Gene therapy for degenerative disc disease

Degenerative disc disease (DDD) is a chronic process that can become clinically manifest in multiple disorders such as idiopathic low back pain, disc herniation, radiculopathy, myelopathy, and spinal stenosis. The limited available technology for the treatment of these and other pathologic and disabling conditions arising from DDD is highly invasive (eg, surgical discectomy and fusion), manifesting a certain degree of complications and unsatisfactory clinical outcomes. Although the precise pathophysiology of DDD remains to be clearly delineated, the progressive decline in aggrecan, the primary proteoglycan of the nucleus pulposus, appears to be a final common pathway. It has been hypothesized that imbalance in the synthesis and catabolism of certain critical extracellular matrix components can be mitigated by the transfer of genes to intervertebral disc cells encoding factors that modulate synthesis and catabolism of these components. The successful in vivo transfer of therapeutic genes to target cells within the intervertebral disc in clinically relevant animal models of DDD is one example of the rapid progress that is being made towards the development of gene therapy approaches for the treatment of DDD. This chapter reviews the ability of gene therapy to alter biologic processes in the degenerated intervertebral disc and outlines the work needed to be done before human clinical trials can be contemplated.

Load-sharing between anterior and posterior elements in a lumbar motion segment implanted with an artificial disc

STUDY DESIGN

A nonlinear three-dimensional finite element model of the osteoligamentous L3-L4 motion segment was used to predict changes in posterior element loads as a function of disc implantation and associated surgical procedures.

OBJECTIVES

To evaluate the effects of disc implantation on the biomechanics of the posterior spinal elements (including the facet joints, pedicles, and lamina) and on the vertebral bodies.

SUMMARY OF BACKGROUND DATA

Although several artificial disc designs have been used clinically, biomechanical data-particularly the change in loads in the posterior elements after disc implantation-are sparse.

METHODS

A previously validated intact finite element model was implanted with a ball-and-cup-type artificial disc model via an anterior approach. The implanted model predictions were compared with in vitro data. To study surgical variables, small and large windows were cut into the anulus, and the implant was placed anteriorly and posteriorly within the disc space. The anterior longitudinal ligament was also restored. Models were subjected to either 800 N axial compression force alone or to a combination of 10 N-m flexion-extension moment and 400 N axial preload. Implanted model predictions were compared with those of the intact model.

RESULTS

Facet loads were more sensitive to the anteroposterior location of the artificial disc than to the amount of anulus removed. Under 800 N axial compression, implanted models with an anteriorly placed artificial disc exhibited facet loads 2.5 times greater than loads observed with the intact model, whereas posteriorly implanted models predicted no facet loads in compression. Implanted models with a posteriorly placed disc exhibited greater flexibility than the intact and implanted models with anteriorly placed discs. Restoration of the anterior longitudinal ligament reduced pedicle stresses, facet loads, and extension rotation to nearly intact levels.

CONCLUSIONS

The models suggest that, by altering placement of the artificial disc in the anteroposterior direction, a surgeon can modulate motion-segment flexuralstiffness and posterior load-sharing, even though the specific disc replacement design has no inherent rotational stiffness.

Human intervertebral disc cells are genetically modifiable by adenovirus-mediated gene transfer: implications for the clinical management of intervertebral disc disorders

STUDY DESIGN

Human intervertebral disc cells were cultured in monolayer and treated with adenovirus-containing marker genes to determine the susceptibility of the cells to adenovirus-mediated gene transfer.

OBJECTIVES

To test the efficacy of the adenovirus-mediated gene transfer technique for transferring exogenous genes to human intervertebral disc cells in vitro.

SUMMARY OF BACKGROUND DATA

Upregulated proteoglycan synthesis after direct in vivo adenovirus-mediated transfer of growth factor genes to the rabbit intervertebral disc has previously been reported. Before contemplating extending this approach to the treatment of human disc disease, it is necessary to demonstrate that human intervertebral disc cells are indeed susceptible to adenovirus-mediated gene transduction.

