Complex Neck Loading and Injury Tolerance in Lateral Bending With Head Rotation From Human Cadaver Tests.

Advancements in automated vehicles may position the occupant in postures different from the current standard posture. It may affect human tolerance responses. The objective of this study was to determine the lateral bending tolerance of the head-cervical spine with initial head rotation posture using loads at the occipital condyles and lower neck and describe injuries. Using a custom loading device, head-cervical spine complexes from human cadavers were prepared with load cells at the ends. Lateral bending loads were applied to prerotated specimens at 1.5 m/s. At the occipital condyles, peak axial and antero-posterior and medial-lateral shear forces were: 316-954 N, 176-254 N, and 327-508 N, and coronal, sagittal, and axial moments were: 27-38 N·m, 21-38 N·m, and 9.7-19.8 N·m, respectively. At the lower neck, peak axial and shear forces were: 677-1004 N, 115-227 N, and 178-350 N, and coronal, sagittal, and axial moments were: 30-39 N·m, 7.6-21.3 N·m, and 5.7-13.4 N·m, respectively. Ipsilateral atlas lateral mass fractures occurred in four out of five specimens with varying joint diastasis and capsular ligament involvements. Acknowledging that the study used a small sample size, initial tolerances at the occipital condyles and lower neck were estimated using survival analysis. Injury patterns with posture variations are discussed.

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.

Pelvis-Sacrum-Lumbar Spine Injury Characteristics From Underbody Blast Loading.

INTRODUCTION: Combat-related injuries from improvised explosive devices occur commonly to the lower extremity and spine. As the underbody blast impact loading traverses from the seat to pelvis to spine, energy transfer occurs through deformations of the combined pelvis-sacrum-lumbar spine complex, and the time factor plays a role in injury to any of these components. Previous studies have largely ignored the role of the time variable in injuries, injury mechanisms, and warfighter tolerance. The objective of this study is to relate the time or temporal factor using a multi-component, pelvis-sacrum-lumbar spinal column complex model. MATERIALS AND METHODS: Intact pelvis-sacrum-spine specimens from pre-screened unembalmed human cadavers were prepared by fixing at the superior end of the lumbar spine, pelvis and abdominal contents were simulated, and a weight was added to the cranial end of the fixation to account for torso effective mass. Prepared specimens were placed on the platform of a custom vertical accelerator device and aligned in a seated soldier posture. An accelerometer was attached to the seat platen of the device to record the time duration to peak velocity. Radiographs and computed tomography images were used to document and associate injuries with time duration. RESULTS: The mean age, stature, weight, body mass index, and bone density of 12 male specimens were as follows: 65 ± 11 years, 1.8 ± 0.01 m, 83 ± 13 kg, 27 ± 5.0 kg/m2, and 114 ± 21 mg/cc. They were equally divided into short, medium, and long time durations: 4.8 ± 0.5, 16.3 ± 7.3, and 34.5 ± 7.5 ms. Most severe injuries associated with the short time duration were to pelvis, although they were to spine for the long time duration. CONCLUSIONS: With adequate time for the underbody blast loading to traverse the pelvis-sacrum-spine complex, distal structures are spared while proximal/spine structures sustain severe/unstable injuries. The time factor may have implications in seat and/or seat structure design in future military vehicles to advance warfighter safety.

Preliminary Data of Neck Muscle Morphology With Head-Supported Mass in Male and Female Volunteers.

INTRODUCTION: This study quantified parameters related to muscle morphology using a group of upright seated female and male volunteers with a head-supported mass. MATERIALS AND METHODS: Upright magnetic resonance images (MRIs) were obtained from 23 healthy volunteers after approval from the U.S. DoD. They were asymptomatic for neck pain, with no history of injury. The volunteers were scanned using an upright MRI scanner with a head-supported mass (army combat helmet). T1 and T2 sagittal and axial images were obtained. Measurements were performed by an engineer and a neurosurgeon. The cross-sectional areas of the sternocleidomastoid and multifidus muscles were measured at the inferior endplate in the sub-axial column, and the centroid angle and centroid radius were quantified. Differences in the morphology by gender and spinal level were analyzed using a repeated measures analysis of variance model, adjusted for multiple corrections. RESULTS: For females and males, the cross-sectional area of the sternocleidomastoid muscle ranged from 2.3 to 3.6 cm2 and from 3.4 to 5.4 cm2, the centroid radius ranged from 4.1 to 5.1 cm and from 4.7 to 5.7 cm, and the centroid angle ranged from 75° to 131° and from 4.8° to 131.2°, respectively. For the multifidus muscle, the area ranged from 1.7 to 3.9 cm2 and from 2.4 to 4.2 cm2, the radius ranged from 3.1 to 3.4 cm and from 3.3 to 3.8 cm, the angle ranged from 15° to 24.4° and 16.2° to 24.4°, respectively. Results from all levels for both muscles and male and female spines are given. CONCLUSIONS: The cross-sectional area, angulation, and centroid radii data for flexor and extensor muscles of the cervical spine serve as a dataset that may be used to better define morphologies in computational models and obtain segmental motions and loads under external mechanical forces. These data can be used in computational models for injury prevention, mitigation, and readiness.

