Skin marker-based subject-specific spinal alignment modeling: A feasibility study.

Musculoskeletal models have the potential to improve diagnosis and optimize clinical treatment by predicting accurate outcomes on an individual basis. However, the subject-specific modeling of spinal alignment is often strongly simplified or is based on radiographic assessments, exposing subjects to unnecessary radiation. We therefore developed and introduced a novel skin marker-based approach for modeling subject-specific spinal alignment and evaluated its feasibility by comparing the predicted L1/L2 spinal loads during various functional activities with the loads predicted by the generically scaled models as well as with in vivo measured data obtained from the OrthoLoad database. Spinal loading simulations resulted in considerably higher compressive forces for both scaling approaches over all simulated activities, and AP shear forces that were closer or similar to the in vivo data for the subject-specific approach during upright standing activities and for the generic approach during activities that involved large flexions. These results underline the feasibility of the proposed method and associated workflow for inter- and intra-subject investigations using musculoskeletal simulations. When implemented into standard model scaling workflows, it is expected to improve the accuracy of muscle activity and joint loading simulations, which is crucial for investigations of treatment effects or pathology-dependent deviations.

Bone density optimized pedicle screw instrumentation improves screw pull-out force in lumbar vertebrae.

Pedicle screw instrumentation is performed in the surgical treatment of a wide variety of spinal pathologies. A common postoperative complication associated with this procedure is screw loosening. It has been shown that patient-specific screw fixation can be automated to match standard clinical practice and that failure can be estimated preoperatively using computed tomography images. Hence, we set out to optimize three-dimensional preoperative planning to achieve more mechanically robust screw purchase allowing deviation from intuitive, standard screw parameters. Toward this purpose, we employed a genetic algorithm optimization to find optimal screw sizes and trajectories by maximizing the CT derived bone mechanical properties. The method was tested on cadaveric lumbar vertebrae (L1 to L5) of four human spines (2 female/2 male; age range 60-78 years). The main boundary conditions were the predefined, level-dependent areas of possible screw entry points, as well as the automatically located pedicle structures. Finite element analysis was used to compare the genetic algorithm output to standard clinical planning of screw positioning in terms of the simulated pull-out strength. The genetic algorithm optimization successfully found screw sizes and trajectories that maximize the sum of the Young's modulus within the screw's volume for all 40 pedicle screws included in this study. Overall, there was a 26% increase in simulated pull-out strength for optimized compared to traditional screw trajectories and sizes. Our results indicate that optimizing pedicle screw instrumentation in lumbar vertebrae based on bone quality measures improves screw purchase as compared to traditional instrumentation.

Musculoskeletal biomechanics of patients with or without adjacent segment degeneration after spinal fusion.

STUDY DESIGN: A retrospective, single center, case-control study was performed. OBJECTIVE: The present study employed patient-specific biomechanical modeling to find potential biomechanical differences after spinal fusion at L4/5 in patients with and without subsequent development of adjacent segment disease (ASD). METHODS: The study population comprised patients who underwent primary spinal fusion at L4/5 and were either asymptomatic during > 4 years of follow-up (CTRL; n = 18) or underwent revision surgery for ASD at L3/4 (n = 20). Landmarks were annotated on preoperative and follow-up lateral radiographs, and specific musculoskeletal models were created using a custom-built modeling pipeline. Simulated spinal muscle activation and lumbar intervertebral shear loads in unfused segments were analyzed in upright standing and forward flexion. Differences between the pre- and postoperative conditions were computed for each patient. RESULTS: The average postoperative muscle activity in the upright standing posture was 88.4% of the preoperative activity in the CTRL group (p <  0.0001), but did not significantly change from pre- to postoperatively in the ASD group (98.0%). The average shear load magnitude at the epifusional joint L3/4 during upright standing increased from pre- to postoperatively in the ASD group (+ 3.9 N, +/- 17.4 (n = 18)), but decreased in the CTRL group (- 4.6 N, +/- 23.3 (n = 20); p <  0.001). CONCLUSION: Patient-specific biomechanical simulation revealed that spinal fusion surgery resulted in greater shear load magnitude and muscle activation and therefore greater forces at the epifusional segment in those with ASD compared with those without ASD. This is a first report of patient-specific disc load and muscle force calculation with predictive merits for ASD.

