L4-L5 Segments Research Articles

RETRACTED: Repeated electro-acupuncture attenuates chronic visceral hypersensitivity and spinal cord NMDA receptor phosphorylation in a rat irritable bowel syndrome model

Acupuncture has been used in clinical trials for the treatment of abdominal pain in patients with irritable bowel syndrome (IBS). However, scientific evidence is still lacking and the underlying mechanism remains largely unexplored. The aim of this study was to examine the effects of repeated administration of electro-acupuncture (EA) on chronic visceral hypersensitivity and on the phosphorylation of spinal cord N-methyl-D-aspartic acid (NMDA) receptors in a rat model of IBS. The results showed that repeated administration of EA at bilateral points of Zu-san-li (ST-36) and Shang-ju-xu (ST-37) significantly attenuated chronic visceral hypersensitivity induced in young adult rats by neonatal colon irritation. Such an effect was not seen in either of the two controls: sham-EA at ST-36 and ST-37 without electrical stimulation and EA at control points (BL-62 and tail). Furthermore, rats with chronic visceral hypersensitivity exhibited high-level expression of phosphorylated NMDA receptor subunit 1 (pNR1) in the spinal cord (L4-L5 segments), which was markedly attenuated by EA treatment. In addition, EA at ST-36 and ST-37 neither altered the pain threshold of normal rats nor affected the expression of pNR1 in the lumbosacral spinal cord. Altogether, these data indicate that the EA-mediated attenuation of chronic visceral hypersensitivity is correlated with the down-regulation of NMDA receptors phosphorylation at the spinal level.

Analysis of lumbar disc degeneration using three-dimensional nonlinear finite element method

To explore the effects of intervertebral disc degeneration on the biomechanical behavior of the lumbar motion segment. A three-dimensional nonlinear finite element model of L4-L5 segment was established using CAD technique based on CT images. A normal disc model and three degenerative disc models were established by changing the parameters such as disc material properties and disc height. The effects of disc degeneration on the biomechanical properties, including stiffness, nucleus pressure, maximum von Mises stress in the annulus, and force of posterior structure were studied under two moment loads (flexion and extension) and for three different direct forces (compression, and anterior and posterior shear forces), and the stress distribution of vertebral body and end- plate was also analyzed. The stiffness of the lightly degenerative disc model was decreased compared with that of the normal disc, while it was increased in the moderately and severely degenerative disc models when compared with the normal disc. The force of posterior structure in the lightly degenerative disc model was increased while the values of force of posterior structure in the moderately and severely degenerative disc models were decreased gradually. The maximum von Mises stress in the annulus increased, and the nucleus pressure decreased as the disc degeneration progressed. Moreover, the stress of intervertebral disc, vertebral body, and end-plate was distributed more peripherally. Light degeneration of intervertebral disc leads to instability of lumbar spine, while the stability restores with further degeneration of disc. There is a negative correlation between the force of posterior structure and the load on the intervertebral disc. With the disc degeneration progressing, the intervertebral disc load pattern changes, the stress of intervertebral disc, vertebral body, and end-plate is concentrated peripherally.

Effects of Localized Intraspinal Injections of a Noradrenergic Blocker on Locomotion of High Decerebrate Cats

Previous studies demonstrated that neuronal networks located in midlumbar segments (L3-L4) are critical for the expression of locomotion in cats following complete spinalization. In the present study the importance of several thoracolumbar segments (T8-L7) for the generation of spontaneous hindlimb locomotion in decerebrate cats was evaluated. Experiments were performed in high decerebrate cats (n = 18) walking spontaneously. Yohimbine, an alpha2-noradrenergic antagonist, was microinjected intraspinally in various thoracolumbar segments. Locomotor performance was evaluated with kinematics and electromyographic (EMG) recordings before and after each injection. When and if spontaneous locomotion (SL) was abolished, skin or perineal stimuli (exteroceptive stimuli) were used to trigger locomotion (exteroceptive-induced locomotion [EL]). Yohimbine injections at L3 or L4 completely inhibited SL and EL. In contrast, injections at T8 did not interfere with SL or EL. Injections at T10, T11, T12, L5, L6, and L7 inhibited SL but EL could still be evoked. Injections at T13, L1, and L2 had similar effects except that the quality of locomotion evoked by exteroceptive stimulation declined. Combined injections at T13, L1, and L2 abolished SL and EL, in contrast to injections restricted to the same individual segments. Simultaneous injections at L5, L6, and L7 also abolished SL but EL could still be induced. These results suggest that noradrenergic mechanisms in L3-L4 segments are involved in the expression of locomotion in decerebrate cats, whereas antagonizing noradrenergic inputs in individual rostral or caudal segments may alter the expression and overall quality of the locomotor pattern without abolishing locomotion.

