Peter A. Cripton

Interbody cage stabilisation in the lumbar spine: BIOMECHANICAL EVALUATION OF CAGE DESIGN, POSTERIOR INSTRUMENTATION AND BONE DENSITY

We performed a biomechanical study on human cadaver spines to determine the effect of three different interbody cage designs, with and without posterior instrumentation, on the three-dimensional flexibility of the spine. Six lumbar functional spinal units for each cage type were subjected to multidirectional flexibility testing in four different configurations: intact, with interbody cages from a posterior approach, with additional posterior instrumentation, and with cross-bracing. The tests involved the application of flexion and extension, bilateral axial rotation and bilateral lateral bending pure moments. The relative movements between the vertebrae were recorded by an optoelectronic camera system. We found no significant difference in the stabilising potential of the three cage designs. The cages used alone significantly decreased the intervertebral movement in flexion and lateral bending, but no stabilisation was achieved in either extension or axial rotation. For all types of cage, the greatest stabilisation in flexion and extension and lateral bending was achieved by the addition of posterior transpedicular instrumentation. The addition of cross-bracing to the posterior instrumentation had a stabilising effect on axial rotation. The bone density of the adjacent vertebral bodies was a significant factor for stabilisation in flexion and extension and in lateral bending.

Compressive strength of interbody cages in the lumbar spine: the effect of cage shape, posterior instrumentation and bone density

Abstract One goal of interbody fusion is to increase the height of the degenerated disc space. Interbody cages in particular have been promoted with the claim that they can maintain the disc space better than other methods. There are many factors that can affect the disc height maintenance, including graft or cage design, the quality of the surrounding bone and the presence of supplementary posterior fixation. The present study is an in vitro biomechanical investigation of the compressive behaviour of three different interbody cage designs in a human cadaveric model. The effect of bone density and posterior instrumentation were assessed. Thirty-six lumbar functional spinal units were instrumented with one of three interbody cages: (1) a porous titanium implant with endplate fit (Stratec), (2) a porous, rectangular carbon-fibre implant (Brantigan) and (3) a porous, cylindrical threaded implant (Ray). Posterior instrumentation (USS) was applied to half of the specimens. All specimens were subjected to axial compression displacement until failure. Correlations between both the failure load and the load at 3 mm displacement with the bone density measurements were observed. Neither the cage design nor the presence of posterior instrumentation had a significant effect on the failure load. The loads at 3 mm were slightly less for the Stratec cage, implying lower axial stiffness, but were not different with posterior instrumentation. The large range of observed failure loads overlaps the potential in vivo compressive loads, implying that failure of the bone-implant interface may occur clinically. Preoperative measurements of bone density may be an effective tool to predict settling around interbody cages.

During sideways falls proximal femur fractures initiate in the superolateral cortex: Evidence from high-speed video of simulated fractures

Results of recent imaging studies and theoretical models suggest that the superior femoral neck is a location of local weakness due to an age-related thinning of the cortex, and thus the site of hip fracture initiation. The purpose of this study was to experimentally determine the spatial and temporal characteristics of the macroscopic failure process during a simulated hip fracture that would occur as a result of a sideways fall. Twelve fresh frozen human cadaveric femora were used in this study. The femora were fractured in an apparatus designed to simulate a fall on the greater trochanter. Image sequences of the surface events related to the fractures were captured using two high-speed video cameras at 9111 Hz. The videos were analyzed with respect to time and load to determine the location and sequence of these events occurring in the proximal femur. The mean failure load was 4032 N (SD 370 N). The first surface events were identified in the superior femoral neck in eleven of the twelve specimens. Nine of these specimens fractured in a clear two-step process that initiated with a failure in the superior femoral neck, followed by a failure in the inferior femoral neck. This cadaveric model of hip fracture empirically confirms hypotheses that suggested that hip fractures initiate with a failure in the superior femoral neck where stresses are primarily compressive during a sideways fall impact, followed by a failure in the inferior neck where stresses are primarily tensile. Our results confirm the superolateral neck of the femur as an important region of interest for future hip fracture screening, prevention and treatment research.

