The current testing protocols for biomechanical evaluation of lumbar spinal implants in laboratory setting: a review of the literature

Evaluating the stability of external fixators following pelvic injury: A systematic review of biomechanical testing methods

INTRODUCTION

This systematic review aims to identify previously used techniques in biomechanics to assess pelvic instability following pelvic injury, focusing on external fixation constructs.

METHODS

A systematic literature search was conducted to include biomechanical studies and to exclude clinical trials.

RESULTS

Of an initial 4666 studies found, 38 met the inclusion criteria. 84% of the included studies were retrieved from PubMed, Scopus, and Web of Science. The studies analysed 106 postmortem specimens, 154 synthetic bones, and 103 computational models. Most specimens were male (97% synthetic, 70% postmortem specimens). Both the type of injury and the classification system employed varied across studies. About 82% of the injuries assessed were of type C. Two different fixators were tested for FFPII and type A injury, five for type B injury, and fifteen for type C injury. Large variability was observed for external fixation constructs concerning device type and configuration, pin size, and geometry. Biomechanical studies deployed various methods to assess injury displacement, deformation, stiffness, and motion. Thereby, loading protocols differed and inconsistent definitions of failure were determined. Measurement techniques applied in biomechanical test setups included strain gauges, force transducers, and motion tracking techniques.

DISCUSSION AND CONCLUSION

An ideal fixation method should be safe, stable, non-obstructive, and have low complication rates. Although biomechanical testing should ensure that the load applied during testing is representative of a physiological load, a high degree of variability was found in the current literature in both the loading and measurement equipment. The lack of a standardised test design for fixation constructs in pelvic injuries across the studies challenges comparisons between them. When interpreting the results of biomechanical studies, it seems crucial to consider the limitations in cross-study comparability, with implications on their applicability to the clinical setting.

Inter-Specimen Analysis of Diverse Finite Element Models of the Lumbar Spine

Over the past few decades, there has been a growing popularity in utilizing finite element analysis to study the spine. However, most current studies tend to use one specimen for their models. This research aimed to validate multiple finite element models by comparing them with data from in vivo experiments and other existing finite element studies. Additionally, this study sought to analyze the data based on the gender and age of the specimens. For this study, eight lumbar spine (L2-L5) finite element models were developed. These models were then subjected to finite element analysis to simulate the six fundamental motions. CT scans were obtained from a total of eight individuals, four males and four females, ranging in age from forty-four (44) to seventy-three (73) years old. The CT scans were preprocessed and used to construct finite element models that accurately emulated the motions of flexion, extension, lateral bending, and axial rotation. Preloads and moments were applied to the models to replicate physiological loading conditions. This study focused on analyzing various parameters such as vertebral rotation, facet forces, and intradiscal pressure in all loading directions. The obtained data were then compared with the results of other finite element analyses and in vivo experimental measurements found in the existing literature to ensure their validity. This study successfully validated the intervertebral rotation, intradiscal pressure, and facet force results by comparing them with previous research findings. Notably, this study concluded that gender did not have a significant impact on the results. However, the results did highlight the importance of age as a critical variable when modeling the lumbar spine.

A 20-Year Review of Biomechanical Experimental Studies on Spine Implants Used for Percutaneous Surgical Repair of Vertebral Compression Fractures

A vertebral compression fracture (VCF) is an injury to a vertebra of the spine affecting the cortical walls and/or middle cancellous section. The most common risk factor for a VCF is osteoporosis, thus predisposing the elderly and postmenopausal women to this injury. Clinical consequences include loss of vertebral height, kyphotic deformity, altered stance, back pain, reduced mobility, reduced abdominal space, and reduced thoracic space, as well as early mortality. To restore vertebral mechanical stability, overall spine function, and patient quality of life, the original percutaneous surgical intervention has been vertebroplasty, whereby bone cement is injected into the affected vertebra. Because vertebroplasty cannot fully restore vertebral height, newer surgical techniques have been developed, such as kyphoplasty, stents, jacks, coils, and cubes. But, relatively few studies have experimentally assessed the biomechanical performance of these newer procedures. This article reviews over 20 years of scientific literature that has experimentally evaluated the biomechanics of percutaneous VCF repair methods. Specifically, this article describes the basic operating principles of the repair methods, the study protocols used to experimentally assess their biomechanical performance, and the actual biomechanical data measured, as well as giving a number of recommendations for future research directions.

