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Li K, Cao S, Chen J, Qin J, Yuan B, Li J. Determining a relative total lumbar range of motion to alleviate adjacent segment degeneration after transforaminal lumbar interbody fusion: a finite element analysis. BMC Musculoskelet Disord 2024; 25:197. [PMID: 38443904 PMCID: PMC10913564 DOI: 10.1186/s12891-024-07322-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 02/28/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND A reduction in total lumbar range of motion (ROM) after lumbar fusion may offset the increase in intradiscal pressure (IDP) and facet joint force (FJF) caused by the abnormally increased ROM at adjacent segments. This study aimed to determine a relative total lumbar ROM rather than an ideal adjacent segment ROM to guide postoperative waist activities and further delay adjacent segment degeneration (ASD). METHODS An intact L1-S1 finite element model was constructed and validated. Based on this, a surgical model was created to allow the simulation of L4/5 transforaminal lumbar interbody fusion (TLIF). Under the maximum total L1-S1 ROM, the ROM, IDP, and FJF of each adjacent segment between the intact and TLIF models were compared to explore the biomechanical influence of lumbar fusion on adjacent segments. Subsequently, the functional relationship between total L1-S1 ROM and IDP or total L1-S1 ROM and FJF was fitted in the TLIF model to calculate the relative total L1-S1 ROMs without an increase in IDP and FJF. RESULTS Compared with those of the intact model, the ROM, IDP, and FJF of the adjacent segments in the TLIF model increased by 12.6-28.9%, 0.1-6.8%, and 0-134.2%, respectively. As the total L1-S1 ROM increased, the IDP and FJF of each adjacent segment increased by varying degrees. The relative total L1-S1 ROMs in the TLIF model were 11.03°, 12.50°, 12.14°, and 9.82° in flexion, extension, lateral bending, and axial rotation, respectively. CONCLUSIONS The relative total L1-S1 ROMs after TLIF were determined, which decreased by 19.6-29.3% compared to the preoperative ones. Guiding the patients to perform postoperative waist activities within these specific ROMs, an increase in the IDP and FJF of adjacent segments may be effectively offset, thereby alleviating ASD.
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Affiliation(s)
- Ke Li
- Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, 157th West Fifth Road, Xi'an, Shaanxi Province, 710004, China
| | - Shuai Cao
- Department of Orthopedics, Civil Aviation General Hospital, No. 1, Gaojing Stress, Chaoyang District, Beijing, 100123, China
| | - Jing Chen
- Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, 157th West Fifth Road, Xi'an, Shaanxi Province, 710004, China
| | - Jie Qin
- Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, 157th West Fifth Road, Xi'an, Shaanxi Province, 710004, China
| | - Bo Yuan
- Department of Orthopedics, Civil Aviation General Hospital, No. 1, Gaojing Stress, Chaoyang District, Beijing, 100123, China
| | - Jie Li
- Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, 157th West Fifth Road, Xi'an, Shaanxi Province, 710004, China.
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Khalaf K, Nikkhoo M, Shams S, Niu CC, Cheng CH. Impact of osteoporosis and Cement-Augmented fusion on adjacent spinal levels Post-Fusion Surgery: Patient-Specific finite element analysis. J Biomech 2024; 166:112070. [PMID: 38569456 DOI: 10.1016/j.jbiomech.2024.112070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 03/26/2024] [Accepted: 03/30/2024] [Indexed: 04/05/2024]
Abstract
Cement-augmentation is a technique commonly used during posterior lumbar instrumented fusion (PLIF) to reinforce compromised osteoporotic vertebral bone, minimize the risk of loosening screws, enhance stability, and improve overall surgical outcomes. In this study, we introduce a novel segmented vertebral body regional modeling approach to investigate the effects of osteoporosis and cement-augmented lumbar fusion on disc biomechanics at spinal levels adjacent to the fused vertebrae. Using our previously validated personalized-poroelastic-osteoligamentous FE model of the spine, fusion was simulated at L4-L5, and the biomechanics of adjacent levels were studied for 30 patients (non-osteoporotic patients (N = 15), osteoporotic patients (N = 15)). PLIF models, with and without cement-augmentation, were developed and compared after an 8 h-rest period (200 N), following a 16 h-cyclic compressive loading of 500-1000 N (40 and 20 min, respectively). Movement in different directions (flexion/ extension/ lateral bending/ axial rotation) was simulated using 10Nm moment before and after cyclic loading. The material mapping algorithm was validated by comparing the results of voxel-based and parametric models. The FE cement-augmented models, subject to daily activity loading, demonstrated significant differences in disc height loss and fluid loss as compared to non-cemented models. The calculated axial stress and fiber strain values were also significantly higher for these models. This work demonstrates that although osteoporosis does not significantly alter the time-dependent characteristics of adjacent IVDs post-surgery, cement-augmentation increases the risk of adjacent segment disease (ASD) incidence. A holistic understanding of the trade-offs and long-term complex interplay between structural reinforcement modalities, including cement augmentation, and altered biomechanics warrants further investigation.