METHODS

Human intervertebral disc cells were isolated from disc tissue obtained from 15 patients during surgical disc procedures. The cells were cultured in monolayer and treated with saline containing five different doses of adenovirus carrying the lacZ gene (Ad/CMV-lacZ), saline containing adenovirus carrying the luciferase gene (Ad/CMV-luciferase), or saline alone. Transgene expression was analyzed by 5-bromo-4-chloro-3-indolyl-beta-galactosidase (X-Gal) staining and luciferase assay.

RESULTS

Adenovirus efficiently transferred lacZ and luciferase marker genes to cells from degenerated discs as well as to cells from nondegenerated discs. A minimum dose of 150 MOI Ad/CMV-lacZ was found to be sufficient to achieve transduction of approximately 100% of disc cells-regardless of patient age, sex, surgical indication, disc level, and degeneration grade. No statistically significant difference in the luciferase activities could be detected in disc cell cultures from degenerated and nondegenerated discs treated with Ad/CMV-luciferase.

CONCLUSIONS

In vitro transducibility of human intervertebral disc cells by adenovirus is relatively insensitive to disc degeneration grade. Because the rate-limiting step for successful gene therapy is the ability to transfer genes efficiently to the target tissue, the achievement of efficient gene transfer to human intervertebral disc cells(using a direct, adenovirus-mediated approach) is an important and necessary step in the development of gene therapy strategies for the management of human intervertebral disc disorders.

Potential applications of gene therapy to the treatment of intervertebral disc disorders

Gene therapy involves the transfer of genes to cells such that the recipient cells express these genes and thereby synthesize the ribonucleic acid and protein that they encode. Recent investigations suggest that gene therapy may have potential applications in the treatment of intervertebral disc disorders, particularly those associated with disc degeneration. The successful in vivo transfer of therapeutic genes to target cells within the intervertebral disc in clinically relevant animal models is one example of the rapid progress that is being made. The purpose of the current review is to address several important technical issues, including choice of vectors and gene delivery strategy and the characteristics of the target tissues, which are relevant to future clinical applications of gene therapy for the treatment of intervertebral disc disorders. It already is apparent from the growing literature that gene therapy has the potential of becoming a valuable clinical treatment mode for intervertebral disc disorders in the twenty-first century.

Modulation of the biologic activity of the rabbit intervertebral disc by gene therapy: an in vivo study of adenovirus-mediated transfer of the human transforming growth factor beta 1 encoding gene

STUDY DESIGN

In vivo studies using a rabbit model to determine the biologic effects of direct, adenovirus-mediated transfer of a therapeutic gene to the intervertebral disc.

OBJECTIVES

1) To deliver an exogenous therapeutic gene to rabbit lumbar intervertebral discs in vivo, 2) to quantify the resulting amount of gene expression, and 3) to determine the effect on the biologic activity of the discs.

SUMMARY OF BACKGROUND DATA

Although growth factors such as transforming growth factor beta 1 appear to have promising therapeutic properties, there currently is no practical method for sustained delivery of exogenous growth factors to the disc for the management of certain chronic types of disease (e.g., disc degeneration). A possible solution is to modify the disc cells genetically through gene transfer such that the cells manufacture the desired growth factors endogenously on a continuous basis.

METHODS

Saline, with or without virus, was injected directly into lumbar discs of 22 skeletally mature female New Zealand white rabbits. Group 1 (n = 11) received the adenovirus construct Ad/CMV-hTGF beta 1 containing the therapeutic human transforming growth factor beta 1-encoding gene. Group 2 (n = 6) received adenovirus containing the luciferase marker gene. Group 3 (n = 5) received saline only. The rabbits were killed 1 week after injection. Immunohistochemical staining for human transforming growth factor beta 1 was performed on the disc tissues of one rabbit from Group 1. Nucleus pulposus tissues from the remaining rabbits were cultured in serumless medium. Bioassays were performed to determine human transforming growth factor beta 1 production and proteoglycan synthesis.

