Multi-Surface Simplex Spine Segmentation for Spine Surgery Simulation and Planning

This research proposes to develop a knowledge-based multi-surface simplex deformable model for segmentation of healthy as well as pathological lumbar spine data. It aims to provide a more accurate and robust segmentation scheme for identification of intervertebral disc pathologies to assist with spine surgery planning. A robust technique that combines multi-surface and shape statistics-aware variants of the deformable simplex model is presented. Statistical shape variation within the dataset has been captured by application of principal component analysis and incorporated during the segmentation process to refine results. In the case where shape statistics hinder detection of the pathological region, user-assistance is allowed to disable the prior shape influence during deformation. Results have been validated against user-assisted expert segmentation

Deformable Multisurface Segmentation of the Spine for Orthopedic Surgery Planning and Simulation

Purpose: We describe a shape-aware multisurface simplex deformable model for the segmentation of healthy as well as pathological lumbar spine in medical image data. Approach: This model provides an accurate and robust segmentation scheme for the identification of intervertebral disc pathologies to enable the minimally supervised planning and patient-specific simulation of spine surgery, in a manner that combines multisurface and shape statistics-based variants of the deformable simplex model. Statistical shape variation within the dataset has been captured by application of principal component analysis and incorporated during the segmentation process to refine results. In the case where shape statistics hinder detection of the pathological region, user assistance is allowed to disable the prior shape influence during deformation. Results: Results demonstrate validation against user-assisted expert segmentation, showing excellent boundary agreement and prevention of spatial overlap between neighboring surfaces. This section also plots the characteristics of the statistical shape model, such as compactness, generalizability and specificity, as a function of the number of modes used to represent the family of shapes. Final results demonstrate a proof-of-concept deformation application based on the open-source surgery simulation Simulation Open Framework Architecture toolkit. Conclusions: To summarize, we present a deformable multisurface model that embeds a shape statistics force, with applications to surgery planning and simulation

Surgical GPS Proof of Concept for Scoliosis Surgery

Scoliotic deformities may be addressed with either anterior or posterior approaches for scoliosis correction procedures. While typically quite invasive, the impact of these operations may be reduced through the use of computer-assisted surgery. A combination of physician-designated anatomical landmarks and surgical ontologies allows for real-time intraoperative guidance during computer-assisted surgical interventions. Predetermined landmarks are labeled on an identical patient model, which seeks to encompass vertebrae, intervertebral disks, ligaments, and other soft tissues. The inclusion of this anatomy permits the consideration of hypothetical forces that are previously not well characterized in a patient-specific manner. Updated ontologies then suggest procedural directions throughout the surgical corridor, observing the positioning of both the physician and the anatomical landmarks of interest at the present moment. Merging patient-specific models, physician-designated landmarks, and ontologies to produce real-time recommendations magnifies the successful outcome of scoliosis correction through enhanced pre-surgical planning, reduced invasiveness, and shorted recovery time