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.

Upper cervical spine bone mineral content variations in elderly females.

The purpose of the study was to determine the bone mineral densities (BMDs) of the C1 and C2 vertebrae and discuss their implications for autonomous vehicle environments and vulnerable road users. Using quantitated computed tomography (QCT), the BMDs were obtained at eight regions for the C1 vertebra and seven regions for the C2 vertebra. The spine surgeon author outlined the boundaries of each region, and nine elderly female human cadaver specimens were used. The regions were based on potential stabilization locations for fracture fixation. In the C1 vertebra, the BMD was greatest at the anterior tubercle, followed by the posterior tubercle, the posterior arch, and the lateral and anterior lateral masses. In the C2 vertebra, the distal odontoid had the greatest BMD, followed by the spinous process, the C2-lateral mass, the odontoid-body interface, and the anterior inferior aspect of the body. Use of these data in female-specific finite element models may lead to a better understanding of load paths, injuries, mechanisms, and tolerance.

Regional brain strain dependance on direction of head rotation.

Brain injuries in automated vehicles during crash events are likely to include mechanisms of head impact in non-standard positions and postures (i.e., occupants not facing forward in an upright position). Federal regulations currently focus on impact conditions in primary planes of motion, such as frontal or rear impacts (sagittal plane of motion) or side impact (coronal plane of motion) and do not account for out of position occupants or non-standard postures. The objective of the present study was to develop and use the anatomically accurate brain finite element model to parametrically determine the injury metrics under different vectors with head rotation. A custom developed brain finite element model with anatomical accuracy and several anatomical regions defined was used to evaluate whole-brain strain as well as regional brain strain. Cumulative Strain Damage Measure (CSDM) at a threshold of 20% strain and the 95th percentile of the maximum principal strain (MPS95) were calculated for the whole brain and each brain region under multiple rotational directions. The model was exposed to a sinusoidal angular acceleration pulse of 5000 rad per second squared (rad/s2-) over 12.5 ms. The same pulse was used in the primary axes of motion and (lateral bending, flexion, extension, axial rotation) and combined axes representing oblique flexion and oblique extension. Whole brain CSDM20 was highest for lateral bending. Whole brain MPS95 was highest for axial rotation. The rCSDM20 was more susceptible to impact direction, with several brain regions having substantial accumulation of strain for oblique flexion and lateral bending. Comparatively, rMPS95 was more consistent across all rotation directions. The present study quantified the regional brain strain response under multiple rotational vectors identifying a high amount of variability in the accumulation of strain (i.e., CSDM20) in the hypothalamus, hippocampus, and midbrain specifically. While there was a high amount of variability in the accumulation of strain for multiple regions, the maximum strain measured (i.e., MPS95) in the regions was more consistent.

Regional variations in C1-C2 bone density on quantitated computed tomography and clinical implications.