RESULTS

Discs injected with Ad/CMV-hTGF beta 1 exhibited extensive and intense positive immunostaining for transforming growth factor beta 1. The nucleus pulposus tissues from the discs injected with Ad/CMV-hTGF beta 1 exhibited a 30-fold increase in active transforming growth factor beta 1 production, and a 5-fold increase in total (active + latent) transforming growth factor beta 1 production over that from intact control discs (P < 0.05). Furthermore, these tissues exhibited a 100% increase in proteoglycan synthesis compared with intact control tissue, which was statistically significant (P < 0.05).

CONCLUSIONS

The results of this study suggest that the intervertebral disc is an appropriate site for adenovirus-mediated transfer of exogenous genes and subsequent production of therapeutic growth factors. Gene therapy therefore may have useful applications for study of the basic science of the intervertebral disc and for clinical management of degenerative disc disease.

Improvement of accuracy in a high-capacity, six degree-of-freedom load cell: application to robotic testing of musculoskeletal joints

This study investigated a previously unaccounted for source of error in a high-capacity, six degree-of-freedom load cell used in multi-degree-of-freedom robotic testing of musculoskeletal joints, an application requiring a load cell with high accuracy in addition to high load capacity. A method of calibration is presented for reducing the error caused by changes in universal force-moment sensor (UFS) orientation within a gravitational field. Uncorrected, this error can exceed a magnitude of 1% of the full-scale load capacity-the manufacturer-stated accuracy of the UFS. Implementation of the calibration protocol reduced this error by approximately 75% for a variety of loading conditions. This improvement in load cell accuracy (while maintaining full load capacity) should improve both the measurement and control of specimen kinetics by robotic/UFS and other biomechanical testing systems.

Adenovirus-mediated gene transfer to nucleus pulposus cells. Implications for the treatment of intervertebral disc degeneration

STUDY DESIGN

In vitro and in vivo studies using a rabbit model were performed to determine the feasibility of adenovirus-mediated gene transfer to the intervertebral disc.

OBJECTIVES

This study was conducted to determine whether it is possible to transfer genes to cells within the intervertebral disc by direct injection of an adenovirus and to determine the duration of gene expression obtained by this method.

SUMMARY OF BACKGROUND DATA

Although growth factors have the potential to stimulate the regeneration of nucleus pulposus, sustained delivery of growth factors to a degenerated disc is clinically unfeasible with present technology. Novel approaches such as gene transfer should be investigated as possible solutions to this problem.

METHODS

The lacZ marker gene was used to evaluate gene delivery to cells within intervertebral discs. For the in vitro study, cell cultures were established from the nucleus pulposus tissue of New Zealand white rabbits and infected with an adenovirus encoding the lacZ gene (Ad-lacZ). For the in vivo study, the anterior aspects of lumbar intervertebral discs were surgically exposed, and Ad-lacZ in saline solution was directly injected into the nucleus pulposus. An equal volume of saline only was injected into control discs. Expression of the transferred gene was detected by staining with 5-bromo-4-chloro-3-indolyl-beta-galactosidase (X-Gal).

RESULTS

The in vitro experiments confirmed that nucleus pulposus cells were efficiently transduced by an adenoviral vector carrying the lacZ gene. In vivo injection of Ad-lacZ into the nucleus pulposus resulted in the transduction of a considerable number of cells. Marker gene expression in vivo persisted at an apparently undiminished level for at least 12 weeks. No staining was noted in control discs.

CONCLUSIONS

The results show the feasibility of adenovirus-mediated gene transfer to the intervertebral disc. Expression of the marker gene persisted at least 12 weeks in vivo. This successful demonstration of exogenous gene transfer to the disc and sustained, long-term expression suggests that the adenoviral vector may be suitable for delivery of appropriate genes to the disc for the treatment of spinal disorders.

