Load-sharing between anterior and posterior elements in a lumbar motion segment implanted with an artificial disc.

STUDY DESIGN: A nonlinear three-dimensional finite element model of the osteoligamentous L3-L4 motion segment was used to predict changes in posterior element loads as a function of disc implantation and associated surgical procedures. OBJECTIVES: To evaluate the effects of disc implantation on the biomechanics of the posterior spinal elements (including the facet joints, pedicles, and lamina) and on the vertebral bodies. SUMMARY OF BACKGROUND DATA: Although several artificial disc designs have been used clinically, biomechanical data-particularly the change in loads in the posterior elements after disc implantation-are sparse. METHODS: A previously validated intact finite element model was implanted with a ball-and-cup-type artificial disc model via an anterior approach. The implanted model predictions were compared with in vitro data. To study surgical variables, small and large windows were cut into the anulus, and the implant was placed anteriorly and posteriorly within the disc space. The anterior longitudinal ligament was also restored. Models were subjected to either 800 N axial compression force alone or to a combination of 10 N-m flexion-extension moment and 400 N axial preload. Implanted model predictions were compared with those of the intact model. RESULTS: Facet loads were more sensitive to the anteroposterior location of the artificial disc than to the amount of anulus removed. Under 800 N axial compression, implanted models with an anteriorly placed artificial disc exhibited facet loads 2.5 times greater than loads observed with the intact model, whereas posteriorly implanted models predicted no facet loads in compression. Implanted models with a posteriorly placed disc exhibited greater flexibility than the intact and implanted models with anteriorly placed discs. Restoration of the anterior longitudinal ligament reduced pedicle stresses, facet loads, and extension rotation to nearly intact levels. CONCLUSIONS: The models suggest that, by altering placement of the artificial disc in the anteroposterior direction, a surgeon can modulate motion-segment flexuralstiffness and posterior load-sharing, even though the specific disc replacement design has no inherent rotational stiffness.

Evaluation of low back muscle surface EMG signals using wavelets.

OBJECTIVE: To compare the ability of observers to correctly detect the reaction time of erector spinae response to unexpected load by inspecting nonprocessed electromyographic signals versus inspection of wavelet transformed electromyographic signals and versus automatic detection on the same wavelet transformed signals. BACKGROUND: Traditionally, electromyographic signal analysis is performed using Fourier transform based methods. However, muscle response to transients such as unexpected load, have limitations when using these methods of electromyographic processing. DESIGN: A comparison was made of the three methods using the same signals attained during sudden loading of the trunk. METHODS: 11 chronic low back pain patients and eleven normal subjects were investigated in sudden loading. Surface electromyographic signals were obtained from the erector spine muscle at L3. The ability of observers to detect reaction time of erector spinae muscle responses of nonprocessed electromyographic signals versus inspection of wavelet transformed electromyographic signals versus an automatic peak detection program was determined. RESULTS: The results have shown that the spine muscle reaction time was easier and more accurately determined in the wavelet domain rather than in its original signal representation. CONCLUSION: Wavelet transform methods improved the analysis of electromyographic signals in the time domain by facilitating the determination of the time of muscle activity. RELEVANCE: Wavelet transform could be a valuable tool for electromyographic analysis in resolving the psychophysical problem of perception involved in the analysis of nonprocessed signals. In clinical environments, where the speed and the accuracy of the analysis of electromyographic signal is critical, the wavelet based signal processing could be very important.

Is there a rational basis for post-surgical lifting restrictions? 1. Current understanding.

Lifting restrictions postoperatively are quite common, but there appears to be little scientific basis for them. Lifting restrictions are inhibitory in terms of return to work and may be a factor in chronicity. The mean functional spinal motion unit stiffness changes with in vitro or computer-simulated discectomies, facetectomies and laminectomies were reviewed from the literature. We modified the NIOSH lifting equation to include another multiplier related to stiffness change post surgery. The new recommended lifts were computed for different lifting conditions seen in industry. The reduction of rotational stiffness ranged from 21% to 41% for a discectomy, 1% to 59% for a facetectomy and 4% to 16% for a partial laminectomy. The recommended lifts based on our modified equation were adjusted accordingly. There is no rational basis for current lifting restrictions. The risk to the spine is a function of many other variables as well as weight (i.e., distance of weight from body). The adjusted NIOSH guidelines provide a reasonable way to estimate weight restrictions and accommodations such as lifting aids. Such restrictions should be as liberal as possible so as to facilitate, not prevent, return to work. Patients need more advice regarding lifting activities and clinicians should be more knowledgeable about the working conditions and constraints of a given workplace to effectively match the solution to the patient's condition.

