Yvan Petit

Assessment of the 3-D reconstruction and high-resolution geometrical modeling of the human skeletal trunk from 2-D radiographic images

This paper presents an in vivo validation of a method for the three-dimensional (3-D) high-resolution modeling of the human spine, rib cage, and pelvis for the study of spinal deformities. The method uses an adaptation of a standard close-range photogrammetry method called direct linear transformation to reconstruct the 3-D coordinates of anatomical landmarks from three radiographic images of the subjects trunk. It then deforms in 3-D 1-mm-resolution anatomical primitives (reference bones) obtained by serial computed tomography-scan reconstruction of a dry specimen. The free-form deformation is calculated using dual kriging equations. In vivo validation of this method on 40 scoliotic vertebrae gives an overall accuracy of 3.3 /spl plusmn/ 3.8 mm, making it an adequate tool for clinical studies and mechanical analysis purposes.

Patient-specific mechanical properties of a flexible multi-body model of the scoliotic spine

The flexibility of the scoliotic spine is an important biomechanical parameter to take into account in the planning of surgical instrumentation. The objective of the paper was to develop a method to characterisein vivo the mechanical properties of the scoliotic spine using a flexible multi-body model. Vertebrae were represented as rigid bodies, and intervertebral elements were defined at every level using a spherical joint and three torsion springs. The initial mechanical properties of motion segments were defined fromin vitro experimental data reported in the literature. They were adjusted using an optimisation algorithm to reduce the discrepancy between the simulated and the measured Ferguson angles in lateral bending of three spine segments (major or compensatory left thoracic, right thoracic and left lumbar scoliosis curves). The flexural rigidity of the spine segments was defined in three categories (flexible, nominal, rigid) according to the estimated mechanical factors (α). This approach was applied with ten scoliotic patients under-going spinal correction. Personalisation of the model resulted in an increase of the initial flexural rigidity for seven of the ten lumbar segments (1.38≤α≤10.0) and four of the ten right thoracic segments (1.74≤α≤5.18). The adjustment of the mechanical parameters based on the lateral bending tests improved the models ability to predict the spine shape change described by the Ferguson angles by up to 50%. The largest differences after personalisation were for the left lumbar segments in left bending (40±30). Thein vivo identification of the mechanical properties of the scoliotic spine will improve the ability of biomechanical models adequately to predict the surgical correction, which should help clinicians in the planning of surgical instrumentation manoeuvres.

Biomechanical modeling of posterior instrumentation of the scoliotic spine

Scoliosis is a three-dimensional deformation of the spine that can be treated by vertebral fusion using surgical instrumentation. However, the optimal configuration of instrumentation remains controversial. Simulating the surgical maneuvers with personalized biomechanical models may provide an analytical tool to determine instrumentation configuration during the pre-operative planning. Finite element models used in surgical simulations display convergence difficulties as a result of discontinuities and stiffness differences between elements. A kinetic model using flexible mechanisms has been developed to address this problem, and this study presents its use in the simulation of Cotrel-Dubousset Horizon surgical maneuvers. The model of the spine is composed of rigid bodies corresponding to the thoracic and lumbar vertebrae, and flexible elements representing the intervertebral structures. The model was personalized to the geometry of three scoliotic patients (with a thoracic Cobb angle of 45°, 49° and 39°). Binary joints and kinematic constraints were used to represent the rod-implant-vertebra joints. The correction procedure was simulated using three steps: (1) Translation of hooks and screws on the first rod; (2) 90° rod rotation; (3) Hooks and screws look-up on the rod. After the simulation, slight differences of 0-6° were found for the thoracic spine scoliosis and the kyphosis, and of 1-8° for the axial rotation of the apical vertebra and for the orientation of the plane of maximum deformity, compared to the real post-operative shape of the patient. Reaction loads at the vertebra-implant link were mostly below 1000 N, while reaction loads at the boundary conditions (representing the overall action of the surgeon) were in the range 7-470 N and maximum torque applied to the rod was 1.8 Nm. This kinetic modeling approach using flexible mechanisms provided a realistic representation of the surgical maneuvers. It may offer a tool to predict spinal geometry correction and assist in the pre-operative planning of surgical instrumentation of the scoliotic spine.

