The diagnostic precision of computed tomography for traumatic cervical spine injury: An in vitro biomechanical investigation.

BACKGROUND: CT is considered the best method for vertebral fracture detection clinically, but its efficacy in laboratory studies is unknown. Therefore, our objective was to determine the sensitivity, precision, and specificity of high-resolution CT imaging compared to detailed anatomic dissection in an axial compression and lateral bending cervical spine biomechanical injury model. METHODS: 35 three-vertebra human cadaver cervical spine specimens were impacted in dynamic axial compression (0.5 m/s) at one of three lateral eccentricities (low 5% of the spine transverse diameter, middle 50%, high 150%) and two end conditions (19 constrained lateral translation and 16 unconstrained). All specimens were imaged using high resolution CT imaging (246 µm). Two clinicians (spine surgeon and neuroradiologist) diagnosed the vertebral fractures based on 34 discrete anatomical structures using both the CT images and anatomical dissection. FINDINGS: The sensitivity of CT was highest for fractures of the facet joint (59%) and vertebral endplate (57%), and was lowest for pedicle (13%) and lateral mass fractures (23%). The precision of CT was highest for spinous process fractures (83%) and lowest for pedicle (21%), uncinate process and lateral mass (both 23%) fractures. The specificity of CT exceeded 90% for all fractures. The Kappa value between the two reviewers was 0.52, indicating moderate agreement. INTERPRETATION: In this in vitro cervical spine injury model, high resolution CT scanning missed many fractures, notably those of the lateral mass and pedicle. This finding is potentially important clinically, as the integrity of these structures is important to clinical stability and surgical fixation planning.

The effect of end condition on spine segment biomechanics in compression with lateral eccentricity.

During axial impact compression of the cervical spine, injury outcome is highly dependent on initial posture of the spine and the orientation, frictional properties and stiffness of the impact surface. These properties influence the "end condition" the spine experiences in real-world impacts. The effect of end condition on compression and sagittal plane bending in laboratory experiments is well-documented. The spine is able to escape injury in an unconstrained flexion-inducing end condition (e.g. against an angled, low friction surface), but when the end condition is constrained (e.g. head pocketing into a deformable surface) the following torso can compress the aligned spine causing injury. The aim of this study was to determine whether this effect exists under combined axial compression and lateral bending. Over two experimental studies, twenty-four human three vertebra functional spinal units were subjected to controlled dynamic axial compression at two levels of laterally eccentric force and in two end conditions. One end condition allowed the superior spine to laterally rotate and translate (T-Free) and the other end condition allowed only lateral rotation (T-Fixed). Spine kinetics, kinematics, injuries and occlusion of the spinal canal were measured during impact and pre- and post-impact flexibility. In contrast to typical spine responses in flexion-compression loading, the cervical spine specimens in this study did not escape injury in lateral bending when allowed to translate laterally. The specimen group that allowed lateral translation during compression had more injuries at high laterally eccentric force, saw greater peak canal occlusions and post-impact flexibility than constrained specimens.

The Effect of Compression Applied Through Constrained Lateral Eccentricity on the Failure Mechanics and Flexibility of the Human Cervical Spine.

In contrast to sagittal plane spine biomechanics, little is known about the response of the cervical spine to axial compression with lateral eccentricity of the applied force. This study evaluated the effect of lateral eccentricity on the kinetics, kinematics, canal occlusion, injuries, and flexibility of the cervical spine in translationally constrained axial impacts. Eighteen functional spinal units were subjected to flexibility tests before and after an impact. Impact axial compression was applied at one of three lateral eccentricity levels based on percentage of vertebral body width (low = 5%, medium = 50%, high = 150%). Injuries were graded by dissection. Correlations between intrinsic specimen properties and injury scores were examined for each eccentricity group. Low lateral force eccentricity produced predominantly bone injuries, clinically recognized as compression injuries, while medium and high eccentricity produced mostly contralateral ligament and/or disc injuries, an asymmetric pattern typical of lateral loading. Mean compression force at injury decreased with increasing lateral eccentricity (low = 3098 N, medium = 2337 N, and high = 683 N). Mean ipsilateral bending moments at injury were higher at medium (28.3 N·m) and high (22.9 N·m) eccentricity compared to low eccentricity specimens (0.1 N·m), p < 0.05. Ipsilateral bony injury was related to vertebral body area (VBA) (r = -0.974, p = 0.001) and disc degeneration (r = 0.851, p = 0.032) at medium eccentricity. Facet degeneration was correlated with central bony injury at high eccentricity (r = 0.834, p = 0.036). These results deepen cervical spine biomechanics knowledge in circumstances with coronal plane loads.

