Biomechanical Analysis of the Cervical Spine Following Disc Degeneration, Disc Fusion, and Disc Replacement: A Finite Element Study.

BACKGROUND: Discectomy and fusion is considered the "gold standard" treatment for clinical manifestations of degenerative disc disease in the cervical spine. However, clinical and biomechanical studies suggest that fusion may lead to adjacent-segment disease. Cervical disc arthroplasty preserves the motion at the operated level and may potentially decrease the occurrence of adjacent segment degeneration. The purpose of this study was to investigate the effect of disc generation, fusion, and disc replacement on the motion, disc stresses, and facet forces on the cervical spine by using the finite element method. METHODS: A validated, intact, 3-dimensional finite element model of the cervical spine (C2-T1) was modified to simulate single-level (C5-C6) and 2-level (C5-C7) degeneration. The single-level degenerative model was modified to simulate both single-level fusion and arthroplasty (total disc replacement [TDR]) using the Bryan and Prestige LP discs. The 2-level degenerative model was modified to simulate a 2-level fusion, 2-level arthroplasty, and single-level disc replacement adjacent to single-level fusion (hybrid). The intact models were loaded by applying a moment of ±2 Nm in flexion-extension, lateral bending, and axial rotation. The motion in each direction was noted and the other modified models were loaded by increasing the moment until the primary C2-T1 motion matched that of the intact (healthy) C2-T1 motion. RESULTS: Both Bryan and Prestige discs preserved motion at the implanted level and maintained normal motions at the adjacent nonoperative levels. A fusion resulted in a decrease in motion at the fused level and an increase in motion at the unfused levels. In the hybrid construct, the TDR (both) preserved motion adjacent to the fusion, thus reducing the demand on the other levels. The disc stresses followed the same trends as motion. Facet forces increased considerably at the index level following a TDR. CONCLUSION: The Bryan and Prestige LP TDRs both preserved motion at the implanted level and maintained normal motion and disc stresses at the adjacent levels. The motion patterns of the spine with a TDR more closely resembled that of the intact spine than those of the degenerative or fused models.

The effect of multi-level laminoplasty and laminectomy on the biomechanics of the cervical spine: a finite element study.

Laminectomy has been regarded as a standard treatment for multi-level cervical stenosis. Concern for complications such as kyphosis has limited the indication of multi-level laminectomy; hence it is often augmented with an instrumented fusion. Laminoplasty has emerged as a motion preserving alternative. The purpose of this study was to compare the multidirectional flexibility of the cervical spine in response to a plate-only open door laminoplasty, double door laminoplasty, and laminectomy using a computational model. A validated three-dimensional finite element model of a specimen-specific intact cervical spine (C2-T1) was modified to simulate each surgical procedure at levels C3-C6. An additional goal of this work was to compare the instrumented computational model to our multi-specimen experimental findings to ensure similar trends in response to the surgical procedures. Model predictions indicate that mobility was retained following open and double door laminoplasty with a 5.4% and 20% increase in flexion, respectively, compared to the intact state. Laminectomy resulted in 57% increase in flexion as compared to the intact state, creating a concern for eventual kyphosis--a known risk/complication of multi-level laminectomy in the absence of fusion. Increased disc stresses were observed at the altered and adjacent segments post-laminectomy in flexion.

Hexahedral meshing of subject-specific anatomic structures using mapped building blocks.

To extend the use of computational techniques like finite element analysis to clinical settings, it would be beneficial to have the ability to generate a unique model for every subject quickly and efficiently. This work is an extension of two previously developed mapped meshing tools that utilised force and displacement control to map a template mesh to a subject-specific surface. The objective of this study was to map a template block structure, common to multiblock meshing techniques, to a subject-specific surface. The rationale is that the blocks are considerably less refined and may be readily edited after mapping, thereby yielding a mesh of high quality in less time than mapping the mesh itself. In this paper, the versatility and robustness of the method was verified by processing four data-sets. The method was found to be robust enough to cope with the variability of bony surface size, spatial position and geometry, producing building block structures (BBSs) that generated meshes comparable to those produced using BBSs that were created manually.

Growing multiblock structures: a semi-automated approach to block placement for multiblock hexahedral meshing.

