Sensitivity of lumbar spine response to follower load and flexion moment: finite element study

Finite element analysis of implanted lumbar spine: Effects of open laminectomy plus PLF and open laminectomy plus TLIF surgical approaches on L3-L4 FSU

Several finite element (FE) studies reported performances of various lumbar fusion surgical approaches. However, comparative studies on the performance of Open Laminectomy plus Posterolateral Fusion (OL-PLF) and Open Laminectomy plus Transforaminal Interbody Fusion (OL-TLIF) surgical approaches are rare. In the current FE study, the variation in ranges of motions (ROM), stress-strain distributions in an implanted functional spinal unit (FSU) and caudal adjacent soft structures between OL-PLF and OL-TLIF virtual models were investigated. The implanted lumbar spine FE models were developed from subject-specific computed tomography images of an intact spine and solved for physiological loadings such as compression, flexion, extension and lateral bending. Reductions in the ROMs of L1-L5 (49 % to 59 %) and L3-L4 implanted FSUs (91 % to 96 %) were observed for both models. Under all the loading cases, the maximum von Mises strain observed in the implanted segment of both models exceeds the mean compressive yield strain for the vertebra. The maximum von Mises stress and strain observed on the caudal adjacent soft structures of both the implanted models are at least 22 % higher than the natural spine model. The findings indicate the risk of failure in the implanted FSUs and higher chances of adjacent segment degeneration for both models.

Impact of osteoporosis and Cement-Augmented fusion on adjacent spinal levels Post-Fusion Surgery: Patient-Specific finite element analysis

Cement-augmentation is a technique commonly used during posterior lumbar instrumented fusion (PLIF) to reinforce compromised osteoporotic vertebral bone, minimize the risk of loosening screws, enhance stability, and improve overall surgical outcomes. In this study, we introduce a novel segmented vertebral body regional modeling approach to investigate the effects of osteoporosis and cement-augmented lumbar fusion on disc biomechanics at spinal levels adjacent to the fused vertebrae. Using our previously validated personalized-poroelastic-osteoligamentous FE model of the spine, fusion was simulated at L4-L5, and the biomechanics of adjacent levels were studied for 30 patients (non-osteoporotic patients (N = 15), osteoporotic patients (N = 15)). PLIF models, with and without cement-augmentation, were developed and compared after an 8 h-rest period (200 N), following a 16 h-cyclic compressive loading of 500-1000 N (40 and 20 min, respectively). Movement in different directions (flexion/ extension/ lateral bending/ axial rotation) was simulated using 10Nm moment before and after cyclic loading. The material mapping algorithm was validated by comparing the results of voxel-based and parametric models. The FE cement-augmented models, subject to daily activity loading, demonstrated significant differences in disc height loss and fluid loss as compared to non-cemented models. The calculated axial stress and fiber strain values were also significantly higher for these models. This work demonstrates that although osteoporosis does not significantly alter the time-dependent characteristics of adjacent IVDs post-surgery, cement-augmentation increases the risk of adjacent segment disease (ASD) incidence. A holistic understanding of the trade-offs and long-term complex interplay between structural reinforcement modalities, including cement augmentation, and altered biomechanics warrants further investigation.

Effects of open and minimally invasive Transforaminal Lumbar Interbody Fusion (TLIF) surgical techniques on mechanical behaviour of fused L3-L4 FSU: A comparative finite element study

For predicting the biomechanical effects of the fusion procedure, finite element (FE) analysis is widely used as a preclinical tool. Although several FE studies examined the efficacies of various fusion surgical techniques, comparative studies on Open and minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) procedures incorporating a follower coordinate system have not been investigated yet. The current FE study evaluates the ranges of motion (ROM) and load distributions of Open-TLIF and MIS-TLIF implanted models, under physiological loading such as compression, flexion, extension and lateral bending. The most noteworthy finding from the investigation is that both the fusion procedures significantly reduced the ROMs of the implanted segment (L3-L4) and full model (L1-L5) by at least 89 % and 44 %, respectively, compared to the intact model. For all loading situations, over 95 % of the implanted models' cancellous bone volume was subjected to von Mises strains ranging from 0.0003 to 0.005. The maximum von Mises strain was observed to be localized on a small amount of cancellous bone volume (<5 %). The likelihood of adjacent segment degeneration is higher in the case of MIS-TLIF due to the higher stress (22-53 MPa) and strain (0.018-0.087) noticed on the upper facet of the L3 vertebra.