Prediction of biomechanical parameters in the lumbar spine during static sagittal plane lifting

A combined approach involving optimization and the finite element technique was used to predict biomechanical parameters in the lumbar spine during static lifting in the sagittal plane. Forces in muscle fascicles of the lumbar region were first predicted using an optimization-based force model including the entire lumbar spine. These muscle forces as well as the distributed upper body weight and the lifted load were then applied to a three-dimensional finite element model of the thoracolumbar spine and rib cage to predict deformation, the intradiskal pressure, strains, stresses, and load transfer paths in the spine. The predicted intradiskal pressures in the L3-4 disk at the most deviated from the in vivo measurements by 8.2 percent for the four lifting cases analyzed. The lumbosacral joint flexed, while the other lumbar joints extended for all of the four lifting cases studied (rotation of a joint is the relative rotation between its two vertebral bodies). High stresses were predicted in the posterolateral regions of the endplates and at the junctions of the pedicles and vertebral bodies. High interlaminar shear stresses were found in the posterolateral regions of the lumbar disks. While the facet joints of the upper two lumbar segments did not transmit any load, the facet joints of the lower two lumbar segments experienced significant loads. The ligaments of all lumbar motion segments except the lumbosacral junction provided only marginal moments. The limitations of the current model and possible improvements are discussed.

Basic science of spinal instrumentation

A wide variety of spinal implants are available to the clinician for the surgical treatment of spinal disorders. Most of the implants are associated with fusion--they are designed either to promote fusion, or, in the case of the newer devices such as artificial discs and disc implants, to offset the perceived disadvantages of fusion. The contributions of biomechanics to the improvement of spinal implant design and clinical implementation are detailed. Benchtop tests of device components and assemblies, in vitro studies of spinal constructs using osteoligamentous spinal segments, and analytical (finite element) and animal models are reviewed. Through these studies, the quantification of parameters such as stresses and strains within the spinal structures and within the fixation devices has permitted a better understanding of the relationship between the clinical observations after surgery and the mechanical factors. However, despite improvements in fusion techniques that have reduced the pseudarthrosis rate, there is still room for improvement. New concepts such as the biological enhancement of spinal fusion and alternatives to fusion such as the artificial disc are currently the subjects of intense, multidisciplinary study, but await the ultimate test of clinical trial with long term followup.

Effects of muscle dysfunction on lumbar spine mechanics. A finite element study based on a two motion segments model

STUDY DESIGN

A combined finite element and optimization approach was developed to investigate the clinically relevant biomechanical parameters of the muscular lumbar spine under five quasistatic back-lifting conditions.

OBJECTIVES

To quantify the effects of muscle "dysfunction" on the mechanical behavior of the lumbar spine.

SUMMARY OF BACKGROUND DATA

Trunk muscles have been proven to play an important role in the normal functioning of the spine. Although passive structures of the spine are believed to be subjected increasingly to mechanical stresses when muscular support is inadequate, supportive quantitative data have been lacking.

METHODS

External loads at L3-L4 for various lifting tasks were estimated experimentally and partitioned to the disc and muscles across the L3-L4 segment using an optimization scheme. These forces were incorporated into a finite element model of the ligamentous L3-L5 lumbar spine. Muscle "dysfunction" was simulated by decreasing the computed muscle forces.

RESULTS

The range of motion intradiscal pressure forces in ligaments, and load across facets increased nonlinearly with the increases in trunk flexion and the load held in hands. At higher loads or at larger flexed postures, muscles were found to play a more crucial role in stabilizing the spine compared with the passive structures. Muscle "dysfunction" destabilized the spine, reduced the role of facet joints in transmitting load, and shifted loads to the discs and ligaments.

CONCLUSIONS

Muscle dysfunction disturbs the normal functioning of other spinal components and may cause spinal disorders.

Effect of specimen fixation method on pullout tests of pedicle screws

STUDY DESIGN

Experimental axial pullout tests of a new type of pedicle screw were done on cadaveric lumbar vertebrae. The manner in which specimens were secured in the testing apparatus was varied to determined influence of specimen fixation method on the maximum pedicle screw pullout force.

OBJECTIVES

To determine the appropriateness of embedding (i.e., potting) spinal specimens in polymer resin (e.g., bone cement or Plastic Padding [Plastic Padding Ltd., High Wycombe, Buckinghamshire, England]) for axial pullout tests of pedicle screws. Several different specimen fixation methods were examined to make recommendations for the standardization of future experimental testing protocols.

