Analysis of Injury Metrics From Experimental Cardiac Injuries From Behind Armor Blunt Trauma Using Live Swine Tests: A Pilot Study.

INTRODUCTION: Warfighters are issued hard body armor designed to defeat ballistic projectiles. The resulting backface deformation can injure different thoracoabdominal organs. Developed over decades ago, the behind armor blunt impact criterion of maximum 44 mm depth in clay continues to be used independent of armor type or impact location on the thoracoabdominal region covered by the armor. Because thoracoabdominal components have different energy absorption capabilities, their mode of failures and mechanical properties are different. These considerations underscore the lack of effectiveness of using the single standard to cover all thoracoabdominal components to represent the same level of injury risk. The objective of this pilot study is to conduct cardiac impact tests with a live animal model and analyze biomechanical injury candidate metrics for behind armor blunt trauma applications. MATERIALS AND METHODS: Live swine tests were conducted after obtaining approvals from the U.S. DoD. Trachea tubes. An intravenous line were introduced into the swine before administering anesthesia. Pressure transducers were inserted into lungs and aorta. An indenter simulating backface deformation profiles produced by body armor from military-relevant ballistics to human cadavers delivered impact to the heart region. The approved test protocol included 6-hour monitoring and necropsies. Indenter accelerometer signals were processed to compute the velocity and deflection, and their peak magnitudes were obtained. The deflection-time signal was normalized with respect to chest depth along the impact axis. The peak magnitude of the viscous criterion, kinetic energy, force, momentum and stiffness were obtained. RESULTS: Out of the 8 specimens, 2 were sham controls. The mean total body mass and soft tissue thickness at the impact site were 81.1 ± 4.1 kg and 3.8 ± 1.1 cm. The peak velocities ranged from 30 to 59 m/s, normalized deflections ranged from 15 to 21%, and energies ranged from 105 to 407 J. The range in momentum and stiffness were 7.0 to 13.9 kg-m/s and 22.3 to 79.9 N/m. The maximum forces and impulse data ranged from 2.9 to 11.7 kN and 1.9 to 5.8 N-s. The peak viscous criterion ranged from 2.0 to 5.3 m/s. One animal did not sustain any injuries, 2 had cardiac injuries, and others had lung and skeletal injuries. CONCLUSIONS: The present study applied blunt impact loads to the live swine cardiac region and determined potential candidate injury metrics for characterization. The sample size of 6 swine produced injuries ranging from none to pure skeletal to pure organ trauma. The viscous criterion metric associated with the response of the animal demonstrated a differing pattern than other variables with increasing velocity. These findings demonstrate that our live animal experimental design can be effectively used with testing additional samples to develop behind armor blunt injury criteria for cardiac trauma in the form of risk curves. Injury criteria obtained for cardiac trauma can be used to enhance the effectiveness of the body armor, reduce morbidity and mortality, and improve warfighter readiness in combat operations.

Direct Combat-related U.S. Army Aviation Injuries 2003-2014.

INTRODUCTION: The U.S. Army Aeromedical Research Laboratory (USAARL), a partner in the Joint Trauma Analysis for the Prevention of Injury in Combat (JTAPIC) partnership, conducted a series of retrospective reviews to investigate injuries sustained by occupants of U.S. Army rotary-wing aircraft involved in combat damage incidents. The reviews were conducted to provide occupant survivability information to the Aviation Survivability Development and Tactics team, an agency within the U.S. Army Aviation Center of Excellence. For these reviews, combat damage incidents that produced casualties were separated into direct events (i.e., events in which an enemy weapon system directly injured occupants) and indirect events (i.e., incidents in which occupants were injured as a result of a crash caused by the enemy weapon system). The previous USAARL reviews provided an overview of injuries sustained during direct and indirect events. The objective of this review was to conduct a detailed analysis of injuries occurring during direct events. MATERIALS AND METHODS: A descriptive retrospective review was conducted on injuries sustained by occupants of U.S. Army rotary-wing aircraft involved in combat damage incidents between 2003 and 2014. All Black Hawk, Apache, and Chinook combat aviation damage incidents for the study period were reviewed. Personnel casualty information from the Defense Casualty Information Processing System (DCIPS) was linked to combat damage incident information by matching the aircraft platform, incident date, and circumstantial information found in incident narratives. Injury information for personnel identified in DCIPS as being wounded in action was obtained from the JTAPIC partnership; injury data for personnel killed in action were retrieved from the Armed Forces Medical Examiner System. All injuries were coded using the Abbreviated Injury Scale (AIS). Descriptive statistics were used to describe the frequency and distribution of injuries to personnel involved in direct events. RESULTS: Overall, the extremities were the most commonly injured body regions, with lower extremities suffering more injuries than upper extremities. Penetrating injuries were identified as the primary injury mechanism for all body regions. Injuries to each AIS body region were predominantly of minor (AIS 1) and moderate (AIS 2) severity. CONCLUSIONS: Although injury severities were generally low (AIS 1 or AIS 2), the results of this effort indicate which body regions may benefit from additional protection during rotary-wing operations in hostile environments. The influence of occupant position within the aircraft and the use and effectiveness of personal protective equipment could not be effectively analyzed due to a lack of information.