Anatomical parameters alter the biomechanical responses of adjacent segments following lumbar fusion surgery: Personalized poroelastic finite element modelling investigations

Introduction: While the short-term post-operative outcome of lumbar fusion is satisfying for most patients, adjacent segment disease (ASD) can be prevalent in long-term clinical observations. It might be valuable to investigate if inherent geometrical differences among patients can significantly alter the biomechanics of adjacent levels post-surgery. This study aimed to utilize a validated geometrically personalized poroelastic finite element (FE) modeling technique to evaluate the alteration of biomechanical response in adjacent segments post-fusion. Methods: Thirty patients were categorized for evaluation in this study into two distinct groups [i.e., 1) non-ASD and 2) ASD patients] based on other long-term clinical follow-up investigations. To evaluate the time-dependent responses of the models subjected to cyclic loading, a daily cyclic loading scenario was applied to the FE models. Different rotational movements in different planes were superimposed using a 10 Nm moment after daily loading to compare the rotational motions with those at the beginning of cyclic loading. The biomechanical responses of the lumbosacral FE spine models in both groups were analyzed and compared before and after daily loading. Results: The achieved comparative errors between the FE results and clinical images were on average below 20% and 25% for pre-op and post-op models, respectively, which confirms the applicability of this predictive algorithm for rough pre-planning estimations. The results showed that the disc height loss and fluid loss were increased for the adjacent discs in post-op models after 16 h of cyclic loading. In addition, significant differences in disc height loss and fluid loss were observed between the patients who were in the non-ASD and ASD groups. Similarly, the increased stress and fiber strain in the annulus fibrosus (AF) was higher in the adjacent level of post-op models. However, the calculated stress and fiber strain values were significantly higher for patients with ASD. Discussion: Evaluating the biomechanical response of pre-op and post-op modeling in the non-ASD and ASD groups showed that the inherent geometric differences among patients cause significant variations in the estimated mechanical response. In conclusion, the results of the current study highlighted the effect of geometrical parameters (which may refer to the anatomical conditions or the induced modifications regarding surgical techniques) on time-dependent responses of lumbar spine biomechanics.

Novel force-displacement control passive finite element models of the spine to simulate intact and pathological conditions; comparisons with traditional passive and detailed musculoskeletal models

Passive finite element (FE) models of the spine are commonly used to simulate intact and various pre- and postoperative pathological conditions. Being devoid of muscles, these traditional models are driven by simplistic loading scenarios, e.g., a constant moment and compressive follower load (FL) that do not properly mimic the complex in vivo loading condition under muscle exertions. We aim to develop novel passive FE models that are driven by more realistic yet simple loading scenarios, i.e., in vivo vertebral rotations and pathological-condition dependent FLs (estimated based on detailed musculoskeletal finite element (MS-FE) models). In these novel force-displacement control FE models, unlike the traditional passive FE models, FLs vary not only at different spine segments (T12-S1) but between intact, pre- and postoperative conditions. Intact, preoperative degenerated, and postoperative fused conditions at the L4-L5 segment for five static in vivo activities in upright and flexed postures were simulated by the traditional passive FE, novel force-displacement control FE, and gold-standard detailed MS-FE spine models. Our findings indicate that, when compared to the MS-FE models, the force-displacement control passive FE models could accurately predict the magnitude of disc compression force, intradiscal pressure, annulus maximal von Mises stress, and vector sum of all ligament forces at adjacent segments (L3-L4 and L5-S1) but failed to predict disc shear and facet joint forces. In this regard, the force-displacement control passive FE models were much more accurate than the traditional passive FE models. Clinical recommendations made based on traditional passive FE models should, therefore, be interpreted with caution.

Biomechanical modeling of spinal ligaments: finite element analysis of L4-L5 spinal segment

The complex mechanical structure of spine is usually simplified in finite element (FE) modes. In this study, different 3D models of L4-L5 spinal segment distinguished by their ligament modelling were developed (1D truss, 2D shell and 3D space truss elements). All models could be considered validated with respect to range of motion and intradiscal pressure, although their ligament stresses/forces were substantially different. The models with 2D shell and 3D space truss ligaments showed the stress distribution and identified the potential failure/injury locations in ligaments. The model with 3D space truss ligaments showed the stress/force direction (representing collagen fiber directions).

