Intradiscal pressure, shear strain, and fiber strain in the intervertebral disc under combined loading

The restoration of lumbar intervertebral disc load distribution: a comparison of three nucleus replacement technologies

STUDY DESIGN

A validated L3-L4 nonlinear finite element model was used to evaluate strain and pressure in the surrounding structures for 4 nucleus replacement technologies.

OBJECTIVE

The objective of the current study was to compare subsidence and anular damage potential between 4 current nucleus replacement technologies. It was hypothesized that a fully conforming nucleus replacement would minimize the risk of both subsidence and anular damage.

SUMMARY OF BACKGROUND DATA

Nucleus pulposus replacements are emerging as a less invasive alternative to total disc replacement and fusion as a solution to degenerative intervertebral discs. Multiple technologies have been developed and are currently undergoing clinical investigation.

METHODS

The testing conditions were applied by excavating the nucleus of the intact model and virtually implanting models representing the various nucleus replacement technologies. The implants consisted of a conforming injectable polyurethane (E = 4 MPa), soft hydrogel (E = 4 MPa), stiff hydrogel (E = 20 MPa), and polyether-etherketone (PEEK) on PEEK articulating designs. The model was exercised in flexion, extension, lateral bending, axial rotation (7.5 Nm with 450 N preload), and compression (1000 N). Vertebral body strain, anular maximum shear strain, endplate contact pressure, anulus-implant contact pressure, and bone remodeling stimulus were reported.

RESULTS

The PEEK implant induced strain maxima in the vertebral bodies with associated endplate contact pressure concentrations. For the PEEK and hydrogel implants, areas of nonconformity with the endplate indicated adjacent bone resorption. Lack of conformity between the implant and inner anulus for the PEEK and hydrogel implants resulted in inward anular bulging with associated increased maximum shear strain. The conforming polyurethane implant maintained outward bulging of the inner anular wall and indicated no bone resorption or stress shielding adjacent to the implant.

CONCLUSION

A fully conforming nucleus replacement resulted in a decreased propensity for subsidence, anular bulging, and further degeneration of the anulus when compared with nonconforming implants.

Obesity increases the risk of recurrent herniated nucleus pulposus after lumbar microdiscectomy

BACKGROUND CONTEXT

Recurrent herniation of the nucleus pulposus (HNP) frequently causes poor outcomes after lumbar discectomy. The relationship between obesity and recurrent HNP has not previously been reported.

PURPOSE

The purpose of this study was to investigate the association of obesity with recurrent HNP after lumbar microdiscectomy.

STUDY DESIGN

Retrospective Cohort.

PATIENT SAMPLE

We reviewed all cases of one- or two-level lumbar microdiscectomy from L2-S1 performed by a single surgeon with a minimum follow-up of 6 months.

OUTCOME MEASURES

The primary clinical outcomes were evidence of recurrent HNP on magnetic resonance imaging (MRI) and need for repeat surgery.

METHODS

All patients with recurrent radicular pain or new neurological deficits underwent a postoperative MRI scan. Recurrent HNP was defined as a HNP at the same side and same level as the index procedure.

RESULTS

Seventy-five patients were included in the study. The average body mass index (BMI) was 27.6+/-4.6. Thirty-two patients received an MRI scan. The time from operation to repeat MRI scan varied widely (3 days to 15 months). Eight patients (10.7%) had recurrent HNP. Four patients had persistent symptoms requiring reoperation (5.3%). The mean BMI of patients with recurrent HNP was significantly higher than that of those without recurrence (33.6+/-5.1 vs. 26.9+/-3.9, p<.001). In univariate analysis, obese patients (BMI >or=30) were 12 times more likely to have recurrent HNP than nonobese patients (odds ratio [OR]: 12.46, 95% confidence interval [CI]: 2.25-69.90). Obese patients were 30 times more likely to require reoperation (OR: 32.81, 95% CI: 1.67-642.70). Age, sex, smoking, and being a manual laborer were not significantly associated with recurrent HNP. A logistic regression analysis supported the findings of the univariate analysis. In a survival analysis using a Cox proportional hazards model, the hazard ratio of recurrent HNP for obese patients was 17 (OR: 17.08, 95% CI: 2.85-102.30, p=.002).

CONCLUSIONS

Obesity was a strong and independent predictor of recurrent HNP after lumbar microdiscectomy. Surgeons should incorporate weight loss counseling into their preoperative discussions with patients.

