• Hector Soriano-Baron, Anna G U S Newcomb, Devika Malhotra, Kaylee de Tranaltes, Eduardo Martinez-Del-Campo, Phillip M Reyes, Neil R Crawford, Nicholas Theodore, and Luis M Tumialán.
• *Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; ‡Division of Neurological Surgery, Spine Group Arizona, HonorHealth Research Institute, Scottsdale, Arizona.
• Neurosurgery. 2016 Feb 1; 78 (2): 297-304.

BackgroundArthrodesis is optimized when the structural graft occupies most of the surface area within a disc space. The transforaminal corridor inherently limits interbody size.ObjectiveTo evaluate the biomechanical implications of nested interbody spacers (ie, a second curved cage placed behind a first) to increase disc space coverage in transforaminal approaches.MethodsSeven lumbar human cadaveric specimens (L3-S1) underwent nondestructive flexibility and axial compression testing intact and after transforaminal instrumentation at L4-L5. Specimens were tested in 5 conditions: (1) intact, (2) interbody, (3) interbody plus bilateral pedicle screws and rods (PSR), (4) 2 nested interbodies, and (5) 2 nested interbodies plus PSR.ResultsMean range of motion (ROM) with 1 interbody vs 2 nested interbodies, respectively, was: flexion, 101% vs 85%; extension, 97% vs 92%; lateral bending, 127% vs 132%; and axial rotation, 145% vs 154%. One interbody and 2 nested interbodies did not differ significantly by loading mode (P > .10). With PSR, ROM decreased significantly compared with intact, but not between interbody and interbody plus PSR or 2 interbodies plus PSR (P > .80). Mean vertical height during compressive loading (ie, axial compressive stiffness) was significantly different with 2 nested interbodies vs 1 interbody alone (P < .001) (compressive stiffness, 89% of intact vs 67% of intact, respectively).ConclusionInserting a second interbody using a transforaminal approach is anatomically feasible and nearly doubles the disc space covered without affecting ROM. Compressive stiffness significantly increased with 2 nested interbodies, and foraminal height increased. Evaluation of the clinical safety and efficacy of nested interbodies is underway.

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