Motion capture evaluation of sagittal spino-pelvic biomechanics after lumbar spinal fusion

PURPOSE

The spine and pelvis coexist as a dynamic linked system in which spinal and pelvic parameters are correlated. Investigation of this system can inform the understanding and treatment of spinal deformity. Here, we demonstrate the use of motion capture technology to measure spine biomechanical parameters using a novel testing apparatus.

METHODS

Three complete cadaveric spines with skull and pelvis were mounted into a biomechanical testing apparatus. Each lumbar vertebra was monitored by motion capture cameras as the spines underwent maximal anterior and posterior pelvic tilts about two sagittal axes at a controlled speed and applied force. These axes were defined as the sacral axis which passes transversely through the ilium and S1, and the acetabular axis which passes transversely through both acetabula. The experiments were repeated after L4-L5 fusion, and then, after both L4-L5 and T12-S1 fusion with pedicle screw instrumentation. Data were collected for total range of motion and for coupled translation at each functional spinal unit (FSU).

RESULTS

Total range of motion and coupled translation within functional spinal units (FSUs) was decreased after spinal fusion. The displacement of each individual FSU was captured and summarized along with the observed patterns under each experimental condition.

CONCLUSION

Lumbar fusion decreases spinal motion in the sagittal plane in both overall ROM and individual coupled translations of lumbar vertebrae. This was demonstrated using motion capture technology which is useful for quantifying the translations of individual FSUs in a multisegmental spinal model.

The effects of viscoelasticity on residual strain in aortic soft tissues

Residual stress is thought to play a critical role in modulating stress distributions in soft biological tissues and in maintaining the mechanobiological stress environment of cells. Residual stresses in arteries and other tissues are classically assessed through opening angle experiments, which demonstrate the continuous release of residual stresses over hours. These results are then assessed through nonlinear biomechanical models to provide estimates of the residual stresses in the intact state. Although well studied, these analyses typically focus on hyperelastic material models despite significant evidence of viscoelastic phenomena over both short and long timescales. In this work, we extended the state-of-the-art structural tensor model for arterial tissues from Holzapfel and Ogden for fractional viscoelasticity. Models were tuned to capture consistent levels of hysteresis observed in biaxial experiments, while also minimizing the fractional viscoelastic weighting and opening angles to correctly capture opening angle dynamics. Results suggest that a substantial portion of the human abdominal aorta is viscoelastic, but exhibits a low fractional order (i.e. more elastically). Additionally, a significantly larger opening angle in the fully unloaded state is necessary to produce comparable hysteresis in biaxial testing. As a consequence, conventional estimates of residual stress using hyperelastic approaches over-estimate their viscoelastic counterparts by a factor of 2. Thus, a viscoelastic approach, such as the one illustrated in this study, in combination with an additional source of rate-controlled viscoelastic data is necessary to accurately analyze the residual stress distribution in soft biological tissues. STATEMENT OF SIGNIFICANCE: Residual stress plays a crucial role in achieving a homeostatic stress environment in soft biological tissues. However, the analysis of residual stress typically focuses on hyperelastic material models despite evidence of viscoelastic behavior. This work is the first attempt at analyzing the effects of viscoelasticity on residual stress. The application of viscoelasticity was crucial for producing realistic opening dynamics in arteries. The overall residual stresses were estimated to be 50% less than those from using hyperelastic material models, while the opening angles were projected to be 25% more than those measured after 16 hours, suggesting underestimated residual strain. This study highlights the importance viscoelasticity in the analysis of residual stress even in weakly dissipative materials like the human aorta.

Lag-Screw Osteosynthesis in Thoracolumbar Pincer Fractures

STUDY DESIGN

Biomechanical.

OBJECTIVE

This study evaluates the biomechanical properties of lag-screws used in vertebral pincer fractures at the thoracolumbar junction.

METHODS

Pincer fractures were created in 18 bisegmental human specimens. The specimens were assigned to three groups depending on their treatment perspective, either bolted, with the thread positioned in the cortical or cancellous bone, or control. The specimens were mounted in a servo-hydraulic testing machine and loaded with a 500 N follower load. They were consecutively tested in 3 different conditions: intact, fractured, and bolted/control. For each condition 10 cycles in extension/flexion, torsion, and lateral bending were applied. After each tested condition, a computed tomography (CT) scan was performed. Finally, an extension/flexion fatigue loading was applied to all specimens.

RESULTS

Biomechanical results revealed a nonsignificant increase in stiffness in extension/flexion of the fractured specimens compared with the intact ones. For lateral bending and torsion, the stiffness was significantly lower. Compared with the fractured specimens, no changes in stiffness due to bolting were discovered. CT scans showed an increasing fracture gap during axial loading both in extension/flexion, torsion, and lateral bending in the control specimens. In bolted specimens, the anterior fragment was approximated, and the fracture gap nullified. This refers to both the cortical and the cancellous thread positions.