Validity of Goniometric Elbow Measurements: Comparative Study with a Radiographic Method

BackgroundA universal goniometer is commonly used to measure the elbow’s ROM and carrying angle; however, some authors question its poor intertester reliability.Questions/purposesWe (1) assessed the validity of goniometric measurements as compared with radiographic measurements in the evaluation of ROM of the elbow and (2) determined the reliability of both.MethodsThe ROM and carrying angle of 51 healthy subjects (102 elbows) were measured using two methods: with a universal goniometer by one observer three times and on radiographs by two independent examiners. Paired t-test and Pearson’s correlation were used to compare and detect the relationship between mean ROM. The maximal error was calculated according to the Bland and Altman method.ResultsThe intraclass correlation coefficients (ICC) ranged from 0.945 to 0.973 for the goniometric measurements and from 0.980 to 0.991 for the radiographic measurements. The two methods correlated when measuring the total ROM in flexion and extension. The maximal errors of the goniometric measurement were 10.3° for extension, 7.0° for flexion, and 6.5° for carrying angle 95% of the time. We observed differences for maximum flexion, maximal extension, and carrying angle between the methods.ConclusionBoth measurement methods differ but they correlate. When measured with a goniometer, the elbow ROM shows a maximal error of approximately 10°.Clinical RelevanceThe goniometer is a reasonable and simple clinical tool, but for research protocols, we suggest using the radiographic method because of the higher level of precision required.

Variability of strap tension in brace treatment for adolescent idiopathic scoliosis.

STUDY DESIGN A mechanical evaluation of brace strap tensions to document their variability in different patient positions and to assess their biomechanical effectiveness. OBJECTIVES To measure the strap tensions at which adolescents with scoliosis are wearing their braces and to determine the variations in strap tension in different patient positions. SUMMARY OF BACKGROUND DATA The biomechanical action of thoracolumbosacral orthoses in still not well understood, and there is no standardized strap tension at which the brace should be fastened to obtain optimal results. METHODS This study was conducted in 34 adolescents with idiopathic scoliosis wearing thoracolumbosacral orthoses. Brace straps were instrumented with load cells and tightened at four tensions (the ones prescribed by their treating physician and three standardized values: 20, 40, and 60 N). In each case, the tension was recorded while the patients assumed nine positions corresponding to normal daily tasks. The variability of strap tension was evaluated by comparing the changes from the original standing position. RESULTS The prescribed tensions measured in thoracic and pelvic straps were markedly variable. The greatest changes in tension occurred when the patients were lying down. Relaxation of strap tension was found when the patients returned to the standing position after having completed the tasks. CONCLUSIONS If strap tension affects the biomechanical actions of the brace, these results indicate that regular brace strap tension adjustments are needed and raise questions about the efficacy of nighttime bracing to correct spinal deformities.

Boston brace correction in idiopathic scoliosis: a biomechanical study.

Study Design. To analyze Boston brace biomechanics, pressure measurements and finite element simulations were done on 12 adolescent idiopathic scoliosis patients. Objectives. The aim was to analyze the Boston brace effectiveness using a finite element model and experimental measurements. Summary of Background Data. There are not very many biomechanical studies of Boston brace effectiveness, and its biomechanical action is not completely understood. Methods. This study was performed on 12 girls with scoliosis treated with the Boston brace system. The experimental protocol was composed of the acquisition of two sets of multiplanar radiographs with and without brace followed by the pressure acquisition at the brace–torso interface. A personalized finite element modeling of the trunk was generated from the 3D reconstruction of the patient’s geometry. The brace treatment was simulated by the application of equivalent forces calculated from the pressure measurements. Results. Two Boston brace force patterns were defined from the pressure measurements. The first one consisted of high right thoracic forces of 31–113 N, lumbar forces less than 47 N, and included a left thoracic extension working as a counter pad. The second one consisted of low thoracic forces less than 20 N, lumbar forces up to 70 N, without left thoracic extension. The simulations showed that the passive forces only produced a coronal Cobb angle correction up to 9°, whereas real correction was up to 16°. Conclusion. High thoracic pads reduced more effectively both thoracic and lumbar scoliotic curves than lumbar pads only. The study suggests that mechanisms other than brace pads produce correction and contribute to the force equilibrium within the brace.