Investigation of Reaction Forces in the Thoracolumbar Fascia during Different Activities: A Mechanistic Numerical Study

Spinal instability remains a complex phenomenon to study while the cause of low back pain continues to challenge researchers. The role of fascia in biomechanics adds to the complexity of spine biomechanics but offers a new window from which to investigate our spines. Specifically, the thoracolumbar fascia may have an important role in spine biomechanics, and thus the purpose of this study was to access the mechanical influence of the thoracolumbar fascia on spine biomechanics during different simulated activities. A numerical finite element model of the lumbar spine inclusive of the intra-abdominal and intra-muscular regions as well as the thoracolumbar fascia was constructed and validated. Four different loading scenarios were simulated while deformation, stress, pressure, and reaction forces between the thoracolumbar fascia and spine were measured. Model validation was accomplished through comparison to in vivo and ex vivo published studies. Force transmission between the thoracolumbar fascia and the spine increased 40% comparing kyphotic and squatting lifting patterns. Further, the importance of reciprocating paraspinal and intra-abdominal pressures was demonstrated. It was also found that tension in the thoracolumbar fascia remains even in a simulated prone position. This numerical analysis allowed for an objective interpretation of the loads conveyed through the thoracolumbar fascia in different positional or lifting scenarios. Based on validation studies, it would appear to be a viable experimental platform from which insight can be derived. The loads in the thoracolumbar fascia vary considerably based on simulated tasks and are linked to the pressures in the paraspinal and intra-abdominal regions.

Biomechanical Investigation Between Rigid and Semirigid Posterolateral Fixation During Daily Activities: Geometrically Parametric Poroelastic Finite Element Analyses

While spinal fusion using rigid rods remains the gold standard treatment modality for various lumbar degenerative conditions, its adverse effects, including accelerated adjacent segment disease (ASD), are well known. In order to better understand the performance of semirigid constructs using polyetheretherketone (PEEK) in fixation surgeries, the objective of this study was to analyze the biomechanical performance of PEEK versus Ti rods using a geometrically patient-specific poroelastic finite element (FE) analyses. Ten subject-specific preoperative models were developed, and the validity of the models was evaluated with previous studies. Furthermore, FE models of those lumbar spines were regenerated based on postoperation images for posterolateral fixation at the L4–L5 level. Biomechanical responses for instrumented and adjacent intervertebral discs (IVDs) were analyzed and compared subjected to static and cyclic loading. The preoperative model results were well comparable with previous FE studies. The PEEK construct demonstrated a slightly increased range of motion (ROM) at the instrumented level, but decreased ROM at adjacent levels, as compared with the Ti. However, no significant changes were detected during axial rotation. During cyclic loading, disc height loss, fluid loss, axial stress, and collagen fiber strain in the adjacent IVDs were higher for the Ti construct when compared with the intact and PEEK models. Increased ROM, experienced stress in AF, and fiber strain at adjacent levels were observed for the Ti rod group compared with the intact and PEEK rod group, which can indicate the risk of ASD for rigid fixation. Similar to the aforementioned pattern, disc height loss and fluid loss were significantly higher at adjacent levels in the Ti rod group after cycling loading which alter the fluid–solid interaction of the adjacent IVDs. This phenomenon debilitates the damping quality, which results in disc disability in absorbing stress. Such finding may suggest the advantage of using a semirigid fixation system to decrease the chance of ASD.

