The balance between proliferation and transcription of angiogenic factors of mesenchymal stem cells in hypoxia.

Bridging large bone defects with mesenchymal stromal cells-seeded scaffolds remains a big challenge in orthopedic surgery, due to the lack of vascularization. Within such a cell-scaffold construct, cells are exposed to ischemic conditions. When human mesenchymal stem cells (hMSCs) encounter hypoxic conditions, they show higher cell proliferation than at ambient oxygen levels. However, when hMSCs are exposed to prolonged ischemia, cell proliferation ceases completely. Exposure of hMSCs to hypoxic conditions is known to result in the transcription of angiogenic factors (AGF), which can promote the development of new blood vessels. In this study, we investigated at which oxygen level hMSC proliferation and the transcription of AGF were optimal. Human bone marrow-derived hMSCs were cultured at 0.1, 1, 2, 3, 4, 5, and 21% oxygen. Cell proliferation over 14 days was assayed using a DNA quantification method. hMSC metabolic activity over 14 days was measured using a MTT test. Quantitative RT-PCR was used to assess mRNA levels of angiogenic factors at the tested oxygen percentages. hMSCs showed the highest cell proliferation rate at 1% oxygen. The highest corrected cell metabolic rate was found at 21% oxygen, followed by 2% oxygen. HIF1α transcription did not increase under hypoxic conditions compared to 21% oxygen conditions. However, transcription of VEGF and ANG-1 was significantly higher at 2% oxygen than at 21% O2. The optimum oxygen range at which hMSCs proliferated rapidly and angiogenic factors ANG-1 and VEGF simultaneously came to expression was from 1 to 2% oxygen.

Coupled motions in human and porcine thoracic and lumbar spines.

Coupled motions, i.e., motions along axes other than the loaded axis, have been reported to occur in the human spine, and are likely to be influenced by inclined local axes due to the sagittal plane spine curvature. Furthermore, the role of facet joints in such motions is as yet unclear. Therefore, this study aimed at assessing coupled motions in multiple spine sections in vitro, before and after removal of posterior elements. Six elderly human and 6 young porcine spines were sectioned in four segments (high thoracic, mid thoracic, low thoracic and lumbar), each consisting of four vertebrae and three intervertebral discs. Segments were loaded along each of the three axes, and three-dimensional rotations of the middle segment were quantified. Subsequently, posterior elements were removed and the protocol was repeated. To avoid mixed loading between Axial Rotation (AR) and Lateral Bending (LB), in contrast to other studies, local axes at the vertebrae were defined as aligned with the loading device prior to each load application. Expressed as a percentage of motion in the loaded direction, coupled motions were on average larger in human (22.7%, SD = 2.2%) than in porcine (11.9%, SD = 1.2%) spines (p < .001). Largest coupled motions were obtained in AR loading of the lumbar spine segments, with mean magnitudes averaged over coupling axes for human L2-L3 joints of 48.9% (SD = 13.2%), including somewhat more LB (56.4%, SD = 18.6) than FE (41.4%, SD = 14.1%) coupling. For porcine L3-L4 joints average coupling in AR loading was 29.3% (SD = 8.2%). In human segments removal of posterior elements only had substantial effects in the lumbar spine segments, where posterior element removal decreased coupled motion during AR loading, averaged over LB and FE coupling, from 48.9% (SD = 13.2%) to 27.7% (SD = 6.1%), mainly through increased motion in the loaded direction. The present results indicate that coupled motions were largest in the lumbar spine. In human spines, posterior elements only contributed to coupled motions in lumbar axial rotation loading.

Control of oxygen release from peroxides using polymers.