Degenerative lumbar spondylolisthesis: Anatomy, biomechanics and risk factors

Degenerative spondylolisthesis (DS) is a major cause of spinal stenosis and is often related to low back and leg pain. We reviewed the anatomical and biomechanical predisposition of lumbar DS and discuss possible predictors and risk factors for this condition. Spinal segment L4-L5 is most vulnerable because of the great forces in this region and the increased mobility of this segment due to the specific anatomy of quadratus lumborum muscle and iliolumbar ligament. A high pelvic incidence and lumbar lordosis increase the forces on the low spinal segments and probably raise the risk for DS. Individuals with relatively more sagittal orientation of the lumbar facets have a higher probability of developing DS because such joints have less ability to resist the shearing forces. Disc degeneration is not an important predisposing factor for DS. Reduced disc space caused by disc degeneration increases the facet joint articulation overlap and together with osteophyte formation and ossification of spinal ligaments, can be seen as a part of the restabilization process. Deep abdominal and paraspinal muscles, most likely, play an important role in dynamic lumbar stability. Factors found to be associated with lumbar DS include age > 50, female gender, pregnancy, African American race, and generalized joint laxity.

Postnatal changes in the Rexed lamination and markers of nociceptive afferents in the superficial dorsal horn of the rat

In this study, we investigated postnatal changes in Rexed's laminae and distribution of nociceptive afferents in the dorsal horn of the rat lumbar spinal cord at postnatal days 0, 5, 10, 15, 20, and 60. Transverse sections of the L4-L5 segments were processed for triple labeling with isolectin B4 (IB4)-binding as a marker of nonpeptidergic C-fibers, calcitonin gene-related peptide (CGRP) immunoreactivity to label peptidergic nociceptive afferents, and a fluorescent Nissl stain to visualize cells and lamination at different stages of postnatal development. The Nissl staining revealed that the thickness of lamina I (LI) and outer lamina II remained mostly unchanged from birth until adulthood. CGRP afferents terminated mostly in LI and the outer two-thirds of lamina II, whereas the termination area of fibers binding IB4 was centered on the middle one-third of lamina II at all ages studied. In absolute values, the overall width of the bands of intense CGRP and IB4 labeling increased with age but decreased as a percentage of the overall thickness of the dorsal horn with maturation. The overlap of CGRP termination area with that of IB4 afferents increased with age. The consequences of these findings are twofold. First, the size of the different laminae does not grow evenly across the dorsal horn. Second, CGRP and IB4 labeling cannot be considered per se to be reliable markers of lamination during development. These findings have implications for comparing data obtained in immature and mature tissues with respect to localization of structures in the dorsal horn.

Pseudomeningocele after Lumbar Discectomy

We report a case of postlaminectomy pseudomeningocele which treated successfully by surgical removal with fat graft. A 23-year-old man complained of low back pain and right leg pain and a soft mass in the back at the site of the incision. Four months earlier, he had undergone surgery for herniated nucleus pulposus on L4-L5 segment and three times revision surgery for CSF leakage. A magnetic resonance imaging(MRI) study revealed a large cystic formation in the low back which communicated with a laminectomy site. At surgery, the pseudomeningocele was exposed subcutaneously and explored inside without further laminectomy. A dural tear was identified just around the nerve root with some suture materials and there was persistent CSF leaks. The dura was closed with interrupted sutures. Then we performed sandwich-typed fat graft with glue. Postoperatively, his leg pain was relieved completely and the wound was healed satisfactory without palpable back mass.