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Affiliation(s)
- Kinda Khalaf
- College of Medicine and Health Sciences, Khalifa University of Science and Technology, and Health Engineering Innovation Center, Abu Dhabi, United Arab Emirates.
| | - Mohammad Nikkhoo
- School of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Biomedical Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Shohreh Shams
- Department of Biomedical Engineering, Amirkabir University of Technology, Tehran, Iran
| | - Chi-Chien Niu
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chih-Hsiu Cheng
- School of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan.
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Daroudi S, Arjmand N, Mohseni M, El-Rich M, Parnianpour M. Evaluation of ground reaction forces and centers of pressure predicted by AnyBody Modeling System during load reaching/handling activities and effects of the prediction errors on model-estimated spinal loads. J Biomech 2024; 164:111974. [PMID: 38331648 DOI: 10.1016/j.jbiomech.2024.111974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/03/2024] [Accepted: 01/29/2024] [Indexed: 02/10/2024]
Abstract
Full-body and lower-extremity human musculoskeletal models require feet ground reaction forces (GRFs) and centers of pressure (CoPs) as inputs to predict muscle forces and joint loads. GRFs/CoPs are traditionally measured via floor-mounted forceplates that are usually restricted to research laboratories thus limiting their applicability in real occupational and clinical setups. Alternatively, GRFs/CoPs can be estimated via inverse dynamic approaches as also implemented in the Anybody Modeling System (AnyBody Technology, Aalborg, Denmark). The accuracy of Anybody in estimating GRFs/CoPs during load-handling/reaching activities and the effect of its prediction errors on model-estimated spinal loads remain to be investigated. Twelve normal- and over-weight individuals performed total of 480 static load-handling/reaching activities while measuring (by forceplates) and predicting (by AnyBody) their GRFs/CoPs. Moreover, the effects of GRF/CoP prediction errors on the estimated spinal loads were evaluated by inputting measured or predicted GRFs/CoPs into subject-specific musculoskeletal models. Regardless of the subject groups (normal-weight or overweight) and tasks (load-reaching or load-handling), results indicated great agreements between the measured and predicted GRFs (normalized root-mean-squared error, nRMSEs < 14% and R2 > 0.90) and between their model-estimated spinal loads (nRMSEs < 14% and R2 > 0.83). These agreements were good but relatively less satisfactory for CoPs (nRMSEs < 17% and 0.57 < R2 < 0.68). The only exception, requiring a more throughout investigation, was the situation when the ground-foot contact was significantly reduced during the activity. It appears that occupational/clinical investigations performed in real workstation/clinical setups with no access to forceplates may benefit from the AnyBody GRF/CoP prediction tools for a wide range of load-reaching/handling activities.
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Affiliation(s)
- S Daroudi
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran
| | - N Arjmand
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran.