An important limitation in cell therapy for the regeneration of tissue is the initial lack of oxygen. After implantation of large 3D cell-seeded structures, cells die rather than contribute to tissue regenerating. Here we've tested oxygen-releasing materials to improve cell survival and growth after implantation. Calcium peroxide (CaO2) in a polymer matrix was used as source of oxygen. Two polymers were tested in order to slow down and extend the period of oxygen release, poly(D,L-lactic acid) and poly(lactic-co-glycolic acid). Compared to CaO2 particles, both releasing systems showed an initially higher and shorter oxygen release. Human mesenchymal stromal cells cultured on casted films of these oxygen-releasing composites required catalase to proliferate, indicating the production of cytotoxic hydrogen peroxide as intermediate. Poly(D,L-lactic acid) and poly(lactic-co-glycolic acid) are less suited for slowly oxygen-releasing materials. Catalase was able to reduce the cytotoxic effect of H2O2.

Static versus vacuum cell seeding on high and low porosity ceramic scaffolds.

An adequate cell seeding technique is essential for effective bone regeneration on cell seeded constructs of porous tricalcium phosphates. In previous studies, dynamic cell seeding, in which an external force is applied to seed cells on a biomaterial, resulted in more homogeneous cell seeding in low porosity scaffolds than static seeding. The optimal cell seeding technique for high porosity scaffolds has not been defined yet. Human mesenchymal stem cells were isolated from bone marrow and characterized. The cells were seeded on low porosity (45%) and high porosity (90%) tricalcium phosphate scaffolds using a static and a vacuum seeding technique. LIVE/DEAD® staining of the cell-scaffold complexes followed by confocal laser scanning microscopy was used to measure cell proliferation, cell distribution and cell viability one, three and seven days after seeding. Cell proliferation was also quantified using a DNA quantification assay. Neither static nor vacuum seeding resulted in homogeneous cell seeding on both low and high porosity scaffolds. Cell density was lower on the inside than on the outside of the scaffolds. On low porosity scaffolds, the vacuum method yielded the highest numbers of cells compared to the static method. Low porosity scaffolds were seeded most homogeneously using the static seeding method. Seven days after seeding, numbers of adherent cells were comparable for both scaffold types and independent of the cell seeding technique used. In conclusion, on high porosity scaffolds, static seeding results in more homogeneous cell seeding and it is easier to use than a vacuum seeding technique.

A new lumbar posterior fixation system, the memory metal spinal system: an in-vitro mechanical evaluation.

BACKGROUND: Spinal systems that are currently available for correction of spinal deformities or degeneration such as lumbar spondylolisthesis or degenerative disc disease use components manufactured from stainless steel or titanium and typically comprise two spinal rods with associated connection devices (for example: DePuy Spines Titanium Moss Miami Spinal System). The Memory Metal Spinal System of this study consists of a single square spinal rod made of a nickel titanium alloy (Nitinol) used in conjunction with connecting transverse bridges and pedicle screws made of Ti-alloy. Nitinol is best known for its shape memory effect, but is also characterized by its higher flexibility when compared to either stainless steel or titanium. A higher fusion rate with less degeneration of adjacent segments may result because of the elastic properties of the memory metal. In addition, the use of a single, unilateral rod may be of great value for a TLIF procedure. Our objective is to evaluate the mechanical properties of the new Memory Metal Spinal System compared to the Titanium Moss Miami Spinal System. METHODS: An in-vitro mechanical evaluation of the lumbar Memory Metal Spinal System was conducted. The test protocol followed ASTM Standard F1717-96, "Standard Test Methods for Static and Fatigue for Spinal Implant Constructs in a Corpectomy Model." 1. Static axial testing in a load to failure mode in compression bending, 2. Static testing in a load to failure mode in torsion, 3. Cyclical testing to estimate the maximum run out load value at 5.0 x 10^6 cycles. RESULTS: In the biomechanical testing for static axial compression bending there was no statistical difference between the 2% yield strength and the stiffness of the two types of spinal constructs. In axial compression bending fatigue testing, the Memory Metal Spinal System construct showed a 50% increase in fatigue life compared to the Titanium Moss Miami Spinal System. In static torsional testing the Memory Metal Spinal System constructs showed an average 220% increase in torsional yield strength, and an average 30% increase in torsional stiffness. CONCLUSIONS: The in-vitro mechanical evaluation of the lumbar Memory Metal Spinal System showed good results when compared to a currently available spinal implant system. Throughout testing, the Memory Metal Spinal System showed no failures in static and dynamic fatigue.

