Power-assisted Pedicle Screw Technique Protects Against Risk of Surgeon Overuse Injury: A Comparative Electromyography Study of the Neck and Upper Extremity Muscle Groups in a Simulated Surgical Environment.

STUDY DESIGN: Cadaveric. OBJECTIVE: The aim of this study was to quantify the amplitude and duration of surgeons' muscle exertion from pedicle cannulation to screw placement using both manual and power-assisted tools in a simulated surgical environment using surface electromyography (EMG). SUMMARY OF BACKGROUND DATA: A survey of Scoliosis Research Society members reported rates of neck pain, rotator cuff disease, lateral epicondylitis, and cervical radiculopathy at 3 ×, 5 ×, 10 ×, and 100â€Š× greater than the general population. The use of power-assisted tools in spine surgery to facilitate pedicle cannulation through screw placement during open posterior fixation surgery may reduce torque on the upper limb and risk of overuse injury. METHODS: Pedicle preparation and screw placement was performed from T4-L5 in four cadavers by two board-certified spine surgeons using both manual and power-assisted techniques. EMG recorded muscle activity from the flexor carpi radialis, extensor carpi radialis, biceps, triceps, deltoid, upper trapezius, and neck extensors. Muscle activity was reported as a percentage of the maximum voluntary exertion of each muscle group (%MVE) and muscle exertion was linked to low- (0-20% MVE), moderate- (20%-45% MVE), high- (45%-70% MVE) and highest- (70%-100% MVE) risk of overuse injury based on literature. RESULTS: Use of power-assisted tools for pedicle cannulation through screw placement maintains average muscle exertion at low risk for overuse injury for every muscle group. Conversely with manual technique, the extensor carpi radialis, biceps, upper trapezius and neck extensors operate at levels of exertion that risk overuse injury for 50% to 92% of procedure time. Powerassisted tools reduce average muscle exertion of the biceps, triceps, and deltoid by upwards of 80%. CONCLUSION: Power-assisted technique protects against risk of overuse injury. Elevated muscle exertion of the extensor carpi radialis, biceps, upper trapezius, and neck extensors during manual technique directly correlate with surgeons' self-reported diagnoses of lateral epicondylitis, rotator cuff disease, and cervical myelopathy.Level of Evidence: N/A.

Asymmetric in-plane shear behavior of isolated cadaveric lumbar facet capsular ligaments: Implications for subject specific biomechanical models.

The facet capsular ligaments (FCLs) flank the spinous process on the posterior aspect of the spine. The lumbar FCL is collagenous, with collagen fibers aligned primarily bone-to-bone (medial-lateral) and experiences significant shear, especially during spinal flexion and extension. We characterized the mechanical response of the lumbar FCL to in-plane shear, and we evaluated that response in the context of the fiber architecture. In-plane shear tests with both positive and negative shear (i.e., corresponding to flexion and to extension) were performed on eight cadaveric human L4-L5 FCLs. Our most striking observation was subject-dependent asymmetry in the response. All samples showed a toe region of low stiffness, transitioning to greater stiffness at higher strains, for both shear directions. Different samples showed profoundly different transition strains, with some samples stiffening more rapidly in positive shear and some in negative shear. This unpredictable asymmetry, which did not correlate with age, side, or degeneration state, suggesting that collagen fibers in the FCL are sometimes aligned at a slight positive angle from the bone-to-bone axis and sometimes at a negative angle. Fitting the experimental data to a fiber-composite-based finite element model supported this idea, yielding optimal fits with positive or negative off-axis fiber directions (-40° to +40°). Subsequent examination of selected FCLs by small-angle x-ray scattering (SAXS) showed a similar variability in fiber direction. We conclude that small individual differences in lumbar FCL architecture may have a significant effect on lumbar FCL mechanics, especially at moderate strains.

Human Disc Nucleotomy Alters Annulus Fibrosus Mechanics at Both Reference and Compressed Loads.