The influence of torsion on disc herniation when combined with flexion

The role of torsion in the mechanical derangement of intervertebral discs remains largely undefined. The current study sought to investigate if torsion, when applied in combination with flexion, affects the internal failure mechanics of the disc wall when exposed to high nuclear pressure. Thirty ovine lumbar motion segments were each positioned in 2 degrees axial rotation plus 7 degrees flexion. Whilst maintained in this posture, the nucleus of each segment was gradually injected with a viscous radio-opaque gel, via an injection screw placed longitudinally within the inferior vertebra, until failure occurred. Segments were then inspected using micro-CT and optical microscopy in tandem. Five motion segments failed to pressurize correctly. Of the remaining 25 successfully tested motion segments, 17 suffered vertebral endplate rupture and 8 suffered disc failure. Disc failure occurred in mature motion segments significantly more often than immature segments. The most common mode of disc failure was a central posterior radial tear involving a systematic annulus-endplate-annulus failure pattern. The endplate portion of these radial tears often propagated contralateral to the direction of applied axial rotation, and, at the lateral margin, only those fibres inclined in the direction of the applied torque were affected. Apart from the 2 degrees of applied axial rotation, the methods employed in this study replicated those used in a previously published study. Consequently, the different outcome obtained in this study can be directly attributed to the applied axial rotation. These inter-study differences show that when combined with flexion, torsion markedly reduces the nuclear pressure required to form clinically relevant radial tears that involve cartilaginous endplate failure. Conversely, torsion appears to increase the disc wall's resistance to radial tears that do not involve cartilaginous endplate failure, effectively halving the disc wall's overall risk of rupture.

The effect of different design concepts in lumbar total disc arthroplasty on the range of motion, facet joint forces and instantaneous center of rotation of a L4-5 segment

Although both unconstrained and constrained core lumbar artificial disc designs are in clinical use, the effect of their design on the range of motion, center of rotations, and facet joint forces is not well understood. It is assumed that the constrained configuration causes a fixed center of rotation with high facet forces, while the unconstrained configuration leads to a moving center of rotation with lower loaded facets. The authors disagree with both assumptions and hypothesized that the two different designs do not lead to substantial differences in the results. For the different implant designs, a three-dimensional finite element model was created and subsequently inserted into a validated model of a L4-5 lumbar spinal segment. The unconstrained design was represented by two implants, the Charité disc and a newly developed disc prosthesis: Slide-Disc. The constrained design was obtained by a modification of the Slide-Disc whereby the inner core was rigidly connected to the lower metallic endplate. The models were exposed to an axial compression preload of 1,000 N. Pure unconstrained moments of 7.5 Nm were subsequently applied to the three anatomical main planes. Except for extension, the models predicted only small and moderate inter-implant differences. The calculated values were close to those of the intact segment. For extension, a large difference of about 45% was calculated between both Slide-Disc designs and the Charité disc. The models predicted higher facet forces for the implants with an unconstrained core compared to an implant with a constrained core. All implants caused a moving center of rotation. Except for axial rotation, the unconstrained and constrained configurations mimicked the intact situation. In axial rotation, only the Slide- Disc with mobile core reproduced the intact behavior. Results partially support our hypothesis and imply that different implant designs do not lead to strong differences in the range of motion and the location of center of rotations. In contrast, facet forces appeared to be strongly dependent on the implant design. However, due to the great variability in facet forces reported in the literature, together with our results, we could speculate that these forces may be more dependent on the individual spine geometry rather than a specific implant design.

Magnetic resonance imaging findings of the lumbar spine in elite horseback riders: correlations with back pain, body mass index, trunk/leg-length coefficient, and riding discipline

BACKGROUND

Most orthopaedic problems experienced by competitive horseback riders are related to pain in the lower back, hip joint, and hamstring muscles. Riders-especially, show jumpers-are frequently hampered in their performance because of lumbar pain. To date, there has been no research into lumbar disk degeneration in elite competitive riders.

HYPOTHESIS

Competitive horseback riding accelerates lumbar disk degeneration.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Fifty-eight elite riders (18 men, 40 women; mean age, 32.4 years) and a control group of 30 nonriding volunteers (17 men, 13 women; mean age, 28.7 years) were evaluated for lumbar disk degeneration, cross-sectional area of paraspinal muscles, spondylolysis, and spondylolisthesis, using magnetic resonance imaging (MRI). The prevalence of disk degeneration between the 2 groups was compared, and the relationship was investigated between low back pain (LBP), riding discipline, body mass index (BMI), trunk/leg-length coefficient, and MRI results.