A novel coupled musculoskeletal finite element model of the spine - Critical evaluation of trunk models in some tasks

Spine musculoskeletal (MS) models make simplifying assumptions on the intervertebral joint degrees-of-freedom (rotational and/or translational), representation (spherical or beam-like joints), and properties (linear or nonlinear). They also generally neglect the realistic structure of the joints with disc nuclei/annuli, facets, and ligaments. We aim to develop a novel MS model where trunk muscles are incorporated into a detailed finite element (FE) model of the ligamentous T12-S1 spine thus constructing a gold standard coupled MS-FE model. Model predictions are compared under some tasks with those of our earlier spherical joints, beam joints, and hybrid (uncoupled) MS-FE models. The coupled model predicted L4-L5 intradiscal pressures (R² ≅ 0.97, RMSE ≅ 0.27 MPa) and L1-S1 centers of rotation (CoRs) in agreement to in vivo data. Differences in model predictions grew at larger trunk flexion angles; at the peak (80°) flexion the coupled model predicted, compared to the hybrid model, much smaller global/local muscle forces (~38%), segmental (~44%) and disc (~22%) compression forces but larger segmental (~9%) and disc (~17%) shear loads, ligament forces at the lower lumbar levels (by up to 57%) and facet forces at all levels. The spherical/beam joints models predicted much greater muscle forces and segmental loads under larger flexion angles. Unlike the spherical joints model with fixed CoRs, the beam joints model predicted CoRs closer (RMSE = 2.3 mm in flexion tasks) to those of the coupled model. The coupled model offers a great potential for future studies towards improvement of surgical techniques, management of musculoskeletal injuries and subject-specific simulations.

Microgravity and Hypergravity Induced by Parabolic Flight Differently Affect Lumbar Spinal Stiffness

The objective of this study was to determine the response of the lumbar spinal motor control in different gravitational conditions. This was accomplished by measuring indicators of lumbar motor control, specifically lumbar spinal stiffness, activity of lumbar extensor and flexor muscles and lumbar curvature, in hypergravity and microgravity during parabolic flights. Three female and five male subjects participated in this study. The mean age was 35.5 years (standard deviation: 8.5 years). Spinal stiffness of the L3 vertebra was measured using impulse response; activity of the erector spinae, multifidi, transversus abdominis, and psoas muscles was recorded using surface electromyography; and lumbar curvature was measured using distance sensors mounted on the back-plate of a full-body harness. An effect of gravity condition on spinal stiffness, activity of all muscles assessed and lumbar curvature (p’s < 0.007) was observed (Friedman tests). Post hoc analysis showed a significant reduction in stiffness during hypergravity (p < 0.001) and an increase in stiffness during microgravity (p < 0.001). Activity in all muscles significantly increased during hypergravity (p’s < 0.001). During microgravity, the multifidi (p < 0.002) and transversus abdominis (p < 0.001) increased significantly in muscle activity while no significant difference was found for the psoas (p = 0.850) and erector spinae muscles (p = 0.813). Lumbar curvature flattened in hypergravity as well as microgravity, albeit in different ways: during hypergravity, the distance to the skin decreased for the upper (p = 0.016) and the lower sensor (p = 0.036). During microgravity, the upper sensor showed a significant increase (p = 0.016), and the lower showed a decrease (p = 0.005) in distance. This study emphasizes the role of spinal motor control adaptations in changing gravity conditions. Both hypergravity and microgravity lead to changes in spinal motor control. The decrease in spinal stiffness during hypergravity is interpreted as a shift of the axial load from the spine to the pelvis and thoracic cage. In microgravity, activity of the multifidi and of the psoas muscles seems to ensure the integrity of the spine. Swiss (BASEC-NR: 2018-00051)/French “EST-III” (Nr-ID-RCB: 2018-A011294-51/Nr-CPP: 18.06.09).

Development of a novel geometrically-parametric patient-specific finite element model to investigate the effects of the lumbar lordosis angle on fusion surgery

The success of lumbar interbody fusion, the key surgical procedure for treating different pathologies of the lumbar spine, is highly dependent on determining the patient-specific lumbar lordosis (LL) and restoring sagittal balance. This study aimed to (1) develop a personalized finite element (FE) model that automatically updates spinal geometry for different patients; and (2) apply this technique to study the influence of LL on post-fusion spinal biomechanics. Using an X-Ray image-based algorithm, the geometry of the lumbar spine (L1-S1) was updated using independent parameters. Ten subject-specific nonlinear osteoligamentous FE models were developed based on pre-operative images of fusion surgery candidate patients. Post-operative FE models of the same patients were consequently created. Comparison of the obtained results from FE models with pre- and post-operation functional images demonstrated the potential value of this technique in clinical applications. A parametric study of the effect of LL was conducted for cases with zero LL angle, positive LL angles (+6° and +12°) and negative LL angles (-3° and -6°) on fused level (L4-L5), resulting in a total of 50 fusion simulation models. The average range of motion, intradiscal pressure, and fiber strain at adjacent levels were significantly higher with decreased LL during different directions except axial rotation. This study demonstrates that the LL alters both the intersegmental motion and load-sharing in fusion, which may influence the initiation and rate of adjacent level degeneration. This personalized FE platform provides a practical, clinically applicable approach for the analyses of the biomechanical changes associated with lumbar spine fusion.