Nucleotomy is a common surgical procedure and is also performed in ex vivo mechanical testing to model decreased nucleus pulposus (NP) pressurization that occurs with degeneration. Here, we implement novel and noninvasive methods using magnetic resonance imaging (MRI) to study internal 3D annulus fibrosus (AF) deformations after partial nucleotomy and during axial compression by evaluating changes in internal AF deformation at reference loads (50 N) and physiological compressive loads (∼10% strain). One particular advantage of this methodology is that the full 3D disc deformation state, inclusive of both in-plane and out-of-plane deformations, can be quantified through the use of a high-resolution volumetric MR scan sequence and advanced image registration. Intact grade II L3-L4 cadaveric human discs before and after nucleotomy were subjected to identical mechanical testing and imaging protocols. Internal disc deformation fields were calculated by registering MR images captured in each loading state (reference and compressed) and each condition (intact and nucleotomy). Comparisons were drawn between the resulting three deformation states (intact at compressed load, nucleotomy at reference load, nucleotomy at compressed load) with regard to the magnitude of internal strain and direction of internal displacements. Under compressed load, internal AF axial strains averaged -18.5% when intact and -22.5% after nucleotomy. Deformation orientations were significantly altered by nucleotomy and load magnitude. For example, deformations of intact discs oriented in-plane, whereas deformations after nucleotomy oriented axially. For intact discs, in-plane components of displacements under compressive loads oriented radially outward and circumferentially. After nucleotomy, in-plane displacements were oriented radially inward under reference load and were not significantly different from the intact state at compressed loads. Re-establishment of outward displacements after nucleotomy indicates increased axial loading restores the characteristics of internal pressurization. Results may have implications for the recurrence of pain, design of novel therapeutics, or progression of disc degeneration.

Image-based multiscale mechanical modeling shows the importance of structural heterogeneity in the human lumbar facet capsular ligament.

The lumbar facet capsular ligament (FCL) primarily consists of aligned type I collagen fibers that are mainly oriented across the joint. The aim of this study was to characterize and incorporate in-plane local fiber structure into a multiscale finite element model to predict the mechanical response of the FCL during in vitro mechanical tests, accounting for the heterogeneity in different scales. Characterization was accomplished by using entire-domain polarization-sensitive optical coherence tomography to measure the fiber structure of cadaveric lumbar FCLs ([Formula: see text]). Our imaging results showed that fibers in the lumbar FCL have a highly heterogeneous distribution and are neither isotropic nor completely aligned. The averaged fiber orientation was [Formula: see text] ([Formula: see text] in the inferior region and [Formula: see text] in the middle and superior regions), with respect to lateral-medial direction (superior-medial to inferior-lateral). These imaging data were used to construct heterogeneous structural models, which were then used to predict experimental gross force-strain behavior and the strain distribution during equibiaxial and strip biaxial tests. For equibiaxial loading, the structural model fit the experimental data well but underestimated the lateral-medial forces by [Formula: see text]16% on average. We also observed pronounced heterogeneity in the strain field, with stretch ratios for different elements along the lateral-medial axis of sample typically ranging from about 0.95 to 1.25 during a 12% strip biaxial stretch in the lateral-medial direction. This work highlights the multiscale structural and mechanical heterogeneity of the lumbar FCL, which is significant both in terms of injury prediction and microstructural constituents' (e.g., neurons) behavior.

Computer simulation of lumbar flexion shows shear of the facet capsular ligament.

BACKGROUND CONTEXT: The lumbar facet capsular ligament (FCL) is a posterior spinal ligament with a complex structure and kinematic profile. The FCL has a curved geometry, multiple attachment sites, and preferentially aligned collagen fiber bundles on the posterior surface that are innervated with mechanoreceptive nerve endings. Spinal flexion induces three-dimensional (3D) deformations, requiring the FCL to maintain significant tensile and shear loads. Previous works aimed to study 3D facet joint kinematics during flexion, but to our knowledge none have reported localized FCL surface deformations likely created by this complex structure. PURPOSE: The purpose of this study was to elucidate local deformations of both the posterior and anterior surfaces of the lumbar FCL to understand the distribution and magnitude of in-plane and through-plane deformations, including the prevalence of shear. STUDY DESIGN/SETTING: The FCL anterior and posterior surface deformations were quantified through creation of a finite element model simulating facet joint flexion using a realistic geometry, physiological kinematics, and fitted constitutive material. METHODS: Geometry was obtained from the micro-CT data of a healthy L3-L4 facet joint capsule (n=1); kinematics were extracted from sagittal plane fluoroscopic data of healthy volunteers (n=10) performing flexion; and average material properties were determined from planar biaxial extension tests of L4-L5 FCLs (n=6). All analyses were performed with the non-linear finite element solver, FEBio. A grid of equally spaced 3×3 nodes on the posterior surface identified regional differences within the strain fields and was used to create comparisons against previously published experimental data. This study was funded by the National Institutes of Health and the authors have no disclosures. RESULTS: Inhomogeneous in-plane and through-plane shear deformations were prominent through the middle body of the FCL on both surfaces. Anterior surface deformations were more pronounced because of the small width of the joint space, whereas posterior surface deformations were more diffuse because the larger area increased deformability. We speculate these areas of large deformation may provide this proprioceptive system with an excellent measure of spinal motion. CONCLUSIONS: We found that in-plane and through-plane shear deformations are widely present in finite element simulations of a lumbar FCL during flexion. Importantly, we conclude that future studies of the FCL must consider the effects of both shear and tensile deformations.