A Novel Paradigm to Develop Regional Thoracoabdominal Criteria for Behind Armor Blunt Trauma Based on Original Data.

INTRODUCTION: For behind armor blunt trauma (BABT), recent prominent BABT standards for chest plate define a maximum deformation distance of 44 mm in clay. It was developed for soft body armor applications with limited animal, gelatin, and clay tests. The legacy criterion does not account for differing regional thoracoabdominal tolerances to behind armor-induced injury. This study examines the rationale and approaches used in the legacy BABT clay criterion and presents a novel paradigm to develop thoracoabdominal regional injury risk curves. MATERIALS AND METHODS: A review of the original military and law enforcement studies using animals, surrogates, and body armor materials was conducted, and a reanalysis of data was performed. A multiparameter model analysis describes survival-lethality responses using impactor/projectile (mass, diameter, and impact velocity) and specimen (weight and tissue thickness) variables. Binary regression risk curves with ±95% confidence intervals (CIs) and peak deformations from simulant tests are presented. RESULTS: Injury risk curves from 74 goat thorax tests showed that peak deflections of 44.7 mm (±95% CI: 17.6 to 55.4 mm) and 49.9 mm (±95% CI: 24.7 to 60.4 mm) were associated with the 10% and 15% probability of lethal outcomes. 20% gelatin and Roma Plastilina #1 clay were stiffer than goat. The clay was stiffer than 20% gelatin. Penetration diameters showed greater variations (on a test-by-test basis, difference 36-53%) than penetration depths (0-12%) across a range of projectiles and velocities. CONCLUSIONS: While the original authors stressed limitations and the importance of additional tests for refining the 44 mm recommendation, they were not pursued. As live swine tests are effective in developing injury criteria and the responses of different areas of the thoracoabdominal regions are different because of anatomy, structure, and function, a new set of swine and human cadaver tests are necessary to develop scaling relationships. Live swine tests are needed to develop incapacitation/lethal injury risk functions; using scaling relationships, human injury criteria can be developed.

A Biomechanical Investigation of Cervical Spine Range of Motion for UH-60 Aviators in Real and Simulated Flight Environments.

INTRODUCTION: Military flight surgeons evaluating aviators for flight fitness based on the cervical spine range of motion (CROM) have no operationally relevant reference with which to make a reliable determination. The published physiological limits for the general population do not necessarily apply to military aviators. CROM requirements for rotary-wing aviators would ideally be defined by measurements taken directly within their operational environment. MATERIALS AND METHODS: Nine subjects performed the same predetermined 1-hour flight mission in a UH-60 aircraft and then, at least 2 days later, in the U.S. Army Aeromedical Research Laboratory (USAARL) NUH-60 flight simulator. Head position was recorded using an optical-based inertial tracker attached to the night vision goggle mount of the subjects' flight helmets. Matched-pair t-tests were implemented to compare the maximum CROM between aircraft and simulated flights and the published general population. RESULTS: The percent of flight time in severe flexion and lateral bending was not statistically different (P > 0.05) between real and simulated flights but was statistically lower in the simulator for severe twist rotation (P < 0.05). The maximum CROM for the advanced maneuvers was significantly lower than the norms for the general population (P < 0.05). CONCLUSIONS: The flight simulator could be a useful platform for flight surgeons determining CROM-related flight fitness if methods to increase the frequency of neck twist rotation movements during flight were implemented. The published maximum CROM values for the general population are not an appropriate reference for flight surgeons making flight fitness determinations related to CROM.

