In Vivo Graft Elongation After Arthroscopic Dermal Superior Capsular Reconstruction.

BACKGROUND: Superior capsular reconstruction (SCR) is a procedure purported to restore stability of the glenohumeral joint after an irreparable rotator cuff tear, but the in vivo behavior of the graft is unknown. Previous work has not evaluated the relationship between graft deformation, kinematics, and healing. PURPOSE: To (1) determine regional graft elongation after SCR, (2) determine if graft elongation is related to graft healing, and (3) identify associations between graft elongation and changes in kinematics from presurgery to postsurgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Ten patients who underwent SCR performed abduction and shoulder rotation with the arm at 90° of humerothoracic abduction before and 1 year after surgery while biplane radiographs were collected at 50 images per second. Kinematics was determined with submillimeter accuracy by matching patient-specific digitally reconstructed radiographs of the humerus and scapula to the biplane radiographs using a validated volumetric tracking technique. Graft elongation was calculated using motion of the graft anchors that were identified on postoperative magnetic resonance imaging. Differences in elongation between anterior and posterior regions of the graft, as well as associations between graft elongation, graft healing, and kinematics, were analyzed. RESULTS: Peak graft elongation ranged from a 3% decrease in the anterior region during rotation to up to a 171% increase in the anterior region during abduction and the posterior region during rotation. Grafts that were healed at both anterior anchors reached the intraoperative length at lower abduction angles (60°) than grafts that were not healed at 1 or both of the anterior anchors (87°) (P = .005). The posterior anchor graft origin to insertion distances were 2.1 mm farther apart after surgery compared with before surgery during both abduction and rotation. CONCLUSION: SCR dermal allografts are stretched well beyond their intraoperative length in vivo. Graft healing appears to be associated with less graft elongation. The posterior portion of the SCR graft does not appear to improve glenohumeral joint stability 1 year after surgery. Improved clinical outcomes after dermal allograft SCR may be because of the spacer effect of the graft rather than improved glenohumeral joint stability 1 year after surgery.

The Effects of Cervical Orthoses on Head and Intervertebral Range of Motion.

STUDY DESIGN: Prospective Cohort. OBJECTIVE: Quantify and compare the effectiveness of cervical orthoses in restricting intervertebral kinematics during multiplanar motions. SUMMARY OF BACKGROUND DATA: Previous studies evaluating the efficacy of cervical orthoses measured global head motion and did not evaluate individual cervical motion segment mobility. Prior studies focused only on the flexion/extension motion. METHODS: Twenty adults without neck pain participated. Vertebral motion from the occiput through T1 was imaged using dynamic biplane radiography. Intervertebral motion was measured using an automated registration process with validated accuracy better than 1 degree. Participants performed independent trials of maximal flexion/extension, axial rotation, and lateral bending in a randomized order of unbraced, soft collar (foam), hard collar (Aspen), and cervical thoracic orthosis (CTO) (Aspen) conditions. Repeated-measures ANOVA was used to identify differences in the range of motion (ROM) among brace conditions for each motion. RESULTS: Compared with no collar, the soft collar reduced flexion/extension ROM from occiput/C1 through C4/C5, and reduced axial rotation ROM at C1/C2 and from C3/C4 through C5/C6. The soft collar did not reduce motion at any motion segment during lateral bending. Compared with the soft collar, the hard collar reduced intervertebral motion at every motion segment during all motions, except for occiput/C1 during axial rotation and C1/C2 during lateral bending. The CTO reduced motion compared with the hard collar only at C6/C7 during flexion/extension and lateral bending. CONCLUSIONS: The soft collar was ineffective as a restraint to intervertebral motion during lateral bending, but it did reduce intervertebral motion during flexion/extension and axial rotation. The hard collar reduced intervertebral motion compared with the soft collar across all motion directions. The CTO provided a minimal reduction in intervertebral motion compared with the hard collar. The utility in using a CTO rather than a hard collar is questionable, given the cost and little or no additional motion restriction.

Dynamic Changes in Lumbar Spine Kinematics During Gait May Explain Improvement in Back Pain and Disability in Patients With Hip-Spine Syndrome.