Automatic Cobb angle determination from radiographic images.

STUDY DESIGN: Automatic measurement of Cobb angle in patients with scoliosis. OBJECTIVE: To test the accuracy of an automatic Cobb angle determination method from frontal radiographical images. SUMMARY OF BACKGROUND DATA: Thirty-six frontal radiographical images of patients with scoliosis. METHODS: A modified charged particle model is used to determine the curvature on radiographical spinal images. Three curve fitting methods, piece-wise linear, splines, and polynomials, each with 3 variants were used and evaluated for the best fit. The Cobb angle was calculated out of these curve fit lines and compared with a manually determined Cobb angle. The best-automated method is determined on the basis of the lowest mean absolute error and standard deviation, and the highest R2. RESULTS: The error of the manual Cobb angle determination among the 3 observers, determined as the mean of the standard deviations of all sets of measurements, was 3.37°. For the automatic method, the best piece-wise linear method is the 3-segments method. The best spline method is the 10-steps method. The best polynomial method is poly 6. Overall, the best automatic methods are the piece-wise linear method using 3 segments and the polynomial method using poly 6, with a mean absolute error of 4,26° and 3,91° a standard deviation of 3,44° and 3,60°, and a R2 of 0.9124 and 0.9175. The standard measurement error is significantly lower than the upper bound found in the literature (11.8°). CONCLUSION: The automatic Cobb angle method seemed to be better than the manual methods described in the literature. The piece-wise linear method using 3 segments and the polynomial method using poly 6 yield the 2 best results because the mean absolute error, standard deviation, and R2 are the best of all methods. LEVEL OF EVIDENCE: 3.

Predicting the peak growth velocity in the individual child: validation of a new growth model.

Predicting the peak growth velocity in an individual patient with adolescent idiopathic scoliosis is essential or determining the prognosis of the disorder and timing of the (surgical) treatment. Until the present time, no accurate method has been found to predict the timing and magnitude of the pubertal growth spurt in the individual child. A mathematical model was developed in which the partial individual growth velocity curve was linked to the generic growth velocity curve. The generic curve was shifted and stretched or shrunk, both along the age axis and the height velocity axis. The individual age and magnitude of the PGV were obtained from the new predicted complete growth velocity curve. Predictions were made using 2, 1.5, 1 and 0.5 years of the available longitudinal data of the individual child, starting at different ages. The predicted values of 210 boys and 162 girls were compared to the child's own original values of the PGV. The individual differences were compared to differences obtained when using the generic growth velocity curve as a standard. Using 2 years of data as input for the model, all predictions of the age of the PGV in boys and girls were significantly better in comparison to using the generic values. Using only 0.5 years of data as input, the predictions with a starting age from 13 to 15.5 years in boys and from 9.5 to 14.5 years in girls were significantly better. Similar results were found for the predictions of the magnitude of the PGV. This model showed highly accurate results in predicting the individual age and magnitude of the PGV, which can be used in the treatment of patients with adolescent idiopathic scoliosis.

Cervical cystic swelling in an adolescent: unusual association of a cervical mature teratoma with vertebral anomalies and a history of gastric duplication cyst.

A 14-year-old girl presented with a cervical cystic swelling in association with deformity of cervical vertebrae. As a child, she had been treated for gastric duplication. Pathologic examination of the resected cervical swelling revealed a mature teratoma. We discuss possible embryologic associations, which could explain the unusual combination of a mature teratoma with vertebral anomalies and gastric duplication.

Influence of interpersonal geometrical variation on spinal motion segment stiffness: implications for patient-specific modeling.