RESULTS

Eighty-eight percent of elite riders (n = 51) had a history of LBP, versus 33% of the controls (P < .05). There was no statistical difference for the prevalence of LBP among the different riding disciplines. However, there was a high rate of pathologic T2 signal intensity of the lumbar intervertebral disk among riders-specifically, dressage riders-yet no significant increase when compared with controls. History of LBP symptoms, riding discipline, BMI, and trunk/leg-length ratio had no significant effect on the development of lumbar disk degeneration. Occult fractures of the pars interarticularis and manifest spondylolysis were not seen for any rider. Two controls had spondylolisthesis Meyerding grade 1 not associated with back pain.

CONCLUSION

Although riders have a high prevalence of LBP, there is no conclusive MRI evidence to suggest that the cause lies in undue disk degeneration, spondylolysis, spondylolisthesis, or pathologic changes of the paraspinal muscles of the lumbar spine.

Effect of nucleus replacement device properties on lumbar spine mechanics

STUDY DESIGN

A validated nonlinear three-dimensional finite element model of a single lumbar motion segment (L3-L4) was used to evaluate a range of moduli for ideally conforming nucleus replacement devices.

OBJECTIVE

The objective of the current study was to determine the biomechanical effects of nucleus replacement technology for a variety of implant moduli. We hypothesized that there would be an optimal modulus for a nucleus replacement that would provide loading in the surrounding bone and anulus similar to the intact state.

SUMMARY OF BACKGROUND DATA

Nucleus pulposus replacements are interventional therapies that restore stiffness and height to mildly degenerated intervertebral discs. Currently a wide variety of nucleus replacement technologies with a large range of mechanical properties are undergoing preclinical testing.

METHODS

A finite element model of L3-L4 was created and validated using range of motion, disc pressure, and bony strains from previously published data. The intact model was altered by changing the mechanical properties of the nucleus pulposus to represent a wide range of nucleus replacement technologies (E = 0.1, 1, 4, and 100 MPa). All of the models were exercised in compression, flexion, extension, lateral bending, and axial rotation. Vertebral body strain, peak anulus fibrosus shear strain, initial bone remodeling stimulus, range of motion, and center of rotation were analyzed.

RESULTS

A nucleus replacement modulus of 1 and 4 MPa resulted in vertebral body strains similar to the intact model. The softest device indicated increased loading in the AF and bone resorption adjacent to the implant. Areas of strain maxima and bone formation were observed adjacent to the implant for the stiffest device.

CONCLUSION

The current study predicted an optimal nucleus replacement of 1 to 4 MPa. An overly stiff implant could result in subsidence, which would preclude the benefit of disc height increase or restoration. Conversely, an overly soft implant could accelerate a degenerative cascade in the anulus.

Measurement of geometric deformation of lumbar intervertebral discs under in-vivo weightbearing condition

Quantitative data of spinal intervertebral disc deformation is instrumental for investigation of spinal disc pathology. In this study, we employed a combined dual fluoroscopic imaging system and the MR imaging technique to determine the lumbar disc deformation in living human subjects. Discs at L2-3, L3-4 and L4-5 levels were investigated in 8 normal subjects. The geometric deformation of the discs under full body weight loading condition (upright standing) was determined using the supine, non-weightbearing condition as a reference. The average maximum tensile deformation was -21% in compression and 24% in tension, and maximum shear deformation on the disc surface reached 26%. The data indicated that different portions of the disc are under different tensile and shear deformation. Further, discs of L2-3, L3-4 and L4-5 have different deformation behavior under the physiological weightbearing condition. In general, the higher level discs have higher deformation values. The technique used in this study can be used to investigate the deformation behaviors of diseased discs as well as the efficacy of different surgical modalities at restoring normal disc deformation patterns.

Dependency of disc degeneration on shear and tensile strains between annular fiber layers for complex loads

BACKGROUND

One of the first signs of disc degeneration is the formation of circumferential tears within the annulus fibrosus. It is assumed that high shear and tensile strains between the lamellae mainly cause the initiation of these failures. However, it is not known which load application and which degree of disc degeneration could lead to the highest strains and therefore, might induce the formation of tears. Therefore, the aim of this finite element (FE) study was, to find load combinations that would yield highest shear and tensile strains in differently degenerated discs.

MATERIALS AND METHODS

A three-dimensional FE-model of a motion segment L4-5 was utilized in different degrees of disc degeneration (healthy, mild, moderate, and severe). The degenerated models consider the reduction of disc height, endplate curvatures, the osteophyte formation, the increase of nucleus compressibility, and the decrease of fiber and ligament stiffness. An axial compression load of 500 N together with moments of 7.5 Nm in single and combined load directions were simulated.