SUMMARY OF BACKGROUND DATA

Axial pullout of transpedicular screws, although not a likely clinical mode of failure, is a popular experimental testing mode for evaluating screw-bone biomechanics. A wide variety of techniques for securing a vertebral specimen to counter the axial pullout force has been reported (including the use of polymer resin) with a correspondingly wide range in the resulting axial pullout strengths. The possible influence of the specimen fixation method on pedicle screw axial pullout strength has not been addressed previously.

METHODS

Axial pullout tests of pedicle screws (DDS, Plus Endoprothetik, Rotkreuz, Switzerland) from the pedicles of 21 isolated lumber vertebral bodies were done using a Model 810 MTS Universal Testing Machine (MTS Systems, Inc., Minneapolis, Minnesota). The specimens were secured in a custom-made vise fixture either as is or after the vertebral bodies were potted in Plastic Padding up to the pedicle origin. Some of the potted specimens were wrapped first in latex to prevent polymer resin intrusion, and the others were unprotected. Pullout tests were attempted on both the left and right pedicles of each specimen, and the maximum pedicle screw pullout force was recorded. Measurement of bone mineral density by means of dual energy x-ray absorptiometry, in addition to macroscopic and scanning electron microscopy histologic analyses, microradiography, and energy dispersive X-ray spectroscopy, was done post-test to assist in the interpretation of the data.

RESULTS

The maximum pedicle screw pullout force was found to be dependent on both the bone mineral density and the mode of fixation of the vertebrae. Embedding in polymer resin without protection of the specimen (i.e., latex wrapping) led to several instances of well-documented polymer resin intrusion; in these specimens, mean maximum pedicle screw pullout force was significantly greater than that of specimens secured without polymer resin and that of embedded specimens for which intrusion did not occur.

CONCLUSIONS

Polymer resin intrusion can have a significant effect on the biomechanical characteristics of the bone-pedicle screw interface. When polymer resins are used to secure vertebral specimens for in vitro biomechanical tests of the bone-pedicle screw interface, it is important to either prevent intrusion (e.g., with a latex wrapping) or document post-test (e.g., through the methods described in this article) that intrusion did not occur for the specimens included in the analysis.

Applications of the finite element method to thoracolumbar spinal research--past, present, and future

The finite element method has been used in spine biomechanics research for nearly a quarter of a century. Recent developments have made it possible to simulate a variety of clinical situations in an increasingly realistic manner, and have elevated the finite element method into a fully complementary partnership with experimental approaches for investigating clinical problems of the spine. The impact of several of these new developments on present and future spine biomechanics research is addressed in this update.

Cancellous bone Young's modulus variation within the vertebral body of a ligamentous lumbar spine--application of bone adaptive remodeling concepts

Bone remodeling theory based on strain energy density (SED) as the feedback control variable was used in conjunction with the finite element method to analyze the shape of the vertebral bodies within the ligamentous motion segment. The remodeling theory was once again applied to the altered two motion segments model to predict the Young's modulus distribution of the cancellous bone within the vertebral bodies. A three-dimensional finite element model of the two motion segments ligamentous lumbar spine (L3-5) was developed. Bone remodeling response (external as well as internal) of the motion segments to a uniaxial compressive load of 424.7 N was studied. The external shape of the converged model matched the normal shape of a vertebral body. The internal remodeling resulted in regional cancellous bone Young's moduli (or bone density) distributions similar to those reported in the literature; posterocentral regions of the vertebrae were predicted to have greater values of the elastic modulus than that of the outer regions. The results of the present study suggest that vertebral body assumes an adequate/optimum structure in terms of both its shape and its elastic moduli distribution within the cancellous region in response to the applied load. Extensions of the present model and its clinically relevant applications are discussed.