STUDY DESIGN: A validated finite element model of an L3-L4 motion segment is used to analyze the effects of interpersonal differences in geometry on spinal stiffness. OBJECTIVE: The objective of this study is to determine which of the interpersonal variations of the geometry of the spine have a large effect on spinal stiffness. This will improve patient-specific modeling. SUMMARY OF BACKGROUND DATA: The parameters that define the geometry of a motion segment are vertebral height, disc height, endplate width, endplate depth, spinous process length, transverse process width, nucleus size, lordosis angle, facet area, facet orientation, and the cross-sectional areas of the ligaments. All these parameters differ between patients. The influence of each parameter on spinal stiffness is largely unknown and such knowledge would greatly help in patient-specific modeling of the spine. METHODS: The range of interpersonal variation of each of the geometric parameters was set at mean±2SD (covering 95% of the population). Subsequently, we determined the effect of each of these ranges on the bending stiffness in flexion, extension, axial rotation, and lateral bending. RESULTS: Disc height had the largest influence; a maximal disc height reduced the spinal stiffness to 75-86% of the mean motion segment stiffness, and a minimal disc height increased the spinal stiffness to 154-226% of the mean motion segment stiffness. Lordosis angle, transversal and longitudinal facet angle, endplate depth, and area of the capsular ligament also had a substantial influence (>5%) on the stiffness, but considerable less than the influence of the disc height. Ligament areas, nucleus size, spinous process length, and length of processes are of negligible effect (<2%) on the stiffness. CONCLUSION: The disc height should be accurately determined in patients to estimate the spinal stiffness. Ligament areas, nucleus size, spinous process length, and transverse process width do not need patient-specific modeling.

The effects of creep and recovery on the in vitro biomechanical characteristics of human multi-level thoracolumbar spinal segments.

BACKGROUND: Several physiological and pathological conditions in daily life cause sustained static bending or torsion loads on the spine resulting in creep of spinal segments. The objective of this study was to determine the effects of creep and recovery on the range of motion, neutral zone, and neutral zone stiffness of thoracolumbar multi-level spinal segments in flexion, extension, lateral bending and axial rotation. METHODS: Six human cadaveric spines (age at time of death 55-84 years) were sectioned in T1-T4, T5-T8, T9-T12, and L1-L4 segments and prepared for testing. Moments were applied of +4 to -4 N m in flexion-extension, lateral bending, and axial rotation. This was repeated after 30 min of creep loading at 2 N m in the tested direction and after 30 min of recovery. Displacement of individual motion segments was measured using a 3D optical movement registration system. The range of motion, neutral zone, and neutral zone stiffness of the middle motion segments were calculated from the moment-angular displacement data. FINDINGS: The range of motion increased significantly after creep in extension, lateral bending and axial rotation (P<0.05). The range of motion after flexion creep showed an increasing trend as well, and the neutral zone after flexion creep increased by on average 36% (P<0.01). The neutral zone stiffness was significantly lower after creep in axial rotation (P<0.05). INTERPRETATION: The overall flexibility of the spinal segments was in general larger after 30 min of creep loading. This higher flexibility of the spinal segments may be a risk factor for potential spinal instability or injury.

The value of shoe size for prediction of the timing of the pubertal growth spurt.

BACKGROUND: Knowing the timing of the pubertal growth spurt of the spine, represented by sitting height, is essential for the prognosis and therapy of adolescent idiopathic scoliosis. There are several indicators that reflect growth or remaining growth of the patient. For example, distal body parts have their growth spurt earlier in adolescence, and therefore the growth of the foot can be an early indicator for the growth spurt of sitting height. Shoe size is a good alternative for foot length, since patients can remember when they bought new shoes and what size these shoes were. Therefore the clinician already has access to some longitudinal data at the first visit of the patient to the outpatient clinic.The aim of this study was to describe the increase in shoe size during adolescence and to determine whether the timing of the peak increase could be an early indicator for the timing of the peak growth velocity of sitting height. METHODS: Data concerning shoe sizes of girls and boys were acquired from two large shoe shops from 1991 to 2008. The longitudinal series of 242 girls and 104 boys were analysed for the age of the "peak increase" in shoe size, as well as the age of cessation of foot growth based on shoe size. RESULTS: The average peak increase in shoe size occurred at 10.4 years (SD 1.1) in girls and 11.5 years (SD 1.5) in boys. This was on average 1.3 years earlier than the average peak growth velocity of sitting height in girls, and 2.5 years earlier in boys. The increase in shoe size diminishes when the average peak growth velocity of sitting height takes place at respectively 12.0 (SD 0.8) years in girls, and 13.7 (SD 1.0) years in boys. CONCLUSIONS: Present data suggest that the course of the shoe size of children visiting the outpatient clinic can be a useful first tool for predicting the timing of the pubertal growth spurt of sitting height, as a representative for spinal length.This claim needs verification by direct comparison of individual shoe size and sitting height data and than a step forward can be made in clinical decision making regarding adolescent idiopathic scoliosis.