RESULTS

High strains for the healthy and degenerated discs were predicted for load combinations, particularly for the combination of lateral bending plus flexion or extension. The maximum strains were located in the postero-lateral region of the disc. In comparison to the healthy disc, the maximum strains increased slightly for the mildly and moderately degenerated disc. Strains decreased strongly for the severely degenerated disc. With progressive degeneration, the size of the region of maximum strains diminished and the location transferred from the inner annulus to the adjacent bony endplates.

CONCLUSIONS

The results could be a possible explanation for the initiation of circumferential tears. The mildly degenerated disc model, which represents early stages of life, suggests that circumferential tears could primarily occur at these stages, especially for the load combinations of lateral bending plus axial rotation and lateral bending plus flexion.

Prospective design delineation and subsequent in vitro evaluation of a new posterior dynamic stabilization system

STUDY DESIGN

Finite element and in vitro study.

OBJECTIVE

Finite element calculations to delineate a dynamic fixator and confirmation with an in vitro experiment.

SUMMARY AND BACKGROUND DATA

In the last few years, there was a paradigm shift from rigid to dynamic fixation of spinal segments. However, some so-called dynamic implants like the Dynesys performed still stiffer than anticipated. The aim of this study was to optimize a dynamic stabilization system.

METHODS

The development steps of this implant design can be summarized in a development loop. First, a finite element model of an intact human L4-L5 segment was used to delineate implant stiffness parameters for the implant, in consideration of clinical concerns and safety aspects. These data were used in a second step, leading to the final implant design. This development process was completed with an appropriate in vitro experiment. The optimal axial and bending stiffness were computed to reduce the spinal motion by 30%. For the validation process, in vitro tests were performed on 6 human lumbar spinal segments L2-L3 with a median age of 52. The model and the specimens were loaded with pure unconstrained moments of 7.5 Nm in flexion, extension, lateral bending, and axial rotation.

RESULTS

This study demonstrated the advantages of employing a finite element model for the implant parameter delineation. It was possible to prospectively outline the needed stiffness parameters for a desired spinal range of motion achievement.

CONCLUSION

In summary, FEM may accelerate the development and the realization of a new implant design.

Intervertebral neural foramina deformation due to two types of repetitive combined loading

BACKGROUND

Tissue compression and noxious stimuli are known to elicit pain from neural tissues in the spine. Compression of nerve roots due to decreases in the intervertebral foramina may be caused by posture, sustained loading and disc height loss, herniation, or altered mechanics. It has been established that non-neutral postures combined with repeated loading can cause disc herniations, however information regarding the effect of repetitive axial twist loading is limited. The objectives of this study were twofold; to measure the occlusion of the foramina due to two types of repetitive loading and to investigate whether repetitive combined axial twist loading can contribute to disc injury.

METHODS

Sixteen porcine cervical spine segments (C5/6) were subjected to 1500 N of compression combined with either repetitive flexion-extension motions or 16.4 degrees (Standard Deviation 2.1) of static flexion with repetitive axial twist motions. The foramina pressure was measured bilaterally using plastic tubing and a custom pressure monitoring system. Specimens were loaded until 10,000 cycles were reached or disc herniation occurred.

FINDINGS

Significantly larger pressure (pre-post difference) developed in the intervertebral foramina of specimens that were repetitively flexed-extended (P=0.028) compared to those that were repetitively twisted. All of the flexed-extended specimens herniated, whereas in the twisted specimens five (62.5%) had incomplete herniations, one (12.5%) sustained a facet fracture, and two (25%) had no damage. There was no difference between the loading groups for vertical height loss (P=0.994).

INTERPRETATION

Repetitive loading of flexion-extension motions are a viable pain generating pathway in absence of distinguishing height loss. This information may be useful to consider for the diagnosis and treatment of nerve root compression.

Mechanobiological bone growth: comparative analysis of two biomechanical modeling approaches

Mechanobiological growth is the process whereby bone growth is modulated by mechanical loading. Analytical formulations of mechanobiological growth have been developed by Stokes et al. (J Orthop Res 17(5):646-653, 1990) and Carter et al. (J Orthop Res 6:804-816, 1988). The purpose of this study was to compare these two modeling approaches in a finite element model of a vertebra to investigate whether growth pattern induced by these models were equivalent. A finite element model of a thoracic vertebra, integrating a conceptual model of the growth plate, was developed and combined with the mechanobiological growth models. This model was further used to simulate vertebral growth modulation resulting from different physiological loading conditions. Different growth magnitudes were obtained under compression and combined tension/shear loading, whereas dissimilar growth patterns were triggered by shear forces and combined compression/shear. These two models represent mechanobiological bone growth under limited mechanical environment. Carter's model takes into account three-dimensional stress stimuli, but does not intrinsically incorporate the resulting growth orientation. Stokes' model adequately represents the mechanobiological contribution of axial stresses but does not take into account the contribution of non-axial stresses, which can occur in complex mechanical environment.