Background: Our elderly population is growing and the number of spine fractures in the elderly is also growing. The elderly population in general may be considered as poor surgical candidates experience a high rate of fractures at C1 and C2 compared with the general population. Nonoperative management of upper cervical fractures is not benign as there is a high nonunion rate for both C1 and C2 fractures in the elderly, and orthosis compliance is often suboptimal, or complicated by skin breakdown. The optimal technique for upper cervical stabilization in the elderly may be different than in younger populations as the bone quality is inferior in the elderly. The objective of this basic science study is to determine whether the bone mineral density (BMD) of C1 and C2 vary by region, and if this is a gender difference in this elderly age group. Methods: Twenty cadaveric spines from 45 to 83 years of age were used to obtain BMD using quantitated computed tomography (QCT). BMD was measured using a QCT. For C1, 8 regions were determined: anterior tubercle, bilateral anterior and medial lateral masses, bilateral posterior arches, and posterior tubercle. For C2, 7 regional BMDs were determined: top of odontoid, base of odontoid-body interface, mid body, bilateral lateral masses, anterior inferior body near the discs space, and the C2 spinous process. Results: The BMD was greatest at the C1 anterior tubercle (564.4±175.8 mg/cm3) and C1 posterior ring (420.8±110.2 mg/cm3), and least at the anterior and medial lateral masses (262.8±59.5 mg/cm3, 316.9±72.6 mg/cm3). At C2 QCT BMD was greatest at the top of the dens (400.6±107.9 mg/cm3) decreasing down through the odontoid-C2 body junction (267.8±103.5 mg/cm3) and least in the mid C2 body 249.1±68.8 mg/cm3). The posterior arch of C1 and the spinous process of C2 had higher BMD's 420.8±110.2 mg/cm3 and 284.1±93.0 mg/cm3, respectively. A high correlation was observed between the BMD at the interface of the dens-vertebral body with the vertebral body with a Pearson correlation coefficient of 0.86. The BMD of the top of dens was significantly higher (p<.05) than all the regions in C2. Conclusions: Regional and segmental BMD variations at C1 and C2 have clinical implications for surgical constructs in the elderly population. Given the higher BMDs of the C1 and C2 spinous process and posterior arches, consideration should be given to incorporate these areas using various C1-C2 wiring techniques. In the elderly, lateral masses particularly at C1 with lower BMD may result in potential screw loosening and nonunion in this age group. Old-school wiring techniques have a track record of efficacy and safety with less blood loss, reduced operative time, reduced X-ray exposure, and should be considered in the elderly as a primary stabilization technique or a belt-over suspenders approach based on regional variations in BMD in the elderly.

Temporal corridors of forces and moments, and injuries to pelvis-lumbar spine in vertical impact simulating underbody blast.

Pelvis and lumbar spine fractures occur in falls, motor vehicle crashes, and military combat events. They are attributed to vertical impact from the pelvis to the spine. Although whole-body cadavers were exposed to this vector and injuries were reported, spinal loads were not determined. While previous studies determined injury metrics such as peak forces using isolated pelvis or spine models, they were not conducted using the combined pelvis-spine columns, thereby not accounting for the interaction between the two body regions. Earlier studies did not develop response corridors. The study objectives were to develop temporal corridors of loads at the pelvis and spine and assess clinical fracture patterns using a human cadaver model. Vertical impact loads were delivered at the pelvic end to twelve unembalmed intact pelvis-spine complexes, and pelvis forces and spinal loads (axial, shear and resultant and bending moments) were obtained. Injuries were classified using clinical assessments from post-test computed tomography scans. Spinal injuries were stable in eight and unstable in four specimens. Pelvis injuries included ring fractures in six and unilateral pelvis in three, sacrum fractures in ten, and two specimens did not sustain any injuries to the pelvis or sacrum complex. Data were grouped based on time to peak velocity, and ± one standard deviation corridors about the mean of the biomechanical metrics were developed. Time-history corridors of loads at the pelvis and spine, hitherto not reported in any study, are valuable to assess the biofidelity of anthropomorphic test devices and assist validating finite element models.

Morphometry of lumbar muscles in the seated posture with weight-bearing MR scans.

Conventional imaging studies of human spine are done in a supine posture in which the axial loading of the spine is not considered. Upright images better reveal the interrelationships between the various internal structures of the spine. The objective of the current study is to determine the cross-sectional areas, radii, and angulations of the psoas, erector spinae, and multifidus muscles of the lumbar spine in the sitting posture. Ten young (mean age 31 ± 4.8 years) asymptomatic female subjects were enrolled. They were seated in an erect posture and weight-bearing T1 and T2 MRIs were obtained. Cross-sectional areas, radii, and angulations of the muscles were measured from L1-L5. Two observers repeated all the measurements for all parameters, and reliability was determined using the inter- and intra-class coefficients. The Pearson product moment correlation was used for association between levels, while level differences were used using a linear regression model. The cross-sectional areas of the psoas and multifidus muscles increased from L1 to L5 (1.9 ± 1.1 to 12.1 ± 2.5 cm2 and 1.8 ± 0.3 to 5.7 ± 1.4 cm2). The cross-sectional area of the erector spinae was greatest at the midlevel (13.9 ± 2.2 cm2) and it decreased in both directions. For the angle, the range for psoas muscles was 75-105°, erector spinae were 39-46° and multifidus was 11-19°. Correlations magnitudes were inconsistent between levels and muscle types. These quantitated data improve our understanding of the geometrical properties in the sitting posture. The weight-bearing MRI-quantified morphometrics of human lumbar spine muscles from this study can be used in biomechanical models for predicting loads on spinal joints under physiological and traumatic situations.