STUDY DESIGN: Prospective cohort. OBJECTIVE: Determine if total hip arthroplasty (THA) changes lumbar spine kinematics during gait in a manner that explains the improvements in back pain seen in patients with hip-spine syndrome. SUMMARY OF BACKGROUND DATA: For patients with hip-spine syndrome, improvements in both hip and back pain have been demonstrated after THA; however, the exact mechanism of improvement in back pain remains unknown, as no corresponding changes in lumbar spine static radiographic parameters have been identified. METHODS: Thirteen patients with severe, unilateral hip osteoarthritis scheduled to undergo THA with concomitant back pain and disability were tested at baseline and 6 months after THA. Harris Hip Score (HHS) and Oswestry Disability Index questionnaires were completed; the static orientation of the spine and pelvis were measured on standing radiographs, and lumbar spine kinematics were measured during treadmill walking using a validated measurement system that matched subject-specific bone models created from CT scans to dynamic biplane radiographs. RESULTS: After THA, both the Oswestry Disability Index (36.3-11.3, P <0.001) and Harris Hip Score (55.7-77.9, P <0.001) improved; however, there were no changes in static intervertebral or pelvis orientation. During gait after THA, the overall lumbar spine (L1 to L5) was less lordotic from heel strike to contralateral toe off ( P <0.001), the L4 and L5 vertebra were less anteriorly tilted by 3.9° ( P =0.038) from midstance to contralateral heel strike and by 3.9° ( P =0.001) during stance, respectively. CONCLUSION: The decreased anterior tilt of the 2 lowest lumbar vertebrae and the corresponding loss of lumbar lordosis may reduce facet loading during the stance phase of gait after THA. This change in lumbar spine kinematics during gait is a potential mechanism to explain the observed improvements in back pain and disability after THA. LEVEL OF EVIDENCE: 4.

Changes in intervertebral sagittal alignment of the cervical spine from supine to upright.

Cervical sagittal alignment is a critical component of successful surgical outcomes. Unrecognized differences in intervertebral alignment between supine and upright positions may affect clinical outcomes; however, these differences have not been quantified. Sixty-four patients scheduled to undergo one or two-level cervical arthrodesis for symptomatic pathology from C4-C5 to C6-C7, and forty-seven controls were recruited. Upright sagittal alignment was obtained through biplane radiographic imaging and measured using a validated process with accuracy better than 1° in rotation. Supine alignment was obtained from computed tomography scans. Coordinate systems used to measure supine and upright alignment were identical. Distances between adjacent bony endplates were measured to calculate disc height in each position. For both patients and controls, the C1-C2, C2-C3, and C3-C4 motion segments were in more lordosis when upright as compared with supine (all p < 0.001). However, the C4-C5, C5-C6, and C6-C7 motion segments were in less lordosis when upright as compared with supine (all p ≤ 0.004). There was an interaction between group and position at the C1-C2 (p = 0.002) and C2-C3 (p = 0.001) motion segments, with the controls demonstrating a greater increase in lordosis at both motion segments when moving from supine to upright. The results indicate that cervical motion segment alignment changes between supine and upright positioning, those changes differ among motion segments, and cervical pathology affects the magnitude of these changes. Clinical Significance: Surgeons should be mindful of the differences in alignment between supine and upright imaging and the implications they may have on clinical outcomes.

In Vivo Evidence of Early Instability and Late Stabilization in Motion Segments Immediately Superior to Anterior Cervical Arthrodesis.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: The aim was to identify patient factors that affect adjacent segment kinematics after anterior cervical discectomy and fusion (ACDF) as measured by biplane radiography. SUMMARY OF BACKGROUND DATA: The etiology of adjacent segment disease (ASD) may be multifactorial. Previous studies have investigated associations between patient factors and ASD, although few attempted to link patient factors with mechanical changes in the spine that may explain ASD development. Previous studies manually measured intervertebral motion from static flexion/extension radiographs, however, manual measurements are unreliable, and those studies failed to measure intervertebral motion during rotation. METHODS: Patients had continuous cervical spine flexion/extension and axial rotation movements captured at 30 images per second in a dynamic biplane radiography system preoperatively and 1 year after ACDF. Digitally reconstructed radiographs generated from subject-specific computed tomography scans were matched to the biplane radiographs using a validated tracking process. Dynamic kinematics and preoperative disc height were calculated from this tracking process. Preoperative magnetic resonance imagings were evaluated for disc bulge. Patient age, sex, body mass index, smoking status, diabetes, psychiatric history, presence of an inciting event, and length of symptoms were collected. Multivariate linear regression was performed to identify patient factors associated with 1-year postoperative changes in adjacent segment kinematics. RESULTS: Sixty-three patients completed preoperative and postoperative testing. Superior adjacent segment disc height and disc bulge predicted the change in superior adjacent segment range of motion after surgery. Inferior adjacent segment disc bulge, smoking history, and the use of psychiatric medications predicted the change in inferior adjacent segment flexion/extension range of motion after surgery. CONCLUSIONS: Preexisting adjacent segment disc degeneration, as indicated by disc height and disc bulge, was associated with reduced adjacent segment motion after ACDF, while lack of preexisting adjacent disc degeneration was associated with increased adjacent segment motion after ACDF. These findings provide in vivo evidence supporting early instability and late stabilization in the pathophysiology of disc degeneration.