Interaction between finite helical axes and facet joint forces under combined loading

STUDY DESIGN

Finite element study.

OBJECTIVE

To investigate the interaction between the finite helical axis and facet joint loads under combined loading.

SUMMARY OF BACKGROUND DATA

Finite helical axes (FHA) in a functional spinal unit can indicate mechanical disorders and are relevant for the development of new arthoplasty techniques. The facet joints protect the intervertebral discs from excessive movements. The relationship between the FHAs and facet joint forces is not well-understood, because previous studies have separated both, spinal motion and facet forces.

METHODS

A finite element model of a lumbar spinal segment L4-L5 was used to simulate axial compression load of 500 N together with moments starting from 0 to 7.5 Nm in single anatomic main planes. Load combinations of 7.5 Nm were generated by changing the load direction in steps of 15 degrees between each pair of the 3 anatomic mainplanes.

RESULTS

For single axes loading, the FHAs were found to be in the center of the disc under small moments, independently from load directions. The facet joints were only slightly loaded. Higher moments increased the forces in facet joints up to 105 N in axial rotation, followed by extension (50 N) and lateral bending (36 N). Combined moments did not essentially increase the facet forces compared with the same moment applied in an anatomic main direction. High facet forces might have directed the FHAs to migrate posteriorly, especially for axial rotation. This situation resulted in FHAs outside the disc toward the compressed facet joint.

CONCLUSION

For clinical practice, patients immediately after the operation, or patients with facet joint arthritis should reduce or avoid axial rotation alone or in combination with other load applications, especially axial rotation plus lateral bending or flexion.

Which axial and bending stiffnesses of posterior implants are required to design a flexible lumbar stabilization system?

Dynamic stabilization devices have been introduced to clinics as an alternative to rigid fixation. The stiffness of these devices varies widely, whereas the optimal stiffness, achieving a predefined stabilization of the spine, is unknown. This study was focused on the determination of stiffness values for posterior stabilization devices achieving a flexible, semi-flexible or rigid connection between two vertebrae. An extensively validated finite element model of a lumbar spinal segment L4-5 with an implanted posterior fixation device was used in this study. The model was exposed to pure moments of 7.5 and 20Nm around the three principal anatomical directions, simulating flexion, extension, lateral bending and axial rotation. In parametrical studies, the influence of the axial and bending fixator stiffness on the spinal range of motion was investigated. In order to examine the validity of the computed results, an in-vitro study was carried out. In this, the influence of two posterior stabilization devices (DSS and rigidly internal fixator) on the segmental stabilization was investigated. The finite element (FE)-model predicted that each load direction caused a pairing of stiffness relations between axial and bending stiffness. In flexion and extension, however, the bending stiffness had a neglectable effect on the segmental stabilization, compared to the axial stiffness. In contrast, lateral bending and axial rotation were influenced by both stiffness parameters. Except in axial rotation, the model predictions were in a good agreement with the determined in-vitro data. In axial rotation, the FE-model predicted a stiffer segmental behavior than it was determined in the in-vitro study. It is usually expected that high stiffness values are required for a posterior stabilization device to stiffen a spinal segment. We found that already small stiffness values were sufficient to cause a stiffening. Using these data, it may possible to develop implants for certain clinical indications.

The influence of posture and loading on interfacet spacing: an investigation using magnetic resonance imaging on porcine spinal units

STUDY DESIGN

Basic scientific investigation using porcine spine segments and magnetic resonance imaging.

OBJECTIVE

To quantify the effects of flexion-extension postures and loading history on the distance between the facet articular surfaces.

SUMMARY OF BACKGROUND DATA

Increased axial twist motion is used clinically to indicate instability and has been implicated as a potential cause of low back pain. Recently, it has been demonstrated that larger twist angles can be achieved when coupled with forward flexion in vivo. These findings suggest a postural mechanism may be responsible for modulating how the facet joints articulate, thereby affecting the moment resisting capability of the facets and altering the load distribution between the facet joints and the disc.

METHODS

Four porcine cervical spine motion segments (C3-C4) were exposed to a compressive preload. Two of these specimens were also exposed to 5000 repeats of flexion-extension motions. The interfacet spacing was measured from magnetic resonance images of 6 postures: neutral, maximum flexed, maximum extended, neutral-twisted, maximum flexed-twisted, and maximum extended-twisted. The range of axial twist angle was quantified in the neutral, flexed, and extended postures.