Double stimulation modulates afterhyperpolarization phase following action potentials evoked in rat motoneurones

The influence of a pair of stimuli running in time sequence between 5–10 ms (a doublet) on the basic parameters of antidromic action potentials was studied in rat motoneurones. Electrophysiological experiments were based on stimulation of axons in the sciatic nerve and intracellular recording of antidromic action potentials from individual motoneurones located in L4–L5 segments of the spinal cord. The following parameters were analyzed after application of a single stimulus and a doublet: amplitude and duration of the antidromic spike, amplitude, total duration, time to minimum, half-decay time of the afterhyperpolarization (AHP). It was demonstrated that application of a pair of stimuli resulted in: (1) a prolongation of action potentials, (2) a prolongation of the total duration and half-decay time of the AHP, (3) a decline of the time to minimum of the AHP, (4) an increase of the AHP amplitude of the spike evoked by the second stimulus. Significant differences in AHP parameters were found either in fast or slow motoneurones. We suppose that doublet-evoked changes in the AHP amplitude and duration are linked to intrinsic properties of individual motoneurones and may lead to the prolongation of the time interval to subsequent motoneuronal discharges during voluntary activity.

Vertebral Endplate Morphology Follows Bone Remodeling Principles

A finite element model coupled with an iterative bone remodeling algorithm was used to optimize the morphology of the lumbar vertebrae. To theoretically predict the optimal vertebral density and thickness of the vertebral cortex and endplates. Regional bone density variations have been reported. Both density and thickness of the endplate have been shown to increase toward the vertebral periphery. This study sought to address the possibility that the subchondral bone seeks an optimal morphology based on the principles of bone remodeling. An adaptive remodeling algorithm, driven by strain energy density, was applied to a previously validated 3D, nonlinear finite element model of an intact ligamentous L3-L5 segment. Both internal and external remodeling changes were considered. The density of the vertebral cortex approached that of cortical bone, whereas the thickness of the anterior cortex exceeded that of the posterior shell and either endplate. The endplates thinned regionally over- and underlying the nucleus, increasing in thickness toward the periphery. The similarities between the models of the present investigation and various experimental reports indicate that the changes in the morphology of vertebral bone as the result of a mechanical adaptive process may be described via an adaptive bone remodeling theory.

The risk of disc prolapses with complex loading in different degrees of disc degeneration – A finite element analysis

Disc prolapses can result from various complex load situations and degenerative changes in the intervertebral disc. The aim of this finite element study was to find load combinations that would lead to the highest internal stresses in a healthy and in degenerated discs. A three-dimensional finite element model of a lumbar spinal segment L4-L5 in different grades of disc degeneration (healthy, mild, moderate, and severe) were generated, in which the disc height reduction, the formation of osteophytes and the increasing of nucleus' compressibility were considered. The intradiscal pressure in the nucleus, the fiber strains, and the shear strains between the annulus and the adjacent endplates under pure and complex loads were investigated. In all grades of disc degeneration the intradiscal pressure was found to be highest in flexion. The shear and fiber strains predicted a strong increase under lateral bending+flexion for the healthy disc and under axial rotation and lateral bending+axial rotation for all degenerated discs, mostly located in the postero-lateral annulus. Compared to the healthy disc, the mildly degenerated disc indicated an increase of the intradiscal pressure and of the fiber strains, both of 25% in axial rotation. The shear strains showed an increase of 27% in axial rotation+flexion. As from the moderately degenerated disc all measurement parameters strongly decreased. The results support how specifically changes associated with disc degeneration might contribute to risk of prolapse. Thus, the highest risk of prolapses can be found for healthy and mildly degenerated discs.

Stress Reduction in Adjacent Level Discs via Dynamic Instrumentation: A Finite Element Analysis

Background Conventional (rigid) fusion instrumentation is believed to accelerate the degeneration of adjacent discs by increasing stresses caused by motion discontinuity. Fusion instrumentation that employs reduced rod stiffness and increased axial motion, or dynamic instrumentation, may partially alleviate this problem, but the effects of this instrumentation on the stresses in the adjacent disc are unknown. We used a finiteelement model to calculate and compare the stresses in the adjacent-level disc that are induced by rigid and dynamic posterior lumbar fusion instrumentation. Methods A 3-dimensional finite-element model of the lumbar spine was obtained that simulated flexion and extension. The L5–S1 segment of this model was fused, and the L4–L5 segment was fixed with rigid or dynamic instrumentation. The mechanical properties of the dynamic instrumentation were determined by laboratory testing and then used in the finite-element model. Peak stresses in the lumbar discs were calculated and compared. Results The reduced-stiffness component of the dynamic instrumentation was associated with a 1% to 2% reduction in peak compressive stresses in the adjacent-level disc (at 45° flexion), and the increased axial motion component of this instrumentation reduced peak disc stress by 8% to 9%. Areas of disc tissue exposed to 80% of peak stresses of 6.17 MPa were 47% less for discs adjacent to dynamic instrumentation than for those adjacent to rigid instrumentation. Conclusions Reduced stiffness and increased axial motion of dynamic posterior lumbar fusion instrumentation designs result in an approximately 10% cumulative stress reduction for each flexion cycle. The effect of this stress reduction over many cycles may be substantial. Clinical Relevance The cumulative effect of this reduced amplitude and distribution of peak stresses in the adjacent disc may partially alleviate the problem of adjacent-level disc degeneration.

