The effect of multiplanar loading on the intradiscal pressure of the whole human spine: systematic review and meta-analysis

For spinal load and muscle force estimation as well as for numerical model and experimental setup validation, data on human intradiscal pressure are essential. Therefore, the aim of the present meta-analysis was to summarise all in vitro measurements of human intradiscal pressure performed under defined boundary conditions, i.e. without external loading (intrinsic pressure), under axial loading (compression, traction, shear) and under single-planar bending loading (flexion, extension, lateral bending, axial rotation). Data were evaluated based on segmental level and normalised to force and moment. Regression analysis was performed to investigate coefficients of determination and statistical significance of relationships between intradiscal pressure and segmental level for the single loading conditions. 35 studies fulfilled the inclusion criteria, from which a total of 451 data points were collected for the meta-analysis. High coefficients of determination were found in axial compression (r2 = 0.875) and flexion (r2 = 0.781), while being low for intrinsic pressure (r2 = 0.266) and lateral bending (r2 = 0.385), all showing significant regression fitting (p < 0.01). Intradiscal pressure decreases from the upper cervical spine to the sacrum in all loading conditions, considering the same amount of loading for all segmental levels, while the intrinsic pressure exhibits a minimum of the regression curve in the mid-thoracic spine. Apart from its potential for numerical and experimental model validation, this dataset may help to understand the load distribution along the human spine.

Biomechanical Study of Cervical Disc Arthroplasty Devices Using Finite Element Modeling

Many artificial discs for have been introduced to overcome the disadvantages of conventional anterior discectomy and fusion. The purpose of this study was to evaluate the performance of different U.S. Food and Drug Administration (FDA)-approved cervical disc arthroplasty (CDA) on the range of motion (ROM), intradiscal pressure, and facet force variables under physiological loading. A validated three-dimensional finite element model of the human intact cervical spine (C2-T1) was used. The intact spine was modified to simulate CDAs at C5-C6. Hybrid loading with a follower load of 75 N and moments under flexion, extension, and lateral bending of 2 N·m each were applied to intact and CDA spines. From this work, it was found that at the index level, all CDAs except the Bryan disc increased ROM, and at the adjacent levels, motion decreased in all modes. The largest increase occurred under the lateral bending mode. The Bryan disc had compensatory motion increases at the adjacent levels. Intradiscal pressure reduced at the adjacent levels with Mobi-C and Secure-C. Facet force increased at the index level in all CDAs, with the highest force with the Mobi-C. The force generally decreased at the adjacent levels, except for the Bryan disc and Prestige LP in lateral bending. This study demonstrates the influence of different CDA designs on the anterior and posterior loading patterns at the index and adjacent levels with head supported mass type loadings. The study validates key clinical observations: CDA procedure is contraindicated in cases of facet arthroplasty and may be protective against adjacent segment degeneration.

Comparative Finite Element Modeling Study of Anterior Cervical Arthrodesis Versus Cervical Arthroplasty With Bryan Disc or Prodisc C

ABSTRACT Introduction Cervical disc arthroplasty (CDA), a motion-preserving alternative to anterior cervical discectomy and fusion (ACDF), is used in military patients for the treatment of disorders such as spondylosis. Since 2007, the FDA has approved eight artificial discs. The objective of this study is to compare the biomechanics after ACDF and CDA with two FDA-approved devices of differing designs under head and head supported mass loadings. Materials and Methods A previously validated osteoligamentous C2-T1 finite element model was used to simulate ACDF and two types of CDA (Bryan and Prodisc C) at the C5-C6 level. The hybrid loading protocol associated with in vivo head and head supported mass was used to apply flexion and extension loading. First, intact spine was subjected to 2 Nm of flexion extension and the range of motion (ROM) was measured. Next, for each surgical option, flexion-extension moments duplicating the same ROM as the intact spine were determined. Under these surgery-specific moments, ROM and facet force were obtained at the index level, and ROM, facet force, and intradiscal pressure at the rostral and caudal adjacent levels. Results ACDF led to increased motion, force and pressures at the adjacent levels. Prodisc C led to increased motion and facet force at the index level, and decreased motion, facet force, and intradiscal pressure at both adjacent levels. Bryan produced less dramatic biomechanical alterations compared with ACDF and Prodisc C. Numerical results are given in the article. Conclusions Recognizing that ROM is a clinical measure of spine stability/performance, CDA demonstrates a more physiological biomechanical response than ACDF, although the exact pattern depends on the implant design. Anterior and posterior column load-sharing patterns were different between the two implants and may affect implant selection based on the anatomical and pathological state at the index and adjacent levels.