Strain Response of an Anatomically Accurate Nonhuman Primate Finite Element Brain Model Under Sagittal Loading.

INTRODUCTION: Prevention and treatment of traumatic brain injuries is critical to preserving soldier brain health. Laboratory studies are commonly used to reproduce injuries, understand injury mechanisms, and develop tolerance limits; however, this approach has limitations for studying brain injury, which requires a physiological response. The nonhuman primate (NHP) has been used as an effective model for investigating brain injury for many years. Prior research using the NHP provides a valuable resource to leverage using modern analysis and modeling techniques to improve our understanding of brain injury. The objectives of the present study are to develop an anatomically accurate finite element model of the NHP and determine regional brain responses using previously collected NHP data. MATERIALS AND METHODS: The finite element model was developed using a neuroimaging-based anatomical atlas of the rhesus macaque that includes both cortical and subcortical structures. Head kinematic data from 10 sagittal NHP experiments, four +Gx (rearward) and six -Gx (frontal), were used to test model stability and obtain brain strain responses from multiple severities and vectors. RESULTS: For +Gx tests, the whole-brain cumulative strain damage measure exceeding a strain threshold of 0.15 (CSDM15) ranged from 0.28 to 0.89, and 95th percentile of the whole-brain maximum principal strain (MPS95) ranged from 0.21 to 0.59. For -Gx tests, whole-brain CSDM15 ranged from 0.02 to 0.66, and whole-brain MPS95 ranged from 0.08 to 0.39. CONCLUSIONS: Recognizing that NHPs are the closest surrogate to humans combined with the limitations of conducting brain injury research in the laboratory, a detailed anatomically accurate finite element model of an NHP was developed and exercised using previously collected data from the Naval Biodynamics Laboratory. The presently developed model can be used to conduct additional analyses to act as pilot data for the design of newer experiments with statistical power because of the sensitivity and resources needed to conduct experiments with NHPs.

Regional Strain Response of an Anatomically Accurate Human Finite Element Head Model Under Frontal Versus Lateral Loading.

INTRODUCTION: Because brain regions are responsible for specific functions, regional damage may cause specific, predictable symptoms. However, the existing brain injury criteria focus on whole brain response. This study developed and validated a detailed human brain computational model with sufficient fidelity to include regional components and demonstrate its feasibility to obtain region-specific brain strains under selected loading. METHODS: Model development used the Simulated Injury Monitor (SIMon) model as a baseline. Each SIMon solid element was split into 8, with each shell element split into 4. Anatomical regions were identified from FreeSurfer fsaverage neuroimaging template. Material properties were obtained from literature. The model was validated against experimental intracranial pressure, brain-skull displacement, and brain strain data. Model simulations used data from laboratory experiments with a rigid arm pendulum striking a helmeted head-neck system. Data from impact tests (6 m/s) at 2 helmet sites (front and left) were used. RESULTS: Model validation showed good agreement with intracranial pressure response, fair to good agreement with brain-skull displacement, and good agreement for brain strain. CORrelation Analysis scores were between 0.72 and 0.93 for both maximum principal strain (MPS) and shear strain. For frontal impacts, regional MPS was between 0.14 and 0.36 (average of left and right hemispheres). For lateral impacts, MPS was between 0.20 and 0.48 (left hemisphere) and between 0.22 and 0.51 (right hemisphere). For frontal impacts, regional cumulative strain damage measure (CSDM20) was between 0.01 and 0.87. For lateral impacts, CSDM20 was between 0.36 and 0.99 (left hemisphere) and between 0.09 and 0.93 (right hemisphere). CONCLUSIONS: Recognizing that neural functions are related to anatomical structures and most model-based injury metrics focus on whole brain response, this study developed an anatomically accurate human brain model to capture regional responses. Model validation was comparable with current models. The model provided sufficient anatomical detail to describe brain regional responses under different impact conditions.

