椎弓根釘骨水泥強化技術應用進展_《中國修復重建外科雜志》

作者：

劉欣春 , 朱悅

中國醫科大學附屬第一醫院骨科（沈陽，110001）;

關鍵詞：

骨水泥椎弓根釘骨質疏松翻修

DOI：

10.7507/1002-1892.20130276

視頻：

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摘要 全文 圖表 視頻 參考文獻 施引文獻 補充材料

目的總結椎弓根釘骨水泥強化技術的應用進展。方法廣泛查閱近年關于椎弓根釘骨水泥強化技術的基礎與臨床研究文獻，分析比較并總結其規律。結果椎弓根釘骨水泥強化技術包括實心釘強化和中空帶側孔椎弓根釘強化技術兩類，均能提高椎弓根釘固定強度，取得滿意臨床療效；骨水泥滲漏有一定發生率，但有癥狀者發生率較低。結論對于骨質條件不良的脊柱內固定手術，椎弓根釘骨水泥強化技術是有效安全的固定方式。

引用本文： 劉欣春,朱悅. 椎弓根釘骨水泥強化技術應用進展. 中國修復重建外科雜志, 2013, 27(10): 1267-1272. doi: 10.7507/1002-1892.20130276 復制

1.	Roy-Camille R, Saillant G, Mazel C. Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop Relat Res, 1986, (203): 7-17.
2.	Zindrick MR, Wiltse LL, Widell EH, et al. A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop Relat Res, 1986, (203): 99-112.
3.	Halvorson TL, Kelley LA, Thomas KA, et al. Effects of bone mineral density on pedicle screw fixation. Spine (Phila Pa 1976), 1994, 19(21): 2415-2420.
4.	McLain RF, McKinley TO, Yerby SA, et al. The effect of bone quality on pedicle screw loading in axial instability: a synthetic model. Spine (Phila Pa 1976), 1997, 22(13): 1454-1460.
5.	Margulies JY, Casar RS, Caruso SA, et al. The mechanical role of laminar hook protection of pedicle screws at the caudal end vertebra. Eur Spine J, 1997, 6(4): 245-248.
6.	Hasegawa K, Takahashi HE, Uchiyama S, et al. An experimental study of a combination method using a pedicle screw and laminar hook for the osteoporotic spine. Spine (Phila Pa 1976), 1997, 22(9): 958-963.
7.	Tan JS, Kwon BK, Dvorak MF, et al. Pedicle screw motion in the osteoporotic spine after augmentation with laminar hooks, sublaminar wires, or calcium phosphate cement: a comparative analysis. Spine (Phila Pa 1976), 2004, 29(16): 1723-1730.
8.	Hu SS. Internal fixation in the osteoporotic spine. Spine (Phila Pa 1976), 1997, 22(24 Suppl): 43S-48S.
9.	Ghani I, Kroeber M. Role of major revision spine surgery in recurrent adjacent segment osteoporotic vertebral body fracture: a case report. Arch Orthop Trauma Surg, 2012, 132(8): 1089-1094.
10.	Cavagna R, Tournier C, Aunoble S, et al. Lumbar decompression and fusion in elderly osteoporotic patients: a prospective study using less rigid titanium rod fixation. J Spinal Disord Tech, 2008, 21(2): 86-91.
11.	Polly DW Jr, Orchowski JR, Ellenbogen RG. Revision pedicle screws. Bigger, longer shims—what is best? Spine (Phila Pa 1976), 1998, 23(12): 1374-1379.
12.	Kiner DW, Wybo CD, Sterba W, et al. Biomechanical analysis of different techniques in revision spinal instrumentation: larger diameter screws versus cement augmentation. Spine (Phila Pa 1976), 2008, 33(24): 2618-2622.
13.	Hirano T, Hasegawa K, Washio T, et al. Fracture risk during pedicle screw insertion in osteoporotic spine. J Spinal Disord, 1998, 11(6): 493-497.
14.	Cook SD, Salkeld SL, Whitecloud TS 3rd, et al. Biomechanical evaluation and preliminary clinical experience with an expansive pedicle screw design. J Spinal Disord, 2000, 13(3): 230-236.
15.	Cook SD, Barbera J, Rubi M, et al. Lumbosacral fixation using expandable pedicle screws. an alternative in reoperation and osteoporosis. Spine J, 2001, 1(2): 109-114.
16.	Aldini NN, Fini M, Giavaresi G, et al. Pedicular fixation in the osteoporotic spine: a pilot in vivo study on long-term ovariectomized sheep. J Orthop Res, 2002, 20(6): 1217-1224.
17.	Hasegawa T, Inufusa A, Imai Y, et al. Hydroxyapatite-coating of pedicle screws improves resistance against pull-out force in the osteoporotic canine lumbar spine model: a pilot study. Spine J, 2005, 5(3): 239-243.