CONCLUSION

The results of this study concerning the effect of lag-screws on pincer fractures appear promising. Though there was little effect on stiffness, CT scans reveal a bony contact in the bolted specimens, which is a requirement for bony healing.

Biomechanical comparison of 3 types of transdiscal fixation implants for fixing high-grade L5/S1 spine spondylolisthesis

BACKGROUND CONTEXT

There are several options for the stabilization of high-grade lumbosacral spondylolisthesis including transdiscal screws, the Bohlman technique (transdiscal fibular strut) and the modified Bohlman technique (transdiscal titanium mesh cage). The choice of an optimum construct remains controversial; therefore, we endeavoured to study and compare the biomechanical performance of these 3 techniques.

PURPOSE

The aim of this study was to compare 3 types of transdiscal fixation biomechanically in an in vitro porcine lumbar-sacral spine model.

STUDY DESIGN/SETTING

Porcine cadaveric biomechanical study.

METHODS

18 complete lumbar-sacral porcine spines were split into 3 repair groups, transdiscal screws (TS), Bohlman technique, and a modified Bohlman technique (MBT). Range of motion (L3 - S1) was measured in an intact and repaired state for flexion, extension, left/right lateral bending, and left/right torsion. To recreate a high-grade lumbosacral spondylolisthesis a bilateral L5/S1 facetectomy, removing the intervertebral disc completely, and the L5 body was displaced 50%-60% over the sacral promontory. Results were analyzed and compared to intact baseline measurements. Standard quasi-static moments (5 Nm) were applied in all modes.

RESULTS

All range of motion (ROM) were in reference to intact baseline values. TS had the lowest ROM in all modes (p=.006-.495). Statistical difference was found only in extension for TS vs. BT (p=.011) and TS vs. MBT (p=.014). No bone or implant failures occurred.

CONCLUSION

TS provided the lowest ROM in all modes of loading compared to Bohlman technique and MBT. Our study indicates that TS results in the most biomechanically stable construct.

CLINICAL SIGNIFICANCE

Knowledge of the biomechanical attributes of various constructs could aid physicians in choosing a surgical construct for their patients.

Biomechanical comparison of fixation techniques for transverse acetabular fractures - Single-leg stance vs. sit-to-stand loading

OBJECTIVES

To biomechanically compare five different fixation techniques for transverse acetabular fractures using both the single-leg stance (SLS) and the sit-to-stand (STS) loading protocols and to directly compare fracture gap motion (FGM) and relative interfragmentary rotation (RIFR).

METHODS

Transtectal transverse acetabular fractures were created on fourth-generation composite hemipelves in a reproducible manner. Five different fixation techniques were biomechanically assessed using both an SLS and STS loading protocol: anterior plate (AP) only, posterior plate (PP) only, anterior plate plus posterior column screw (AP+PCS), posterior plate plus anterior column screw (PP+ACS) and anterior plus posterior plate (AP+PP). After preconditioning, the specimens were loaded from 50 to 750 N with a ramp of 100 N/s. FGM and RIFR under loads of 750 N were measured using an optical 3D measurement system.

RESULTS

In the three groups of fixation techniques addressing both columns, STS loading resulted in higher mean FGM and in RIFR than SLS loading. No construct failure was observed. In the single plate groups (AP only and PP only), STS loading resulted in failure of all specimens before reaching loads of 750 N, while no failure occurred after SLS loading. No significant differences in FGM and RIFR were found between the double plate (AP+PP) and the single plate plus column screw (AP+PCS and PP+ACS) techniques.

CONCLUSION

SLS loading appeared to overestimate the strength of acetabular fracture fixation constructs and STS loading may be more appropriate to provide clinically relevant biomechanical data. Internal fixation of a single column might not provide adequate stability for transverse fractures, while strength of single plate plus column screw fixation and double plate fixation was comparable.

Range of Motion Testing of a Novel 3D-Printed Synthetic Spine Model

STUDY DESIGN

Biomechanical model study.

OBJECTIVE

The Barrow Biomimetic Spine (BBS) project is a resident-driven effort to manufacture a synthetic spine model with high biomechanical fidelity to human tissue. The purpose of this study was to investigate the performance of the current generation of BBS models on biomechanical testing of range of motion (ROM) and axial compression and to compare the performance of these models to historical cadaveric data acquired using the same testing protocol.