Head Flail Corridors From Sled Impact Acceleration Tests for Use in Occupant-Centric Vehicle Design.

INTRODUCTION: In aircraft crashes, injuries to the head and upper torso are frequently reported, with head injury reported most frequently of all body regions. Because preventing flail of the head and body is of utmost importance for occupant survival, the Aircraft Crash Survival Design Guide (ACSDG), the guide to crashworthy aircraft design, published flail envelopes. However, the ACSDG flail envelopes are based on a single test with an anthropomorphic test device subjected to a frontal acceleration. In this article, human research volunteer (HRV) response data are used to calculate head flail corridors and evaluate the ACSDG flail envelopes. MATERIALS AND METHODS: Data from HRV sled tests were obtained from the historical Naval Biodynamics Laboratory collection of the Biodynamics Data Resource. Digitized high-speed film for each test was tracked and processed to represent the head flail response in a format amenable to corridor development. Time-based and position-based head flail corridors were developed for groups of exposure-matched tests and then compared to the ACSDG flail envelopes. RESULTS: A collection of 714 HRV sled tests conducted in six different impact directions ranging from 3 to 15 g was used to develop time-based and position-based head flail corridors for 39 match groups. The ACSDG vertical limit and anteroposterior limit and curve were not exceeded by the flail corridors, but the lateral limit and curve were exceeded by 4.6 cm to 15.8 cm. CONCLUSIONS: The flail corridors provide a useful baseline for representing the well-restrained occupant response at lower, non-injurious exposure levels and across multiple impact directions. Under these conditions, the ACSDG lateral limit and curve are not adequate. At higher exposure levels or with modified restraints, seating, or equipment, the ACSDG vertical limit and anteroposterior limit and curves may also be inadequate.

Preliminary Head-Supported Mass Performance Guidance for Dismounted Soldier Environments.

INTRODUCTION: The helmet is an ideal platform to mount technology that gives U.S. Soldiers an advantage over the enemy; the total system is recognized quantitatively as head-supported mass (HSM). The stress placed on the head and neck is magnified by adding mass and increasing the center of mass offset away from the atlanto-occipital complex, the head's pivot point on the spine. Previous research has focused on HSM-related spinal degeneration and performance decrement in mounted environments. The increased capabilities and protection provided by helmet systems for dismounted Soldiers have made it necessary to determine the boundaries of HSM and center of mass offset unique to dismounted operations. MATERIALS AND METHODS: A human subject volunteer study was conducted to characterize the head and neck exposures and assess the impact of HSM on performance in a simulated field-dismounted operating environment. Data were analyzed from 21 subjects who completed the Load Effects Assessment Program-Army obstacle course at Fort Benning, GA, while wearing three different experimental HSM configurations. Four variable groups (physiologic/biomechanical, performance, kinematic, and subjective) were evaluated as performance assessments. Weight moments (WMs) corresponding to specific performance decrement levels were calculated using the quantitative relationships developed between each metric and the study HSM configurations. Data collected were used to develop the performance decrement HSM threshold criteria based on an average of 10% total performance decrement of dismounted Soldier performance responses. RESULTS: A WM of 134 N-cm about the atlanto-occipital complex was determined as the preliminary threshold criteria for an average of 10% total performance decrement. A WM of 164 N-cm was calculated for a corresponding 25% average total performance decrement. CONCLUSIONS: The presented work is the first of its kind specifically for dismounted Soldiers. Research is underway to validate these limits and develop dismounted injury risk guidance.

Fracture Injury Risk of the Restrained Mandible to Anterior-Posterior Blunt Impacts.