Patient-specific statistical shape modeling for optimal spinal sagittal alignment in lumbar spinal fusion.

PURPOSE: The present study compared patients developing ASD after L4/5 spinal fusion with a control group using a patient-specific statistical shape model (SSM) to find alignment-differences between the groups. METHODS: This study included patients who had undergone spinal fusion at L4/5 and either remained asymptomatic (control group; n = 25, follow-up of > 4 years) or required revision surgery for epifusional ASD (n = 22). Landmarks on preoperative and postoperative lateral radiographs were annotated, and the optimal spinal sagittal alignment was calculated for each patient. The two-dimensional distance from the SSM-calculated optimum to the actual positions before and after fusion surgery was compared. RESULTS: Postoperatively, the additive mean distance from the SSM-calculated optimum was 86.8 mm in the ASD group and 67.7 mm in the control group (p = 0.119). Greater differences were observed between the groups with a larger distance to the ideal in patients with ASD at more cranial levels. Significant difference between the groups was seen postoperatively in the vertical distance of the operated segment L4. The patients with ASD (5.69 ± 3.0 mm) had a significant greater distance from the SSM as the control group (3.58 ± 3.5 mm, p = 0.034). CONCLUSION: Patients with ASD requiring revision after lumbar spinal fusion have greater differences from the optimal spinal sagittal alignment as an asymptomatic control group calculated by patient-specific statistical shape modeling. Further research might help to understand the value of SSM, in conjunction with already established indexes, for preoperative planning with the aim of reducing the risk of ASD. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Automated Pipeline to Generate Anatomically Accurate Patient-Specific Biomechanical Models of Healthy and Pathological FSUs.

State-of-the-art preoperative biomechanical analysis for the planning of spinal surgery not only requires the generation of three-dimensional patient-specific models but also the accurate biomechanical representation of vertebral joints. The benefits offered by computational models suitable for such purposes are still outweighed by the time and effort required for their generation, thus compromising their applicability in a clinical environment. In this work, we aim to ease the integration of computerized methods into patient-specific planning of spinal surgery. We present the first pipeline combining deep learning and finite element methods that allows a completely automated model generation of functional spine units (FSUs) of the lumbar spine for patient-specific FE simulations (FEBio). The pipeline consists of three steps: (a) multiclass segmentation of cropped 3D CT images containing lumbar vertebrae using the DenseVNet network, (b) automatic landmark-based mesh fitting of statistical shape models onto 3D semantic segmented meshes of the vertebral models, and (c) automatic generation of patient-specific FE models of lumbar segments for the simulation of flexion-extension, lateral bending, and axial rotation movements. The automatic segmentation of FSUs was evaluated against the gold standard (manual segmentation) using 10-fold cross-validation. The obtained Dice coefficient was 93.7% on average, with a mean surface distance of 0.88 mm and a mean Hausdorff distance of 11.16 mm (N = 150). Automatic generation of finite element models to simulate the range of motion (ROM) was successfully performed for five healthy and five pathological FSUs. The results of the simulations were evaluated against the literature and showed comparable ROMs in both healthy and pathological cases, including the alteration of ROM typically observed in severely degenerated FSUs. The major intent of this work is to automate the creation of anatomically accurate patient-specific models by a single pipeline allowing functional modeling of spinal motion in healthy and pathological FSUs. Our approach reduces manual efforts to a minimum and the execution of the entire pipeline including simulations takes approximately 2 h. The automation, time-efficiency and robustness level of the pipeline represents a first step toward its clinical integration.

Fear-avoidance beliefs are associated with reduced lumbar spine flexion during object lifting in pain-free adults.

ABSTRACT: There is a long-held belief that physical activities such as lifting with a flexed spine is generally harmful for the back and can cause low back pain (LBP), potentially reinforcing fear-avoidance beliefs underlying pain-related fear. In patients with chronic LBP, pain-related fear has been shown to be associated with reduced lumbar range of motion during lifting, suggesting a protective response to pain. However, despite short-term beneficial effects for tissue health, recent evidence suggests that maintaining a protective trunk movement strategy may also pose a risk for (persistent) LBP due to possible pronociceptive consequences of altered spinal motion, potentially leading to increased loading on lumbar tissues. Yet, it is unknown if similar protective movement strategies already exist in pain-free individuals, which would yield potential insights into the role of fear-avoidance beliefs in motor behavior in the absence of pain. Therefore, the aim of this study is to test whether fear-avoidance beliefs influence spinal motion during lifting in a healthy cohort of pain-free adults without a history of chronic pain. The study subjects (N = 57) filled out several pain-related fear questionnaires and were asked to perform a lifting task (5kg-box). High-resolution spinal kinematics were assessed using an optical motion capturing system. Time-sensitive analyses were performed based on statistical parametric mapping. The results demonstrated time-specific and negative relationships between self-report measures of pain-related fear and lumbar spine flexion angles during lifting, indicating potential unfavorable interactions between psychological factors and spinal motion during lifting in pain-free subjects.