18.	Pfeifer BA, Krag MH, Johnson C. Repair of failed transpedicle screw fixation. A biomechanical study comparing polymethylmethacrylate, milled bone, and matchstick bone reconstruction. Spine (Phila Pa 1976), 1994, 19(3): 350-353.
19.	Cook SD, Salkeld SL, Stanley T, et al. Biomechanical study of pedicle screw fixation in severely osteoporotic bone. Spine J, 2004, 4(4): 402-408.
20.	Soshi S, Shiba R, Kondo H, et al. An experimental study on transpedicular screw fixation in relation to osteoporosis of the lumbar spine. Spine (Phila Pa 1976), 1991, 16(11): 1335-1341.
21.	Renner SM, Lim TH, Kim WJ, et al. Augmentation of pedicle screw fixation strength using an injectable calcium phosphate cement as a function of injection timing and method. Spine (Phila Pa 1976), 2004, 29(11): E212-216.
22.	Linhardt O, Lüring C, Matussek J, et al. Stability of pedicle screws after kyphoplasty augmentation: an experimental study to compare transpedicular screw fixation in soft and cured kyphoplasty cement. J Spinal Disord Tech, 2006, 19(2): 87-91.
23.	邑曉東, 盧海霖, 陳明. 醫用骨水泥在骨質疏松患者行椎弓根釘固定中的作用. 中國脊柱脊髓雜志, 2005, 15(2): 95-97.
24.	Frankel BM, Jones T, Wang C. Segmental polymethylmethacrylate-augmented pedicle screw fixation in patients with bone softening caused by osteoporosis and metastatic tumor involvement: a clinical evaluation. Neurosurgery, 2007, 61(3): 531-537.
25.	Kim HS, Park SK, Joy H, et al. Bone cement augmentation of short segment fixation for unstable burst fracture in severe osteoporosis. J Korean Neurosurg Soc, 2008, 44(1): 8-14.
26.	Chang MC, Liu CL, Chen TH. Polymethylmethacrylate augmentation of pedicle screw for osteoporotic spinal surgery: a novel technique. Spine (Phila Pa 1976), 2008, 33(10): E317-324.
27.	王剛, 吳峰, 關宏剛, 等. 直入式注入聚甲基丙烯酸甲酯骨水泥強化椎弓根釘內固定治療骨質疏松性胸腰椎骨折. 中華創傷骨科雜志, 2011, 13(6): 549-552.
28.	Aydogan M, Ozturk C, Karatoprak O, et al. The pedicle screw fixation with vertebroplasty augmentation in the surgical treatment of the severe osteoporotic spines. J Spinal Disord Tech, 2009, 22(6): 444-447.
29.	Sawakami K, Yamazaki A, Ishikawa S, et al. Polymethylmethacrylate augmentation of pedicle screws increases the initial fixation in osteoporotic spine patients. J Spinal Disord Tech, 2012, 25(2): E28-35.
30.	Yazu M, Kin A, Kosaka R, et al. Efficacy of novel-concept pedicle screw fixation augmented with calcium phosphate cement in the osteoporotic spine. J Orthop Sci, 2005, 10(1): 56-61.
31.	Fransen P. Increasing pedicle screw anchoring in the osteoporotic spine by cement injection through the implant. Technical note and report of three cases. J Neurosurg Spine, 2007, 7(3): 366-369.
32.	Moon BJ, Cho BY, Choi EY, et al. Polymethylmethacrylate-augmented screw fixation for stabilization of the osteoporotic spine: a three-year follow-up of 37 patients. J Korean Neurosurg Soc, 2009, 46(4): 305-311.
33.	Amendola L, Gasbarrini A, Fosco M, et al. Fenestrated pedicle screws for cement-augmented purchase in patients with bone softening. J Orthop Traumatol, 2011, 12(4): 193-199.
34.	Piñera AR, Duran C, Lopez B, et al. Instrumented lumbar arthrodesis in elderly patients: prospective study using cannulated cemented pedicle screw instrumentation. Eur Spine J, 2011, 20 Suppl 3: 408-414.
35.	Lubansu A, Rynkowski M, Abeloos L, et al. Minimally invasive spinal arthrodesis in osteoporotic population using a cannulated and fenestrated augmented screw: technical description and clinical experience. Minim Invasive Surg, 2012, 2012: 507826.