This study describes the results of anterior-posterior impacts conducted on the mandibles of 22 male postmortem human subjects (PMHSs). The objective of this study was to develop an injury criterion for the mandible based on blunt impact while the jaw was restrained. Previous studies have attempted to characterize the injury risk of blunt impact to the mandible; however, due to the translation of the mandible during impact and a limited number of fractured specimens, previous studies were not able to produce an injury criterion. Blunt impact to a restrained mandible is relevant to a wide array of helmeted individuals, including the military population and sports that require helmets with chinstraps. Therefore, in this study, specimens were positioned with restrained jaws and impacted using a monorail drop tower with a gravity-driven cylindrical impactor. Nineteen of 22 specimens sustained at least one fracture during testing. Injury cases had an average impact energy of 15.0 ± 5.7 J (11.1 ± 4.2 ft-lb) and a fracture force of 2684 ± 726 N (603 ± 163 lbf). Results were used to generate an impactor force based injury criterion through survival analysis. Risk of injury was modeled using a Weibull distribution and a 50% risk of injury was found to occur at approximately 2834 N (637 lbf). The developed injury risk curve can be used to characterize injury to the restrained mandible for future testing and research studies, especially in the development of maxillofacial protective equipment.

A Novel Application of Head Tracking Data in the Analysis and Assessment of Operational Cervical Spine Range of Motion for Army Aviators.

INTRODUCTION: Neck pain among rotary-wing aviators has been established as an important issue in the military community, yet no U.S. Army regulation defines exactly what cervical spine range of motion (CROM) is adequate for flight. This lack of regulation leaves flight surgeons to subjectively determine whether an aviator affected by limited CROM is fit to maintain flight status. The U.S. Army Aeromedical Research Laboratory is conducting a study among AH-64 and UH-60 pilots to define CROM requirements in simulated and actual flight using optical head tracking equipment. Presented here is a preliminary analysis of head position data from a pilot and co-pilot in two AH-64 missions. METHODS: Maintenance data recorder (MDR) files from two AH-64 missions were provided by the Apache Attack Helicopter Project Management Office. Data were filtered down to three-dimensional pilot and co-pilot head position data and each data point was analyzed to determine neck posture. These neck postures were then categorized as neutral, mild, and severe for flexion/extension, lateral bending, and twist rotation postural categories. RESULTS: Twist rotation postures reached 90 degrees, particularly early in the flight; additionally, a few instances of 90-degree lateral bends were observed. Co-pilots spent more time than pilots in mild and severe twist rotation posture for both flights. Co-pilots also spend a high percentage of time in mild flexion and twist rotation. CONCLUSION: This investigation provides a proof of concept for analysis of head tracking data from MDR files as a surrogate measure of neck posture in order to estimate CROM requirements in rotary-wing military flight missions. Future studies will analyze differences in day and night flights, pilot versus co-pilot CROM, and neck movement frequency.

Pelvic Injury Risk Curves for the Military Populations From Lateral Impact.

INTRODUCTION: Current methods for transporting military troops include nonstandard seating orientations, which may result in novel injuries because of different types/directions of loading impact. The objective of this study is to develop pelvic injury risk curves (IRCs) under lateral impacts from human cadaver tests using survival analysis for application to military populations. METHODS: Published data from lateral impacts applied to whole-body cadaver specimens were analyzed. Forces were treated as response variables. Demographics and body mass index (BMI) were covariates. Injury risk curves were developed for forces without covariates, for males, females, 83 kg body mass, and 25 kg/m2 BMI. Mean and ± 95% confidence interval IRCs, normalized confidence interval sizes at discrete risk levels, and quality indices were obtained for each metric-covariate combination curve. RESULTS: Mean age, stature, total body mass, and BMI were 70.1 ± 8.6 years, 1.67 ± 0.1 m, 67.0 ± 14.4 kg, and 23.9 ± 3.97 kg/m2, respectively. For a total body mass of 83 kg, peak forces at 10%, 25%, and 50% probability levels were 5.7 kN, 7.4 kN, and 9.6 kN, respectively. For males, peak forces at the 10%, 25%, and 50% probability levels were 4.8 kN, 6.4 kN, and 8.4 kN, respectively. For females, peak forces at the 10%, 25%, and 50% probability levels were 3.0 kN, 4.0 kN, and 5.2 kN, respectively. Other data and risk curves are given. CONCLUSIONS: The IRCs developed in this study can be used as injury criteria for the crashworthiness of future generation military vehicles. The introduction of BMI, sex, and total body mass as covariates quantified their contributions. These IRCs can be used with finite element models to assess and predict injury in impact environments to advance Soldier safety. Manikins specific to relevant military anthropometry may be designed and/or evaluated with the present IRCs to assess and mitigate musculoskeletal injuries associated with this posture and impact direction.