How is spinal range of motion affected by disc- and facet degeneration and spinopelvic anatomy?

BACKGROUND: We aimed to investigate how disc- and facet joint degeneration relate to ROM and spinopelvic alignment parameters. Their interrelation, however, is not yet understood, although eminent in patient specific modeling approaches and surgical decision making. Further is not yet sufficiently understood whether spinal alignment parameters relate to the degenerative states. METHODS: The ROM of lumbar spinal segments was quantified using flexion/extension radiographs of 90 patients. The grades of degeneration of discs (IDD, Pfirrmann grades, n=440) and facet joints (FJD, Weishaupt classification, n=406) were assessed in CT and MRI scans. RESULTS: The grade of IDD was significantly related to changes in ROM (p<0.01) whereas no association was observed with the amount of FJD. Grade V IDD was associated with a significant decrease in motion (p<0.01) compared to all other IDD grades (II-IV), which did not differ significantly among each other. The combined occurrence of IDD and FJD revealed the largest angular segmental ROM in segments with the lowest IDD (II) and lowest FJD (0). The lowermost ROM was present in fused segments (control), followed by those with severe IDD (V). In combination with FJD, the destabilizing effect of initial IDD was only observed if FJD was already in an advanced state. CONCLUSIONS: While the degree of facet joint degeneration seems not significantly associated with limitations in spinal motion, severe lumbar disc degeneration limits segmental motion, nearly equal to spinal fusion. This should affect counseling patients undergoing spinal fusion with questions on the probability of adjacent segment degeneration compared to the natural course.

Spinal sagittal alignment goals based on statistical modelling and musculoskeletal simulations.

The definition of target alignment for spinal fusion surgery follows anatomical criteria and strongly relies on surgical experience. However, the optimal patient-specific alignment often remains unknown. Statistical models could provide information about physiological alignments, and musculoskeletal models are powerful tools to investigate biomechanics. We aimed to statistically predict alignments and hypothesized they would be biomechanically favorable. A statistical model was trained with 60 annotated radiographs to predict physiological sagittal alignment based on position of femoral heads and sacrum. Predicted alignments for 11 back pain patients were clinically evaluated in terms of balance and compared to Original alignments. The normative ranges for spinal balance parameters were obtained from Surgimap™. Musculoskeletal loads were furthermore simulated in upright standing and 30° forward flexion, using alignment-specific musculoskeletal models. For the majority of Predicted alignments (n = 9) at least two of three investigated balance parameters were within the normative range, as opposed to the minority of the Original alignments (n = 4). Predicted alignments resulted in significantly lowered overall muscle activity and compressive loads (all levels, both postures). Shear force magnitudes in upright standing decreased significantly at levels L1L2 (-68 N) and L2L3 (-69 N) and clearly yet not significantly at L3L4 (-39 N) and L4L5 (-152 N). Shear loads at level L5S1 remained the same. In flexed postures identical trends were observed. The statistical model was able to predict spinal alignments that led to both improved balance and reduced musculoskeletal loads. Further studies are needed to investigate clinical validity of such models.

Kinematics of the Spine Under Healthy and Degenerative Conditions: A Systematic Review.