In Vivo Changes in Dynamic Adjacent Segment Motion 1 Year After One and Two-Level Cervical Arthrodesis.

Biomechanical cadaver testing indicates adjacent segment motion increases after one-level anterior cervical spine arthrodesis, and two-level arthrodesis exacerbates these effects. There is little in vivo evidence to support those biomechanical studies. The purpose of this study was to assess the effects of one- and two-level cervical arthrodesis on adjacent segment motion. Fifty patients received either one-level C56 arthrodesis or two-level C456 or C567 arthrodesis and were tested preoperatively (PRE) and 1 year postoperatively (1YR-POST) along with 23 asymptomatic controls. A validated CT model-based tracking technique was used to measure 3D vertebral motion from biplane radiographs collected during dynamic flexion-extension and axial rotation of the cervical spine. Head and adjacent segment intervertebral end-range range of motion (ROM) and mid-range ROM were compared between one-level and two-level arthrodesis patients and controls. Small (2.3° or less) but non-significant increases in adjacent segment end-range ROM were observed from PRE to 1YR-POST. Mid-range flexion-extension ROM in the C67 motion segment inferior to the arthrodesis and mid-range axial rotation ROM in the C45 motion segment superior to the arthrodesis increased from PRE to 1YR-POST (all p < 0.022). This study provides in vivo evidence that contradicts long-held beliefs that adjacent segment end-range ROM increases appreciably after anterior cervical arthrodesis and that two-level arthrodesis exacerbates these effects. Mid-range ROM appears to be more useful than end-range ROM for detecting early changes in adjacent segment motion after cervical spine arthrodesis.

Implant characteristics affect in vivo shoulder kinematics during multiplanar functional motions after reverse shoulder arthroplasty.

The purpose of this study was to determine how implant characteristics affect in vivo shoulder kinematics after reverse shoulder arthroplasty (RSA). Kinematics of the affected upper limb were measured in 32 participants during five motions (scapular plane abduction, hand-to-head, hand-to-back, internal/external rotation at 90° abduction, and circumduction) using optical motion capture. Shoulder abduction, plane of elevation, and internal/external rotation range of motion (ROM), peak angles, and continuous kinematics waveforms were calculated for each motion. Multiple regression was used to identify associations between kinematics and implant characteristics of lateralization, humeral retroversion, glenosphere size, glenosphere tilt, glenoid eccentricity, and implant neck-shaft angle (135° or 145°). Less humeral retroversion was associated with greater shoulder rotation ROM (p = 0.036) and greater plane of elevation ROM (p = 0.024) during circumduction, while less eccentricity was associated with more posterior plane of elevation during hand-to-back (p = 0.021). The 145° implant was associated with greater internal/external shoulder rotation ROM (p < 0.001), greater internal shoulder rotation (p = 0.002), and greater plane of elevation ROM (p = 001) during the hand-to-back. The 145° implant was also associated with more internal/external rotation ROM (p = 0.043) during shoulder rotation and more abduction ROM during circumduction (p = 0.043). During the hand-to-back motion, individuals having 135° neck-shaft angle implants were more abducted from 21 to 51% of the motion and were less internally rotated from 70 to 100% of the motion, while more lateralization was associated with less internal rotation from 90 to 100% of the motion. Retroversion and implant neck-shaft angle are the primary implant characteristics associated with in vivo shoulder kinematics during complex motions after RSA.

The effects of pathology and one-level versus two-level arthrodesis on cervical spine intervertebral helical axis of motion.