Mass Properties Comparison of Dismounted and Ground-Mounted Head-Supported Mass Configurations to Existing Performance and Acute Injury Risk Guidelines.

In order to limit the aviator's exposure to potentially unsafe helmet configurations, the U.S. Army Aeromedical Research Laboratory (USAARL) developed the USAARL Head-supported mass (HSM) Performance Curve and Acute Injury Risk Curve as guidelines for Army aviation HSM. These Curves remain the only established guidelines for Army HSM, but have limited applicability outside of the aviation environment. Helmet developers and program managers have requested guidelines be developed for the dismounted, ground-mounted, and airborne operating environments that consider currently fielded and proposed HSM configurations. The aim of this project was to measure mass properties (mass and center of mass offset) of currently fielded and proposed HSM configurations and compare them against the existing USAARL HSM Curve guidelines. Mass properties were collected for 71 unique dismounted and ground-mounted HSM configurations. None of the 71 HSM configurations met the Acute Injury Risk Curve recommendations, and only 11 of the 71 configurations met Performance Curve recommendations. While some helmets fell within acceptable limits, the addition of night vision goggles and protective masks pushed all configurations outside of the recommended guidelines. Future guidelines will need to be expanded to consider the operating environment, movement techniques, and primary mechanism of injury.

Preliminary Investigation of Skull Fracture Patterns Using an Impactor Representative of Helmet Back-Face Deformation.

Military combat helmets protect the wearer from a variety of battlefield threats, including projectiles. Helmet back-face deformation (BFD) is the result of the helmet defeating a projectile and deforming inward. Back-face deformation can result in localized blunt impacts to the head. A method was developed to investigate skull injury due to BFD behind-armor blunt trauma. A representative impactor was designed from the BFD profiles of modern combat helmets subjected to ballistic impacts. Three post-mortem human subject head specimens were each impacted using the representative impactor at three anatomical regions (frontal bone, right/left temporo-parietal regions) using a pneumatic projectile launcher. Thirty-six impacts were conducted at energy levels between 5 J and 25 J. Fractures were detected in two specimens. Two of the specimens experienced temporo-parietal fractures while the third specimen experienced no fractures. Biomechanical metrics, including impactor acceleration, were obtained for all tests. The work presented herein describes initial research utilizing a test method enabling the collection of dynamic exposure and biomechanical response data for the skull at the BFD-head interface.

Development of an injury risk curve for pelvic fracture in vertical loading environments.

OBJECTIVE: Pelvis injury mechanisms are dependent upon loading direction (frontal, lateral, and vertical). Studies exist on the frontal and lateral modes; however, similar studies in the vertical mode are relatively sparse. Injury risk curves and response corridors are needed to delineate the biomechanical responses. The objective of the study was to derive risk curves for pelvis injuries using postmortem human subjects (PMHSs). METHODS: Published data from whole-body PMHSs loaded axially through the pelvis were analyzed. Accelerometers were placed on the pelvis/sacrum and seat. Specimens were loaded along the inferior to superior direction using a horizontal sled or a vertical accelerator device. Specimens were positioned supine in the horizontal sled and seated upright on the vertical accelerator. Pre- and posttest images were obtained and autopsies were completed to document the pathology. Variables used in the development of risk curves included velocity, acceleration, time to peak acceleration, pulse duration of acceleration, and jerk for the seat and sacrum. Survival analysis was used for risk curves. To determine the best predictor of pelvis injury, the Brier Score metric (BSM) was used. The best parametric distribution was determined using the corrected Akaike information criterion (AICc). Injury data points were treated as either uncensored or left/interval censored. Noninjury data points were treated as right censored. RESULTS: Twenty-four PMHS specimens were identified from 3 published data sets. Fifteen PMHS specimens sustained injuries and 9 remained intact. The BSM ranged from 1.24 to 24.75 and, in general, the BSMs for the seat metric-related scores were greater than the sacrum data. The sacrum acceleration was the optimal metric for predicting pelvis tolerance (lowest BSM). The Weibull distribution had the lowest AICc, with right and left/interval-censored data. This was also true when injury data were treated as exact (uncensored) observations. The 50% probability of injury was associated with 229 G for the uncensored analysis and 139 G for the censored analysis, and the quality indices in both cases were in the "good" range. CONCLUSIONS: Statistical determination of the best injury metric will help improve the accuracy of injury prediction, prioritize instrumentation choice in dummy development, and improve design criteria for crash mitigation. The present study showed that injury risk curves using response data are better biomechanical descriptors of human responses than exposure data. These data are important in automotive safety because complex loading of the pelvis, including submarining, occurs in frontal car crashes.