RESULTS

Flexion-extension postures and loading history caused a difference in the interfacet spacing and twist angle measured. Repetitive loading and flexed postures independently increased the spacing and twist angle, whereas the preload condition and extended postures independently decreased the measures. The 2 specimens that underwent the preload only condition suffered no damage to the disc or vertebrae. Of the repetitively loaded specimens, 1 had a vertebral fracture with initiation of herniation, and the second had a complete herniation.

CONCLUSION

The findings support a posture-dependent injury mechanism and may account for the previously reported in vivo posture-dependent passive rotational differences quantified for combined postures. The changes in spine mechanics and resulting load distribution due to coupled postures may be a key to understanding the formation of low back injuries and eventually clinical spine instability.

Biomechanical evaluation of conventional anulus fibrosus closure methods required for nucleus replacement

Object

Nucleus replacement implants became increasingly attractive as an alternative to fusion, discectomy, or total disc replacement. The goals of nucleus replacement are to restore disc height and flexibility and to preserve the anatomy. However, implant extrusions have been reported and are the major concern. In this study the authors investigated different conventional surgical methods for anulus closure: suture alone, and fibrin glue and cyanoacrylate glue, alone and with suture.

Methods

The in vitro testing was conducted using 30 lumbar spinal segments obtained from calves. In each specimen, an incision was made; the nucleus was removed and subsequently replaced by a collagen matrix. The incisions were treated with anulus closure methods in 5 groups of animals. Flexibility was assessed in a spine tester. Subsequently, specimens were exposed to cyclic fatigue loading by using a hydraulic loading frame. Specimens were excentrically loaded in sine waveform up to a maximum of 100,000 cycles with 4–24 Nm at 5 Hz while being rotated at 360°/minute.

Results

Removal of the nucleus caused a significant loss of stability. The segmental stability could be restored after the implantation. Fatigue testing indicated that suturing was able to sustain 3400 cycles. Fibrin glue failed earlier than cyanoacrylate glue. Both combinations (suture with glue) provided longer stability to the anulus closure.

Conclusions

The results suggested that closing the anulus incision with suture or fibrin glue alone might not be appropriate. The authors found that the best method was cyanoacrylate glue with suture. Although this method provided the longest duration of closure, it could not sustain the maximum number of fatigue cycles. Conventional methods could improve the outcome compared with using no closure. Nonetheless, the authors' findings highlight the demand for an appropriate anulus reconstruction method or device with good long-term reliability.

Validation of a novel minimally invasive intervertebral disc pressure sensor utilizing in-fiber Bragg gratings in a porcine model: an ex vivo study

STUDY DESIGN

Nucleus pressure was measured within porcine intervertebral discs (IVDs) with a novel in-fiber Bragg grating (FBG) sensor (0.4 mm diameter) and a strain gauge (SG) sensor (2.45 mm).

OBJECTIVE

To validate the accuracy of a new FBG pressure sensor designed for minimally invasive measurements of nucleus pressure.

SUMMARY OF BACKGROUND DATA

Although its clinical utility is controversial, it is possible that the predictive accuracy of discography can be improved with IVD pressure measurements. These measurements are typically obtained using needle-mounted SG sensors inserted into the nucleus. However, by virtue of their size, SG sensors alter disc mechanics, injure anulus fibers, and can potentially initiate or accelerate degenerative changes thereby limiting their utility particularly clinically.

METHODS

Six functional spinal units were loaded in compression from 0 N to 500 N and back to 0 N; nucleus pressure was measured using the FBG and SG sensors at various locations along anterior and anterolateral axes.

RESULTS

On average maximum IVD pressures measured using the FBG and SG sensors were within 9.39% of each other. However, differences between maximum measured pressures from the FBG and SG sensors were larger (22.2%) when the SG sensor interfered with vertebral endplates (P < 0.05). The insertion of the FBG sensor did not result in visible damage to the anulus, whereas insertion of the SG sensor resulted in large perforations in the anulus through which nucleus material was visible.

CONCLUSION

The new FBG sensor is smaller and less invasive than any previously reported disc pressure sensor and gave results consistent with previous disc pressure studies and the SG sensor. There is significant potential to use this sensor during discography while avoiding the controversy associated with disc injury as a result of sensor insertion.

Do flexion/extension postures affect the in vivo passive lumbar spine response to applied axial twist moments?