Biomechanical Evaluation of the Boston Brace System for the Treatment of Adolescent Idiopathic Scoliosis : Relationship between Strap Tension and Brace Interface Forces

Study Design. Prospective study to evaluate the association between strap tension and brace interface forces in the treatment of adolescent idiopathic scoliosis using the Boston brace system. Objectives. To determine the strap tension associated with optimal brace interface forces. Summary of Background Data. Trim lines, pad placement, and areas of relief for the brace are guided by radiographic studies. However, optimal adjustment of strap tension is unclear and remains mostly empirical. Methods. Brace interface forces in all regions of the trunk were measured for 41 patients with adolescent idiopathic scoliosis at three standardized strap tensions (20 N, 40 N, and 60 N). The brace interface forces were assessed using a mat made of force-sensing transducers. Equivalent interface pressure for each trunk region was also calculated to estimate the distribution of the interface forces. Results. The brace interface forces and the corresponding effective areas increased along with the strap tension for all patients. For patients with a single right thoracic curve, the interface pressure tended to increase with increasing strap tension. This increase was significant in the left axillary, right thoracic, right pelvic, and sternal regions. For double right thoracic–left lumbar curves, the increase in interface pressure was significant in the left axillary, right pelvic, and sternal regions. However, most of this increase occurred between 20 N and 40 N of strap tension, with only slight increase or even a decrease in interface pressures between 40 N and 60 N. Conclusions. The strap tension should be set as high as possible (up to 60 N) for right thoracic curves. For right thoracic–left lumbar curves, the optimal strap tension was ∼40 N. However, clinicians should ensure that the prescribed strap tension does not cause excessive skin pressure or affect the compliance with the brace. A side opening in the right lumbar area may improve the effectiveness of the brace for double right thoracic-left lumbar curves, but care must be taken to avoid skin problems at the opening.

Three-dimensional measurement of wedged scoliotic vertebrae and intervertebral disks.

Abstract Idiopathic scoliosis involves complex spinal intrinsic deformations such as the wedging of vertebral bodies (VB) and intervertebral disks (ID), and it is obvious that the clinical evaluation obtained by the spinal projections on the two-dimensional (2D) radiographic planes do not give a full and accurate interpretation of scoliotic deformities. This paper presents a method that allows reconstruction in 3D of the vertebral body endplates and measurement of the 3D wedging angles. This approach was also used to verify whether 2D radiographic measurements could lead to a biased evaluation of scoliotic spine wedging. The 3D reconstruction of VB contours was done using calibrated biplanar X-rays and an iterative projection computer procedure that fits 3D oriented ellipses of adequate diameters onto the 3D endplate contours. “3D wedging angles” of the VB and ID (representing the maximum angle between adjacent vertebrae) as well as their angular locations with respect to the vertebral frontal planes were computed by finding the positions of the shortest and longest distances between consecutive endplates along their contour. This method was extensively validated using several approaches: (1) by comparing the 3D reconstructed endplates of a cadaveric functional unit (T8-T9) with precise 3D measurements obtained using a coordinate measuring machine for 11 different combinations of vertebral angular positions; (2) by a sensitivity study on 400 different vertebral segments mathematically generated, with errors randomly introduced on the digitized points (standard deviations of 0.5, 1, 2, and 3 mm); (3) by comparing the clinical wedging measurements (on postero-anterior and lateral radiographs) at the thoracic apical level of 34 scoliotic patients (15° < Cobb < 45°) to the computed values. Mean errors for the 11 vertebral positions were 0.5 ± 0.4 mm for VB thickness, less than 2.2° for endplate orientation, and about 11° (3 mm) for the location of the maximum 3D wedging angle along the endplate contour. The errors below 2 mm (introduced on the digitized points) slightly affected the 3D wedging angle (< 2°) and its location (< 4°) for the ID. As for the clinical evaluation, average angular errors were less than 0.4° in the radiographic frontal and lateral planes. The mean 3D wedged angles were about 4.9°± 1.9° for the VB and 6.0°± 1.7° for the ID. Linear relations were found between the 2D and the 3D angles, but the 3D angles were located on diagonal planes statistically different than the radiographic ones (between 100° and 221°). There was no statistical relation between the 2D radiographic angles and the locations of the 3D intervertebral wedging angles. These results clearly indicate that VB and ID endplates are wedged in 3D, and that measurements on plain radiographs allow incomplete evaluation of spinal wedging. Clinicians should be aware of these limitations while using wedging measurements from plain radiographs for diagnosis and/or research on scoliotic deformities.