Cervical spine injury biomechanics: Applications for under body blast loadings in military environments.

BACKGROUND: While cervical spine injury biomechanics reviews in motor vehicle and sports environments are available, there is a paucity of studies in military loadings. This article presents an analysis on the biomechanics and applications of cervical spine injury research with an emphasis on human tolerance for underbody blast loadings in the military. METHODS: Following a brief review of published military studies on the occurrence and identification of field trauma, postmortem human subject investigations are described using whole body, intact head-neck complex, osteo-ligamentous cervical spine with head, subaxial cervical column, and isolated segments subjected to differing types of dynamic loadings (electrohydraulic and pendulum impact devices, free-fall drops). FINDINGS: Spine injuries have shown an increasing trend over the years, explosive devices are one of the primary causal agents and trauma is attributed to vertical loads. Injuries, mechanisms and tolerances are discussed under these loads. Probability-based injury risk curves are included based on loading rate, direction and age. INTERPRETATION: A unique advantage of human cadaver tests is the ability to obtain fundamental data to delineate injury biomechanics and establish human tolerance and injury criteria. Definitions of tolerances of the spine under vertical loads based on injuries have implications in clinical and biomechanical applications. Primary outputs such as forces and moments can be used to derive secondary variables such as the neck injury criterion. Implications are discussed for designing anthropomorphic test devices that may be used to predict injuries in underbody blast environments and improve the safety of military personnel.

A kinematic and anthropometric study of the upper cervical spine and the occipital condyles.

The center of rotation (COR) of the upper cervical spine (UCS) is an important biomechanical landmark that is used to determine upper neck moment, particularly when evaluating injury risk in the automotive environment. However, neither the location of the UCS CORs nor the occipital condyles (OCs), which are frequently the referenced landmark for UCS CORs, have been measured with respect to known cranial landmarks. This study determines the CORs using pure bending (+/-3.5 N m), 3D digitization, and image analysis. Landmarks digitized included the OCs, external auditory meatus (EAM), infraorbital foramen, zygion, nasion, and the foramen magnum. The centroid of each occipital condylar surface (area 301+/-29.8 mm(2); length 25.4+/-3.2 mm) was located 18.4 mm posterior, 54.4 mm medial, and 31.0 mm inferior of the EAM. The UCS CORs were distinct: On average, OC-C1 CORs (22.5 mm posterior and 22.6 mm inferior to the left EAM) were superior and more posterior of OCs; C1-C2 CORs (7.4 mm posterior and 46.7 mm inferior to the left EAM) were inferior and more anterior of OC; and OC-C2 CORs (17.0 mm posterior and 33.1 mm inferior to the left EAM) were aligned with OC. There was a statistically significant difference between the percentage of UCS rotation in C1-C2 and OC-C1; 45% of the flexion and 71% of the extension occurred in OC-C1. Details of an anatomical variant with two pairs of distinct condylar surfaces are also presented.

The human cervical spine in tension: effects of frame and fixation compliance on structural responses.