The etiology of adjacent segment disease after anterior cervical discectomy and fusion (ACDF) remains controversial. Range of motion (ROM) is typically used to infer the effects of arthrodesis on adjacent segment motion following ACDF, however, ROM only measures the total amount of motion. In contrast, the helical axis of motion (HAM) quantifies how the motion occurs and may provide additional insight into the etiology of adjacent segment pathology. Synchronized biplane radiographs of the cervical spine were acquired at 30 images per second while 62 ACDF patients and 38 control participants performed dynamic neck flexion/extension. A validated tracking process matched digitally reconstructed radiographs created from subject-specific bone models to the radiographs with sub-millimeter accuracy. The intervertebral HAM was then calculated and compared between pre and 1 year post surgery in patients, and between patients and controls at corresponding motion segments using linear mixed-effects analysis. Small differences in the anterior/posterior location of the HAM were found between the symptomatic motion segments before surgery and corresponding motion segments in controls. No changes in the HAM of motion segments adjacent to the arthrodesis were observed from pre to 1-year post-surgery. No differences in adjacent segment HAM were found between patients with one- versus two-level arthrodesis. Neither symptomatic pathology nor arthrodesis appear to change the way motion occurs in the cervical spine during flexion/extension one year after one or two-level arthrodesis. These results suggest ACDF does not alter short-term adjacent segment kinematics in a way that would contribute to the development of adjacent segment disease.

Improved Outcomes Following Arthroscopic Superior Capsular Reconstruction May Not Be Associated With Changes in Shoulder Kinematics: An In Vivo Study.

PURPOSE: To determine the in vivo effects of superior capsule reconstruction (SCR) on glenohumeral kinematics during abduction and to compare those kinematics results with patient-reported outcomes, range of motion, and strength. METHODS: Dynamic biplane radiography was used to image 10 patients with irreparable rotator cuff tears while performing scapular plane abduction pre- and 1-year post-surgery. Shoulder kinematics were determined by matching subject-specific computed tomography-based bone models to the radiographs using a validated tracking technique. RESULTS: No change was detected in static acromiohumeral distance (-0.7 ± 2.1 mm; P = .35); however, average dynamic acromiohumeral distance decreased (2.7 ± 1.2 mm to 2.3 ± 1.0 mm; P = .035) from pre- to 1-year post-surgery, respectively. The humeral head position was 0.5 ± 0.5 mm more superior 1-year post-surgery compared with pre-surgery (P = .01). Glenohumeral abduction increased from pre-surgery (150 ± 20°) to 1-year post-surgery (165 ± 10°) (P = .04) and all patient-reported outcomes improved from pre-surgery to 1-year post-surgery (all P < .002). A more posterior shift in humeral head position was associated with improved American Shoulder and Elbow Surgeons Shoulder Score from pre-surgery to 1-year post-surgery (r = 0.71, P = .02). CONCLUSIONS: These data suggest that SCR may not depress the humeral head during functional abduction, as previously postulated, and postoperative improvements in subjective and clinical outcomes may be affected by mechanisms other than changes in shoulder kinematics. CLINICAL RELEVANCE: In vivo kinematics changes after SCR are small and do not correspond to previously postulated changes.

Residual Motion and Graft Type Do Not Influence Patient-reported Outcomes Following One- or Two-level Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Prospective cohort. OBJECTIVE: The aim of this study was to determine the effect of graft type on residual motion and the relationship among residual motion, smoking, and patient-reported outcome (PRO) scores following anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Although most patients develop solid fusion based on static imaging following ACDF, dynamic imaging has revealed that many patients continue to have residual motion at the arthrodesis. METHODS: Forty-eight participants performed dynamic neck flexion/extension and axial rotation within a biplane radiography system 1 year following ACDF (21 one-level, 27 two-level). PRO scores included the Short Form-36, Neck Disability Index, and Cervical Spine Outcomes Questionnaire. An automated model-based tracking process matched subject-specific bone models to the biplane radiographs with sub-millimeter accuracy. Residual motion was measured across the entire arthrodesis site for both one- and two-level fusions in patients who received either allograft or autograft. Patients were divided into "pseudarthrosis" (>3° of flexion/extension residual motion) and "solid fusion" groups. Residual motion and PROs were compared between groups using Student t tests. RESULTS: Patients who received allograft showed more total flexion/extension residual motion (4.1° vs. 2.8°, P = 0.12), although this failed to reach significance. No differences were noted in PROs based on graft type (all P > 0.08) or the presence of pseudarthrosis (all P > 0.13). No differences were noted in residual motion between smokers and nonsmokers (all P > 0.15); however, smokers who received allograft reported worse outcomes than nonsmokers who received allograft and smokers who received autograft. CONCLUSION: Allograft may result in slightly more residual motion at the arthrodesis site 1 year after ACDF. However, there is minimal evidence that PROs are adversely affected by slightly increased residual motion, suggesting that the current definition of pseudarthrosis correlates poorly with clinically significant findings. Additionally, autograft appears to result in superior outcomes in patients who smoke.Level of Evidence: 2.