Giraffes and hominins: reductionist model predictions of compressive loads at the spine base for erect exponents of the animal kingdom

In humans, compressive stress on intervertebral discs is commonly deployed as a measurand for assessing the loads that act within the spine. Examining this physical quantity is crucially beneficial: the intradiscal pressure can be directly measured in vivo in humans, and is immediately related to compressive stress. Hence, measured intradiscal pressure data are utterly useful for validating such biomechanical animal models that have the spine incorporated, and can, thus, compute compressive stress values. Here, we utilise human intradiscal pressure data to verify the predictions of a reductionist spine model, which has in fact only one joint degree of freedom. We calculate the pulling force of one lumped anatomical structure that acts past this (intervertebral) joint at the base of the spine—lumbar in hominins, cervical in giraffes—to compensate the torque that is induced by the weight of all masses located cranially to the base. Given morphometric estimates of the human and australopith trunks, respectively, and the giraffe's neck, as well as the respective structures’ lever arms and disc areas, we predict, for all three species, the compressive stress on the intervertebral disc at the spine base, while systematically varying the angular orientation of the species’ spinal columns with respect to gravity. The comparison between these species demonstrates that hominin everyday compressive disc stresses are lower than such in big quadrupedal animals. Within each species, erecting the spine from being bent forward by, for example, thirty degrees to fully upright posture reduces the compressive disc stress roughly to a third. We conclude that erecting the spine immediately allows to carry extra loads of the order of body weight, and yet the compressive disc stress is lower than in a moderately forward-bent posture with none extra load.

Relevance of a novel external dynamic distraction device for treating back pain

Low back pain is a common, expensive, and disabling condition in industrialized countries. There is still no consensus for its ideal management. Believing in the beneficial effect of traction, we developed a novel external dynamic distraction device. The purpose of this work was to demonstrate that external distraction allows limiting the pressure exerted in standing-up position on the lower intervertebral discs. Numerical and cadaveric studies were used as complementary approaches. Firstly, we implemented the device into a numerical model of a validated musculoskeletal software (Anybody Modeling System) and we calculated the lower disc pressure while traction forces were applied. Secondly, we performed an anatomical study using a non-formalin preserved cadaver placed in a sitting position. A pressure sensor was placed in the lower discs under fluoroscopic control through a Jamshidi needle. The intradiscal pressure was then measured continuously at rest while applying a traction force of 200 N. Both numerical and cadaveric studies demonstrated a decrease in intradiscal pressures after applying a traction force with the external device. Using the numerical model, we showed that tensile forces below 500 N in total were sufficient. The application of higher forces seems useless and potentially deleterious. External dynamic distraction device is able to significantly decrease the intradiscal pressure in a sitting or standing position. However, the therapeutic effects need to be proven using clinical studies.

Biomechanical Study of Cervical Disc Arthroplasty Devices Using Finite Element Models