The growth of different body length dimensions is not predictive for the peak growth velocity of sitting height in the individual child.

The aim of this study was to determine whether the differences in timing of the peak growth velocity (PGV) between sitting height, total body height, subischial leg length, and foot length can be used to predict whether the individual patient with adolescent idiopathic scoliosis is before or past his or her PGV of sitting height. Furthermore, ratios of growth of different body parts were considered in order to determine their value in prediction of the PGV of sitting height in the individual patient. Ages of the PGV were determined for sitting height (n=360), total body height (n=432), subischial leg length (n=357), and foot length (n=263), and compared for the whole group and for the individual child in particular. Furthermore, the ages of the highest and lowest ratios between the body length dimensions were determined and compared to the age of the PGV of sitting height. The mean ages of the highest and lowest ratios were significantly different from the mean age of the PGV of sitting height in 3 out of 12 ratios in girls and 8 out of 12 ratios in boys. The variation over children was large and the ratios were too small, leading to a too large influence of measurement errors. The mean ages of the PGV all differed significantly from the mean age of the PGV of sitting height. However, the variation over individual children of the age differences in PGV between body dimensions was large, and the differences in timing of the PGV were not useful to predict whether the individual child is before or past his or her PGV of sitting height.

Predicting growth and curve progression in the individual patient with adolescent idiopathic scoliosis: design of a prospective longitudinal cohort study.

BACKGROUND: Scoliosis is present in 3-5% of the children in the adolescent age group, with a higher incidence in females. Treatment of adolescent idiopathic scoliosis is mainly dependent on the progression of the scoliotic curve. There is a close relationship between curve progression and rapid (spinal) growth of the patient during puberty. However, until present time no conclusive method was found for predicting the timing and magnitude of the pubertal growth spurt in total body height, or the curve progression of the idiopathic scoliosis.The goal of this study is to determine the predictive value of several maturity indicators that reflect growth or remaining growth potential, in order to predict timing of the peak growth velocity of total body height in the individual patient with adolescent idiopathic scoliosis. Furthermore, different parameters are evaluated for their correlation with curve progression in the individual scoliosis patient. METHODS/DESIGN: This prospective, longitudinal cohort study will be incorporated in the usual care of patients with adolescent idiopathic scoliosis. All new patients between 8 and 17 years with adolescent idiopathic scoliosis (Cobb angle >10 degrees) visiting the outpatient clinic of the University Medical Center Groningen are included in this study. Follow up will take place every 6 months. The present study will use a new ultra-low dose X-ray system which can make total body X-rays. Several maturity indicators are evaluated like different body length dimensions, secondary sexual characteristics, skeletal age in hand and wrist, skeletal age in the elbow, the Risser sign, the status of the triradiate cartilage, and EMG ratios of the paraspinal muscle activity. Correlations of all dimensions will be calculated in relationship to the timing of the pubertal growth spurt, and to the progression of the scoliotic curve. An algorithm will be made for the optimal treatment strategy in the individual patient with adolescent idiopathic scoliosis. DISCUSSION: This study will determine the value of many maturity indicators and will be useful as well for other clinicians treating children with disorders of growth. Since not all clinicians have access to the presented new 3D X-ray system or have the time to make EMG's, for example, all indicators will be correlated to the timing of the peak growth velocity of total body height and curve progression in idiopathic scoliosis. Therefore each clinician can chose which indicators can be used best in their practice. TRIAL REGISTRATION NUMBER: NTR2048.