Interlaminar shear stresses and laminae separation in a disc. Finite element analysis of the L3-L4 motion segment subjected to axial compressive loads

STUDY DESIGN

This study analyzed interlaminar shear stresses across the laminae of a ligamentous L3-L4 motion segment. A three-dimensional finite element model of the motion segment was developed and its response in axial compression mode was predicted.

OBJECTIVES

The contributions of "mechanical" factors in producing laminae separation in a disc are not well understood, especially when the nucleus is still gel-like in appearance (stage 1 of disc degeneration). All types of stresses are likely to contribute to laminae separation. The authors believe it is partially due to the interlaminar shear stresses at the laminae interfaces in specific regions of an intact disc because the disc is a composite structure. The effects of anular tears on the interlaminar shear stresses were also investigated. These tears can be circumferential or radial in nature, and commonly occur in the aged, degenerated disc.

SUMMARY OF BACKGROUND DATA

A large number of biomechanical studies dealing with the role of the disc vis-a-vis other spinal components have been reported in the literature. The role of mechanical factors, however, in producing laminae separation, especially when the nucleus is still gel-like in appearance (stage 1 of disc degeneration), is not entirely clear.

METHODS

A three-dimensional nonlinear finite element model of an intact L3-L4 lumbar motion segment, based on the use of a special type of element for the disc anulus, was created to investigate the interlaminar shear stresses in the anulus. The effects of radial "out-in," radial "in-out," and "circumferential" injuries were analyzed. Injury was modeled as element removal in the posterolateral portion of the disc. Models subjected to axial compressive loads, ranging from 200 N to 2000 N, were analyzed. In addition to the interlaminar shear stresses, disc bulge, and displacements including coupled motions were predicted.

RESULTS

The theoretical disc bulge predictions for the radial in-out injury case were in agreement with the disc bulge data obtained experimentally. Displacements, disc bulge, and coupled motions increased with injury, as expected. The interlaminar shear stresses were highest in the posterolateral portions of the intact disc model. Interlaminar shear stresses, in general, increased with injury. Also, a slight increase in circumferential injury was sufficient to see a substantial increase in interlaminar shear stresses.

CONCLUSIONS

The interlaminar shear stresses being higher in the posterolateral regions of the intact disc reinforces that, from clinical studies, tears originate in the posterolateral portion of the disc. The large interlaminar shear stresses, caused by asymmetry in the disc structure due to injury, along with chemical and structural changes in the disc with age, may be an important cause of further degeneration through laminae separation. This is the case for traditional composite laminates. This study points out the importance of interlaminar shear stresses to gain further understanding of the role of mechanical factors in producing disc degeneration, especially delamination of the anulus. Clinical relevance of the findings and possible relationship to the aging process are explored.

Finite element methods in spine biomechanics research

The finite element method has been used in spine biomechanics research for nearly a quarter of a century. Recent developments have made it possible to simulate a variety of clinically relevant situations in an increasingly realistic manner, elevating the finite element method into a fully complementary partnership with experimental approaches for the investigation of clinical problems in the spine. These new developments are presented in a historical context to evaluate their potential impact on future spine biomechanics research.

A combined finite element and optimization investigation of lumbar spine mechanics with and without muscles

A combined finite element and optimization approach to study the effects of muscles on the biomechanics of the lumbar spine was initiated. Briefly, a three-dimensional, nonlinear, finite element model of a ligamentous L3-4 motion segment was formulated (LIG model) for the predictions of stresses, etc., in the motion segment. A separate, biomechanical optimization-based force model with experimental input was developed to predict the forces in muscles and disc across the L3-4 segment in response to a person holding 90 N in his hands with spine flexed 30 degrees, and knees straight. The predicted muscle forces from the optimization model were then incorporated into the L3-4 finite element model as nodal forces to simulate the muscle action (MUS model). The predicted responses from the muscles active (MUS) finite element model were compared to the corresponding results from the ligamentous (LIG) finite element model subjected to an equivalent load. The biomechanical parameters compared were: translation and rotation of L3, disc bulge, intervertebral foramen gap, intradiscal pressure, facet loading, ligament tension, compressive disc load, and stresses in the vertebral body. The addition of muscular forces in the MUS model led to a decrease in the anteroposterior translation and flexion rotation (displacements in the sagittal plane) of the segment compared to the corresponding LIG model predictions. Thus, the muscles imparted stability to the ligamentous segment. The presence of muscles also led to a decrease in stresses in the vertebral body, the intradiscal pressure and other mechanical parameters of importance. However, the load bearing of the facets increased compared to the ligamentous model. Thus, facets play a significant role in transmitting loads in a normal intact spine. These results, for the first time, provide quantitative data on the stabilizing effects of muscles on the mechanics of a ligamentous spine. The results also provide a scientific explanation in support of the "degenerative cascade" concept proposed in the literature. The model predictions, in conjunction with the degenerative cascade concept, also support the observation that the osteoarthritis of facets may follow disc degeneration. Future research directions based on the current model are presented.