Subject-specific loads on the lumbar spine in detailed finite element models scaled geometrically and kinematic-driven by radiography images

Traditional load-control musculoskeletal and finite element (FE) models of the spine fail to accurately predict in vivo intervertebral joint loads due mainly to the simplifications and assumptions when estimating redundant trunk muscle forces. An alternative powerful protocol that bypasses the calculation of muscle forces is to drive the detailed FE models by image-based in vivo displacements. Development of subject-specific models, however, both involves the risk of extensive radiation exposures while imaging in supine and upright postures and is time consuming in terms of the reconstruction of the vertebrae, discs, ligaments, and facets geometries. This study therefore aimed to introduce a remedy for the development of subject-specific FE models by scaling the geometry of an existing detailed FE model of the T12-S1 lumbar spine. Five subject-specific scaled models were driven by their own radiography image-based displacements in order to predict joint loads, ligament forces, facet joint forces, and disc fiber strains during relaxed upright as well as moderate flexion and extension tasks. The predicted intradiscal pressures were found in adequate agreement with in vivo data for upright, flexion, and extension tasks. There were however large intersubject variations in the estimated joint loads and facet forces.

Biomechanical effects of USS fixation with different screw insertion depths on the vertebrae stiffness and screw stress for the treatment of the L1 fracture

OBJECTIVE

To evaluate the biomechanical effects of internal fixation with different screw insertion depths on vertebrae stiffness and screw stress for L1 fracture.

METHODS

The established L1 fracture was fixed with 10 different depths of screw insertion: 10-100% screw-path length (SPL). Loading on the T12 endplate was simulated.

RESULTS

Screws inserted to 60-100% depths has a higher axial displacement of screw against injured vertebrae and maximum stress of screws compared to those of screws inserted to 30-50% depths and 10-20% (P< 0.05). No significant difference was noted among 60-100% SPL groups. Under single loading condition, the incidence rate of maximum stress of each screw ranged from 16.7-50.0%. Chi-square test showed superior screw has a higher incidence rate of maximum stress than inferior screw (P< 0.05).

CONCLUSIONS

Screws inserted to 60% depth or more can achieve effective strength to withstand the postoperative height correction loss of the L1 vertebrae fracture. However, continuous prolonged depth of screw insertion did not significantly increase the effective strength of the screw against injured vertebrae and maximum equivalent stress of screws. The incidence rate of the maximum stress of each screw in correlated with position of screw insertion but not associated with the screw insertion depth.

The Effect of Muscle Direction on the Predictions of Finite Element Model of Human Lumbar Spine

The normal physiological loads from muscles experienced by the spine are largely unknown due to a lack of data. The aim of this study is to investigate the effects of varying muscle directions on the outcomes predicted from finite element models of human lumbar spine. A nonlinear finite element model of L3–L5 was employed. The force of the erector spinae muscle, the force of the rectus abdominis muscle, follower loads, and upper body weight were applied. The model was fixed in a neural standing position and the direction of the force of the erector spinae muscle and rectus abdominis muscle was varied in three directions. The intradiscal pressure, reaction moments, and intervertebral rotations were calculated. The intradiscal pressure of L4-L5 was 0.56–0.57 MPa, which agrees with the in vivo pressure of 0.5 MPa from the literatures. The models with the erector spinae muscle loaded in anterior-oblique direction showed the smallest reaction moments (less than 0.6 Nm) and intervertebral rotations of L3-L4 and L4-L5 (less than 0.2 degrees). In comparison with loading in the vertical direction and posterior-oblique direction, the erector spinae muscle loaded in the anterior-oblique direction required lower external force or moment to keep the lumbar spine in the neutral position.