Mechanisms of cervical spine injury and coupling response with initial head rotated posture - implications for AIS coding.

Objective: This objective of the present study is to describe the responses of the human head-cervical spine in terms of injuries, injury mechanisms, injury scoring, and quantify multiplanar loads.Methods: Pretest radiographs of pre-screened five human cadaver head-neck complexes were obtained. Cranium contents and sectioned the structure rostral to skull base. The caudal end was embedded, and cervical-thoracic disc was unconstrained condition. The loading was applied as a torque about the occipital condyle joint. The head and T1 were angulated 30 degrees and 25 degrees. Peak forces and moments at the occipital condyles were recorded using a six-axis load cell. After testing, x-rays and CT images were obtained. Injuries were scored using the Abbreviated Injury Scale, AIS 2015 version.Results: The mean age, stature, total body mass, body mass index of the five subjects were as follows: 63 years, 1.7 m, 78.0 kg, and 28.1 kg/m2. The mean peak axial force and coronal, sagittal, and axial bending moments were: 754 N, and 36.8 Nm, 14.8 Nm, and 9.5 Nm. All but one specimen sustained injury. Injuries were scored at the AIS 2 level. Two specimens sustained left anterior inferior lateral mass fractures of the atlas. While the transverse atlantal ligament was intact, some capsular ligament involvement was observed. In the other two specimens, although the same injury was noted, joint diastasis of the atlas-axis joint was identified.Conclusions: Using a PMHS model, the present study described the biomechanics of the initially head rotated head-neck complex under lateral bending in terms of injuries, injury mechanisms, quantification of the multiplanar loads at the occipital condyles, and underscored potential injury scoring issues for occupant protection. The issue of diastasis is not addressed in the AIS 2015 version. While this may not always result in immediate instability and require surgical intervention, it may be necessary to revisit this issue. Upper cervical fractures with diastasis and or transverse atlantal ligament involvement may be potential injury scoring factors for AIS consideration.

Normalization technique to build patient specific muscle model in finite element head neck spine.

Finite element models of the head and neck are widely used in automotive and clinical fields to understand spinal biomechanics. These models are developed based on CT and MRI scans of the subjects, but historically the muscle data are obtained from cadaveric specimen. The cadaver data is often obtained from older specimens which commonly have undergone degenerative changes resulting in reduction in muscle cross section area. The objective of the current study is to compare the muscle cross-section area used by various finite element models of neck muscles used in the literature and to develop a normalization technique to scale the MRI muscle cross-section area with those available in the literature. Four male and seven female healthy asymptomatic young adult volunteers enrolled in the study after obtaining necessary approval from Institutional Review Board. T1 and T2 weighted magnetic resonance imaging was performed in neutral upright sitting position wearing military helmet. Muscle cross sectional area was obtained for multifidus muscles from the MRI images. Data was compared with those in the literature. Based on the literature review of prior studies, the cross-sectional area of cadaver specimens was smaller than the MRI obtained muscle area. Multifidus muscle scaling factor was obtained by ratio of sum of MRI cross section area with that of cadaver data. Based on the analysis, the scaling factor for male data is 1.6 and for female data is 1.3. the cadaver data can be multiplied by the scaling factor to obtain the MRI specific cross-sectional area. A Normalization technique was developed for scaling MRI data into finite element model. This technique can be used in developing subject specific finite element model of spine which has applications in clinical, automotive, and military environment.

Loading rate effect on tradeoff of fractures from pelvis to lumbar spine under axial impact loading.