A neck compression injury criterion incorporating lateral eccentricity.

There is currently no established injury criterion for the spine in compression with lateral load components despite this load combination commonly contributing to spinal injuries in rollover vehicle crashes, falls and sports. This study aimed to determine an injury criterion and accompanying tolerance values for cervical spine segments in axial compression applied with varying coronal plane eccentricity. Thirty-three human cadaveric functional spinal units were subjected to axial compression at three magnitudes of lateral eccentricity of the applied force. Injury was identified by high-speed video and graded by spine surgeons. Linear regression was used to define neck injury tolerance values based on a criterion incorporating coronal plane loads accounting for specimen sex, age, size and bone density. Larger coronal plane eccentricity at injury was associated with smaller resultant coronal plane force. The level of coronal plane eccentricity at failure appears to distinguish between the types of injuries sustained, with hard tissue structure injuries more common at low levels of eccentricity and soft tissue structure injuries more common at high levels of eccentricity. There was no relationship between axial force and lateral bending moment at injury which has been previously proposed as an injury criterion. These results provide the foundation for designing and evaluating strategies and devices for preventing severe spinal injuries.

Shear stiffness in the lower cervical spine: Effect of sequential posterior element injury.

The aim of this study was to determine the effect of the posterior ligaments and facet joints on the shear stiffness of lower cervical functional spinal units in anterior, posterior, and lateral shear. Five functional spinal units were loaded in anterior, posterior, and right lateral shear up to 100 N using a custom-designed apparatus in a materials testing machine. Specimens were tested in three conditions: intact, with the posterior ligaments severed, and with the facet joints removed. There was a significant decrease in anterior stiffness in the 20-100 N load range from 186 (range: 98-327) N/mm in the intact condition to 105 (range: 78-142) N/mm in the disc-only condition (p = 0.03). Posterior stiffness between these condition decreased significantly from 134 (range: 92-182) N/mm to 119 (range: 83-181) N/mm (p = 0.03). There was no significant effect of posterior ligament removal on shear stiffness. No significant differences were found in the lateral direction or in the 0-20 N range for any direction. Under a 100-N shear load, the facet joints played a significant role in the stiffness of the cervical spine in the anterior-posterior direction, but not in the lateral direction.

A novel sideways fall simulator to study hip fractures ex vivo.

Falls to the side are the leading cause of hip fractures in the elderly. The load that a person experiences during a fall cannot be measured with volunteers for ethical reasons. To evaluate injurious loads, while considering relevant energy input and body posture for a sideways fall, a subject-specific cadaveric impact experiment was developed. Full cadaveric femur-pelvis constructs (N = 2) were embedded in surrogate soft tissue material and attached to metallic surrogate lower limbs. The specimens were then subjected to an inverted pendulum motion, simulating a fall to the side with an impact to the greater trochanter. The load at the ground and the deformation of the pelvis were evaluated using a 6-axis force transducer and two high-speed cameras. Post-test, a trauma surgeon (PG) evaluated specimen injuries. Peak ground contact forces were 7132 N and 5641 N for the fractured and non-fractured specimen, respectively. We observed a cervical fracture of the femur in one specimen and no injuries in a second specimen, showing that the developed protocol can be used to differentiate between specimens at high and low fracture risk.

Damage Identification on Vertebral Bodies During Compressive Loading Using Digital Image Correlation.