Intradiscal Pressure, Shear Strain, and Fiber Strain in the Intervertebral Disc Under Combined Loading

Finite element study. To investigate intradiscal pressure, shear strain between anulus and adjacent endplates, and fiber strain in the anulus under pure and combined moments. Concerning anulus failures such as fissures and disc prolapses, the mechanical response of the intervertebral disc during combined load situations is still not well understood. A 3-dimensional, nonlinear finite element model of a lumbar spinal segment L4-L5 was used. Pure unconstraint moments of 7.5 Nm in all anatomic planes with and without an axial preload of 500 N were applied to the upper vertebral body. The load direction was incrementally changed with an angle of 15 degrees between the 3 anatomic planes to realize not only moments in the principle motion planes but also moment combinations. Intradiscal pressure was highest in flexion and lowest in lateral bending. Load combinations did not increase the pressure. A combination of lateral bending plus flexion or lateral bending plus extension strongly increased the maximum shear strains. Lateral bending plus axial rotation yielded the highest increase in fiber strains, followed by axial rotation plus flexion or axial rotation plus extension. The highest shear and fiber strains were both located posterolaterally. An additional axial preload tended to increase the pressure, the shear, and fiber strains essentially for all load scenarios. Combined moments seem to lead to higher stresses in the disc, especially posterolaterally. This region might be more susceptible to disc failure and prolapses. These results may help clinicians better understand the mechanical causes of disc prolapses and may also be valuable in developing preventive clinical strategies and postoperative treatments.

Changes in the lumbar foramen following anterior interbody fusion with tapered or cylindrical cages

Background context Anterior lumbar interbody fusion (ALIF) using both cylindrical and tapered threaded interbody cages has been shown to restore disc height, reduce segmental motion, and relieve low back pain. The effectiveness of these stand-alone cage designs in restoration and maintenance of intervertebral foraminal dimensions has received little attention. Purpose To investigate the effects of anterior implantation of cylindrical and tapered interbody cages on morphologic changes of the lumbar neuroforamen and maintenance of foraminal dimensions under dynamic loading. Study design/setting A biomechanical study using bovine calf spine model to compare the deformation of foraminal space after ALIF with either tapered cages or cylindrical cages. Methods Sixteen fresh calf spines were randomly assigned to undergo ALIF at the L3–L4 level using either two threaded cylindrical or two tapered cages. Lumbar spines were subjected to unconstrained loading in flexion, extension, and lateral bending. Rotation of the L3–L4 segment and dynamic deformation in foraminal height were obtained through a motion analysis system, and compared between the two cage groups. Foraminal dimensions were assessed before and after tapered or cylindrical cage implantation with digitized measurement of bilateral foraminal molds. Results Regardless of cage design, anterior implantation of cages increased neuroforaminal area by 17% (p=.0005) and increased the foraminal height by 9% (p=.0004) in the neutral unloaded position. In dynamic loading conditions, foraminal height was significantly stabilized in all loading directions by the cylindrical cages (p=.01) and on both sides during lateral bending by the tapered cages (p<.03). Foraminal stabilization provided by either cage was most prominent in the direction of lateral bending (26–37% of the intact values), while cylindrical cages also provided substantial stabilization in flexion (26% of the intact value). Significant linear relationships were found between foraminal height and residual fusion segment motion under dynamic loading conditions. Conclusion Results from this bovine model biomechanical study indicate that stand-alone anterior interbody fusion cages with either tapered or cylindrical design are effective in restoring neuroforaminal height and stabilize the spine to withstand foraminal deformation during daily loading. The degree of stabilization was influenced substantially by the loading direction, to a lesser degree by the cage type, and was strongly dependent on the segment mobility. Although bovine lumbar spine is widely accepted for comparative studies, direct clinical interpretation should be made with caution owing to the anatomical differences from human.