Understanding spinal kinematics is essential, not only for the comprehension and diagnosis of spinal diseases, but also for improving modern tools and software. The sheer volume and complexity of now available information can be overwhelming. We aimed to distil it into a form that facilitates comparison among diverse studies addressing spinal kinematics under healthy and degenerative conditions. We specifically aimed to define a baseline definition of the spectrum of normal spinal kinematics that in turn allows a comparable definition of kinematics of the degenerative lumbar spine. The considered data was obtained by a systematic MEDLINE search including studies on angular/translational segmental motion contribution, range of motion, coupling and center of rotation. As for degenerative conditions, we collected publications on disc degeneration, facet joint osteoarthritis, facet joint tropism, spondylolisthesis, ligament degeneration and paraspinal muscle degeneration. While we could demonstrate repeating motion patterns for some topics, agreement in other fields is limited due to methodological variances and small sample sizes, particularly in publications with highly accurate but complex techniques. Besides, the high frequency of concurrent degenerative processes complicates the association between diseases and subsequent kinematical changes. Despite several substantial gaps, we stand at the precipice of technological breakthroughs that can power future large-scale studies.

Sensitivity of intervertebral joint forces to center of rotation location and trends along its migration path.

Translational vertebral motion during functional tasks manifests itself in dynamic loci for center of rotation (COR). A shift of COR affects moment arms of muscles and ligaments; consequently, muscle and joint forces are altered. Based on posture- and level-specific trends of COR migration revealed by in vivo dynamic radiography during functional activities, it was postulated that the instantaneous COR location for a particular joint is optimized in order to minimize the joint reaction forces. A musculoskeletal multi-body model was employed to investigate the hypotheses that (1) a posterior COR in upright standing and (2) an anterior COR in forward flexed posture leads to optimized lumbar joint loads. Moreover, it was hypothesized that (3) lower lumbar levels benefit from a more superiorly located COR. The COR in the model was varied from its initial position in posterior-anterior and inferior-superior direction up to ±6 mm in steps of 2 mm. Movement from upright standing to 45° forward bending and backwards was simulated for all configurations. Joint reaction forces were computed at levels L2L3 to L5S1. Results clearly confirmed hypotheses (1) and (2) and provided evidence for the validity of hypothesis (3), hence offering a biomechanical rationale behind the migration paths of CORs observed during functional flexion/extension movement. Average sensitivity of joint force magnitudes to an anterior shift of COR was +6 N/mm in upright and -21 N/mm in 30° forward flexed posture, while sensitivity to a superior shift in upright standing was +7 N/mm and -8N/mm in 30° flexion. The relation between COR loci and joint loading in upright and flexed postures could be mainly attributed to altered muscle moment arms and consequences on muscle exertion. These findings are considered relevant for the interpretation of COR migration data, the development of numerical models, and could have an implication on clinical diagnosis and treatment or the development of spinal implants.

Fusion angle affects intervertebral adjacent spinal segment joint forces-Model-based analysis of patient specific alignment.

This study addresses the hypothesis that adjacent segment intervertebral joint loads are sensitive to the degree of lordosis that is surgically imposed during vertebral fusion. Adjacent segment degeneration is often observed after lumbar fusion, but a causative mechanism is not yet clearly evident. Altered kinematics of the adjacent segments and potentially nonphysiological mechanical joint loads have been implicated in this process. However, little is known of how altered alignment and kinematics influence loading of the adjacent intervertebral joints under consideration of active muscle forces. This study investigated these effects by simulating L4/5 fusions using kinematics-driven musculoskeletal models of one generic and eight sagittal alignment-specific models. Models featured different spinopelvic configurations but were normalized by body height, masses, and muscle properties. Fusion of the L4/5 segment was implemented in an in situ (22°), hyperlordotic (32°), and hypolordotic (8°) fashion and kinematic input parameters were changed accordingly based on findings of an in vitro investigation. Bending motion from upright standing to 45° forward flexion and back was simulated for all models in intact and fused conditions. Joint loads at adjacent levels and moment arms of spinal muscles experienced changes after all types of fusion. Hypolordotic configuration led to an increase of adjacent segment (L3/4) shear forces of 29% on average, whereas hyperlordotic fusion reduced shear by 39%. Overall, L4/5 in situ fusion resulted in intervertebral joint forces closest to intact loading conditions. An artificial decrease in lumbar lordosis (minus 14° on average) caused by an L4/5 fusion lead to adverse loading conditions, particularly at the cranial adjacent levels, and altered muscle moment arms, in particular for muscles in the vicinity of the fusion. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:131-139, 2017.

Intervertebral reaction force prediction using an enhanced assembly of OpenSim models.