36.	Goldring SR, Schiller AL, Roelke M, et al. The synovial-like membrane at the bone-cement interface in loose total hip replacements and its proposed role in bone lysis. J Bone Joint Surg (Am), 1983, 65(5): 575-584.
37.	Whitehill R, Drucker S, McCoig JA, et al. Induction and characterization of an interface tissue by implantation of methylmethacrylate cement into the posterior part of the cervical spine of the dog. J Bone Joint Surg (Am), 1988, 70(1): 51-59.
38.	Moore DC, Maitra RS, Farjo LA, et al. Restoration of pedicle screw fixation with an in situ setting calcium phosphate cement. Spine (Phila Pa 1976), 1997, 22(15): 1696-1705.
39.	Wuisman PI, Van Dijk M, Staal H, et al. Augmentation of (pedicle) screws with calcium apatite cement in patients with severe progressive osteoporotic spinal deformities: an innovative technique. Eur Spine J, 2000, 9(6): 528-533.
40.	Masaki T, Sasao Y, Miura T, et al. An experimental study on initial fixation strength in transpedicular screwing augmented with calcium phosphate cement. Spine (Phila Pa 1976), 2009, 34(20): E724-728.
41.	Watson JT. The use of an injectable bone graft substitute in tibial metaphyseal fractures. Orthopedics, 2004, 27(1 Suppl): s103-107.
42.	盧海霖, 鄭輝, 邑曉東, 等. 可注射硫酸鈣MIIGX3與醫用骨水泥對椎弓根釘固定作用的比較研究. 中國矯形外科雜志, 2006, 14(10): 760-761.
43.	Urban RM, Turner TM, Hall DJ, et al. Effect of altered crystalline structure and increased initial compressive strength of calcium sulfate bone graft substitute pellets on new bone formation. Orthopedics, 2004, 27(1 Suppl): s113-118.
44.	Derincek A, Wu C, Mehbod A, et al. Biomechanical comparison of anatomic trajectory pedicle screw versus injectable calcium sulfate graft-augmented pedicle screw for salvage in cadaveric thoracic bone. J Spinal Disord Tech, 2006, 19(4): 286-291.
45.	Yi X, Wang Y, Lu H, et al. Augmentation of pedicle screw fixation strength using an injectable calcium sulfate cement: an in vivo study. Spine (Phila Pa 1976), 2008, 33(23): 2503-2509.
46.	Liu D, Lei W, Wu ZX, et al. Augmentation of pedicle screw stability with calcium sulfate cement in osteoporotic sheep: biomechanical and screw-bone interfacial evaluation. J Spinal Disord Tech, 2011, 24(4): 235-241.
47.	Gao M, Lei W, Wu Z, et al. Biomechanical evaluation of fixation strength of conventional and expansive pedicle screws with or without calcium based cement augmentation. Clin Biomech (Bristol, Avon), 2011, 26(3): 238-244.
48.	張樹芳, 江建明, 郭婷, 等. geneX 骨水泥強化骨質疏松椎體椎弓根釘的生物力學研究. 中國骨與關節損傷雜志, 2012, 27(5): 421-423.
49.	Zhu Q, Kingwell S, Li Z, et al. Enhancing pedicle screw fixation in the aging spine with a novel bioactive bone cement: an in vitro biomechanical study. Spine (Phila Pa 1976), 2012, 37(17): E1030-1037.
50.	Burval DJ, McLain RF, Milks R, et al. Primary pedicle screw augmentation in osteoporotic lumbar vertebrae: biomechanical analysis of pedicle fixation strength. Spine (Phila Pa 1976), 2007, 32(10): 1077-1083.
51.	Hu MH, Wu HT, Chang MC, et al. Polymethylmethacrylate augmentation of the pedicle screw: the cement distribution in the vertebral body. Eur Spine J, 2011, 20(8): 1281-1288.
52.	Chen LH, Tai CL, Lai PL, et al. Pullout strength for cannulated pedicle screws with bone cement augmentation in severely osteoporotic bone: influences of radial hole and pilot hole tapping. Clin Biomech (Bristol, Avon), 2009, 24(8): 613-618.