MINI: Identifying fracture is important for understanding vertebral mechanics. Isolated cadaveric thoracolumbar vertebrae were compressed, and surface strains were measured using digital image correlation. Fracture locations from video analysis were qualitatively similar to the locations of high compressive strains and local damage occurred before the maximum force was reached. STUDY DESIGN: Ex vivo compression experiments on isolated cadaveric vertebrae. OBJECTIVE: To qualitatively compare the fracture locations identified in video analysis with the locations of high compressive strain measured with digital image correlation (DIC) on vertebral bodies and to evaluate the timing of local damage to the cortical shell relative to the global yield force. SUMMARY OF BACKGROUND DATA: In previous ex vivo experiments, cortical bone fracture has been identified using various methods including acoustic emission sensors, strain gages, video analysis, or force signals. These methods are, however, limited in their ability to detect the location and timing of fracture. We propose use of DIC, a noncontact optical technique that measures surface displacement, to quantify variables related to damage. METHODS: Isolated thoracolumbar human cadaveric vertebral bodies (n = 6) were tested in compression to failure at a quasi-static rate, and the force applied was measured using a load cell. The surface displacement and strain were measured using DIC. Video analysis was performed to identify fractures. RESULTS: The location of fractures identified in the video corresponded well with the locations of high compressive strain on the bone. Before reaching the global yield force, more than 10% of the DIC measurements reached a minimum principal strain of 1.0%, a previously reported threshold for cortical bone damage. CONCLUSION: DIC measurements provide an objective measure that can be used to identify the location and timing of fractures during ex vivo vertebral experiments. This is important for understanding fracture mechanics and for validating vertebral computational models that incorporate failure. LEVEL OF EVIDENCE: N /A.

Responses of the Acutely Injured Spinal Cord to Vibration that Simulates Transport in Helicopters or Mine-Resistant Ambush-Protected Vehicles.

In the military environment, injured soldiers undergoing medical evacuation via helicopter or mine-resistant ambush-protected vehicle (MRAP) are subjected to vibration and shock inherent to the transport vehicle. We conducted the present study to assess the consequences of such vibration on the acutely injured spinal cord. We used a porcine model of spinal cord injury (SCI). After a T10 contusion-compression injury, animals were subjected to 1) no vibration (n = 7-8), 2) whole body vibration at frequencies and amplitudes simulating helicopter transport (n = 8), or 3) whole body vibration simulating ground transportation in an MRAP ambulance (n = 7). Hindlimb locomotor function (using Porcine Thoracic Injury Behavior Scale [PTIBS]), Eriochrome Cyanine histochemistry and biochemical analysis of inflammatory and neural damage markers were analyzed. Cerebrospinal fluid (CSF) expression levels for monocyte chemoattractant protein-1 (MCP-1), interleukin (IL)-6, IL-8, and glial fibrillary acidic protein (GFAP) were similar between the helicopter or MRAP group and the unvibrated controls. Spared white/gray matter tended to be lower in the MRAP-vibrated animals than in the unvibrated controls, especially rostral to the epicenter. However, spared white/gray matter in the helicopter-vibrated group appeared normal. Although there was a relationship between the extent of sparing and the extent of locomotor recovery, no significant differences were found in PTIBS scores between the groups. In summary, exposures to vibration in the context of ground (MRAP) or aeromedical (helicopter) transportation did not significantly impair functional outcome in our large animal model of SCI. However, MRAP vibration was associated with increased tissue damage around the injury site, warranting caution around exposure to vehicle vibration acutely after SCI.

Defining the inherent stability of degenerative spondylolisthesis: a systematic review.