There is little data available on the responses of the human cervical spine to tensile loading. Such tests are mechanistically and technically challenging due to the variety of end conditions that need to be imposed and the difficulty of strong specimen fixation. As a result, spine specimens need to be tested using fairly complex, and potentially compliant, apparati in order to fully characterize the mechanical responses of each specimen. This, combined with the relatively high stiffness of human spine specimens, can result in errors in stiffness calculations. In this study, 18 specimen preparations were tested in tension. Tests were performed on whole cervical spines and on spine segments. On average, the linear stiffness of the segment preparations was 257 N/mm, and the stiffness of the whole cervical spine was 48 N/mm. The test frame was found to have a stiffness of 933 N/mm. Assembling a whole spine from a series combination of eight segments with a stiffness of 257 N/mm results in an estimated whole spine stiffness of 32.1 N/mm (32% error). The segment stiffnesses were corrected by assuming that the segment preparation stiffness is a series combination of the stiffnesses of the segment and the frame. This resulted in an average corrected segment stiffness of 356 N/mm. Taking the frame compliance into account, the whole spine stiffness is 51 N/mm. A series combination of eight segments using the corrected stiffnesses results in an estimated whole spine stiffness of 45.0 N/mm (12% error). We report both linear and nonlinear stiffness models for male spines and conclude that the compliance of the frame and the fixation must be quantified in all tension studies of spinal segments. Further, reported stiffness should be adjusted to account for frame and fixation compliance.

Variation of neck muscle strength along the human cervical spine.

The aim of this study was to describe and explain the variation of neck muscle strength along the cervical spine. A three-dimensional model of the head-neck complex was developed to test the hypothesis that the moment-generating capacity of the neck musculature is lower in the upper cervical spine than in the lower cervical spine. The model calculations suggest that the neck muscles can protect the lower cervical spine from injury during extension and lateral bending. The maximum flexor moment developed in the lower cervical spine was 2 times higher than that developed in the upper spine. The model also predicted that the neck musculature is 30% stronger in the lower cervical spine during lateral bending. Peak compressive forces (up to 3 times body weight) were higher in the lower cervical spine. These results are consistent with the clinical finding that extension loading of the neck often leads to injuries in the upper cervical spine. Analysis of the model results showed that neck flexor strength was greater in the lower cervical spine because of the relatively large size of the sternocleidomastoid muscle. The hyoid muscles developed significant flexor moments about the joints of the upper cervical spine, as these muscles had relatively large flexor moment arms; however, this effect was offset by the action of the sternocleidomastoid, which exerted a large extensor moment in the upper spine. Lateral bending strength of the neck muscles was governed by geometry (i.e., moment arms) rather than by muscle size.

Improved estimation of human neck tensile tolerance: reducing the range of reported tolerance using anthropometrically correct muscles and optimized physiologic initial conditions.

Unlike other modes of loading, the tolerance of the human neck in tension depends heavily on the load bearing capabilities of the muscles of the neck. Because of limitations in animal models, human cadaver, and volunteer studies, computational modeling of the cervical spine is the best way to understand the influence of muscle on whole neck tolerance to tension. Muscle forces are a function of the muscle's geometry, constitutive properties, and state of activation. To generate biofidelic responses for muscle, we obtained accurate three-dimensional muscle geometry for 23 pairs of cervical muscles from a combination of human cadaver dissection and 50(th) percentile male human volunteer magnetic resonance imaging and incorporated those muscles into a computational model of the ligamentous spine that has been previously validated against human cadaver studies. To account for multiple origins, insertions, and lines of action, 82 muscle partition pairs, including nonlinear passive and active elastic components, were included in the model. Using optimization, we determined physiologically appropriate levels of muscle activation for each of the 23 muscles simulating relaxed (no pre-impact awareness) and tensed (pre-impact awareness) states. Unlike all prior neck models, both of these states of activation were mechanically stable in an upright neutral anatomic position resisting gravity as an initial condition prior to tensile loading. Tensile forces were then applied to the models at the head center of gravity at 500 N/s. Both states of activation predicted injury above C3, consistent with clinically observed tensile neck injuries. Using these more physiologically reasonable estimates of muscle activation significantly narrowed the range of estimates of 50(th) percentile male tolerance to tensile loading. Specifically, while the ligamentous spine fails in tension at an average of 1.8 kN and the total muscle activation predicts neck failure at 4.8 kN, the optimized muscle forces resulted in a whole neck tolerance of 3.1 kN and 3.7 kN for the relaxed and tensed neck, respectively. Moreover, these techniques provide quantitative estimates of load sharing between the neck musculature and ligamentous spine that will be useful in the creation of next generation ATD necks.