft stress
(Fig. 3). Compared with the anterior instrumentation
model, the changes in bone graft stresses in both FE models
involving posterior fixation (posterior instrumentation
and combined instrumentation) were the following: flex-
ion (þ250% and 83%), extension (64% and 90%),
axial rotation (þ150% and 73%), and lateral bending
(þ319% and 64%).
Compared with the intact model, the stresses in the end
plates increased at both construct junctions. The end plate
stresses were found to be the greatest with posterior instru-
mentation and the least with combined instrumentation, ex-
cept for extension, in which anterior fixation model allowed
the highest end plate stresses (Fig. 4). In both FE models
involving posterior fixation (posterior instrumentation and
combined instrumentation), the changes in C4 inferior
end plate stresses as compared with the anterior instrumen-
tation model were flexion (þ9% and 11%), extension
(5% and 10%), axial rotation (þ7% and 27%), and
lateral bending (þ5% and 5%); and the changes in C7 su-
perior end plate stresses as compared with the anterior in-
strumentation model were flexion (þ77% and 11%),
extension (9% and 15%), axial rotation (þ14% and
9%), and lateral bending (þ8% and 9%).
Compared with the intact model, the stresses in the bone
near the screws increased at both construct junctions.
The bone-screw stresses were found to be the least with
the combined instrumentation model (Fig. 5). Among the
screws of the combined technique, the anterior screws were
subjected to greater stresses than posterior screws during
flexion and lateral bending, whereas the opposite trend
was observed during extension and axial rotation. Among
the instrumentation techniques, the bone-screw interface

Fig. 2. Effect of fixation techniques on range of motion of the corpectomy

construct. Fig. 3. Effect of fixation techniques on stresses in the bone graft.
328 M. Hussain et al. / The Spine Journal 11 (2011) 324–330
stresses were greatest in the anterior fixation model, except
for extension, when the bone-screw stresses were highest in
the posterior fixation model. Bone-screw stresses were
greater at the caudal level in the three instrumentation FE
models. In both FE models involving posterior fixation (pos-
terior instrumentation and combined instrumentation [ante-
rior screw, posterior screw]), the changes in C4 bone-screw
stresses as compared with the anterior instrumentation
model were flexion (39% and [70%, 83%]), extension
(þ7% and [83%, 59%]), axial rotation (8% and
[26%, 11%]), and lateral bending (30% and [55%,
61%]); and the changes in C7 bone-screw stresses as com-
pared with the anterior instrumentation model were flexion
(32% and [41%, 45%]), extension (þ13% and
[81%, 50%]), axial rotation (4% and [12%, 9%]),
and lateral bending (38% and [62%, 68%]).
Discussion
In this study, an FE model of a C4–C7 corpectomy fu-
sion was stabilized with either anterior, posterior, or com-
bined anterior-posterior instrumentations. Biomechanical
comparisons between these instrumentation techniques
show the least amount of construct motion in the combined
anterior-posterior instrumentation model. The results of the
present study support the hypothesis that the addition of
posterior instrumentation relieves peak stresses on the
screws after an isolated anterior fixation, whereas the addi-
tion of anterior instrumentation to an isolated posterior fix-
ation relieves the bone graft from high stresses.
Although not much difference is noted in the construct
range of motion among the three types of instrumentation
in this study, the combined anterior-posterior fixation
model is the most rigid. Although the increased rigidity
in the combined anterior-posterior instrumentation model
is because of increasing the number of fixation points, seg-
mental fixation compared with terminal fixation is one of
Fig. 4. Effect of fixation techniques on stresses in the end plates superior
and inferior to the corpectomy construct.
Fig. 5. Effect of fixation techniques on stresses in the bone near screw at
cephalad (C4) and caudal (C7) levels to the corpectomy construct.
the reasons behind greater rigidity of posterior instrumenta-
tion over anterior instrumentation. This has been shown in
previous cadaveric models, where the addition of posterior
instrumentation enhanced stability of the construct as com-
pared with the anterior instrumentation alone [26–28]. In
another cadaveric biomechanical study by Singh et al.
[4], a two-level cervical corpectomy model was stabilized
with anterior, posterior, or combined fixations. The authors
suggested the use of posterior segmental fixation with
a screw-rod system, with no need for additional anterior
fixation, as this provided no significant increase in rigidity.
A similar biomechanical study after a three-level corpec-
tomy found that the specimens with posterior lateral mass
plating are more rigid than those with anterior fixation
[10]. The difference in this study is that specimens were
loaded to failure. The anterior fixation group had fewer cy-
cles to initial failure as compared with the posterior fixation
group. These studies found no significant difference be-
tween the combined anterior-posterior and posterior fixation
alone, which is similar to the findings presented in this study.
The reasons behind graft–end plate interface failure are
not clear in the literature and are likely multifactorial.
The graft is subjected to lower loads in the anterior instru-
mentation compared with the posterior instrumentation
models, except for extension. Foley et al. [11] demonstrated
this effect with a cadaveric biomechanical study in which
anterior plating protected the graft from excessive loads
in flexion than in extension, and posterior instrumentation
demonstrated the opposite effect. The addition of posterior
instrumentation has been shown to shift the instantaneous
axis of rotation posteriorly, thereby protecting the graft
from excessive loads in extension [29]. Combined fixation
appears to allow the graft to share the load with both ante-
rior and posterior instrumentations [11], thereby shielding
the strut graft from higher stresses observed in either ante-
rior or posterior instrumentation alone. This may be desir-
able in the osteoporotic patient where there is a concern
 M. Hussain et al. / The Spine Journal 11 (2011) 324–330
that the strut graft may settle into the terminal vertebral
body end plates.