OBJECT A range of surgical options exists for the treatment of degenerative lumbar spondylolisthesis (DLS). The chosen technique inherently depends on the stability of the DLS. Despite a substantial body of literature dedicated to the outcome analysis of numerous DLS procedures, no consensus has been reached on defining or classifying the disorder with respect to stability or the role that instability should play in a treatment algorithm. The purpose of this study was to define grades of stability and to develop a guide for deciding on the optimal approach in surgically managing patients with DLS. METHODS The authors conducted a qualitative systematic review of clinical or biomechanical analyses evaluating the stability of and surgical outcomes for DLS for the period from 1990 to 2013. Research focused on nondegenerative forms of spondylolisthesis or spinal stenosis without associated DLS was excluded. The primary extracted results were clinical and radiographic parameters indicative of DLS instability. RESULTS The following preoperative parameters are predictors of stability in DLS: restabilization signs (disc height loss, osteophyte formation, vertebral endplate sclerosis, and ligament ossification), no disc angle change or less than 3 mm of translation on dynamic radiographs, and the absence of low-back pain. The validity and magnitude of each parameter's contribution can only be determined through appropriately powered prospective evaluation in the future. Identifying these parameters has allowed for the creation of a preliminary DLS instability classification (DSIC) scheme based on the preoperative assessment of DLS stability. CONCLUSIONS Spinal stability is an important factor to consider in the evaluation and treatment of patients with DLS. Qualitative assessment of the best available evidence revealed clinical and radiographic parameters for the creation of the DSIC, a decision aid to help surgeons develop a method of preoperative evaluation to better stratify DLS treatment options.

The effect of whole-body resonance vibration in a porcine model of spinal cord injury.

Whole-body vibration has been identified as a potential stressor to spinal cord injury (SCI) patients during pre-hospital transportation. However, the effect that such vibration has on the acutely injured spinal cord is largely unknown, particularly in the frequency domain of 5 Hz in which resonance of the spine occurs. The objective of the study was to investigate the consequences of resonance vibration on the injured spinal cord. Using our previously characterized porcine model of SCI, we subjected animals to resonance vibration (5.7±0.46 Hz) or no vibration for a period of 1.5 or 3.0 h. Locomotor function was assessed weekly and cerebrospinal fluid (CSF) samples were collected to assess different inflammatory and injury severity markers. Spinal cords were evaluated histologically to quantify preserved white and gray matter. No significant differences were found between groups for CSF levels of monocyte chemotactic protein-1, interleukin 6 (IL-6) and lL-8. Glial fibrillary acidic protein levels were lower in the resonance vibration group, compared with the non-vibrated control group. Spared white matter tissue was increased within the vibrated group at 7 d post-injury but this difference was not apparent at the 12-week time-point. No significant difference was observed in locomotor recovery following resonance vibration of the spine. Here, we demonstrate that exposure to resonance vibration for 1.5 or 3 h following SCI in our porcine model is not detrimental to the functional or histological outcomes. Our observation that a 3.0-h period of vibration at resonance frequency induces modest histological improvement at one week post-injury warrants further study.

Characterization of the behavior of a novel low-stiffness posterior spinal implant under anterior shear loading on a degenerative spinal model.

PURPOSE: Dynamic implants have been developed to address potential adjacent level effects due to rigid instrumentation. Rates of revision surgeries may be reduced by using improved implants in the primary surgery. Prior to clinical use, implants should be rigorously tested ex vivo. The objective of our study was to characterize the load-sharing and kinematic behavior of a novel low-stiffness spinal implant. METHODS: A human cadaveric model of degenerative spondylolisthesis was tested in shear. Lumbar functional spinal units (N = 15) were tested under a static 300 N axial compression force and a cyclic anterior shear force (5-250 N). Translation was tracked with a motion capture system. A novel implant was compared to three standard implants with shear stiffness ranging from low to high. All implants were instrumented with strain gauges to measure the supported shear force. Each implant was affixed to each specimen, and the specimens were tested intact and in two progressively destabilized states. RESULTS: Specimen condition and implant type affected implant load-sharing and specimen translation (p < 0.0001). Implant load-sharing increased across all degeneration-simulating specimen conditions and decreased across the three standard implants (high- to low-stiffness). Translation increased with the three standard implants (trend). The novel implant behaved similarly to the medium-stiffness implant (p > 0.2). CONCLUSIONS: The novel implant behaved similarly to the medium-stiffness implant in both load-sharing and translation despite having a different design and stiffness. Complex implant design and specimen-implant interaction necessitate pre-clinical testing of novel implants. Further in vitro testing in axial rotation and flexion-extension is recommended as they are highly relevant loading directions for non-rigid implants.