Finite element (FE) analysis is a cornerstone of orthopaedic biomechanics research. Three-dimensional medical imaging provides sufficient resolution for the subject-specific FE models to be generated from these data-sets. FE model development requires discretisation of a three-dimensional domain, which can be the most time-consuming component of a FE study. Hexahedral meshing tools based on the multiblock method currently rely on the manual placement of building blocks for mesh generation. We hypothesise that angular analysis of the geometric centreline for a three-dimensional surface could be used to automatically generate building block structures for the multiblock hexahedral mesh generation. Our algorithm uses a set of user-defined points and parameters to automatically generate a multiblock structure based on a surface's geometric centreline. This significantly reduces the time required for model development. We have applied this algorithm to 47 bones of varying geometries and successfully generated a FE mesh in all cases. This work represents significant advancement in automatically generating multiblock structures for a wide range of geometries.

Toward the development of virtual surgical tools to aid orthopaedic FE analyses.

Computational models of joint anatomy and function provide a means for biomechanists, physicians, and physical therapists to understand the effects of repetitive motion, acute injury, and degenerative diseases. Finite element models, for example, may be used to predict the outcome of a surgical intervention or to improve the design of prosthetic implants. Countless models have been developed over the years to address a myriad of orthopaedic procedures. Unfortunately, few studies have incorporated patient-specific models. Historically, baseline anatomic models have been used due to the demands associated with model development. Moreover, surgical simulations impose additional modeling challenges. Current meshing practices do not readily accommodate the inclusion of implants. Our goal is to develop a suite of tools (virtual instruments and guides) which enable surgical procedures to be readily simulated and to facilitate the development of all-hexahedral finite element mesh definitions.

An interactive multiblock approach to meshing the spine.

Finite element (FE) analysis is a useful tool to study spine biomechanics as a complement to laboratory-driven experimental studies. Although individualized models have the potential to yield clinically relevant results, the demands associated with modeling the geometric complexity of the spine often limit its utility. Existing spine FE models share similar characteristics and are often based on similar assumptions, but vary in geometric fidelity due to the mesh generation techniques that were used. Using existing multiblock techniques, we propose mesh generation methods that ease the effort and reduce the time required to create subject-specific allhexahedral finite element models of the spine. We have demonstrated the meshing techniques by creating a C4-C5 functional spinal unit and validated it by comparing the resultant motions and vertebral strains with data reported in the literature.

IA-FEMesh: an open-source, interactive, multiblock approach to anatomic finite element model development.

Finite element (FE) analysis is a valuable tool in musculoskeletal research. The demands associated with mesh development, however, often prove daunting. In an effort to facilitate anatomic FE model development we have developed an open-source software toolkit (IA-FEMesh). IA-FEMesh employs a multiblock meshing scheme aimed at hexahedral mesh generation. An emphasis has been placed on making the tools interactive, in an effort to create a user friendly environment. The goal is to provide an efficient and reliable method for model development, visualization, and mesh quality evaluation. While these tools have been developed, initially, in the context of skeletal structures they can be applied to countless applications.

Automated bony region identification using artificial neural networks: reliability and validation measurements.

OBJECTIVE: The objective was to develop tools for automating the identification of bony structures, to assess the reliability of this technique against manual raters, and to validate the resulting regions of interest against physical surface scans obtained from the same specimen. MATERIALS AND METHODS: Artificial intelligence-based algorithms have been used for image segmentation, specifically artificial neural networks (ANNs). For this study, an ANN was created and trained to identify the phalanges of the human hand. RESULTS: The relative overlap between the ANN and a manual tracer was 0.87, 0.82, and 0.76, for the proximal, middle, and distal index phalanx bones respectively. Compared with the physical surface scans, the ANN-generated surface representations differed on average by 0.35 mm, 0.29 mm, and 0.40 mm for the proximal, middle, and distal phalanges respectively. Furthermore, the ANN proved to segment the structures in less than one-tenth of the time required by a manual rater. CONCLUSIONS: The ANN has proven to be a reliable and valid means of segmenting the phalanx bones from CT images. Employing automated methods such as the ANN for segmentation, eliminates the likelihood of rater drift and inter-rater variability. Automated methods also decrease the amount of time and manual effort required to extract the data of interest, thereby making the feasibility of patient-specific modeling a reality.

Validation of phalanx bone three-dimensional surface segmentation from computed tomography images using laser scanning.