| | - M Mohseni
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran
| | - M El-Rich
- Healthcare Engineering Innovation Center, Department of Mechanical Engineering, Khalifa University, Abu Dhabi, United Arab Emirates
| | - M Parnianpour
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran
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Hsiao CK, Hsiao HY, Tsai YJ, Hsu CM, Tu YK. Influence of Simulated State of Disc Degeneration and Axial Stiffness of Coupler in a Hybrid Performance Stabilisation System on the Biomechanics of a Spine Segment Model. Bioengineering (Basel) 2023; 10:1042. [PMID: 37760144 PMCID: PMC10525081 DOI: 10.3390/bioengineering10091042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 08/21/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
Spinal fusion surgery leads to the restriction of mobility in the vertebral segments postoperatively, thereby causing stress to rise at the adjacent levels, resulting in early degeneration and a high risk of adjacent vertebral fractures. Thus, to address this issue, non-fusion surgery applies some pedicle screw-based dynamic stabilisation systems to provide stability and micromotion, thereby reducing stress in the fusion segments. Among these systems, the hybrid performance stabilisation system (HPSS) combines a rigid rod, transfer screw, and coupler design to offer a semi-rigid fixation method that preserves some mobility near the fusion site and reduces the adjacent segment compensatory effects. However, further research and confirmation are needed regarding the biomechanical effects of the dynamic coupler stiffness of the HPSS on the intrinsic degenerated adjacent segment. Therefore, this study utilised the finite element method to investigate the impact of the coupler stiffness of the HPSS on the mobility of the lumbar vertebral segments and the stress distribution in the intervertebral discs under flexion, extension, and lateral bending, as well as the clinical applicability of the HPSS on the discs with intrinsic moderate and severe degeneration at the adjacent level. The analytical results indicated that, regardless of the degree of disc degeneration, the use of a dynamic coupler stiffness of 57 N/mm in the HPSS may reduce the stress concentrations at the adjacent levels. However, for severely degenerated discs, the postoperative stress on the adjacent segments with the HPSS was still higher compared with that of the discs with moderate degeneration. We conclude that, when the discs had moderate degeneration, increasing the coupler stiffness led to a decrease in disc mobility. In the case of severe disc degeneration, the effect on disc mobility by coupler stiffness was less pronounced. Increasing the coupler stiffness ked to higher stress on intervertebral discs with moderate degeneration, while its effect on stress was less pronounced for discs with severe degeneration. It is recommended that patients with severe degeneration who undergo spinal dynamic stabilisation should remain mindful of the risk of accelerated adjacent segment degeneration.
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Affiliation(s)
- Chih-Kun Hsiao
- Department of Medical Research, E-Da Hospital, I-Shou University, Kaohsiung 824, Taiwan; (C.-K.H.); (Y.-J.T.)
- Department of Orthopedics, E-Da Hospital, I-Shou University, Kaohsiung 824, Taiwan;
| | - Hao-Yuan Hsiao
- Department of Orthopedics, E-Da Hospital, I-Shou University, Kaohsiung 824, Taiwan;
- Institute of Medical Science and Technology, National Sun Yat-sen University, Kaohsiung 804, Taiwan
| | - Yi-Jung Tsai
- Department of Medical Research, E-Da Hospital, I-Shou University, Kaohsiung 824, Taiwan; (C.-K.H.); (Y.-J.T.)
| | - Chao-Ming Hsu
- Department of Mechanical Engineering, National Kaohsiung University of Science and Technology, Kaohsiung 824, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopedics, E-Da Hospital, I-Shou University, Kaohsiung 824, Taiwan;
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Zhang X, Yang Y, Shen YW, Zhang KR, Ma LT, Ding C, Wang BY, Meng Y, Liu H. Biomechanical performance of the novel assembled uncovertebral joint fusion cage in single-level anterior cervical discectomy and fusion: A finite element analysis. Front Bioeng Biotechnol 2023; 11:931202. [PMID: 36970630 PMCID: PMC10031026 DOI: 10.3389/fbioe.2023.931202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 02/22/2023] [Indexed: 03/11/2023] Open
Abstract
Introduction: Anterior cervical discectomy and fusion (ACDF) is widely accepted as the gold standard surgical procedure for treating cervical radiculopathy and myelopathy. However, there is concern about the low fusion rate in the early period after ACDF surgery using the Zero-P fusion cage. We creatively designed an assembled uncoupled joint fusion device to improve the fusion rate and solve the implantation difficulties. This study aimed to assess the biomechanical performance of the assembled uncovertebral joint fusion cage in single-level ACDF and compare it with the Zero-P device.Methods: A three-dimensional finite element (FE) of a healthy cervical spine (C2−C7) was constructed and validated. In the one-level surgery model, either an assembled uncovertebral joint fusion cage or a zero-profile device was implanted at the C5–C6 segment of the model. A pure moment of 1.0 Nm combined