Objectives: The transmission of impact loading from the seat-to-pelvis-to-lumbar spine in a seated occupant in automotive and military events is a mechanism for fractures to these body regions. While postmortem human subject (PMHS) studies have replicated fractures to the pelvis or lumbar spine using isolated/component models, the role of the time factor that manifests as a loading rate issue on injuries has not been fully investigated in literature. The objective of this study was to explore the hypothesis that short duration pulses fracture the pelvis while longer pulses fracture the spine, and intermediate pulses involve both components.Methods: Unembalmed PMHS thoracolumbar spine-pelvis specimens were fixed at the superior end, and a six-axis load cell was attached. The specimens were mounted on a vertical accelerator, and noninjury and injury tests were conducted by applying short, medium, or long pulses with 5, 15, or 35 ms durations, respectively. Peak axial, shear and resultant forces were obtained. Injuries were documented using posttest x-ray and computed tomography images and scaled using the AIS (2015).Results: The mean age, stature, weight, body mass index, and BMD of twelve specimens were 64.8 ± 11.4 years, 1.8 ± 0.01 m, 83 ± 13 kg, 26.7 ± 5.0 kg/m2, and 114.5 ± 21.3 mg/cc, respectively. For the short, long, and medium duration pulses, the mean resultant forces were 5.6 ± 0.9 kN, 5.9 ± 0.94 kN, and 5.4 ± 1.8 kN, and time durations were 4.8 ± 0.5 ms, 16.3 ± 7.3 ms, and 34.5 ± 7.5 ms, respectively. For the short pulse, pelvis injuries were more severe in 3 out 4 specimens, for the medium pulse, they were distributed between the pelvis and spine, and for the long pulse, spine injuries were more severe in 3 out of 4 specimens.Conclusions: While acknowledging the limitations of the sample size, the results of this study support the hypothesis of the time variable in the tradeoff between pelvis and spine injuries with pulse duration. The tradeoff pattern is attributed to mass recruitment: short pulse biases injuries to pelvis while limiting spinal injuries, and the opposite is true for the longer pulse, thus supporting the hypothesis. It is important to account for the time variable in injury analysis.

A biomechanical investigation of lumbar interbody fusion techniques.

The anterior, posterior, transforaminal, and circumferential lumbar interbody fusions (ALIF, PLIF, TLIF, CLIF/360) are used to treat spondylolisthesis, trauma, and degenerative pathologies. This study aims to investigate the biomechanical effects of the lumbar interbody fusion techniques on the spine. A validated T12-sacrum lumbar spine finite-element model was used to simulate surgical fusion of L4-L5 segment using ALIF, PLIF with one and two cages, TLIF with unilateral and bilateral fixation, and CLIF/360. The models were simulated under pure-moment and combined (moment and compression) loadings to investigate the effect of different lumbar interbody fusion techniques on range of motion, forces transferred through the vertebral bodies, disc pressures, and endplate stresses. The range of motion of the lumbar spine was decreased the most for fusions with bilateral posterior instrumentations (TLIF, PLIF, and CLIF/360). The increase in forces transmitted through the vertebrae and increase in disc pressures were directly proportional to the range of motion. The discs superior to fusion were under higher pressure, which was attributed to adjacent segment degeneration in the superior discs. The increase in endplate stresses was directly proportional to the cross-sectional area and was greater in caudal endplates at the fusion level, which was attributed to cage subsidence. The response of the models was in line with overall clinical observations from the patients and can be further used for future studies, which aim to investigate the effect of geometrical and material variations in the spine. The model results will assist surgeons in making informed decisions when selecting fusion procedures based on biomechanical effects.

Biomechanical effects of uncinate process excision in cervical disc arthroplasty.

BACKGROUND: Studies on the role of uncinate process have been limited to responses of the intact spine and patient's outcomes, and procedures to perform the excision. The aim of this study was to determine the role of uncinate process on the biomechanical response at the index and adjacent levels in three artificial discs used in cervical disc arthroplasty. METHODS: A validated finite element model of cervical spine was used. Flexion, extension, and lateral moments and follower load were applied to Bryan, Mobi-C, and Prestige LP artificial discs at C5-C6 level with and without uncinate process. Ranges of motion at index level and adjacent caudal and cranial segments, intradiscal pressures at adjacent segments, and facet loads at index level and adjacent segments were obtained. Data were normalized with respect to the preservation of uncinate process. FINDINGS: Uncinate process removal increased motions up to 27% at index and decreased up to 10% at adjacent levels, decreased disc pressures up to 14% at adjacent segments, decreased facet loads at adjacent segments up to 14%, while at index level, change in loads depended on mode and arthroplasty, with Mobi-C responding with up to 51% increase and Bryan disc up to 11% decrease, while Prestige LP increased loads by 17% in extension and decreased by 9%% in lateral bending. INTERPRETATION: As surgical selection is based on morphology and surgeon's experience, the present computational findings provide quantitative information for an optimal choice of the device and procedure, while further studies (in vitro/clinical) would be required.