OBJECTIVE: To examine the validity of manually defined bony regions of interest from computed tomography (CT) scans. MATERIALS AND METHODS: Segmentation measurements were performed on the coronal reformatted CT images of the three phalanx bones of the index finger from five cadaveric specimens. Two smoothing algorithms (image-based and Laplacian surface-based) were evaluated to determine their ability to represent accurately the anatomic surface. The resulting surfaces were compared with laser surface scans of the corresponding cadaveric specimen. RESULTS: The average relative overlap between two tracers was 0.91 for all bones. The overall mean difference between the manual unsmoothed surface and the laser surface scan was 0.20 mm. Both image-based and Laplacian surface-based smoothing were compared; the overall mean difference for image-based smoothing was 0.21 mm and 0.20 mm for Laplacian smoothing. CONCLUSIONS: This study showed that manual segmentation of high-contrast, coronal, reformatted, CT datasets can accurately represent the true surface geometry of bones. Additionally, smoothing techniques did not significantly alter the surface representations. This validation technique should be extended to other bones, image segmentation and spatial filtering techniques.

Arthroscopic lens distortion correction applied to dynamic cartilage loading.

It is difficult to study the deformation of articular cartilage because it is an inhomogenous material with depth dependent constituents. In many experimental studies, cartilage is assumed to behave homogeneously and is subjected to only static or quasi-static loads. In this study, a thick walled, mechanically active culture device (TRIAX) was used to apply cyclic loading to cartilage explants at physiological stress levels. An arthroscope was fitted into the wall of the TRIAX to monitorand record the cyclic compressive behavior of the cartilage and to measure depth dependent cartilage strains. A common concern with arthroscopy systems is that the images obtained are radially distorted about a central point ("fisheye" view); therefore it is necessary to correct this distortion in order to accurately quantify distances between objects within the images. To do this, an algorithm was developed which used a calibration pattern to create an image transform. Digital video of the cyclic cartilage compression was recorded, and the distortion algorithm was applied to the images to measure the cartilage as it deformed. This technique will provide valuable and practical insight into cartilage mechanics and viability (via calcein AM-stained chondrocytes) during multiday cyclic loading of living cartilage explants. The implementation of an arthroscopy system provides the advantage of bringing microscope-level resolution into a cartilage compression device to allow for digital visualization of the entire explant at the whole-tissue level.

Loading and boundary condition influences in a poroelastic finite element model of cartilage stresses in a triaxial compression bioreactor.

BACKGROUND: We developed a poroelastic finite element (FE) model of cartilage in dynamic triaxial compression to parametrically analyze the effects of loading and boundary conditions on a baseline model. Conventional mechanical tests on articular cartilage such as confined and unconfined compression, indentation, etc., do not fully allow for modulation of compression and shear at physiological levels whereas triaxial compression does. A Triaxial Compression Bioreactor, or TRIAX, has been developed to study chondrocyte responses to multi-axial stress conditions under cyclic loading. In the triaxial setting, however, a cartilage explant's physical testing environment departs from the ideal homogeneous stress state that would occur from strict linear superposition of the applied axial and transverse pressure. METHOD OF APPROACH: An axisymmetric poroelastic FE model of a cartilage explant (4 mm diameter, 1.5 mm thick) in cyclic triaxial compression was created. Axial and transverse loads (2 MPa at 1 Hz.) were applied via a platen and containment sheath. Parameters of interest included the rise time and magnitude of the applied load, in addition to the containment sheath modulus and the friction coefficient at the cartilage/platen interfaces. Metrics of interest in addition to whole explant axial strain included axial (surface normal) stress, shear stress, pore pressure, and the fluid load carriage fraction within the explant. RESULTS: Strain results were compared to experimental data from explants tested in the TRIAX under conditions similar to the baseline model. Explant biomechanics varied considerably over numbers of load cycles and parameter values. Cyclic loading caused an increase in accumulated strain for the various loading and boundary conditions. CONCLUSIONS: Unlike what would be expected from linear superposition of the homogeneous stresses from the applied axial and transverse pressure, we have shown that the stress state within the TRIAX is considerably heterogeneous. Both the boundary influences (variation in the sheath modulus and friction coefficient) and the loading history (due to poroelastic material behavior) interact in a highly nonlinear manner to influence that heterogeneity.