BACKGROUND

The injury potential and mechanical effects of combining axial rotation with non-neutral flexion/extension postures in vivo remains poorly understood, despite being identified as a risk factor in epidemiological and in vitro studies. The purpose of this experiment was to quantify the passive axial twist motion of the lumbar spine in various postures, and to assess whether non-neutral flexion/extension postures cause a detectable change in the range of twist motion and/or spine rotational stiffness.

METHODS

Ten healthy male participants were passively rotated three times from a neutral and six flexed/extended starting postures (maximum-, mid-, mild-), while the moment-angle relationships were measured. The upper body was fixed to an adjustable rigid harness and the lower body was fixed to a cradle that rested on a frictionless table, thereby isolating the lumbar spine.

FINDINGS

The lumbar spine stiffness and rotational range of motion were modulated by the different flexion/extension postures. The average maximum rotational stiffness values were smallest in maximum-flexion (81.0%, SD 16.6), and largest in maximum-/mid-extension postures at 125.4% (SD 24.4, P<0.0001) of the neutral stiffness magnitude. The axial twist angle was significantly different for each posture (P<0.0001), with 13.8% (SD 8.9) greater rotation in the maximum-flexion and 23.8% (SD 7.8) less rotation in the maximum-extension posture. The lateral bend coupled motion with axial twist was significantly different (P<0.0001) between the maximum-flexion (11.4 degrees , SD 6.3), mid-flexion/maximum-extension/mid-extension (6.5 degrees , SD 4.5), and mid-extension/mild-flexion/mild-extension postures (4.4 degrees , SD 3.8).

INTERPRETATION

The lumbar spine stiffness and rotational range were modified by flexed-extended postures. The postural mechanism observed may be due to a change in the initial distance separating the facets prior to rotation. This information will be useful in determining spine rotational injury mechanisms through comparison with in vitro literature and for patient positioning during diagnostic tests.

A new laser scanning technique for imaging intervertebral disc displacement and its application to modeling nucleotomy

BACKGROUND

Nucleotomy is a standard procedure for treating disc prolapse. It can reduce intervertebral disc height, flattening and displacing the disc, which could lead to a painful narrowing of the foramina due to nerve root compression. The purpose of this study was to investigate the disc displacement of a complete spinal segment with and without nucleotomy. We hypothesized that a nucleotomy under a certain load combination might amplify disc displacement.

METHODS

A laser scanner was developed for recording three-dimensional disc displacement of six loaded L4-5 specimens for three conditions: intact, disc with vertebral bodies and subsequent nucleotomy. Specimens were exposed to pure moments of 7.5 N m in the three principal anatomical directions. Disc displacement was obtained at maximal deflection. A finite element model was validated and subsequently utilized to determine disc displacement. The task of the finite element model was to provide supplemental data for the posterolateral region, which could not be measured from intact specimens.

FINDINGS

Disc displacement measurements of intact specimens were limited to the anterior part of discs, whereas the finite element model was able to provide the missing data of the dorsal disc region. The simulation of load combinations showed that the highest disc displacement was 1.9 mm at the lateral or posterolateral region. The nucleotomy increased the disc displacement up to 2.1mm, whereas the displacement zenith migrated posterolaterally.

INTERPRETATION

These results could be a possible explanation for disadvantages of nucleotomy as a treatment. With the methodology presented here, we would be able to assess the performance of nucleus implants by determining the disc displacement map. This could also give us appropriate information of the annular deformation, which is needed for the development of motion preserving implants.

The relation between the instantaneous center of rotation and facet joint forces - A finite element analysis

BACKGROUND

The instantaneous center of rotation in a functional spinal unit is an indicator for mechanical disorders and is relevant for the development of motion preserving techniques. In addition to the intervertebral disc, the facet joints also play a major role for load transmission through the spine, providing stability to it. The relationship between the rotation center and facet joint forces is not fully understood, since previous studies have separated both; spinal motion and facet forces.

METHODS

A finite element model of a L4-5 lumbar spinal segment was exposed to an axial compression preload of 500 N. Pure unconstrained moments of 7.5 Nm were additionally applied in the three anatomical main planes. The instantaneous center of rotation and the facet joint forces were investigated.

FINDINGS

For small moments, the center of rotation was found to be almost in the center of the disc, no matter what motion direction. With an increasing flexion moment, the center of rotation moved anteriorly. The facet joints remained unloaded in flexion. With proceeding extension movement, the center of rotation moved posteriorly. The facet forces increased up to 50 N. In lateral bending, with increasing moment the center of rotation migrated posteriorly in the ipsilateral side of the disc. The forces in the facet joints rose to 36 N. In axial rotation, the center of rotation migrated towards the compressed facet joint with increasing moment. Axial rotation yielded the maximum facet forces with 105 N.