53.	Choma TJ, Pfeiffer FM, Swope RW, et al. Pedicle screw design and cement augmentation in osteoporotic vertebrae: effects of fenestrations and cement viscosity on fixation and extraction. Spine (Phila Pa 1976), 2012, 37(26): E1628-1632.
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1. Roy-Camille R, Saillant G, Mazel C. Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop Relat Res, 1986, (203): 7-17.
2. Zindrick MR, Wiltse LL, Widell EH, et al. A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop Relat Res, 1986, (203): 99-112.
3. Halvorson TL, Kelley LA, Thomas KA, et al. Effects of bone mineral density on pedicle screw fixation. Spine (Phila Pa 1976), 1994, 19(21): 2415-2420.
4. McLain RF, McKinley TO, Yerby SA, et al. The effect of bone quality on pedicle screw loading in axial instability: a synthetic model. Spine (Phila Pa 1976), 1997, 22(13): 1454-1460.
5. Margulies JY, Casar RS, Caruso SA, et al. The mechanical role of laminar hook protection of pedicle screws at the caudal end vertebra. Eur Spine J, 1997, 6(4): 245-248.
6. Hasegawa K, Takahashi HE, Uchiyama S, et al. An experimental study of a combination method using a pedicle screw and laminar hook for the osteoporotic spine. Spine (Phila Pa 1976), 1997, 22(9): 958-963.
7. Tan JS, Kwon BK, Dvorak MF, et al. Pedicle screw motion in the osteoporotic spine after augmentation with laminar hooks, sublaminar wires, or calcium phosphate cement: a comparative analysis. Spine (Phila Pa 1976), 2004, 29(16): 1723-1730.
8. Hu SS. Internal fixation in the osteoporotic spine. Spine (Phila Pa 1976), 1997, 22(24 Suppl): 43S-48S.
9. Ghani I, Kroeber M. Role of major revision spine surgery in recurrent adjacent segment osteoporotic vertebral body fracture: a case report. Arch Orthop Trauma Surg, 2012, 132(8): 1089-1094.
10. Cavagna R, Tournier C, Aunoble S, et al. Lumbar decompression and fusion in elderly osteoporotic patients: a prospective study using less rigid titanium rod fixation. J Spinal Disord Tech, 2008, 21(2): 86-91.
11. Polly DW Jr, Orchowski JR, Ellenbogen RG. Revision pedicle screws. Bigger, longer shims—what is best? Spine (Phila Pa 1976), 1998, 23(12): 1374-1379.
12. Kiner DW, Wybo CD, Sterba W, et al. Biomechanical analysis of different techniques in revision spinal instrumentation: larger diameter screws versus cement augmentation. Spine (Phila Pa 1976), 2008, 33(24): 2618-2622.
13. Hirano T, Hasegawa K, Washio T, et al. Fracture risk during pedicle screw insertion in osteoporotic spine. J Spinal Disord, 1998, 11(6): 493-497.
14. Cook SD, Salkeld SL, Whitecloud TS 3rd, et al. Biomechanical evaluation and preliminary clinical experience with an expansive pedicle screw design. J Spinal Disord, 2000, 13(3): 230-236.
15. Cook SD, Barbera J, Rubi M, et al. Lumbosacral fixation using expandable pedicle screws. an alternative in reoperation and osteoporosis. Spine J, 2001, 1(2): 109-114.
16. Aldini NN, Fini M, Giavaresi G, et al. Pedicular fixation in the osteoporotic spine: a pilot in vivo study on long-term ovariectomized sheep. J Orthop Res, 2002, 20(6): 1217-1224.
17. Hasegawa T, Inufusa A, Imai Y, et al. Hydroxyapatite-coating of pedicle screws improves resistance against pull-out force in the osteoporotic canine lumbar spine model: a pilot study. Spine J, 2005, 5(3): 239-243.
18. Pfeifer BA, Krag MH, Johnson C. Repair of failed transpedicle screw fixation. A biomechanical study comparing polymethylmethacrylate, milled bone, and matchstick bone reconstruction. Spine (Phila Pa 1976), 1994, 19(3): 350-353.