Reproducibility of standing posture for X-ray radiography: a feasibility study of the BalancAid with healthy young subjects.

Unreliable spinal X-ray radiography measurement due to standing postural variability can be minimized by using positional supports. In this study, we introduce a balancing device, named BalancAid, to position the patients in a reproducible position during spinal X-ray radiography. This study aimed to investigate the performance of healthy young subjects' standing posture on the BalancAid compared to standing on the ground mimicking the standard X-rays posture in producing a reproducible posture for the spinal X-ray radiography. A study on the posture reproducibility measurement was performed by taking photographs of 20 healthy young subjects with good balance control standing on the BalancAid and the ground repeatedly within two consecutive days. We analyzed nine posterior-anterior (PA) and three lateral (LA) angles between lines through body marks placed in the positions of T3, T7, T12, L4 of the spine to confirm any translocations and movements between the first and second day measurements. No body marks repositioning was performed to avoid any error. Lin's CCC test on all angles comparing both standing postures demonstrated that seven out of nine angles in PA view, and two out of three angles in LA view gave better reproducibility for standing on the BalancAid compared to standing on the ground. The PA angles concordance is on average better than that of the LA angles.

A framework for human spine imaging using a freehand 3D ultrasound system.

The use of 3D ultrasound imaging to follow the progression of scoliosis, i.e., a 3D deformation of the spine, is described. Unlike other current examination modalities, in particular based on X-ray, its non-detrimental effect enables it to be used frequently to follow the progression of scoliosis which sometimes may develop rapidly. Furthermore, 3D ultrasound imaging provides information in 3D directly in contrast to projection methods. This paper describes a feasibility study of an ultrasound system to provide a 3D image of the human spine, and presents a framework of procedures to perform this task. The framework consist of an ultrasound image acquisition procedure to image a large part of the human spine by means of a freehand 3D ultrasound system and a volume reconstruction procedure which was performed in four stages: bin-filling, hole-filling, volume segment alignment, and volume segment compounding. The overall results of the procedures in this framework show that imaging of the human spine using ultrasound is feasible. Vertebral parts such as the transverse processes, laminae, superior articular processes, and spinous process of the vertebrae appear as clouds of voxels having intensities higher than the surrounding voxels. In sagittal slices, a string of transverse processes appears representing the curvature of the spine. In the bin-filling stage the estimated mean absolute noise level of a single measurement of a single voxel was determined. Our comparative study for the hole-filling methods based on rank sum statistics proved that the pixel nearest neighbour (PNN) method with variable radius and with the proposed olympic operation is the best method. Its mean absolute grey value error was less in magnitude than the noise level of a single measurement.

Comparative anatomical dimensions of the complete human and porcine spine.

New spinal implants and surgical procedures are often tested pre-clinically on human cadaver spines. However, the availability of fresh frozen human cadaver material is very limited and alternative animal spines are more easily available in all desired age groups, and have more uniform geometrical and biomechanical properties. The porcine spine is said to be the most representative model for the human spine but a complete anatomical comparison is lacking. The goal of this descriptive study was to compare the anatomical dimensions of the cervical, thoracic, and lumbar vertebrae of the human and porcine spine in order to determine whether the porcine spine can be a representative model for the human spine. CT scans were made of 6 human and 6 porcine spines, and 16 anatomical dimensions were measured per individual vertebrae. Comparisons were made for the absolute values of the dimensions, for the patterns of the dimensions within four spinal regions, and normalised values of the dimensions within each individual vertebra. Similarities were found in vertebral body height, shape of the end-plates, shape of the spinal canal, and pedicle size. Furthermore, regional trends were comparable for all dimensions, except for spinal canal depth and spinous processus angle. The size of the end-plates increased more caudally in the human spine. Relating the dimensions to the size of the vertebral body, similarities were found in the size of the spinal canal, the transverse processus length, and size of the pedicles. Taking scaling differences into account, it is believed that the porcine spine can be a representative anatomical model for the human spine in specific research questions.