Characteristics and Mechanisms of Locomotion Induced by Intraspinal Microstimulation and Dorsal Root Stimulation in Spinal Cats

Intraspinal microstimulation (ISMS) through a single microelectrode can induce locomotion in cats spinalized at T(13) 1 wk before (untrained) or after 3-5 wk of treadmill training. Here we study the optimal parameters of ISMS and the characteristics of locomotion evoked. ISMS was applied in the dorsal region of segments L(3)-S(1) at different lateralities (midline to 2.5 mm) and after an intravenous injection of clonidine (noradrenergic agonist). Kinematics and electromyographic recordings were used to characterize locomotion. ISMS could induce a bilateral locomotor pattern similar to that obtained with perineal stimulation, and the characteristics of locomotion varied according to the spinal segment stimulated. Mechanisms by which ISMS could evoke locomotion were then investigated by stimulating, inactivating, or lesioning different spinal structures. Dorsal root stimulation (DRS), just like ISMS, could evoke a variety of ipsi- and bilateral nonlocomotor movements as well as locomotor responses. This suggests that sensory afferent pathways are involved in the production of locomotion by ISMS. Microinjections of yohimbine (noradrenergic antagonist) in L(3) and L(4) segments or a complete second spinal lesion at L(3)-L(4) abolished all locomotor activity evoked by ISMS applied at more caudal segments. Progressive dorsoventral spinal lesions at L(3) or L(4) and restricted ventral lesions at L(4) further suggest that the integrity of the ventral or ventrolateral funiculi as well as the L(3)-L(4) segments are critical for the induction of locomotion by ISMS at L(5) to S(1) or by DRS at these caudal segments.

Stress Reduction in Adjacent Level Discs via Dynamic Instrumentation: A Finite Element Analysis.

BackgroundConventional (rigid) fusion instrumentation is believed to accelerate the degeneration of adjacent discs by increasing stresses caused by motion discontinuity. Fusion instrumentation that employs reduced rod stiffness and increased axial motion, or dynamic instrumentation, may partially alleviate this problem, but the effects of this instrumentation on the stresses in the adjacent disc are unknown. We used a finiteelement model to calculate and compare the stresses in the adjacent-level disc that are induced by rigid and dynamic posterior lumbar fusion instrumentation.MethodsA 3-dimensional finite-element model of the lumbar spine was obtained that simulated flexion and extension. The L5–S1 segment of this model was fused, and the L4–L5 segment was fixed with rigid or dynamic instrumentation. The mechanical properties of the dynamic instrumentation were determined by laboratory testing and then used in the finite-element model. Peak stresses in the lumbar discs were calculated and compared.ResultsThe reduced-stiffness component of the dynamic instrumentation was associated with a 1% to 2% reduction in peak compressive stresses in the adjacent-level disc (at 45° flexion), and the increased axial motion component of this instrumentation reduced peak disc stress by 8% to 9%. Areas of disc tissue exposed to 80% of peak stresses of 6.17 MPa were 47% less for discs adjacent to dynamic instrumentation than for those adjacent to rigid instrumentation.ConclusionsReduced stiffness and increased axial motion of dynamic posterior lumbar fusion instrumentation designs result in an approximately 10% cumulative stress reduction for each flexion cycle. The effect of this stress reduction over many cycles may be substantial.Clinical RelevanceThe cumulative effect of this reduced amplitude and distribution of peak stresses in the adjacent disc may partially alleviate the problem of adjacent-level disc degeneration.

Biomechanical Evaluation of the Total Facet Arthroplasty System™

An in vitro biomechanical study to quantify 3-dimensional kinematics of the lumbar spine following facet arthroplasty. 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. 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. 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. 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). 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.

Application of the Finite Element Technique in the Design and Evaluation of the Artificial Facets for the Lumbar Spine

An experimentally validated three-dimensional (3D) finite element (FE) model of the ligamentous L3–S1 segment was used to study the effects of artificial facet designs on the segment biomechanics (motion, facet loads, and stresses). The intact model was modified to simulate several artificial facet designs across the L4–L5 segment including capping with and without screws and pedicle screw based designs with sliding articulating surfaces. For the pedicle screw based design, the effect of increasing the connecting shaft thickness and increasing width surrounding the pedicle screw, butted against the vertebral pedicle for further support, was studied. All of the FE models were evaluated in response to 6 Nm moment in extension, flexion, bending, and rotation. The predicted increases in motion, compared to the intact case, were smaller. The predicted facet loads decreased up to 25.7% in extension and 25.1% in bending at the implanted level as compared to intact spine segment. For all of the loading modes, the stresses in both implant designs were less than the yield stress of titanium. Therefore, the implants are unlikely to fail. Additional cadaver and other experimental protocols are essential for the evaluations of the most appropriate designs identified through the FE investigations.