Is there a rational basis for post-surgical lifting restrictions? 2. Possible scientific approach.

Lifting restrictions postoperatively are quite common but there appears to be little scientific basis for them. Lifting restricitions are inhibitory in terms of return to work and may be a factor in chronicity. The mean changes in functional spinal motion unit (FSU) stiffness with in vitro or computer-simulated discectomies, facetectomies and laminectomies were reviewed from the literature. We modified the NIOSH lifting equation to include another multiplier related to stiffness change post surgery. The new recommended lifts were computed for different lifting conditions seen in industry. The reduction of rotational stiffness ranged from 21% to 41% for a discectomy, 1% to 59% for a facetectomy and 4% to 16% for a partial laminectomy. The recommended lifts based on our modified equation were adjusted accordingly. There is no rational basis for current lifting resctrictions. The risk to the spine is a function of many other variables as well as weight (i.e., distance of weight from body). The adjusted NIOSH guidelines provide a reasonable way to estimate weight restrictions and accomodations such as lifting aids. Such resitrictions should be as liberal as possible so as to facilitate, not prevent, return to work. Patients need more advice regarding lifting activities and clinicians should be more knowledgeable about the working conditions and constraints of a given workplace to effectively match the solution to the patient's condition.

Cervical electromyographic activity during low-speed rear impact.

Whiplash motion of the neck is characterized by having an extension-flexion motion of the neck. It has been previously assumed that muscles do not play a role in the injury. Eight healthy males were seated in a car seat mounted on a sled. The sled was accelerated by a spring mechanism. Muscle electromyographic (EMG) activity was measured by wire electrodes in semi-spinalis capitis, splenius capitis, and levator scapulae. Surface EMG activity was measured over trapezius and sternocleidomastoideus. Wavelet analysis was used to establish the onset of muscle activity with respect to sled movement. Shorter reaction times were found to be as low as 13.2 ms from head acceleration and 65.6 ms from sled acceleration. Thus the muscles could influence the injury pattern. It is of interest that clinical symptoms are often attributed to muscle tendon injuries.

A review of studies on seated whole body vibration and low back pain.

The paper reviews the epidemiologic evidence linking low back pain (LBP) and exposure to whole body vibration (WBV). Particular emphasis is placed on studies where the exposure is quantified. Biomechanical studies show a resonance at 4-5 Hz. At the resonance the transmissibility exceeds 1.0, and is dependent on seat attenuation, posture and seat back inclination. Increased spinal loading is evidenced by increased muscle activity, muscle fatigue, and disc pressure, and by decreased stature. Physiologic changes also occur with WBV. The risk of LBP can be reduced by vibration damping, good ergonomic design, reducing exposure, and reducing other risks such as lifting.

Kappa Delta Award. Low back pain and whole body vibration.

The investigators describe their multifaceted approach to the study of the relationship between whole body vibration and low back pain. The epidemiologic study was a two center study of drivers and sedentary workers in the United States and Sweden. The vibration exposure was measured in the vehicles. It was found that the career vibration exposure was related to low back, neck, and shoulder pain. However, disability was related to job satisfaction. In vivo experiments, using percutaneous pin mounted accelerometers have shown that the natural frequency is at 4.5 Hz. The frequency response is affected by posture, seating, and seat back inclination. The response appears to be determined largely by the rocking of the pelvis. Electromyographic studies have shown that muscle fatigue occurs under whole body vibration. After whole body vibration exposure the muscle response to a sudden load has greater latency. Vehicle driving may be a reason for low back pain or herniated nucleus pulposus. Prolonged seating exposure, coupled with the whole body vibration, should be reduced for those recovering from these problems. Vibration attenuating seats and correct ergonomic layout of the cabs may reduce the risks of recurrence.

A dynamic approach to spinal instability. Part I: Sensitization of intersegmental motion profiles to motion direction and load condition by instability.

