Biomechanical Comparison of TLIF- and Bioflex-Based Topping-Off: A Finite Element Analysis

Adjacent segment degeneration remains a major biomechanical concern after lumbar fusion, whereas fully dynamic topping-off constructs may provide an alternative strategy by preserving segmental motion and unloading degenerated discs. In this study, a three-dimensional nonlinear finite element model of the L1-L5 lumbar spine with L3-L5 double-segment degeneration was developed to compare transforaminal lumbar interbody fusion (TLIF)-based pedicle screw fixation systems (PSFS) and Bioflex-based pedicle screw dynamic stabilization systems (PSDSS). Three interspinous process spacers, namely DIAM, Wallis, and Coflex-F, were implanted at L3-L4, and three pedicle screw diameters of 6.5, 5.5, and 4.5 mm were evaluated under flexion and extension to quantify screw-rod parameter sensitivity. The results showed that both TLIF- and Bioflex-based topping-off constructs reduced intradiscal pressure (IDP) and restricted excessive range of motion (ROM) at the transition segment, especially during extension, with a maximum L3-L4 IDP reduction of 39.49% compared with the degenerated model. Compared with fusion-based constructs, Bioflex-based PSDSS provided greater surgical-segment unloading, reducing L4-L5 IDP by 55.07% in extension and 25.30% in flexion. However, this motion-preserving effect was accompanied by higher pedicle screw stress sensitivity; in the 4.5 mm Bioflex model, the average L4 screw stress reached 15.62 MPa in flexion, representing a 51.71% increase compared with the 6.5 mm screw. In contrast, PSFS constructs showed greater stress variation in the rigid connecting rods. Overall, under the present modeling assumptions, Bioflex-based fully dynamic topping-off constructs showed more favorable disc unloading and transition-segment motion regulation than fusion-based configurations, but their biomechanical benefit should be balanced against diameter-dependent pedicle screw stability.