Surgery-related Factors Do Not Affect Short-term Adjacent Segment Kinematics After Anterior Cervical Arthrodesis.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: The aim of this study was to identify surgical factors that affect adjacent segment kinematics after anterior cervical discectomy and fusion (ACDF) as measured by biplane radiography. SUMMARY OF BACKGROUND DATA: Previous studies investigated the effect of surgical factors on spine kinematics as a potential etiology for adjacent segment disease (ASD). Those studies used static flexion-extension radiographs to evaluate range of motion. However, measurements from static radiographs are known to be unreliable. Furthermore, those studies were unable to evaluate the effect of ACDF on adjacent segment axial rotation. METHODS: Patients had continuous cervical spine flexion/exten- sion and axial rotation movements captured at 30 images per second in a dynamic biplane radiography system preoperatively and 1 year after ACDF. Digitally reconstructed radiographs generated from subject-specific CT scans were matched to biplane radiographs using a previously validated tracking process. Dynamic kinematics, postoperative segmental kyphosis, and disc distraction were calculated from this tracking process. Plate-to-disc distance was measured on postoperative radiographs. Graft type was collected from the medical record. Multivariate linear regression was performed to identify surgical factors associated with 1-year post-surgery changes in adjacent segment kinematics. A secondary analysis was also performed to compare adjacent segment kinematics between each of the surgical factors and previously defined thresholds believed to be associated with adjacent segment degeneration. RESULTS: Fifty-nine patients completed preoperative and postoperative testing. No association was found between any of the surgical factors and change in adjacent segment flexion/exten- sion or axial rotation range of motion (all P > 0.09). The secondary analysis also did not identify differences between adjacent segment kinematics and surgical factors (all P > 0.07). CONCLUSION: Following ACDF for cervical spondylosis, factors related to surgical technique were not associated with short-term changes in adjacent segment kinematics that reflect the hypermobility hypothesized to lead to the development of ASD.Level of Evidence: 2.

Graft healing does not influence subjective outcomes and shoulder kinematics after superior capsule reconstruction: a prospective in vivo kinematic study.

BACKGROUND: A viable treatment option for young patients with massive, irreparable rotator cuff tears is arthroscopic superior capsule reconstruction (SCR). SCR theoretically improves shoulder stability and function and decreases pain. However, no prospective studies to date have correlated magnetic resonance imaging (MRI) healing with in vivo kinematic data. The purpose of this study was to evaluate the association between graft healing and in vivo kinematics, range of motion (ROM), strength, and patient-reported outcomes (PROs). METHODS: Ten patients (8 men and 2 women; mean age, 63 ± 7 years) with irreparable rotator cuff tears underwent arthroscopic SCR with dermal allograft. Strength was measured with isometric internal rotation and external rotation (ER) at 0° of abduction, ER at 90° of abduction, and scapular-plane abduction, whereas ROM was measured during shoulder flexion, abduction, and ER and internal rotation at 90° of abduction both before and 1 year after SCR. PROs included American Shoulder and Elbow Surgeons, Western Ontario Rotator Cuff Index, and Disabilities of the Arm, Shoulder and Hand surveys that were collected before and 1 year after SCR. Synchronized biplane radiographs were collected at 50 images/s before and 1 year after SCR while patients performed 3 trials of scapular-plane abduction. A validated volumetric tracking technique with submillimeter accuracy determined 6-df glenohumeral and scapular kinematics. The acromiohumeral distance (AHD), humeral head translation, and scapulohumeral rhythm (SHR) were calculated from the in vivo kinematics. Healing at 5 locations was evaluated on 1-year postoperative MRI scans: anterior and posterior glenoid, anterior and posterior humerus, and posteriorly along the infraspinatus. Each subject was given a score from 0 to 5 based on number of sites healed. RESULTS: Of the 10 patients, 9 (90%) had complete (n = 4) or partial (n = 5) healing of the graft whereas 1 (10%) had complete failure at the glenoid. No correlation existed between MRI healing and the AHD, SHR, strength, ROM, or PROs. American Shoulder and Elbow Surgeons, Western Ontario Rotator Cuff Index, and Disabilities of the Arm, Shoulder and Hand scores all significantly improved from before to 1 year after SCR regardless of graft healing. CONCLUSIONS: The rate of complete or partial graft healing on MRI mimics findings of prior reports in the literature. MRI healing was correlated with humeral head anterior-posterior translation but not with the static and dynamic AHDs, SHR, humeral head superior-inferior translation, ROM, strength, or PROs 1 year after SCR. All PROs improved significantly from before to 1 year after SCR regardless of graft status on MRI. In vivo kinematic changes were small after SCR and not clinically significant, and the data suggest that improvements in clinical and functional outcomes may occur in the absence of full graft healing.