STUDY DESIGN: Human lumbar functional spinal units (FSUs) were moved throughout their range of motion in sagittal and lateral bending while the dynamics of this movement were computed in vitro. Functional spinal units were tested intact and after subsequent discectomy and unilateral facetectomy. OBJECTIVE: To establish "normal" velocity and acceleration curves during lumbar intersegmental bending in the intact FSU and then evaluate the changes of this dynamic behavior due to surgically induced component instability. SUMMARY OF BACKGROUND DATA: In preliminary clinical studies, researchers have provided evidence that dynamic motion measurements may be useful in the assessment of spinal impairment. METHODS: Human lumbar FSUs moved from extension to flexion, flexion to extension, left to right, and right to left a pure moment. Range of motion, as well as velocity and acceleration patterns of the main and coupled motions, were evaluated in six degrees of freedom by position changes of attached infrared light-emitting diodes recorded by cameras. Functional spinal units were tested in three surgical conditions (intact, discectomy, and unilateral facetectomy) under two preload conditions (no preload and 400 N preload). RESULTS: Motion of intact FSUs progressed with velocity and acceleration patterns that were relatively independent from motion direction and preload condition. After surgery, however, the dynamic motion became unequal between opposite motion directions (even if range of motion was equal between directions) and more sensitive to preload condition. CONCLUSION: The results suggest that equilibrium of dynamic motion parameters within a range of motion is an element of segmental stability. From this approach, segmental instability appears to change intersegmental acceleration and velocity patterns as a function of motion direction and load conditions. Whereas dynamic motion patterns in an intact FSU are relatively invariable between reversed motion directions, instability is characterized by a considerable diversity of dynamic motion parameters between reversed motion directions.

A dynamic approach to spinal instability. Part II: Hesitation and giving-way during interspinal motion.

STUDY DESIGN: Human lumbar functional spinal units (FSUs) were moved throughout their range of motion in sagittal and lateral bending, while the dynamics of this movement were computed in vitro. Functional spinal units were tested intact and after subsequent discectomy and unilateral facetectomy. OBJECTIVE: To determine whether the patterns of small jerks observed during intersegmental motion are sensitive to spinal instability. SUMMARY OF BACKGROUND DATA: Small jerks have been observed as hesitation during increasing velocity and as giving way during decreasing velocity in the experiments described in Part I of this study. METHODS: Human lumbar functional spinal units were moved from extension to flexion, flexion to extension, left to right, and right to left, by a pure moment. Range of motion and velocity and acceleration patterns of the main and coupled motions were evaluated in six degrees of freedom by position changes of attached infrared light-emitting diodes recorded by cameras. Functional spinal units were tested in three surgical conditions (intact, discectomy, and unilateral facetectomy) under two preload conditions (no preload and 400-N preload). Discontinuous accelerations and decelerations (jerks) were computed in these motions and their location in relation to the main angular motion determined. RESULTS: Jerks were observed in almost all motions, in the intact functional spinal units and after surgery. The parameters describing the magnitude of the jerk decreased with increasing component instability. In the sagittal plane, there was a surgical condition by motion direction interaction (P < 0.014) regarding the location of the jerk. Independent from the motion direction, the jerk occurred around the neutral position (in relation to the primary angular motion) in the intact functional spinal units, whereas it shifted from the neutral position toward the beginning of the motion with increasing component instability. CONCLUSION: The results suggest that a small jerk is a normal component of fast intersegmental motion. The jerk has a certain magnitude and location in an intact functional spinal unit, whereas both of the parameters describing the jerk are sensitive to component instability.

Muscular response to sudden load. A tool to evaluate fatigue and rehabilitation.

STUDY DESIGN: Subjects were exposed to fatiguing and restorative interventions to assess their response to sudden loads. OBJECTIVES: To investigate the erector spinae and rectus abdominis response characteristics to "sudden load" and the effect of fatigue and rehabilitation. SUMMARY OF BACKGROUND DATA: Unexpected loads which people often experience, can lead to high forces in the spine and may be a cause of low back injury. METHODS: Muscle responses to sudden load were mediated by fatigue, walking, expectation, method of load application, exposure to vibration, and cognitive-behavioral rehabilitation in patients with chronic low back pain. A novel technique, perfected in this work, called wavelet analysis, was used to analyze these data. RESULTS: Reaction time was affected by fatigue and expectation. Vibration exposure significantly increased the muscle response time. Walking was able to ameliorate that effect. Back muscles responded differently, depending on whether loads were applied to the back through the hands or through the trunk. Electromyographic reaction time and magnitude decreased in patients after a 2-week rehabilitation program. CONCLUSIONS: Sudden loads can exacerbate fatigue effects. Walking after driving reduces the risk to the back caused by handling unpredictable loads. Vibration exposure guidelines should be more conservative. Patients have longer response times than healthy subjects, but patients can improve their response to sudden loads via rehabilitation. Patients exhibit a flexion-extension oscillation at 5 Hz in response to a sudden load, suggesting that the 5-Hz, seated, natural frequency observed during whole-body vibration may result from neurophysiologic control limits.