Biomechanical Rationale for Using Polyetheretherketone (PEEK) Spacers for Lumbar Interbody Fusion–A Finite Element Study

To determine the effect of cage/spacer stiffness on the stresses in the bone graft and cage subsidence. To investigate the effect of cage stiffness on the biomechanics of the fused segment in the lumbar region using finite element analysis. There are a wide variety of cage/spacer designs available for lumbar interbody fusion surgery. These range from circular, tapered, rectangular with and without curvature, and were initially manufactured using titanium alloy. Recent advances in the medical implant industry have resulted in using medical grade polyetheretherketone (PEEK). The biomechanical advantages of using different cage material in terms of stability, subsidence, and stresses in bone graft are not fully understood. A previously validated 3-dimensional, nonlinear finite element model of an intact L3-L5 segment was modified to simulate posterior interbody fusion spacers made of PEEK ("E" = 3.6 GPa) and titanium ("E" = 110 GPa) at the L4/5 disc with posterior instrumentation. Bone graft ("E" = 12 GPa) packed between the spacers in the intervertebral space was also simulated. The posterior lumbar interbody fusion spacer with instrumentation and graft represent a simulation of the condition present immediately after surgery. The peak centroidal Von Mises stresses in the graft bone increased by at least 9-fold with PEEK spacers as compared to titanium spacer. The peak centroidal Von Mises stresses in the endplates increased by at least 2.4-fold with titanium spacers over the PEEK spacers. These stresses were concentrated at places where the spacer interfaced with the endplate. The stiffness of the spacer did not affect the relative motion (stability) across the instrumented (L4/5) segment. Spacers less stiff than the graft will: (1) provide stability similar to titanium cages in the presence of posterior instrumentation, (2) reduce the stresses in endplates adjacent to the spacers, and (3) increase the load transfer through the graft, as evident from the increase in stresses in graft.

Biomechanical Evaluation of a New Total Posterior-Element Replacement System

In vitro study to characterize the flexibility of a new total posterior-element system when instrumented to L4-L5 segments. The goal of this in vitro study was to investigate whether an optimized version of the TOPS implant (Impliant Ltd., Ramat Poleg, Israel) is capable to restore the physiologic motion characteristic of a spinal segment after facetectomy. The TOPS implant is designed to replace the posterior elements of a functional spinal unit, to provide flexible restabilization and spinal alignment, while maintaining the intervertebral disc. The implant is composed of bilateral pedicle screws, connected with 2 crossbars in the transversal plane. The crossbars are joined together by an elastic element capable of transmitting tensile and compressive loads, as well as shear forces. Six human cadaver specimens (L3-S1) (median age 61 years: minimum 47 and maximum 74 years) were used for this in vitro experiment. The specimens were loaded with pure moments of +/-7.5 Nm in flexion/extension, lateral bending, and axial rotation. The following states were investigated: (1) intact; (2) after bilateral laminectomy, including facetectomy of the lower facet joints, of the upper vertebra L4; and (3) after device implantation. The range of motion (ROM), neutral zone, and intradiscal pressure were determined from a third cycle. In a second step, the ROM in axial rotation was determined as a function of different flexion/extension postures. In the neutral position, the laminectomy and facetectomy increased the median values of the ROM in flexion plus extension, lateral bending right plus left, and significantly in axial rotation left plus right from: 8.2 degrees, 7.6 degrees, 3.6 degrees to 12.1 degrees, 8.5 degrees, and 8.5 degrees (Wilcoxon signed rank test; P < 0.05). After fixation of the implant, the ROM was again reduced to 6.8 degrees, 7.8 degrees, and 3.8 degrees. In a flexed posture, the ROM in axial rotation was slightly increased compared to the neutral position. With increasing extension, the axial rotation decreased linearly from 3.7 degrees in neutral position to 2.3 degrees in 4 degrees extension in the segment L4-L5. The characteristic of the intradiscal pressure versus load with the implant was similar to that of the intact specimen. The TOPS implant almost ideally restored the ROM in lateral bending and axial rotation compared to that of the intact specimen. In the sagittal plane, 85% of the intact ROM could be obtained. The ROM in axial rotation as a function of flexion and extension angle also mimics the biomechanical behavior of the posterior complex of a lumbar spine. This relationship between ROM and posture emphasizes the importance of a proper implantation.