Assessing the biofidelity of in vitro biomechanical testing of the human cervical spine.

In vitro biomechanical studies of the osteoligamentous spine are widely used to characterize normal biomechanics, identify injury mechanisms, and assess the effects of degeneration and surgical instrumentation on spine mechanics. The objective of this study was to determine how well four standards in vitro loading paradigms replicate in vivo kinematics with regards to the instantaneous center of rotation and arthrokinematics in relation to disc deformation. In vivo data were previously collected from 20 asymptomatic participants (45.5 ± 5.8 years) who performed full range of motion neck flexion-extension (FE) within a biplane x-ray system. Intervertebral kinematics were determined with sub-millimeter precision using a validated model-based tracking process. Ten cadaveric spines (51.8 ± 7.3 years) were tested in FE within a robotic testing system. Each specimen was tested under four loading conditions: pure moment, axial loading, follower loading, and combined loading. The in vivo and in vitro bone motion data were directly compared. The average in vitro instant center of rotation was significantly more anterior in all four loading paradigms for all levels. In general, the anterior and posterior disc heights were larger in the in vitro models than in vivo. However, after adjusting for gender, the observed differences in disc height were not statistically significant. This data suggests that in vitro biomechanical testing alone may fail to replicate in vivo conditions, with significant implications for novel motion preservation devices such as cervical disc arthroplasty implants.

The effects of age, pathology, and fusion on cervical neural foramen area.

Cervical radiculopathy is a relatively common neurological disorder, often resulting from mechanical compression of the nerve root within the neural foramen. Anterior cervical discectomy and fusion (ACDF) is a common treatment for radicular symptoms that do not resolve after conservative treatment. One mechanism by which ACDF is believed to resolve symptoms is by replacing degenerated disc tissue with bone graft to increase the neural foramen area, however in vivo evidence demonstrating this is lacking. The aim of this study was to evaluate the effects of age, pathology, and fusion on bony neural foramen area. Participants included 30 young adult controls (<35 years old), 23 middle-aged controls (36 to 60 years old), and 36 cervical arthrodesis patients tested before and after ACDF surgery. Participants' cervical spines were imaged in the neutral, full flexion, and full extension positions while seated within a biplane radiography system. A validated model-based tracking technique determined three-dimensional vertebral position and orientation and automated software identified the neural foramen area in each head position. The neural foramen area decreased throughout the entire sub-axial cervical spine with age and pathology, however, no changes in neural foramen area were observed due solely to replacing degenerated disc tissue with bone graft. The neural foramen area was not associated with disc height in young adult controls, but moderate to strong associations were observed in middle-aged controls. The results provide evidence to inform the debate regarding localized versus systemic spinal degeneration and provide novel insight into the mechanism of pain relief after ACDF.

In vivo changes in adjacent segment kinematics after lumbar decompression and fusion.