Dynamic response of the occipito-atlanto-axial (C0-C1-C2) complex in right axial rotation

The torque-angular deformation in right axial rotation until failure of the ligamentous occipito-atlanto-axial complex subjected to variable loading rate (dynamic) axial torque was characterized using a biaxial MTS system. A special fixture and gear box that permitted right axial rotation of the specimen until failure without imposing any additional constraints were used to obtain the data. The specimens were divided into three groups and tested until failure at three different dynamic loading rates: 50, 100, and 400 degrees/s. A previous study by the authors provided data for quasi-static (4 degrees/s) loading conditions. The torque versus rotation curves can be divided into two straight regions and two transition zones. The plots clearly indicated that at loading rates higher than 4 degrees/s, the specimens became stiffer in the region of steadily increasing resistance prior to failure. The increase in stiffness was maximum at 100 degrees/s. The stiffness decreased somewhat at 400 degrees/s in comparison with 100 degrees/s, but this decrease was not significant. The resulting torque-right axial rotation curves were also examined to estimate the magnitude of maximum resistance (torque) and the corresponding angular rotation value. The average maximum resistance torque increased from 13.6 Nm at 4 degrees/s to 27.8 Nm at 100 degrees/s. The corresponding right angular rotation data (65-78 degrees), however, did not show any significant variation with loading rate. Posttest dissection of the specimens indicated that the type of injury observed was related to the rate of axial loading imposed on a specimen during testing.(ABSTRACT TRUNCATED AT 250 WORDS)

Ligamentous laxity across C0-C1-C2 complex. Axial torque-rotation characteristics until failure

The axial torque until failure of the ligamentous occipito-atlanto-axial complex (C0-C1-C2) subjected to axial angular rotation (theta) was characterized using a biaxial MTS system. A special fixture and gearbox that permitted right axial rotation of the specimen until failure without imposing any additional constraints were designed to obtain the data. The average values for the axial rotation and torque at the point of maximum resistance were, respectively, 68.1 degrees and 13.6 N-m. The specimens offered minimal resistance (approximately 0.5 N-m), up to an average axial rotation of 21 degrees across the complex. The torque-angular rotation (T-theta) curve can be divided into four regions: regions of least and steadily increasing resistances, a transition zone that connects these two regions, and the increasing resistance region to the point of maximum resistance. The regions of least and steadily increasing resistances may be represented by two straight lines with average slopes of 0.028 and 0.383 N-m/degree, respectively. Post-test dissection of the specimens disclosed the following. The point of maximum resistance corresponded roughly to the value of axial rotation at which complete bilateral rotary dislocation of the C1-C2 facets occurred. The types of injuries observed were related to the magnitude of axial rotation imposed on a specimen during testing. Soft-tissue injuries alone (like stretch/rupture of the capsular ligaments, subluxation of the C1-C2 facets, etc.) were confined to specimens rotated up to or close to the point of maximum resistance. The specimens that were subjected to rotations up to the point of maximum resistance of the curve spontaneously reduced completely on removal from the testing apparatus. Spontaneous reduction was not possible for specimens tested slightly beyond their points of maximum resistance.(ABSTRACT TRUNCATED AT 250 WORDS)