METHODS

Six synthetic spine models comprising L3-5 segments were manufactured with variable soft-tissue densities and print orientations. Models underwent torque loading to a maximum of 7.5 N m. Torques were applied to the models in flexion-extension, lateral bending, axial rotation, and axial compression. Results were compared with historic cadaveric control data.

RESULTS

Each model demonstrated steadily decreasing ROM on flexion-extension testing with increasing density of the intervertebral discs and surrounding ligamentous structures. Vertically printed models demonstrated markedly less ROM than equivalent models printed horizontally at both L3-4 (5.0° vs 14.0°) and L4-5 (3.9° vs 15.2°). Models D and E demonstrated ROM values that bracketed the cadaveric controls at equivalent torque loads (7.5 N m).

CONCLUSIONS

This study identified relevant variables that affect synthetic spine model ROM and compressibility, confirmed that the models perform predictably with changes in these print variables, and identified a set of model parameters that result in a synthetic model with overall ROM that approximates that of a cadaveric model. Future studies can be undertaken to refine model performance and determine intermodel variability.

Nonlinear viscoelastic constitutive model for bovine liver tissue

Soft tissue mechanical characterisation is important in many areas of medical research. Examples span from surgery training, device design and testing, sudden injury and disease diagnosis. The liver is of particular interest, as it is the most commonly injured organ in frontal and side motor vehicle crashes, and also assessed for inflammation and fibrosis in chronic liver diseases. Hence, an extensive rheological characterisation of liver tissue would contribute to advancements in these areas, which are dependent upon underlying biomechanical models. The aim of this paper is to define a liver constitutive equation that is able to characterise the nonlinear viscoelastic behaviour of liver tissue under a range of deformations and frequencies. The tissue response to large amplitude oscillatory shear (1–50%) under varying preloads (1–20%) and frequencies (0.5–2 Hz) is modelled using viscoelastic-adapted forms of the Mooney–Rivlin, Ogden and exponential models. These models are fit to the data using classical or modified objective norms. The results show that all three models are suitable for capturing the initial nonlinear regime, with the latter two being capable of capturing, simultaneously, the whole deformation range tested. The work presented here provides a comprehensive analysis across several material models and norms, leading to an identifiable constitutive equation that describes the nonlinear viscoelastic behaviour of the liver.

Development and first clinical use of a novel anatomical and biomechanical testing platform for scoliosis

BACKGROUND

Previous studies have demonstrated that, by using various three-dimensional (3D) printing technologies, synthetic spine models can be manufactured to mimic a human spine in its gross and radiographic anatomy and the biomechanical performance of bony and ligamentous tissue. These manufacturing processes have not, however, been used in combination to create a long-segment, biomimetic model of a patient with scoliosis. The purpose of this study was to describe the development of a biomimetic scoliosis model and early clinical experience using this model as a surgical planning and education platform.

METHODS

Synthetic spine models were printed to mimic the anatomy and biomechanical performance of 2 adult patients with scoliosis. Preoperatively, the models were surgically corrected by the attending surgeon of each patient. Patients then underwent surgical correction of their spinal deformities. Correction of the models was compared to the surgical correction in the patients.

RESULTS

Patient 1 had a preoperative coronal Cobb angle of 40° from L1 to S1, as did the patient's synthetic spine model. The patient's spine model was corrected to 17.6°, and the patient achieved a correction of 17.3°. Patient 2 had a preoperative mid-thoracic Cobb angle of 88° and an upper thoracic Cobb angle of 43°. Preoperatively, the patient's spine model was corrected to 19.5° and 9.2° for the mid-thoracic and upper thoracic curves, respectively. Immediately after surgery, the patient's mid-thoracic and upper thoracic Cobb angles measured 18.7° and 9.5°, respectively. In both cases, the use of the spine models preoperatively changed the attending surgeon's operative plan.

CONCLUSIONS

A novel synthetic spine model for corrective scoliosis procedures is presented, along with early clinical experience using this model as a surgical planning platform. This model has tremendous potential not only as a surgical planning platform but also as an adjunct to patient consent, surgical education, and biomechanical research.

The Changing Face of Technologically Integrated Neurosurgery: Today's High-Tech Operating Room

Over the last decade, surgical technology in planning, mapping, optics, robotics, devices, and minimally invasive techniques has changed the face of modern neurosurgery. We explore the current advances in clinical technology across all neurosurgical subspecialties, examine how clinical practice is being shaped by this technology, and suggest what the operating room of tomorrow may look like.