The pathogenesis of lumbar adjacent segment disease is thought to be secondary to altered biomechanics resulting from fusion. Direct in vivo evidence for altered biomechanics following lumbar fusion is lacking. This study's aim was to describe in vivo kinematics of the superior adjacent segment relative to the fused segment before and after lumbar fusion. This study analyzed seven patients with symptomatic lumbar degenerative spondylolisthesis (5 M, 2F; age 65 ± 5.1 years) using a biplane radiographic imaging system. Each subject performed two to three trials of continuous flexion of their torso according to established protocols. Synchronized biplane radiographs were acquired at 20 images per second one month before and six months after single-level fusion at L4-L5 or L5-S1, or two-level fusion at L3-L5 or L4-S1. A previously validated volumetric model-based tracking process was used to track the position and orientation of vertebrae in the radiographic images. Intervertebral flexion/extension and AP translation (slip) at the superior adjacent segment were calculated over the entire dynamic flexion activity. Skin-mounted surface markers were tracked using conventional motion analysis and used to determine torso flexion. Change in adjacent segment kinematics after fusion was determined at corresponding angles of dynamic torso flexion. Changes in adjacent segment motion varied across patients, however, all patients maintained or increased the amount of adjacent segment slip or intervertebral flexion/extension. No patients demonstrated both decreased adjacent segment slip and decreased rotation. This study suggests that short-term changes in kinematics at the superior adjacent segment after lumbar fusion appear to be patient-specific.

Dynamic functional nucleus is a potential biomarker for structural degeneration in cervical spine discs.

If intervertebral disc degeneration can be identified early, preventative treatments may be initiated before symptoms become disabling and costly. Changes in disc mechanics, such as the decrease in the compressive modulus of the nucleus, are some of the earliest signs of degeneration. Therefore, in vivo changes in the disc response to compressive load may serve as a biomarker for pending or early disc degeneration. The aim of this study was to assess the potential for using in vivo dynamic disc deformation to identify pathologic structural degeneration of the intervertebral disc. A validated model-based tracking technique determined vertebral motion from biplane radiographs collected during dynamic flexion/extension and axial rotation of the cervical spine. A computational model of the subaxial intervertebral discs was developed to identify the dynamic functional nucleus of each disc, that is, the disc region that underwent little to no additional compression during dynamic movements. The size and location of the dynamic functional nucleus was determined for 10 C5/C6 spondylosis patients, 10 C5/C6/C7 spondylosis patients, and 10 asymptomatic controls. The dynamic functional nucleus size was sensitive (significantly smaller than controls in 5 of 6 measurements at the diseased disc) and specific (no difference from controls in 9 of 10 measurements at non-diseased discs) to pathologic disc degeneration. These results provide evidence to suggest that structural disc degeneration, manifested by changes in the disc response to functional loading, may be identified in vivo from dynamic imaging collected during functional movements. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 9999:1-7, 2019.

Intervertebral kinematics of the cervical spine before, during, and after high-velocity low-amplitude manipulation.