Are occupational drivers at an increased risk for developing musculoskeletal disorders?

STUDY DESIGN: This study analyzed the role of exposure to driving and other covariates in reports of back, neck, and shoulder pain and resultant disability. Cohorts in Sweden and the United States were compared. OBJECTIVES: To establish the effect of mechanical and psychosocial factors in reporting back, neck, and shoulder pain and work loss. SUMMARY OF BACKGROUND DATA: There are numerous reports of a positive relationship between back pain and driving. However, exposure data are minimal. The influence of job satisfaction has not been assessed. METHODS: The physical factors affecting reports of back, neck, and shoulder pain were investigated in a two-country cohort study of bus and truck drivers and sedentary workers. Vibration exposure was obtained by directly measuring the vibration imposed on the driver during a typical work day. Lifting exposure was attained by questionnaire. Cumulative exposure was computed based on work history. Musculoskeletal health information was based on a modified nordic questionnaire, and other questionnaires recorded the physical and psychosocial aspects of the work environment. RESULTS: Of the sample, 50% reported low back pain, with no difference between countries. The highest risk factors (odds ratios) for back and neck pain were long-term vibration exposure, heavy lifting, and frequent lifting. A combination of long-term vibration exposure and frequent lifting carried the highest risk of low back pain. Work loss from low back pain was influenced by perceived job stress. CONCLUSIONS: Vibration (resulting from driving) and lifting cause back, neck, and shoulder pain, whereas inability to work seems affected by stress at work.

Epidemiological and aetiological aspects of low back pain in vibration environments - an update.

The article reviews the substantial body of epidemiological evidence linking vibration exposure and low back pain. Drivers appear to be at particular risk if exposures exceed those recommended by the ISO exposure limit. Various aetiological factors associated with vehicular vibration, flattening of the lumbar lordosis, increased motion segment flexibility, disc pressure and mechanical softening are discussed. Vibration studies of functional spinal units are also discussed, as are in vivo whole-body vibration experiments. Animal models have shown that vibration leads to compromised nutrition, higher disc pressures, release of neuropeptides, increased creep and histological changes.

Mechanical stress reduction during seated jolt/vibration exposure.

The risk of experiencing low back pain is associated with mechanical factors. Anatomic factors, such as advancing pregnancy, can also place extra mechanical stress on the lower back. Mechanical factors, such as those related to the workplace, can be minimized by ergonomic interventions. A constrained, seated posture, in combination with exposure to whole-body, jolt/vibration can impose significant stresses on the posterior intervertebral disc and can lead to back muscle fatigue. Interventions that reduce the jolt/vibration magnitude and duration of exposure will decrease the mechanical work performed on the intervertebral disc. Such interventions range from jolt/vibration isolating seats and vehicle cabs, to decreasing exposure time and maintaining simple supported postures during ingress and egress. Improvements in seat configuration can reduce the intervertebral disc pressure and the strain on the posterior disc.

European Spine Society--the AcroMed Prize for Spinal Research 1995. Unexpected load and asymmetric posture as etiologic factors in low back pain.

Unexpected loads, which often occur in the working environment, can lead to high forces in the spine and, thus, may be a cause of low back injury. This paper discusses the effect of "sudden load" on the erector spine reaction and amplitude. Muscle responses were mediated by several factors, including fatigue, posture, expectation and rehabilitation, in chronic low back pain patients. The subjects were fatigued by holding a 20% maximum voluntary contraction for 1 min. A functional restoration program was tested for its efficacy in reducing reaction time and EMG amplitude in chronic low back pain patients. Reaction time was longer and EMG amplitude lower in patients than in their matched controls. EMG reaction time and magnitude decreased in patients after a 2-week rehabilitation program, including specific training of coordination and posture control. The results of the modelling showed higher spinal compressive load and lower shear forces when the load was expected than when the load was unexpected. The effect of sudden loads can be exacerbated if a worker is not standing on a flat surface or is fatigued. Chronic low back pain patients have less ability to protect themselves from sudden loads, but they can be trained to improve their response by means of an appropriate rehabilitation program.