INTERPRETATION

The determination of the rotation center is highly sensible against measurement resolution obtained during in vivo and in vitro studies. This finite element method can be used to complement the knowledge of the rotation center location from former experimental findings.

The relation between intervertebral disc bulging and annular fiber associated strains for simple and complex loading

Mechanical failure of the annulus fibrosus is mostly indicated by tears, fissures, protrusions or disc prolapses. Some of these annulus failures can be caused by a high intradiscal pressure. This has an effect on disc bulging. However, it is not fully understood how disc bulging is related to disc loading. Therefore, the aim of this study was to investigate the annular fiber strains and disc bulging under simple and complex spinal loads. A novel laser scanner was used to image surfaces of six L2-3 segments. Specimens were loaded with 500 N or 7.5 Nm in a spine tester while acquiring surface maps. Loading was applied in the three principal main directions and four combined directions. Disc bulging and tissue surface strains in annulus collagen fiber directions were computed. Two conditions were measured; intact and defect (vertebral body-disc-body units). Axial compression resulted in 2.7% fiber associated strains in intact segments and the defect increased strains up to 6.7%. Disc bulging increased from 0.7 mm to 0.87 mm. Flexion produced 7.2% fiber associated strains and 1.63 mm bulge going up to 17.5% and 2.21 mm after the defect. Highest fiber associated strains were found for the combination of axial rotation plus lateral bending with 24.6% and with a maximal bulging of 1.14 mm. It was found that there is no tight relationship between fiber associated strains and disc bulging. This was especially seen for the load combinations. Highest fiber associated strains were found to be located in small posterolateral regions. Fiber associated strains had a much higher magnitude than previously reported fiber associated strains. The results showed that combined loading is most likely to produce higher associated fiber strains compared to single axis loading.

Elastic fibers enhance the mechanical integrity of the human lumbar anulus fibrosus in the radial direction

The anulus fibrosus of the human lumbar intervertebral disc has a complex, hierarchical structure comprised of collagens, proteoglycans, and elastic fibers. Recent histological studies have suggested that the elastic fiber network may play an important functional role. In this study, it was hypothesized that elastic fibers enhance the mechanical integrity of the extracellular matrix in the radial orientation, perpendicular to the plane containing the collagen fibers. Using a combination of biochemically verified enzymatic treatments and biomechanical tests, it was demonstrated that degradation of elastic fibers resulted in a significant reduction in both the initial modulus and the ultimate modulus, and a significant increase in the extensibility, of radially oriented anulus fibrosus specimens. Separate treatments and mechanical tests were used to account for any changes attributable to non-specific degradation of glycosaminoglycans. Additionally, histological assessments provided a unique perspective on structural changes in the elastic fiber network in radially oriented specimens subjected to tensile deformations. The results of this study demonstrate that elastic fibers play an important and unique role in the mechanical properties of the anulus fibrosus, and provide the basis for the development of improved material models to describe intervertebral disc mechanical behavior.

The risk of disc prolapses with complex loading in different degrees of disc degeneration - a finite element analysis

BACKGROUND

Disc prolapses can result from various complex load situations and degenerative changes in the intervertebral disc. The aim of this finite element study was to find load combinations that would lead to the highest internal stresses in a healthy and in degenerated discs.

METHODS

A three-dimensional finite element model of a lumbar spinal segment L4-L5 in different grades of disc degeneration (healthy, mild, moderate, and severe) were generated, in which the disc height reduction, the formation of osteophytes and the increasing of nucleus' compressibility were considered. The intradiscal pressure in the nucleus, the fiber strains, and the shear strains between the annulus and the adjacent endplates under pure and complex loads were investigated.

RESULTS

In all grades of disc degeneration the intradiscal pressure was found to be highest in flexion. The shear and fiber strains predicted a strong increase under lateral bending+flexion for the healthy disc and under axial rotation and lateral bending+axial rotation for all degenerated discs, mostly located in the postero-lateral annulus. Compared to the healthy disc, the mildly degenerated disc indicated an increase of the intradiscal pressure and of the fiber strains, both of 25% in axial rotation. The shear strains showed an increase of 27% in axial rotation+flexion. As from the moderately degenerated disc all measurement parameters strongly decreased.

INTERPRETATION

The results support how specifically changes associated with disc degeneration might contribute to risk of prolapse. Thus, the highest risk of prolapses can be found for healthy and mildly degenerated discs.