Planar biaxial extension of the lumbar facet capsular ligament reveals significant in-plane shear forces.

The lumbar facet capsular ligament (FCL) articulates with six degrees of freedom during spinal motions of flexion/extension, lateral bending, and axial rotation. The lumbar FCL is composed of highly aligned collagen fiber bundles on the posterior surface (oriented primarily laterally between the rigid articular facets) and irregularly oriented elastin on the anterior surface. Because the FCL is a capsule, it has multiple insertion sites across the lumbar facet joint, which, along with its material structure, give rise to complicated deformations in vivo. We performed planar equibiaxial mechanical tests on excised healthy cadaveric lumbar FCLs (n=6) to extract normal and shear reaction forces, and fit sample-specific two-fiber-family finite element models to the experimental force data. An eight-parameter anisotropic, hyperelastic model was used. Shear forces at maximum extension (mean values of 1.68N and 3.01N in the two directions) were of comparable magnitude to the normal forces perpendicular to the aligned collagen fiber bundles (4.67N) but smaller than normal forces in the fiber direction (16.11N). Inclusion of the experimental shear forces in the model optimization yielded fits with highly aligned fibers oriented at a specific angle across all samples, typically with one fiber population aligned nearly horizontally and the other at an oblique angle. Conversely, models fit to only the normal force data resulted in a broad range of fiber angles with low specificity. We found that shear forces generated through planar equibiaxial extension aided the model fit in describing the anisotropic nature of the FCL surface.

Marker-Free Tracking of Facet Capsule Motion Using Polarization-Sensitive Optical Coherence Tomography.

We proposed and tested a method by which surface strains of biological tissues can be captured without the use of fiducial markers by instead, utilizing the inherent structure of the tissue. We used polarization-sensitive optical coherence tomography (PS OCT) to obtain volumetric data through the thickness and across a partial surface of the lumbar facet capsular ligament during three cases of static bending. Reflectivity and phase retardance were calculated from two polarization channels, and a power spectrum analysis was performed on each a-line to extract the dominant banding frequency (a measure of degree of fiber alignment) through the maximum value of the power spectrum (maximum power). Maximum powers of all a-lines for each case were used to create 2D visualizations, which were subsequently tracked via digital image correlation. In-plane strains were calculated from measured 2D deformations and converted to 3D surface strains by including out-of-plane motion obtained from the PS OCT image. In-plane strains correlated with 3D strains (R(2) ≥ 0.95). Using PS OCT for marker-free motion tracking of biological tissues is a promising new technique because it relies on the structural characteristics of the tissue to monitor displacement instead of external fiducial markers.

Combining displacement field and grip force information to determine mechanical properties of planar tissue with complicated geometry.

Performing planar biaxial testing and using nominal stress-strain curves for soft-tissue characterization is most suitable when (1) the test produces homogeneous strain fields, (2) fibers are aligned with the coordinate axes, and (3) strains are measured far from boundaries. Some tissue types [such as lamellae of the annulus fibrosus (AF)] may not allow for these conditions to be met due to their natural geometry and constitution. The objective of this work was to develop and test a method utilizing a surface displacement field, grip force-stretch data, and finite-element (FE) modeling to facilitate analysis of such complex samples. We evaluated the method by regressing a simple structural model to simulated and experimental data. Three different tissues with different characteristics were used: Superficial pectoralis major (SPM) (anisotropic, aligned with axes), facet capsular ligament (FCL) (anisotropic, aligned with axes, bone attached), and a lamella from the AF (anisotropic, aligned off-axis, bone attached). We found that the surface displacement field or the grip force-stretch data information alone is insufficient to determine a unique parameter set. Utilizing both data types provided tight confidence regions (CRs) of the regressed parameters and low parameter sensitivity to initial guess. This combined fitting approach provided robust characterization of tissues with varying fiber orientations and boundaries and is applicable to tissues that are poorly suited to standard biaxial testing. The structural model, a set of C++ finite-element routines, and a Matlab routine to do the fitting based on a set of force/displacement data is provided in the on-line supplementary material.