Cervical fusion for treatment of degenerative conditions: development of appropriate use criteria.

BACKGROUND CONTEXT: High quality evidence is difficult to generate, leaving substantial knowledge gaps in the treatment of spinal conditions. Appropriate use criteria (AUC) are a means of determining appropriate recommendations when high quality evidence is lacking. PURPOSE: Define appropriate use criteria (AUC) of cervical fusion for treatment of degenerative conditions of the cervical spine. STUDY DESIGN/SETTING: Appropriate use criteria for cervical fusion were developed using the RAND/UCLA appropriateness methodology. Following development of clinical guidelines and scenario writing, a one-day workshop was held with a multidisciplinary group of 14 raters, all considered thought leaders in their respective fields, to determine final ratings for cervical fusion appropriateness for various clinical situations. OUTCOME MEASURES: Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain" or "Rarely Appropriate" based on the median final rating among the raters. METHODS: Inclusion criteria for scenarios included patients aged 18 to 80 with degenerative conditions of the cervical spine. Key modifiers were defined and combined to develop a matrix of clinical scenarios. The median score among the raters was used to determine the final rating for each scenario. The final rating was compared between modifier levels. Spearman's rank correlation between each modifier and the final rating was determined. A multivariable ordinal regression model was fit to determine the adjusted odds of an "Appropriate" final rating while adjusting for radiographic diagnosis, number of levels and symptom type. Three decision trees were developed using decision tree classification models and variable importance for each tree was computed. RESULTS: Of the 263 scenarios, 47 (17.9 %) were rated as rarely appropriate, 66 (25%) as uncertain and 150 (57%) were rated as appropriate. Symptom type was the modifier most strongly correlated with the final rating (adjusted ρ2 = 0.58, p<.01). A multivariable ordinal regression adjusting for symptom type, diagnosis, and number of levels and showed high discriminative ability (C statistic = 0.90) and the adjusted odds ratio (aOR) of receiving a final rating of "Appropriate" was highest for myelopathy (aOR, 7.1) and radiculopathy (aOR, 4.8). Three decision tree models showed that symptom type and radiographic diagnosis had the highest variable importance. CONCLUSIONS: Appropriate use criteria for cervical fusion in the setting of cervical degenerative disorders were developed. Symptom type was most strongly correlated with final rating. Myelopathy or radiculopathy were most strongly associated with an "Appropriate" rating, while axial pain without stenosis was most associated with "Rarely Appropriate."

Vertebral Level-dependent Kinematics of Female and Male Necks Under G+x Loading.

INTRODUCTION: Size-matched volunteer studies report gender-dependent variations in spine morphology, and head mass and inertia properties. The objective of this study was to determine the influence of these properties on upper and lower cervical spine temporal kinematics during G+x loading. METHODS: Parametrized three-dimensional head-neck finite element models were used, and impacts were applied at 1.8 and 2.6 m/s at the distal end. Details are given in the article. Contributions of population-based variations in morphological and mass-related variables on temporal kinematics were evaluated using sensitivity analysis. Influence of variations on time to maximum nonphysiological curve formation, and flexion of upper and extension of the lower spines were analyzed for male-like and female-like spines. RESULTS: Upper and lower spines responded with initial flexion and extension, resulting in a nonphysiological curve. Time to maximum nonphysiological curve and range of motions (ROMs) of the cervical column ranged from 45 to 66 ms, and 30 to 42 deg. Vertebral depth and location of the head center of gravity (cg) along anteroposterior axis were most influential variables for the upper spine flexion. Location of head cg along anteroposterior axis had the greatest influence on the time of the curve. Both anteroposterior and vertical locations of head cg, disc height, vertebral depth, head mass, and size were influential for the lower spine extension kinematics. CONCLUSIONS: Models with lesser vertebral depth, that is, female-like spines, experienced greater range of motions and pronounced nonphysiological curves. This results in greater distraction/stretch of the posterior upper spine complex, a phenomenon attributed to suboccipital headaches. Forward location of head cg along anteroposterior axis had the greatest influence on upper and lower spine motions and time of formation of the curve. Any increased anteroposterior location of cg attributable to head supported mass may induce greater risk of injuries/neck pain in women during G+x loading.