19. Cook SD, Salkeld SL, Stanley T, et al. Biomechanical study of pedicle screw fixation in severely osteoporotic bone. Spine J, 2004, 4(4): 402-408.
20. Soshi S, Shiba R, Kondo H, et al. An experimental study on transpedicular screw fixation in relation to osteoporosis of the lumbar spine. Spine (Phila Pa 1976), 1991, 16(11): 1335-1341.
21. Renner SM, Lim TH, Kim WJ, et al. Augmentation of pedicle screw fixation strength using an injectable calcium phosphate cement as a function of injection timing and method. Spine (Phila Pa 1976), 2004, 29(11): E212-216.
22. Linhardt O, Lüring C, Matussek J, et al. Stability of pedicle screws after kyphoplasty augmentation: an experimental study to compare transpedicular screw fixation in soft and cured kyphoplasty cement. J Spinal Disord Tech, 2006, 19(2): 87-91.
23. 邑曉東, 盧海霖, 陳明. 醫用骨水泥在骨質疏松患者行椎弓根釘固定中的作用. 中國脊柱脊髓雜志, 2005, 15(2): 95-97.
24. Frankel BM, Jones T, Wang C. Segmental polymethylmethacrylate-augmented pedicle screw fixation in patients with bone softening caused by osteoporosis and metastatic tumor involvement: a clinical evaluation. Neurosurgery, 2007, 61(3): 531-537.
25. Kim HS, Park SK, Joy H, et al. Bone cement augmentation of short segment fixation for unstable burst fracture in severe osteoporosis. J Korean Neurosurg Soc, 2008, 44(1): 8-14.
26. Chang MC, Liu CL, Chen TH. Polymethylmethacrylate augmentation of pedicle screw for osteoporotic spinal surgery: a novel technique. Spine (Phila Pa 1976), 2008, 33(10): E317-324.
27. 王剛, 吳峰, 關宏剛, 等. 直入式注入聚甲基丙烯酸甲酯骨水泥強化椎弓根釘內固定治療骨質疏松性胸腰椎骨折. 中華創傷骨科雜志, 2011, 13(6): 549-552.
28. Aydogan M, Ozturk C, Karatoprak O, et al. The pedicle screw fixation with vertebroplasty augmentation in the surgical treatment of the severe osteoporotic spines. J Spinal Disord Tech, 2009, 22(6): 444-447.
29. Sawakami K, Yamazaki A, Ishikawa S, et al. Polymethylmethacrylate augmentation of pedicle screws increases the initial fixation in osteoporotic spine patients. J Spinal Disord Tech, 2012, 25(2): E28-35.
30. Yazu M, Kin A, Kosaka R, et al. Efficacy of novel-concept pedicle screw fixation augmented with calcium phosphate cement in the osteoporotic spine. J Orthop Sci, 2005, 10(1): 56-61.
31. Fransen P. Increasing pedicle screw anchoring in the osteoporotic spine by cement injection through the implant. Technical note and report of three cases. J Neurosurg Spine, 2007, 7(3): 366-369.
32. Moon BJ, Cho BY, Choi EY, et al. Polymethylmethacrylate-augmented screw fixation for stabilization of the osteoporotic spine: a three-year follow-up of 37 patients. J Korean Neurosurg Soc, 2009, 46(4): 305-311.
33. Amendola L, Gasbarrini A, Fosco M, et al. Fenestrated pedicle screws for cement-augmented purchase in patients with bone softening. J Orthop Traumatol, 2011, 12(4): 193-199.
34. Piñera AR, Duran C, Lopez B, et al. Instrumented lumbar arthrodesis in elderly patients: prospective study using cannulated cemented pedicle screw instrumentation. Eur Spine J, 2011, 20 Suppl 3: 408-414.
35. Lubansu A, Rynkowski M, Abeloos L, et al. Minimally invasive spinal arthrodesis in osteoporotic population using a cannulated and fenestrated augmented screw: technical description and clinical experience. Minim Invasive Surg, 2012, 2012: 507826.
36. Goldring SR, Schiller AL, Roelke M, et al. The synovial-like membrane at the bone-cement interface in loose total hip replacements and its proposed role in bone lysis. J Bone Joint Surg (Am), 1983, 65(5): 575-584.