Route Infrastructure and the Risk of Injuries to Bicyclists: A Case-Crossover Study

OBJECTIVES We compared cycling injury risks of 14 route types and other route infrastructure features. METHODS We recruited 690 city residents injured while cycling in Toronto or Vancouver, Canada. A case-crossover design compared route infrastructure at each injury site to that of a randomly selected control site from the same trip. RESULTS Of 14 route types, cycle tracks had the lowest risk (adjusted odds ratio [OR] = 0.11; 95% confidence interval [CI] = 0.02, 0.54), about one ninth the risk of the reference: major streets with parked cars and no bike infrastructure. Risks on major streets were lower without parked cars (adjusted OR = 0.63; 95% CI = 0.41, 0.96) and with bike lanes (adjusted OR = 0.54; 95% CI = 0.29, 1.01). Local streets also had lower risks (adjusted OR = 0.51; 95% CI = 0.31, 0.84). Other infrastructure characteristics were associated with increased risks: streetcar or train tracks (adjusted OR = 3.0; 95% CI = 1.8, 5.1), downhill grades (adjusted OR = 2.3; 95% CI = 1.7, 3.1), and construction (adjusted OR = 1.9; 95% CI = 1.3, 2.9). CONCLUSIONS The lower risks on quiet streets and with bike-specific infrastructure along busy streets support the route-design approach used in many northern European countries. Transportation infrastructure with lower bicycling injury risks merits public health support to reduce injuries and promote cycling.

The relative importance of vertebral bone density and disc degeneration in spinal flexibility and interbody implant performance. An in vitro study.

Study Design An in vitro biomechanical investigation in the human lumbar spine focuses on the functional significance of vertebral bone density and intervertebral disc degeneration. Objective To determine the interrelationship between vertebral bone density and intervertebral disc degeneration, their effect on normal spine motion, and their significance in the biomechanical performance of interbody fixation techniques. Summary of Background Data A relationship between vertebral bone density and intervertebral disc degeneration has been suggested, but a definitive relationship has not been established. The effect of vertebral bone density and intervertebral disc degeneration on interbody stabilization remains unknown despite the rapidly increasing use of this surgical method for patients with chronic low back pain. Methods The vertebral bone density and intervertebral disc degeneration of 72 functional spinal units were determined using dual energy x‐ray absorptiometry scans and macroscopic grading, respectively. A three‐dimensional flexibility test was performed on 24 functional spinal units in the intact and stabilized conditions. The compressive behavior of the bone‐implant interface was evaluated in 48 functional spinal units. Results The vertebral bone density in moderately degenerated discs was significantly lower than at all other levels of intervertebral disc degeneration. Increasing intervertebral disc degeneration resulted in more axial rotation and less lateral bending. In flexion‐extension and lateral bending, better vertebral bone resulted in significantly better stabilization. This trend was observed also in axial compression, in which higher failure loads were observed with greater bone densities. Conclusion The authors conclude a significant relationship exists between bone density and disc degeneration, bone density is a highly important factor in the performance of interbody stabilization, and disc degeneration is of moderate importance in spinal motion.

The biomechanical effects of kyphoplasty on treated and adjacent nontreated vertebral bodies.

It remains unclear whether adjacent vertebral body fractures are related to the natural progression of osteoporosis or if adjacent fractures are a consequence of augmentation with bone cement. Experimental or computational studies have not completely addressed the biomechanical effects of kyphoplasty on adjacent levels immediately following augmentation. This study presents a validated two–functional spinal unit (FSU) T12–L2 finite element model with a simulated kyphoplasty augmentation in L1 to predict stresses and strains within the bone cement and bone of the treated and adjacent nontreated vertebral bodies. The findings from this multiple-FSU study and a recent retrospective clinical study suggest that changes in stresses and strains in levels adjacent to a kyphoplasty-treated level are minimal. Furthermore, the stress and strain levels found in the treated levels are less than injury tolerance limits of cancellous and cortical bone. Therefore, subsequent adjacent level fractures may be related to the underlying etiology (weakening of the bone) rather than the surgical intervention.

A method to simulate in vivo cervical spine kinematics using in vitro compressive preload.

Study Design. An in vitro flexibility study of C2–T1 specimens under compressive preload. Objective. To determine three-dimensional flexibility test moments needed to obtain spinal kinematics representative of the in vivo spine studies. Summary of Background Data. Most previous three-dimensional in vitro cervical spine studies have used equal moments in all three planes to evaluate spinal flexibilities. Recent advances have made it possible to apply physiologic compressive preload. It is unclear what moments should be applied to these preloaded spine segments to simulate in vivo kinematics. Methods. Six fresh human cadaveric cervical spine specimens (C2–T1) were used. The preload (100 N) was applied by flexible cables, which passed through guides attached to each vertebra. Flexibility tests of flexion–extension and bilateral axial torsion and lateral bending were performed. Two protocols were compared, 1:1:1 with equal pure moments of 1 Nm for each direction and 2:4:2 with pure moments of 2 Nm for flexion–extension and lateral bending and 4 Nm for axial torsion. Ranges of motion were calculated from the flexibility tests. Results. The 2:4:2 protocol resulted in significantly better agreement with in vivo data than did the 1:1:1 protocol. In flexion–extension, the 2 Nm value was within 17% of the average in vivo value. In axial torsion, the 4 Nm value was within 22% of the in vivo average. In lateral bending, the 2 Nm value was within 15% of the in vivo average. Conclusions. To obtain human in vivo-like kinematics using 100 N preload, the 2:4:2 protocol is to be recommended.