with a follower load of 75 N was imposed at C2 to determine flexion, extension, lateral bending, and axial rotation. The segmental range of motion (ROM), facet contact force (FCF), maximum intradiscal pressure (IDP), and screw−bone stress were determined and compared with those of the zero-profile device.Results: The results showed that the ROMs of the fused levels in both models were nearly zero, while the motions of the unfused segments were unevenly increased. The FCF at adjacent segments in the assembled uncovertebral joint fusion cage group was less than that that of the Zero-P group. The IDP at the adjacent segments and screw–bone stress were slightly higher in the assembled uncovertebral joint fusion cage group than in those of the Zero-P group. Stress on the cage was mainly concentrated on both sides of the wings, reaching 13.4–20.4 Mpa in the assembled uncovertebral joint fusion cage group.Conclusion: The assembled uncovertebral joint fusion cage provided strong immobilization, similar to the Zero-P device. When compared with the Zero-P group, the assembled uncovertebral joint fusion cage achieved similar resultant values regarding FCF, IDP, and screw–bone stress. Moreover, the assembled uncovertebral joint fusion cage effectively achieved early bone formation and fusion, probably due to proper stress distributions in the wings of both sides.
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Nikkhoo M, Chen WC, Lu ML, Fu CJ, Niu CC, Lien HY, Cheng CH. Anatomical parameters alter the biomechanical responses of adjacent segments following lumbar fusion surgery: Personalized poroelastic finite element modelling investigations. Front Bioeng Biotechnol 2023; 11:1110752. [PMID: 36860879 PMCID: PMC9968854 DOI: 10.3389/fbioe.2023.1110752] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
Introduction: While the short-term post-operative outcome of lumbar fusion is satisfying for most patients, adjacent segment disease (ASD) can be prevalent in long-term clinical observations. It might be valuable to investigate if inherent geometrical differences among patients can significantly alter the biomechanics of adjacent levels post-surgery. This study aimed to utilize a validated geometrically personalized poroelastic finite element (FE) modeling technique to evaluate the alteration of biomechanical response in adjacent segments post-fusion. Methods: Thirty patients were categorized for evaluation in this study into two distinct groups [i.e., 1) non-ASD and 2) ASD patients] based on other long-term clinical follow-up investigations. To evaluate the time-dependent responses of the models subjected to cyclic loading, a daily cyclic loading scenario was applied to the FE models. Different rotational movements in different planes were superimposed using a 10 Nm moment after daily loading to compare the rotational motions with those at the beginning of cyclic loading. The biomechanical responses of the lumbosacral FE spine models in both groups were analyzed and compared before and after daily loading. Results: The achieved comparative errors between the FE results and clinical images were on average below 20% and 25% for pre-op and post-op models, respectively, which confirms the applicability of this predictive algorithm for rough pre-planning estimations. The results showed that the disc height loss and fluid loss were increased for the adjacent discs in post-op models after 16 h of cyclic loading. In addition, significant differences in disc height loss and fluid loss were observed between the patients who were in the non-ASD and ASD groups. Similarly, the increased stress and fiber strain in the annulus fibrosus (AF) was higher in the adjacent level of post-op models. However, the calculated stress and fiber strain values were significantly higher for patients with ASD. Discussion: Evaluating the biomechanical response of pre-op and post-op modeling in the non-ASD and ASD groups showed that the inherent geometric differences among patients cause significant variations in the estimated mechanical response. In conclusion, the results of the current study highlighted the effect of geometrical parameters (which may refer to the anatomical conditions or the induced modifications regarding surgical techniques) on time-dependent responses of lumbar spine biomechanics.
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Affiliation(s)
- Mohammad Nikkhoo
- School of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan,Department of Biomedical Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Wen-Chien Chen
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan,Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Meng-Ling Lu
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan,Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chen-Ju Fu
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan,Division of Emergency and Critical Care Radiology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chi-Chien Niu
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan,Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Hen-Yu Lien
- School of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hsiu Cheng
- School of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan,*Correspondence: Chih-Hsiu Cheng,
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