BACKGROUND CONTEXT: Neck pain is one of the most commonly reported symptoms in primary care settings, and a major contributor to health-care costs. Cervical manipulation is a common and clinically effective intervention for neck pain. However, the in vivo biomechanics of manipulation are unknown due to previous challenges with accurately measuring intervertebral kinematics in vivo during the manipulation. PURPOSE: The objectives were to characterize manual forces and facet joint gapping during cervical spine manipulation and to assess changes in clinical and functional outcomes after manipulation. It was hypothesized that patient-reported pain would decrease and intervertebral range of motion (ROM) would increase after manipulation. STUDY DESIGN/SETTING: Laboratory-based prospective observational study. PATIENT SAMPLE: 12 patients with acute mechanical neck pain (4 men and 8 women; average age 40 ± 15 years). OUTCOME MEASURES: Amount and rate of cervical facet joint gapping during manipulation, amount and rate of force applied during manipulation, change in active intervertebral ROM from before to after manipulation, and numeric pain rating scale (NPRS) to measure change in pain after manipulation. METHODS: Initially, all participants completed a NPRS (0-10). Participants then performed full ROM flexion-extension, rotation, and lateral bending while seated within a custom biplane radiography system. Synchronized biplane radiographs were collected at 30 images/s for 3 seconds during each movement trial. Next, synchronized, 2.0-milliseconds duration pulsed biplane radiographs were collected at 160 images/s for 0.8 seconds during the manipulation. The manipulation was performed by a licensed chiropractor using an articular pillar push technique. For the final five participants, two pressure sensors placed on the thumb of the chiropractor (Novel pliance system) recorded pressure at 160 Hz. After manipulation, all participants repeated the full ROM movement testing and once again completed the NPRS. A validated volumetric model-based tracking process that matched subject-specific bone models (from computed tomography) to the biplane radiographs was used to track bone motion with submillimeter accuracy. Facet joint gapping was calculated as the average distance between adjacent articular facet surfaces. Pre- to postmanipulation changes were assessed using the Wilcoxon signed-rank test. RESULTS: The facet gap increased 0.9 ± 0.40 mm during manipulation. The average rate of facet gapping was 6.2 ± 3.9 mm/s. The peak force and rate of force application during manipulation were 65 ± 4 N and 440 ± 58 N/s. Pain score improved from 3.7 ± 1.2 before manipulation to 2.0 ± 1.4 after manipulation (p <. 001). Intervertebral ROM increased after manipulation by 1.2° (p = .006), 2.1° (p = .01), and 3.9° (p = .003) at the C4/C5, C5/C6, and C6/C7 motion segments, respectively, during flexion-extension; by 1.5° (p = .028), 1.9° (p = .005), and 1.3° (p = .050) at the C3/C4, C4/C5, and C5/C6 motion segments, respectively, during rotation; and by 1.3° (p = .034) and 1.1° (p = .050) at the C4/C5 and C5/C6 motion segments, respectively, during lateral bending. Global head ROM relative to the torso increased after manipulation by 8º (p = .023), 10º (p = .002), and 13º (p = .019) during lateral bending, axial rotation and flexion-extension, respectively, after manipulation. CONCLUSIONS: This study is the first to measure facet gapping during cervical manipulation on live humans. The results demonstrate that target and adjacent motion segments undergo facet joint gapping during manipulation and that intervertebral ROM is increased in all three planes of motion after manipulation. The results suggest that clinical and functional improvement after manipulation may occur as a result of small increases in intervertebral ROM across multiple motion segments. This study demonstrates the feasibility of characterizing in real time the manual inputs and biological responses that comprise cervical manipulation, including clinician-applied force, facet gapping, and increased intervertebral ROM. This provides a basis for future clinical trials to identify the mechanisms behind manipulation and to optimize the mechanical factors that reliably and sufficiently impact the key mechanisms behind manipulation.

ISSLS PRIZE IN BIOENGINEERING SCIENCE 2018: dynamic imaging of degenerative spondylolisthesis reveals mid-range dynamic lumbar instability not evident on static clinical radiographs.

PURPOSE: Degenerative spondylolisthesis (DS) in the setting of symptomatic lumbar spinal stenosis is commonly treated with spinal fusion in addition to decompression with laminectomy. However, recent studies have shown similar clinical outcomes after decompression alone, suggesting that a subset of DS patients may not require spinal fusion. Identification of dynamic instability could prove useful for predicting which patients are at higher risk of post-laminectomy destabilization necessitating fusion. The goal of this study was to determine if static clinical radiographs adequately characterize dynamic instability in patients with lumbar degenerative spondylolisthesis (DS) and to compare the rotational and translational kinematics in vivo during continuous dynamic flexion activity in DS versus asymptomatic age-matched controls. METHODS: Seven patients with symptomatic single level lumbar DS (6 M, 1 F; 66 ± 5.0 years) and seven age-matched asymptomatic controls (5 M, 2 F age 63.9 ± 6.4 years) underwent biplane radiographic imaging during continuous torso flexion. A volumetric model-based tracking system was used to track each vertebra in the radiographic images using subject-specific 3D bone models from high-resolution computed tomography (CT). In vivo continuous dynamic sagittal rotation (flexion/extension) and AP translation (slip) were calculated and compared to clinical measures of intervertebral flexion/extension and AP translation obtained from standard lateral flexion/extension radiographs. RESULTS: Static clinical radiographs underestimate the degree of AP translation seen on dynamic in vivo imaging (1.0 vs 3.1 mm; p = 0.03). DS patients demonstrated three primary motion patterns compared to a single kinematic pattern in asymptomatic controls when analyzing continuous dynamic in vivo imaging. 3/7 (42%) of patients with DS demonstrated aberrant mid-range motion. CONCLUSION: Continuous in vivo dynamic imaging in DS reveals a spectrum of aberrant motion with significantly greater kinematic heterogeneity than previously realized that is not readily seen on current clinical imaging. LEVEL OF EVIDENCE: Level V data These slides can be retrieved under Electronic Supplementary Material.