In vitro biomechanical characteristics of the spine: a comparison between human and porcine spinal segments.

STUDY DESIGN: An in vitro study on human and porcine multilevel spinal segments. OBJECTIVE: To compare human and porcine thoracolumbar spinal segments with respect to their biomechanical characteristics and the effects of creep, recovery, and removal of ligaments and posterior parts on the biomechanical characteristics. SUMMARY OF BACKGROUND DATA: Availability of human cadaver spines for in vitro testing of new spinal implants and surgical procedures is limited. Therefore, it is important to search for animal models with representative biomechanical characteristics. METHODS: A total of 6 human and 6 porcine cadaver spines were dissected in multilevel spinal segments. Pure moments were applied to each segment in flexion/extension, lateral bending, and axial rotation. Creep tests were performed for 30 minutes in 4 creep directions, followed by cyclic tests, a recovery period of 30 minutes, and a series of cyclic tests after removal of ligaments and posterior parts. The range of motion, neutral zone (NZ), and neutral zone stiffness (NZStiff) were calculated from the acquired load-displacement data and results were compared between human and porcine segments. RESULTS: The porcine segments generally had significantly higher absolute values for range of motion and NZ and significantly lower absolute values for NZStiff than the human segments in all directions. The effects of creep and recovery were quite similar in the higher and midthoracic regions of the spine. The influence of removal of ligaments was the same in human and porcine segments. After removal of posterior parts, the lower thoracic porcine spine behaved quite similar to the lumbar human spine. CONCLUSION: This study showed that the porcine spine can be a good biomechanical model for the human spine in specific situations. The question if the porcine spine can be used to predict the behavior of a human spine depends mainly on the application and the research question.

Biomechanical characteristics of different regions of the human spine: an in vitro study on multilevel spinal segments.

STUDY DESIGN.: An in vitro study on human multilevel spinal segments. OBJECTIVE.: To determine the differences in biomechanical characteristics between 4 separate regions of the human spine and to provide quantitative information is derived on the range of motion (ROM), neutral zone (NZ), neutral zone stiffness (NZstiff), and flexibility (FLEX). SUMMARY OF BACKGROUND DATA.: Limited literature is available about the biomechanical behavior of different regions of the human spine, in particular with multilevel segments. Test setup en protocols were different between studies and therefore outcomes of separate regions are hardly comparable. METHODS.: A total of 24 spinal segments of 6 human cadaveric spines were prepared for biomechanical testing. Each specimen contained 4 vertebrae and 3 intervertebral discs: T1-T4, T5-T8, T9-T12, and L1-L4. Pure moments were applied to a maximum of 4 Nm in flexion/extension, lateral bending, and axial rotation. Displacement of individual motion segments was measured using a 3-dimensional movement registration system. ROM, NZ, NZstiff, and FLEX of the spinal regions were calculated from the acquired load-displacement data. RESULTS.: In axial direction, ROM and NZ decreased and NZ stiffness increased from high to low vertebral levels. For flexion/extension and lateral flexion highest ROM and NZ and lowest NZ stiffness values were found at the T1-T4 and L1-L4 regions. NZ magnitudes and NZ stiffnesses were negatively correlated (P < 0.05). Flexibility of the spinal regions was variable; no significant differences were found between the 4 spinal regions. CONCLUSION.: This study showed the differences in ROM, NZ, and NZ stiffness between thoracolumbar regions of the human spine in axial rotation, flexion/extension, and lateral bending. Separate multilevel spinal segments were tested in 1 study, and therefore characteristics of different regions are truly comparable.