The effect of disc degeneration on anterior shear translation in the lumbar spine.

Many pathologies involving disc degeneration are treated with surgery and spinal implants. It is important to understand how the spine behaves mechanically as a function of disc degeneration. Shear loading is especially relevant in the natural and surgically stabilized lumbar spine. The objective of our study was to determine the effect of disc degeneration on anterior translation of the lumbar spine under shear loading. We tested 30 human cadaveric functional spinal units (L3-4 and L4-5) in anterior shear loading. First, the specimens were imaged in a 1.5 T magnetic resonance scanner. The discs were graded according to the Pfirrmann classification. The specimens were then loaded up to 250 N in anterior shear with an axial compression force of 300 N. Motion of the vertebrae was captured with an optoelectronic camera system. Inter- and intra-observer reliability for disc grading was determined (Cohen's and Fleiss' Kappa), and a non-parametric test was performed on the translation data to characterize the effect of disc degeneration on this parameter. We found fair to moderate agreement between and within observers for the disc grading. We found no significant effect of disc degeneration on anterior shear translation (Kruskal-Wallis ANOVA). Our results indicate that disc degeneration, as classified with the Pfirrmann scale, does not predict lumbar spinal motion in shear.

An in vitro model of degenerative lumbar spondylolisthesis.

STUDY DESIGN: A biomechanical human cadaveric study. OBJECTIVE: To create a biomechanical model of low-grade degenerative lumbar spondylolisthesis (DLS), defined by anterior listhesis, for future testing of spinal instrumentation. SUMMARY OF BACKGROUND DATA: Current spinal implants are used to treat a multitude of conditions that range from herniated discs to degenerative diseases. The optimal stiffness of these instrumentation systems for each specific spinal condition is unknown. Ex vivo models representing degenerative spinal conditions are scarce in the literature. A model of DLS for implant testing will enhance our understanding of implant-spine behavior for specific populations of patients. METHODS: Four incremental surgical destabilizations were performed on 8 lumbar functional spinal units. The facet complex and intervertebral disc were targeted to represent the tissue changes associated with DLS. After each destabilization, the specimen was tested with: (1) applied shear force (-50 to 250 N) with a constant axial compression force (300 N) and (2) applied pure moments in flexion-extension, lateral bending and axial rotation (±5 Nm). Relative motion between the 2 vertebrae was tracked with a motion capture system. The effect of specimen condition on intervertebral motion was assessed for shear and flexibility testing. RESULTS: Shear translation increased, specimen stiffness decreased and range of motion increased with specimen destabilization (P < 0.0002). A mean anterior translation of 3.1 mm (SD 1.1 mm) was achieved only after destabilization of both the facet complex and disc. Of the 5 specimen conditions, 3 were required to achieve grade 1 DLS: (1) intact, (3) a 4-mm facet gap, and (5) a combined nucleus and annulus injury. CONCLUSION: Destabilization of both the facet complex and disc was required to achieve anterior listhesis of 3.1 mm consistent with a grade 1 DLS under an applied shear force of 250 N. Sufficient listhesis was measured without radical specimen resection. Important anatomical structures for supporting spinal instrumentation were preserved such that this model can be used in future to characterize behavior of novel instrumentation prior to clinical trials.

Load transfer characteristics between posterior spinal implants and the lumbar spine under anterior shear loading: an in vitro investigation.