Various types and designs of artificial discs for cervical disc arthroplasty (CDA) have been introduced to overcome the disadvantages of the conventional anterior cervical discectomy and fusion (ACDF). The purpose of this study was to evaluate the effects of different CDA designs on the range of motion (ROM), intradiscal pressure (IDP), and facet force variables with different types of FDA-approved CDA devices under normal physiological loading conditions. A validated three-dimensional finite element model (FEM) of the intact cervical spinal column (C2-T1) was used in the present study. The intact spine model was modified and used for postoperative FE models simulating CDAs implanted at the C5-C6 intervertebral disc space. The normal surgical procedures were used in the simulations. The hybrid loading protocol (intact spine loading: 2 Nm) with a compressive follower force of 75 N was applied at the superior end of the spine. The inferior endplate of C7 vertebra was constrained in all directions. Flexion, extension, and lateral bending loading conditions were simulated in all models: intact spine and models with different CDA devices. At the index level, all CDAs except the Bryan disc showed an increase in motion, and the range of motions at the adjacent levels decreased in flexion, extension, and lateral bending modes. The largest increase in motion occurred during lateral bending. The Bryan disc reduced the segmental motion at the index level under flexion, extension, and lateral bending, and had compensatory increases in motion at the adjacent levels. The intradiscal pressure reduced at the adjacent levels with Mobi-C and Secure-C devices. The Bryan and Prestige LP devices showed increases in the intradiscal pressure at the adjacent levels due to the reduced index level motion (Bryan disc) and the metal-on-metal design (Prestige LP). The facet force increased at the index level in all CDAs, with the highest force with Mobi-C, and this was attributed to its unrestrained design. The facet force generally decreased at the adjacent levels with CDAs, except for the Bryan disc, due to reduced index level motion, and the Prestige LP in lateral bending, likely due to its metal-on-metal design. The present study demonstrates the influence of different CDA designs on the anterior and posterior loading patterns at the index and adjacent levels. In addition, the study validates key clinical observations: CDA procedure is contraindicated in cases of facet arthropathy; and CDA may be protective against adjacent segment degeneration.

Combined Effects of Graded Foraminotomy and Annular Defect on Biomechanics after Percutaneous Endoscopic Lumbar Decompression: A Finite Element Study

Percutaneous endoscopic technology has been widely used in the treatment of lumbar disc stenosis and herniation. However, the quantitative influence of percutaneous endoscopic lumbar decompression on spinal biomechanics of the L5–S1 lumbosacral segment remains poorly understood. Hence, the objective of this study is to investigate the combined effects on the biomechanics of different grades of foraminotomy and annular defect for the L5–S1 segment. A 3D, nonlinear, detailed finite element model of L4–S1 was established and validated. Changes in biomechanical responses upon stimulation to the intact spine during different degrees of resection were analyzed. Measurements included intervertebral rotation, intradiscal pressure, and the strain of disc structure under flexion, extension, left/right lateral bending, and left/right axial rotation under pure bending moments and physiological loads. Compared with the intact model, under prefollower load, annular defect slightly decreased intervertebral rotation by −5.0% in extension and 2.2% in right axial rotation and significantly increased the mean strain of the exposed disc by 237.7% in all loading cases. For right axial rotation, unilateral total foraminotomy with an annular detect increased intervertebral rotation by 29.5% and intradiscal pressure by 57.6% under pure bending moment while the maximum corresponding values were 9.8% and 6.6% when the degree of foraminotomy was below 75%, respectively. These results indicate that percutaneous endoscopic lumbar foraminotomy highly maintains spinal stability, even if the effect of annular detect is taken into account, when the unilateral facet is not totally removed. Patients should avoid excessive extension and axial rotation after surgery on L5–S1. The postoperative open annular defect may substantially increase the risk of recurrent disc herniation.

Finite element modelling of hybrid stabilization systems for the human lumbar spine

Intersomatic fusion is a very popular treatment for spinal diseases associated with intervertebral disc degeneration. The effects of three different hybrid stabilization systems on both range of motion and intradiscal pressure were investigated, as there is no consensus in the literature about the efficiency of these systems. Finite element simulations were designed to predict the variations of range of motion and intradiscal pressure from intact to implanted situations. After hybrid stabilization system implantation, L4-L5 level did not lose its motion completely, while L5-S1 had no mobility as a consequence of disc removal and fusion process. BalanC hybrid stabilization system represented higher mobility at the index level, reduced intradiscal pressure of adjacent level, but caused to increment in range of motion by 20% under axial rotation. Higher tendency by 93% to the failure was also detected under axial rotation. Dynesys hybrid stabilization system represented more restricted motion than BalanC, and negligible effects to the adjacent level. B-DYN hybrid stabilization system was the most rigid one among all three systems. It reduced intradiscal pressure and range of motion at the adjacent level except from motion under axial rotation being increased by 13%. Fracture risk of B-DYN and Dynesys Transition Optima components was low when compared with BalanC. Mobility of the adjacent level around axial direction should be taken into account in case of implantation with BalanC and B-DYN systems, as well as on the development of new designs. Having these findings in mind, it is clear that hybrid systems need to be further tested, both clinically and numerically, before being considered for common use.