OpenSim offers a valuable approach to investigating otherwise difficult to assess yet important biomechanical parameters such as joint reaction forces. Although the range of available models in the public repository is continually increasing, there currently exists no OpenSim model for the computation of intervertebral joint reactions during flexion and lifting tasks. The current work combines and improves elements of existing models to develop an enhanced model of the upper body and lumbar spine. Models of the upper body with extremities, neck and head were combined with an improved version of a lumbar spine from the model repository. Translational motion was enabled for each lumbar vertebrae with six controllable degrees of freedom. Motion segment stiffness was implemented at lumbar levels and mass properties were assigned throughout the model. Moreover, body coordinate frames of the spine were modified to allow straightforward variation of sagittal alignment and to simplify interpretation of results. Evaluation of model predictions for level L1-L2, L3-L4 and L4-L5 in various postures of forward flexion and moderate lifting (8 kg) revealed an agreement within 10% to experimental studies and model-based computational analyses. However, in an extended posture or during lifting of heavier loads (20 kg), computed joint reactions differed substantially from reported in vivo measures using instrumented implants. We conclude that agreement between the model and available experimental data was good in view of limitations of both the model and the validation datasets. The presented model is useful in that it permits computation of realistic lumbar spine joint reaction forces during flexion and moderate lifting tasks. The model and corresponding documentation are now available in the online OpenSim repository.

Pelvic incidence-lumbar lordosis mismatch results in increased segmental joint loads in the unfused and fused lumbar spine.

PURPOSE: Symptomatic adjacent segment disease (ASD) has been reported to occur in up to 27 % of lumbar fusion patients. A previous study identified patients at risk according to the difference of pelvic incidence and lordosis. Patients with a difference between pelvic incidence and lumbar lordosis >15° have been found to have a 20 times higher risk for ASD. Therefore, it was the aim of the present study to investigate forces acting on the adjacent segment in relation to pelvic incidence-lumbar lordosis (PILL) mismatch as a measure of spino-pelvic alignment using rigid body modeling to decipher the underlying forces as potential contributors to degeneration of the adjacent segment. METHODS: Sagittal configurations of 81 subjects were reconstructed in a musculoskeletal simulation environment. Lumbar spine height was normalized, and body and segmental mass properties were kept constant throughout the population to isolate the effect of sagittal alignment. A uniform forward/backward flexion movement (0°-30°-0°) was simulated for all subjects. Intervertebral joint loads at lumbar level L3-L4 and L4-L5 were determined before and after simulated fusion. RESULTS: In the unfused state, an approximately linear relationship between sagittal alignment and intervertebral loads could be established (shear: 0° flexion r = 0.36, p < 0.001, 30° flexion r = 0.48, p < 0.001; compression: 0° flexion r = 0.29, p < 0.01, 30° flexion r = 0.40, p < 0.001). Additionally, shear changes during the transition from upright to 30° flexed posture were on average 32 % higher at level L3-L4 and 14 % higher at level L4-L5 in alignments that were clinically observed to be prone to ASD. Simulated fusion affected shear forces at the level L3-L4 by 15 % (L4-L5 fusion) and 23 % (L4-S1 fusion) more for alignments at risk for ASD. CONCLUSION: Higher adjacent segment shear forces in alignments at risk for ASD already prior to fusion provide a mechanistic explanation for the clinically observed correlation between PILL mismatch and rate of adjacent segment degeneration.

An integrated model of active glenohumeral stability.

We present the first model of the glenohumeral joint implementing active muscle driven humeral positioning and stabilization without a priori constraints on glenohumeral kinematics. Previously established methods were used to predetermine the path, activation timing and resultant force contribution of 27 individual muscle segments at any given joint position. Artificial boundary conditions were applied in a three-dimensional finite element model of the joint and progressively released until the humeral head was completely free to rotate and translate within the fixed glenoid according to the compressive component of the predetermined resultant force. The shear component was then added such that no boundary conditions other than muscular force were applied. The framework was exploited to simulate elevation as a composite of instantaneous positions and theoretically demonstrate that joint stability can be achieved exclusively through muscular activity. Predicted muscle moment arms, muscle activation timing, humeral head translations, joint contact forces and stability ratio were comparable with existing experimental and in vivo data. This framework could be valuable for subject specific modeling and may be used to address clinical hypotheses related to shoulder joint stability that cannot be pursued using simplified modeling approaches.