Assessment of spinal flexibility in adolescent idiopathic scoliosis: suspension versus side-bending radiography.

Study Design. Prospective evaluation of a new suspension test to determine curve flexibility in adolescent idiopathic scoliosis (AIS) in comparison with erect side-bending. Objective. To verify whether the suspension is a better method than side-bending to estimate curve reducibility and to assess spine flexibility. Summary of Background Data. Spinal flexibility is a decisive biomechanical parameter for the planning of AIS surgery. Side-bending is often referred as the gold standard, but it has a low reproducibility and there is no agreement amongst surgeons about the most advantageous method to use. Even more, every technique evaluates reducibility instead of flexibility since the forces involved in the change in shape of the spine are not considered. Methods. Eighteen patients scheduled for AIS surgery were studied. Preoperative radiological evaluation consisted of 4 radiographs: standing posteroanterior, left and right erect side-bending, and suspension. The side-bending and the suspension tests were compared on the basis of the apical vertebrae derotation and the scoliosis curve reduction. Frontal and axial flexibility indices, expressed as the ratio between the moment induced by the body weight and the reduction, were calculated from the suspension data. Results. The average scoliosis curve reduction and apical vertebra derotation were 21° (37%) and 3° (12%), respectively for erect side-bending and 26° (39%) and 7° (28%), respectively for suspension. The erect side-bending test generated a larger curve reduction (P = 0.05) when considering the moderate curves only and the suspension test (P = 0.02) when considering the severe curves. The suspension test produced a larger axial derotation (P = 0.007) when considering all the curves. The average traction force during suspension was 306 N (187 N–377 N). The average estimation for the frontal flexibility index was 1.64°/Nm (0.84–2.82) and 0.51°/Nm (0.01–1.39) for the axial flexibility index. Conclusion. Results of this study demonstrate the feasibility to really evaluate the spine flexibility with the suspension test. The estimated flexibility values are realistic and similar to those reported in vitro. Suspension should be used in the future for spine flexibility assessment.

Geometrical variations in white and gray matter affect the biomechanics of spinal cord injuries more than the arachnoid space

Traumatic spinal cord contusions lead to loss of quality of life, but their pathomechanisms are not fully understood. Previous studies have underlined the contribution of the cerebrospinal fluid in spinal cord protection. However, it remains unclear how important the contribution of the cerebrospinal fluid is relative to other factors such as the white/gray matter ratio. A finite element model of the spinal cord and surrounding morphologic features was used to investigate the spinal cord contusion mechanisms, considering subarachnoid space and white/gray matter ratio. Two vertebral segments (T6 and L1) were impacted transversely at 4.5 m s−1, which demonstrated three major results: While the presence of cerebrospinal fluid plays a significant contributory role in spinal cord protection (compression percentage decreased by up to 19%), the arachnoid space variation along the spine appears to have a limited (3% compression decrease) impact. Differences in the white and gray matter geometries from lumbar to thoracic spine levels decrease spinal cord compression by up to 14% at the thoracic level. Stress distribution in the sagittal spinal cord section was consistent with central cord syndrome, and local stress concentration on the anterior part of the spinal cord being highly reduced by the presence of cerebrospinal fluid. The use of a refined spinal cord finite element method showed that all the geometrical parameters are involved in the spinal cord contusion mechanisms. Hence, spinal cord injury criteria must be considered at each vertebral level.