Biomechanics of two-level Charité artificial disc placement in comparison to fusion plus single-level disc placement combination

Biomechanical studies of artificial discs that quantify parameters such as load sharing and stresses have been reported in literature for single-level disc placements. However, literature on the effects of using the Charité artificial disc (ChD) at two levels (2LChD) as compared with one-level fusion (using a cage [CG] and a pedicle screw system) plus one-level artificial disc combination (CGChD) is sparse. To determine the effects of the 2LChD and CGChD across the implanted and adjacent segments. A finite element model of a L3-S1 segment was used to compare the biomechanical effects of the ChD placed at two lower levels (2LChD model) with L5-S1 fusion (using a CG and a pedicle screw system) plus L4-L5 level ChD placement combination (CGChD model). We used our recently published and experimentally validated L3-S1 finite element model for the present study. The intact model was subjected to 400 N axial compression and 10.6 Nm of flexion/extension moments. The experimental constructs described above were then subjected to 400 N axial compression and a moment that produced overall motion equal to the intact model predictions (hybrid testing protocol). Resultant motion, loads across facets, and other parameters were analyzed at the experimental and adjacent levels. In flexion, the bending moments for the CGChD and 2LChD models were 15.4 Nm (fusion effect) and 7.3 Nm (increase in flexibility effect), respectively in comparison to 10.6 Nm for the intact model. The corresponding values in the extension mode were 11.2 Nm and 7.2 Nm. The predicted flexion rotations across the L5-S1 segment for the CGChD decreased by 76% (fusion effect), and increased at the L4-L5 and the L3-L4 levels by 68.5% and 28%, respectively. In the extension mode, motion across the L5-S1 segment decreased by 96.4% whereas it increased 74.6% and 18.2% across the L4-L5 and L3-L4 levels, respectively. For the 2LChD model, the flexion rotation across the L5-S1 segment increased by 28.2%. The motions across the L4-L5 and L3-L4 segments decreased by 12% and 24%, respectively. In extension, the corresponding changes were 10% increase, 10% increase, and 21% decrease at the L5-S1, L4-L5, and L3-L4 levels, respectively. The facet loads were in line with the changes in motion, except for the 2LChD case. The changes at L3-L4 level for both of the cases were of similar magnitude (approximately 25%), although in the CGChD model it increased and in the 2LChD model it decreased. The changes in motion at the L4-L5 level were large for the CGChD model as compared with the 2LChD model predictions (approximately 70% increase vs. 10% increase). It is difficult to speculate if an increase in motion across a segment, as compared with the intact case, is more harmful than a decrease in motion.

Fatigue Failure in Shear Loading of Porcine Lumbar Spine Segments

An in vitro study on porcine spinal segments. To determine the differences in mechanical behavior and fatigue strength in shear loading between intact spinal segments and segments without posterior elements, and between segments in neutral and flexed positions. Limited data are available on shear strength of spinal segments. Literature suggests that shear loading can lead to failure of the posterior elements and failure of the disc, when the posterior elements cannot provide adequate protection. In 2 experiments, 18 and 20 spines of pigs (80 kg) were used, respectively. Shear strength of the T13-L1 segment was tested, while loaded with 1600-N compression. L2-L3 and L4-L5 segments were loaded with a sinusoidal shear between 20% and 80% of the strength of the corresponding T13-L1 segment and 1600-N compression. In experiment No. 1, the posterior elements were removed in half the segments. In experiment No. 2, half the segments were tested in the neutral position, and half were tested in 10 degrees flexion. The group without posterior elements had failure earlier than the intact group. In the group without posterior element, stiffness increased on failure; in the intact group, it decreased. In experiment No. 2, no differences between groups were found. Repetitive shear loading can induce failure of porcine spinal segments, likely caused by fracture of the posterior elements, and, although repetitive anterior shear forces can also induce disc damage, this appears not to occur in intact segments, not even when flexed close to maximal.