Biomechanical evaluation of the vertebral jack tool and the inflatable bone tamp for reduction of osteoporotic spine fractures.

STUDY DESIGN: Controlled in vitro study. OBJECTIVE: To compare two kyphoplasty techniques in cadaveric fractured vertebrae: an experimental vertebral jack tool (VJT) and an inflatable bone tamp (IBT). SUMMARY OF BACKGROUND DATA: A previous biomechanical study showed restored strength and stiffness after height restoration in cadaveric-fractured osteoporotic vertebrae using a new device for reduction of osteoporotic vertebral fractures. METHODS: Anterior wedge fractures (AO type A1.2) were created in 8 (4 lumbar, 4 thoracic) vertebrae by displacement eccentric external forces. In all vertebrae the amount of height reduction was 35%. After compression, 4 vertebrae were restored in height using the VJT procedure. Four vertebrae were restored in height using the IBT procedure. Posttreatment strength and stiffness of the vertebrae were determined by a compression test identical to the pretreatment compression protocol. RESULTS.: In the VJT group the post-restoration strength was 81% +/- 13% of the original strength and in the IBT group it was 96% +/- 32%. The post-restoration stiffness in the VJT group was 61% +/- 42% of the original stiffness and in the IBT group 76% +/- 62% of the original stiffness. The vertebrae in the VJT group were restored to 101% +/- 2% of their original height whereas this was 104% +/- 14% in the IBT group. In this study, no cases of cement leakage were found. No cases of damaging of the end plates, new fractures or perforations were seen in both groups. The mean amount of cement inserted for the VJT group was 3.6 +/- 0.9 cm and for the IBT group 5.9 +/- 0.8 cm. CONCLUSION: Both kyphoplasty procedures were able to restore height in this in vitro study, while strength and stiffness were partially restored, with no significant differences. In this study on average significant less cement was used in the VJT procedure. No complications were noted in both groups. This new end plate-to-end plate laminar augmentation technique may be of clinical advantage.

Clinical effect of continuous corrective force delivery in the non-operative treatment of idiopathic scoliosis: a prospective cohort study of the TriaC-brace.

A prospective cohort study of skeletally immature idiopathic scoliotic patients treated with the TriaC brace. To determine if the TriaC brace is effective in preventing curve progression in immature adolescent idiopathic scoliotic patients with a very high risk of curve progression based on reported natural history data. The aim of the newly introduced TriaC brace is to reverse the pathologic transverse force pattern by externally applied and continuously present orthotic forces. In the frontal plane the force system used in the TriaC brace is similar to the force system of the conventional braces. However, in the sagittal plane the force system acts only on the thoracic region. In addition, the brace allows upper trunk flexibility without affecting the corrective forces during body motion. In a preliminary study it is demonstrated that the brace prevents further progression of both the Cobb angle and axial rotation in idiopathic scoliosis. Skeletally immature patients with idiopathic scoliosis with curves between 20 and 40 degrees were studied prospectively. Skeletally immature was defined as a Risser sign 0 or 1 for both boys and girls, or pre-menarche or less than 1-year post-menarche for girls. Curves of less than 30 degrees had to have documented progression before entry. The mean age of the patients at the start of treatment was 11.3 +/- 3.1 years. All measurements were collected by a single observer, and all patients were followed up to skeletal maturity. Treatment was complete for all participants when they had reached Risser sign 4 and did not show any further growth at length measurements. This was at a mean age of 15.6 +/- 1.1 years, with a mean follow-up of 1.6 years post bracing. In our study a successful outcome was obtained in 76% of patients treated with the TriaC brace. Comparing our data to literature data on natural history of a similar cohort shows that the TriaC brace significantly alters the predicted natural history. The current study demonstrates that treatment with the TriaC brace reduces the scoliosis, and that the achieved correction is maintained in some degree after skeletal maturity is reached and bracing is discontinued. It also prevents further progression of the Cobb angle in idiopathic scoliosis. The new brace does not differ from the conventional braces as far as maintaining the deformity is concerned.