37. Whitehill R, Drucker S, McCoig JA, et al. Induction and characterization of an interface tissue by implantation of methylmethacrylate cement into the posterior part of the cervical spine of the dog. J Bone Joint Surg (Am), 1988, 70(1): 51-59.
38. Moore DC, Maitra RS, Farjo LA, et al. Restoration of pedicle screw fixation with an in situ setting calcium phosphate cement. Spine (Phila Pa 1976), 1997, 22(15): 1696-1705.
39. Wuisman PI, Van Dijk M, Staal H, et al. Augmentation of (pedicle) screws with calcium apatite cement in patients with severe progressive osteoporotic spinal deformities: an innovative technique. Eur Spine J, 2000, 9(6): 528-533.
40. Masaki T, Sasao Y, Miura T, et al. An experimental study on initial fixation strength in transpedicular screwing augmented with calcium phosphate cement. Spine (Phila Pa 1976), 2009, 34(20): E724-728.
41. Watson JT. The use of an injectable bone graft substitute in tibial metaphyseal fractures. Orthopedics, 2004, 27(1 Suppl): s103-107.
42. 盧海霖, 鄭輝, 邑曉東, 等. 可注射硫酸鈣MIIGX3與醫用骨水泥對椎弓根釘固定作用的比較研究. 中國矯形外科雜志, 2006, 14(10): 760-761.
43. Urban RM, Turner TM, Hall DJ, et al. Effect of altered crystalline structure and increased initial compressive strength of calcium sulfate bone graft substitute pellets on new bone formation. Orthopedics, 2004, 27(1 Suppl): s113-118.
44. Derincek A, Wu C, Mehbod A, et al. Biomechanical comparison of anatomic trajectory pedicle screw versus injectable calcium sulfate graft-augmented pedicle screw for salvage in cadaveric thoracic bone. J Spinal Disord Tech, 2006, 19(4): 286-291.
45. Yi X, Wang Y, Lu H, et al. Augmentation of pedicle screw fixation strength using an injectable calcium sulfate cement: an in vivo study. Spine (Phila Pa 1976), 2008, 33(23): 2503-2509.
46. Liu D, Lei W, Wu ZX, et al. Augmentation of pedicle screw stability with calcium sulfate cement in osteoporotic sheep: biomechanical and screw-bone interfacial evaluation. J Spinal Disord Tech, 2011, 24(4): 235-241.
47. Gao M, Lei W, Wu Z, et al. Biomechanical evaluation of fixation strength of conventional and expansive pedicle screws with or without calcium based cement augmentation. Clin Biomech (Bristol, Avon), 2011, 26(3): 238-244.
48. 張樹芳, 江建明, 郭婷, 等. geneX 骨水泥強化骨質疏松椎體椎弓根釘的生物力學研究. 中國骨與關節損傷雜志, 2012, 27(5): 421-423.
49. Zhu Q, Kingwell S, Li Z, et al. Enhancing pedicle screw fixation in the aging spine with a novel bioactive bone cement: an in vitro biomechanical study. Spine (Phila Pa 1976), 2012, 37(17): E1030-1037.
50. Burval DJ, McLain RF, Milks R, et al. Primary pedicle screw augmentation in osteoporotic lumbar vertebrae: biomechanical analysis of pedicle fixation strength. Spine (Phila Pa 1976), 2007, 32(10): 1077-1083.
51. Hu MH, Wu HT, Chang MC, et al. Polymethylmethacrylate augmentation of the pedicle screw: the cement distribution in the vertebral body. Eur Spine J, 2011, 20(8): 1281-1288.
52. Chen LH, Tai CL, Lai PL, et al. Pullout strength for cannulated pedicle screws with bone cement augmentation in severely osteoporotic bone: influences of radial hole and pilot hole tapping. Clin Biomech (Bristol, Avon), 2009, 24(8): 613-618.
53. Choma TJ, Pfeiffer FM, Swope RW, et al. Pedicle screw design and cement augmentation in osteoporotic vertebrae: effects of fenestrations and cement viscosity on fixation and extraction. Spine (Phila Pa 1976), 2012, 37(26): E1628-1632.
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