Biomechanical evaluation of the Total Facet Arthroplasty System: 3-dimensional kinematics.

Study Design. An in vitro biomechanical study to quantify 3-dimensional kinematics of the lumbar spine following facet arthroplasty. Objectives. To compare the multidirectional flexibility properties and helical axis of motion of the Total Facet Arthroplasty System™ (TFAS™) (Archus Orthopedics, Redmond, WA) to the intact condition and to posterior pedicle screw fixation. Summary of Background Data. Facet arthroplasty in the lumbar spine is a new concept in the field of spinal surgery. The kinematic behavior of any complete facet arthroplasty device in the lumbar spine has not been reported previously. Methods. Flexibility tests were conducted on 13 cadaveric specimens in an intact and injury model, and after stabilization with the TFAS and posterior pedicle screw fixation at the L4–L5 level. A pure moment of ±10 Nm with a compressive follower preload of 600 N was applied to the specimen in flexion-extension, axial rotation, and lateral bending. Range of motion (ROM), neutral zone, and helical axis of motion were calculated for the L4–L5 segment. Results. ROM with the TFAS was 81% of intact in flexion (P = 0.035), 68% in extension (P = 0.079), 88% in lateral bending (P = 0.042), and 128% in axial rotation (P = 0.013). The only significant change in neutral zone with TFAS compared to the intact was an increase in axial rotation (P = 0.011). The only significant difference in helical axis of motion location or orientation between the TFAS and intact condition was an anterior shift of the helical axis of motion in axial rotation (P = 0.013). Conclusions. The TFAS allowed considerable motion in all directions tested, with ROM being less than the intact in flexion and lateral bending, and greater than the intact in axial rotation. The helical axis of motion with the TFAS was not different from intact in flexion-extension and lateral bending, but it was shifted anteriorly in axial rotation. The kinematics of the TFAS were more similar to the intact spine than were the kinematics of the posterior fixation when applied to a destabilized lumbar spine.

A minimally disruptive technique for measuring intervertebral disc pressure in vitro: application to the cervical spine.

A novel technique to measure in vitro disc pressures in human cervical spine specimens was developed. A miniature pressure transducer was used and an insertion technique was designed to minimise artefacts due to insertion. The technique was used to measure the intradiscal pressure in cervical spines loaded in pure axial compression. The resulting pressure varied linearly with the applied compressive force with coefficients of determination (r(2)) greater than 0.99 for each of the four specimens. Peak pressures between 2.4 and 3.5MPa were recorded under 800N of compression.

Comparing the effects of infrastructure on bicycling injury at intersections and non-intersections using a case–crossover design

Background This study examined the impact of transportation infrastructure at intersection and non-intersection locations on bicycling injury risk. Methods In Vancouver and Toronto, we studied adult cyclists who were injured and treated at a hospital emergency department. A case–crossover design compared the infrastructure of injury and control sites within each injured bicyclists route. Intersection injury sites (N=210) were compared to randomly selected intersection control sites (N=272). Non-intersection injury sites (N=478) were compared to randomly selected non-intersection control sites (N=801). Results At intersections, the types of routes meeting and the intersection design influenced safety. Intersections of two local streets (no demarcated traffic lanes) had approximately one-fifth the risk (adjusted OR 0.19, 95% CI 0.05 to 0.66) of intersections of two major streets (more than two traffic lanes). Motor vehicle speeds less than 30 km/h also reduced risk (adjusted OR 0.52, 95% CI 0.29 to 0.92). Traffic circles (small roundabouts) on local streets increased the risk of these otherwise safe intersections (adjusted OR 7.98, 95% CI 1.79 to 35.6). At non-intersection locations, very low risks were found for cycle tracks (bike lanes physically separated from motor vehicle traffic; adjusted OR 0.05, 95% CI 0.01 to 0.59) and local streets with diverters that reduce motor vehicle traffic (adjusted OR 0.04, 95% CI 0.003 to 0.60). Downhill grades increased risks at both intersections and non-intersections. Conclusions These results provide guidance for transportation planners and engineers: at local street intersections, traditional stops are safer than traffic circles, and at non-intersections, cycle tracks alongside major streets and traffic diversion from local streets are safer than no bicycle infrastructure.