Biomechanical testing of the spine. Load-controlled versus displacement-controlled analysis.

Mechanical testing of the spine can be carried out in either a load-controlled or a displacement-controlled manner. Each method requires certain assumptions and offers different advantages. Dr. W. Thomas Edwards believes that displacement-controlled testing most accurately reflects the in vivo environment, while Drs. Vijay Goel, David Wilder, and Malcolm Pope support the use of the load-controlled method as most logical and easily standardized.

Multidirectional stability of the Graf system.

STUDY DESIGN: To assess the biomechanical influences of the Graf fixation system on the spine, motion segments were tested. In normal spines, destabilized and restabilized with the Graf system conditions, the range of motion and flexibilities were found under various loading conditions. OBJECTIVES: These results should explain how the Graf Fixation system affects the biomechanical response of a motion segment. METHODS: Motion segments (L2-3) and (L4-5) were subjected to these loading conditions: compressive loading, flexion-extension, lateral bending, and axial rotation moments. During the loading, the main and coupled motions were measured, and flexibilities were computed. The position of the balance point in axial loading was also determined. The motion segments were tested under three conditions: intact, destabilized, and restabilized. The destabilization consisted of a bilateral total laminectomy (pedicle-to-pedicle). Restabilization was affected with the Graf stabilization system, consisting of polyester bands between pedicle screw implants. RESULTS: The total laminectomy significantly changed the balance point location by moving it forward. The restabilized motion segment had a balance point more similar to normal conditions. The mean compressive compliance was significantly less after application of the Graf system compared with destabilization. The range of motion for flexion-extension and axial rotation was significantly reduced for the main motion with the Graf system. For lateral bending, the main and coupled rotations were affected significantly, with lateral bending and flexion-extension motion reduced and axial rotation increased after restabilization. Restabilization decreased the flexibility of the destabilized motion segment for all of the moments. CONCLUSIONS: The Graf fixation system reduced the range of motion and the flexibility values in some loading conditions. These results only assess the immediate stabilization characteristics of this implant system in cadaveric material. Further research should address the fatigue characteristics.

The effect of vibration on back discomfort and serum levels of von Willebrand factor antigen: a preliminary communication.

The von Willebrand factor (vWf) is a complex protein whose release is a marker for endothelial damage; serum levels of its antigen (vWFAg) can be used as a marker for such changes. We measured the levels of back discomfort and vWFAg in 11 subjects following 25-min periods of (1) lying down, (2) sitting upright, (3) vibrating whilst sitting and (4) sitting upright. Back discomfort appeared and vWf levels were significantly increased following sitting upright, compared with lying flat, and increased further following vibration. They fell thereafter with a period of sitting still upright. These results demonstrate that vibration has a significant effect in increasing back discomfort and the serum levels of vWFAg, and it is possible that vibration may induce vascular damage within the spine.

L4-5 isthmic spondylolisthesis. A biomechanical analysis comparing stability in L4-5 and L5-S1 isthmic spondylolisthesis.

The authors have previously reported that the L4-5 isthmic spondylolisthesis lesion often progresses more than the L5-S1 lesion in adult patients. This biomechanical study compares the in vitro stability of the L4-5 isthmic spondylolisthesis lesion compared with the L5-S1 isthmic lesion. The authors also analyzed the role of the L5 iliolumbar ligament as a contributing factor to stability. Six fresh frozen human cadaveric specimens (L4 to the sacrum including the iliolumbar ligamentous complex) were tested by applying 10 Nm flexion-extension moments. Sagittal plane motion was measured with the specimens intact and after sequential transection of the pars interarticulares at L4 and L5 and finally with the iliolumbar ligaments cut at L5-S1. L4-5 and L5-S1 both showed significant increases in rotation with the pars defect compared with normal (L4-5 = +2.0, L5-S1 = +3.2 degrees). Decreased translation of L5-S1 occurred with pars defect at this level. There were no significant differences at the L5-S1 level after sectioning of the iliolumbar ligament. Calculating the percentage difference from normal, L4-5 with a pars defect exhibited significantly greater relative motion compared with L5-S1 with the same defect; 12% more rotation, 33% more shear, and 43% more axial translation. The iliolumbar ligament did not appear to contribute to these differences because there was no significant change in the L5-S1 kinematics after its transection. These results support the hypothesis that L4-5 pars defects are more unstable than L5-S1 lesions. The iliolumbar ligament could not be implicated as the major contributing factor in these differences.