STUDY DESIGN: A biomechanical human cadaveric study. OBJECTIVE: To determine the percentage of shear force supported by posterior lumbar spinal devices of varying stiffnesses under anterior shear loading in a degenerative spondylolisthesis model. SUMMARY OF BACKGROUND DATA: Clinical studies have demonstrated beneficial results of posterior arthrodesis for the treatment of degenerative spinal conditions with instability. Novel spinal implants are designed to correct and maintain spinal alignment, share load with the spine, and minimize adjacent level stresses. The optimal stiffness of these spinal systems is unknown. To our knowledge, low-stiffness posterior instrumentation has not been tested under an anterior shear force, a highly relevant force to be neutralized in the clinical case of degenerative spondylolisthesis. METHODS: The effects of implant stiffness and specimen condition on implant load and intervertebral motion were assessed in a biomechanical study. Fifteen human cadaveric lumbar functional spinal units were tested under a static 300 N axial compression force and a cyclic anterior shear force (5-250 N). Implants (high-stiffness [HSI]: ø 5.5-mm titanium, medium-stiffness [MSI]: ø 6.35 × 7.2-mm oblong PEEK, and low-stiffness [LSI]: ø 5.5-mm round PEEK) instrumented with strain gauges were used to calculate loads and were tested in each of 3 specimen conditions simulating degenerative changes: intact, facet instability, and disc instability. Intervertebral motions were measured with a motion capture system. RESULTS: As predicted, implants supported a significantly greater shear force as the specimen was progressively destabilized. Mean implant loads as a percent of the applied shear force in order of increasing specimen destabilization for the HSI were 43%, 67%, and 76%; mean implant loads for the MSI were 32%, 56%, and 77%; and mean implant loads for the LSI were 18%, 35%, and 50%. Anterior translations increased with decreasing implant stiffness and increasing specimen destabilization. CONCLUSION: Implant shear stiffness significantly affected the load sharing between the implant and the natural spine in anterior shear ex vivo. Low-stiffness implants transferred significantly greater loads to the spine. This study supports the importance of load-sharing behavior when designing new implants.

Shear force measurements on low- and high-stiffness posterior fusion devices.

Low-stiffness posterior fusion devices for the lumbar spine have been developed to treat degenerative spinal conditions. However, the demands on an implant vary between a stable motion segment and one which exhibits a significant degree of sagittal plane instability. Shear motion in the antero-posterior direction is a relevant mode of instability for clinical conditions such as degenerative lumbar spondylolisthesis. Shear load-sharing between the implant and spine in conditions of antero-posterior instability has not been studied, nor have there been comparisons between traditional rigid implants and novel low-stiffness implants. The objective of this study was to develop a method to measure in vitro shear forces on three clinically relevant fusion implants when they are applied to an unstable model of degenerative spondylolisthesis in a human cadaver spine. Uniaxial strain gauges were affixed to the surface of the implants and a spine-segment-specific calibration method was used to calibrate the strain output to an applied shear force. The accuracy of the force measurements was within 3.4N for all implant types and the repeatability was within 5.4N. The force measurement technique was sufficiently accurate and reliable to conclude that it is suitable for use in in vitro experiments to measure implant shear force.

Pediatric and adult three-dimensional cervical spine kinematics: effect of age and sex through overall motion.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To determine the effect of age and sex on the three-dimensional kinematics of the cervical spine. SUMMARY OF BACKGROUND DATA: Spine kinematics information has important implications for biomechanical model development, anthropomorphic test device development, injury prevention, surgical treatment, and safety equipment design. There is a paucity of data of this type available for children, and it is unknown whether cervical spine kinematics of the pediatric population is different than that of adults. The helical axis of motion (HAM) of the spine provides unique information about the quantity and quality (coupling etc.) of the measured motion. METHODS: Ninety subjects were recruited and divided into 6 groups based on sex and age (young children aged 4-10 years, older children aged 11-17 years, adults aged 25+ years). Subjects actively moved their head in axial rotation, lateral bending, and flexion/extension. An optoelectronic motion analysis system recorded the position of infrared markers placed on the first thoracic vertebrae (T1) and on tight-fitting headgear worn by the subjects. HAM parameters were calculated for the head motion with respect to T1. RESULTS: HAM location in axial rotation and flexion/extension was more anterior in young females compared to adult females. Young females had a more anterior HAM location in flexion/extension compared to young males, indicating an effect of sex. For females, the HAM locations of adults were superior to those of children in flexion/extension and lateral bending whereas in males the HAM locations of adults were inferior to those of children. Age-related differences in HAM orientation were also observed in axial rotation and lateral bending. CONCLUSION.: Cervical spine kinematics vary with age and sex. The variation in spine mechanics based on age and sex found in the present study may indicate general trends that would grow stronger in even younger children (age <4 years).