Loads observed in the end plates also play an important
role in determining the fusion mechanics between graft and
end plate that further governs subsidence, migration, and
dislodgement of the grafts. Posterior end plates are stronger
than their anterior counterparts [21], which is why graft
subsidence is more pronounced at the anterior graft–end
plate interface [30]. End plate stresses are directly related
to the graft forces, and any over or underdistraction of
the construct because of graft height variations may accord-
ingly affect end plate compressive loads [31]. Our model
demonstrated lower C7 superior end plate stresses, which
may indicate higher chances of failures because of non-
union, resulting in graft dislodgement and migration,
whereas higher C4 inferior end plate stresses may increase
the chances of an end plate fracture and graft subsidence.
Higher end plate stresses observed in this study at the ceph-
alad fusion level, as compared with the caudal one, may
also be a result of greater localization of graft distraction
forces at the cephalad level. Greater compressive stresses
on the end plates in the posterior instrumentation model
are because of increased graft compression in most modes
of testing; however, unloading of the graft is observed in
extension. Similar to the graft, compressive forces in the
end plates are lower in combined fixation compared with
the anterior or posterior fixation models alone. This is com-
patible with the load-sharing mechanics, as the increased
number of screws in the anterior and posterior locations re-
sists more of the load.
Screw loosening caused by insufficient mechanical sta-
bility at the bone-screw interface is not only dependent
on the type of fixation but also a function of several other
variables, such as screw thread type, the length and diame-
ter of the screws, uni or bicortical purchase, and the bone
mineral density of the vertebrae. How stresses in the bone
near screws vary in accordance with these additional vari-
ables in the vertebrae and posterior lateral mass remains
to be determined. Panjabi et al. [6] studied screw failures
in one- and three-level fusion models. Increased motion be-
tween the screws and bone in the multilevel construct,
caused by fatigue mechanism, is cited as a reason for screw
failure at the caudal end. The present study also noted that
bone-screw interface stresses were greatest in the caudal
screws whether anterior, posterior, or combined fixation
techniques are used. It is bone material and cortical layer
thickness that governs the stability and pullout strength of
the screws [32,33]. This may be why stresses in the hard
cortical portion of the lateral masses posteriorly may be
sustainable; whereas the stresses observed in the anterior
fixation model may be enough for screw pullout, mostly
in the cancellous bone of the vertebral body. The present
study also recorded greater stresses in the anterior screws
than screws inserted in the posterior lateral mass. The addi-
tion of posterior instrumentation reduces the anterior bone-
screw interface stresses in the combined fixation model,
329
possibly decreasing the chances of anterior construct failure
because of screw pullout.
While the study findings are consistent with current lit-
erature, the conclusions of this study should be understood
in the context of the limitations of FE analysis discussed
here. The current cervical spine models are based on the
data from a computed tomography of a healthy 38-year-
old female; therefore, the findings presented here should
not be extrapolated to the males and females in different
age groups. Modifications along the corner regions are per-
formed on the spinal structures and instrumentation without
much disruption in the original shape to develop smooth
curve shapes and minimize stress concentration points.
Annulus anisotropy contributed by collagen fibers is sim-
ulated by varying regional elasticity of the tissue matrix in-
stead of modeling the tensile fibers. Furthermore, screws
without heads are used in FE models. This is theorized to
have a negligible effect on the study outcome, as screw-
heads are often rigidly fixed with anterior plates or
posterior rods in most current instrumentation systems.
Moreover, straight posterior rods and grafts, instead of
slightly curved ones, are used in the present study. Finally,
construct stability is affected by neck musculature, which is
absent in the current analysis. The present study results
may be challenged if these limitations are appropriately
addressed in future FE models.
It is also to be noted that the static screw trajectories are
adopted in this FE study for the anterior construct and for
the posterior lateral mass construct. To stabilize the fusion
constructs, the biomechanical roles of the anterior screws
with dynamic and divergent trajectories, and the posterior
screws inserted into pedicles are, so far, well debated. Al-
though the current FE models have potential to incorporate
the dynamic behavior with divergent trajectories in anterior
screws and also change the insertion points of posterior
screws to pedicles, these new screw modeling aspects are
a different set of a project design; therefore, it would be in-
teresting to include such modeling behavior in anterior and
posterior screws as a part of the future studies.
In conclusion, our study suggests that the use of poste-
rior fixation, whether alone or in combination with anterior
fixation, infers comparable stability after a two-level ce-
rvical corpectomy fusion. The use of both anterior and pos-
terior fixation shields the graft–end plate and screw-bone
interfaces from peak stresses as compared with an isolated
anterior or an isolated posterior fixation, thereby supporting
the hypothesis of this study. However, the combined fixa-
tion should be balanced against increased operating room
time and surgery costs because of dual anterior and poste-
rior fixation and the increased risk of long anterior plating,
such as dysphasia, plate or screw dislodgement, or migra-
tion. There is also the theoretical concern that the place-
ment of an anterior plate may limit the correction of
sagittal alignment that posterior fixation affords. Although
the findings of current FE models are consistent with exist-
ing biomechanical studies as discussed here, and while they
330 M. Hussain et al. / The Spine Journal 11 (2011) 324–330
show promise in answering future research questions not
easily addressed with cadaveric studies, further studies
are still warranted to confirm our findings.
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