Biomechanical study of intervertebral disc degeneration

Degeneration and age affect the biomechanics of the intervertebral disc, by reducing its stiffness, flexibility and shock absorption capacities against daily movement and spinal load. The biomechanical characterization of intervertebral discs is achieved by conducting mechanical testing to vertebra-disc-vertebra segments and applying axial, shear, bend and torsion loads, statically or dynamically, with load magnitudes corresponding to the physiological range. However, traditional testing does not give a view of the load and deformation states of the disc components: nucleus pulposus, annulus fibrosus and endplate. Thus, the internal state of stress and strains of the disc can only be predicted by numerical methods, one of which is the finite element method. The objective of this thesis was, to study the biomechanics of degenerated intervertebral discs to load conditions in compression, bending and torsion, by using mechanical testing and a finite element model of disc degeneration, based on magnetic resonance imaging (MRI). Therefore, lumbar discs obtained from cadavers corresponding to spinal levels L2-L3 and L4-L5 with mild to severe degeneration were used. Intervertebral osteochondrosis and spondylosis deformans were identified, being the disc space collapse, the most striking feature. Next, all discs were tested to static and dynamic load conditions, the results gained corresponded to the disc stiffness (in compression, bending and torsion), stress relaxation and dynamic response. Of these, the stiffness response was used to validate the disc model. The testing results suggest that discs with advanced degeneration over discs with mild degeneration are, less rigid in compression, less stiffer under bending and torsion, showed less radial bulge, and reduce their viscoelastic and damping properties. This study shows that degeneration has an impact on the disc biomechanical properties which can jeopardize normal functionality. Development of one finite element model of disc degeneration started by choosing a MRI of a L2-L3 disc. Segmentation of vertebra bone and disc materials followed, and were based on pixel brightness and radiology fundamentals, then a finite element mesh was created to account for the disc irregular shape. The disc materials were modeled as hyperelastic and the bone materials were modeled as orthotropic and isotropic. Adjustment of material properties was based on integrity of the annulus fibrosus, giving a stiffness value matching that of a mild degeneration disc. Then, validation of the model was performed, and included a study of the distributions of stress and strain under loads of compression, bending and torsion. The results from all load simulations show that the disc undergoes large deformations. In contrast, the vertebrae are subjected to higher stress but with negligible deformations. In compression, the model predicted formation of symmetrical disc bulge which agree with the testing behavior. The nucleus pulposus showed to be the principal load carrier with negative principal stresses and strains. In bending and torsion, the annulus fibrosus showed to be the principal load carrier with large symmetrical principal strains and stresses for the former loading and large shearing for the latter. The study showed the importance of soft tissue deformation, mostly noticed in advanced degeneration. In contrast, the higher stresses in the vertebra over those of the intervertebral disc showed the relevance of bone predisposition to fracture. Such kind of studies, should contribute to the understanding of the biomechanics of the intervertebral disc.La degeneración y edad afectan la biomecánica del disco intervertebral, reduciendo la capacidad de rigidez, flexibilidad y atenuación de impactos, contra el movimiento y carga del raquis. La caracterización biomecánica del disco se realiza con ensayos mecánicos a segmentos de vértebra-disco-vértebra y aplicando cargas axiales, cortantes, flexión y torsión, estáticas ó dinámicas, con magnitudes de carga según el intervalo fisiológico. Sin embargo, las pruebas tradicionales no dan una visión de los estados de carga y deformación de los componentes del disco: núcleo pulposo, anillo fibroso y placa terminal. Por lo tanto, el estado interno de esfuerzos y deformaciones del disco, solo puede ser predicho con métodos numéricos, uno de los cuales es el método de elemento finito. El objetivo de esta tesis fue, estudiar la biomecánica de discos intervertebrales degenerados a las condiciones de carga en compresión, flexión y torsión, mediante el uso de ensayos mecánicos y de un modelo de elementos finitos de la degeneración de disco, basado en imágenes con resonancia magnética (MRI). Por lo tanto, se usaron discos lumbares L2-L3 y L4-L5 obtenidos de cadáveres, con degeneración leve a severa. Se identificó osteocondrosis intervertebral y espondilosis deformante, siendo el colapso del espacio intervertebral el aspecto más relevante. Luego, todos los discos fueron ensayados a condiciones de carga estática y dinámica, y los resultados correspondieron a la rigidez del disco (a compresión, flexión y torsión), a la relajación de tensiones y a la respuesta dinámica. De éstos, la rigidez fue usada para validar el modelo de disco. Los resultados de los ensayos sugieren que los discos con degeneración avanzada sobre aquellos con degeneración leve son, menos rigidos a compresión, menos rigidos a flexión y torsión, presentan menor protuberancia radial, y reducen sus propiedades viscoelásticas y de amortiguamiento. El estudio muestra que la degeneración impacta las propiedades biomecánicas del disco, poniendo en riesgo la funcionalidad normal. El desarollo de un modelo de elementos finitos de la degeneración de disco inició eligiendo una secuencia de resonancia magnética de un disco L2-L3. La segmentación de los materiales del disco y de las vértebras se realizó basado en intensidad de brillo del pixel y en fundamentos de radiología, y se creó una malla de elementos finitos correspondiente a la forma irregular del disco. Los materiales del disco se modelaron como hiperelásticos y los tejidos óseos se modelaron como materiales ortotrópicos e isotrópicos. El ajuste de propiedades de los materiales fue basado en la integridad del anillo fibroso, y dio una rigidez correspondiente a la de un disco con degeneración leve. Luego, se realizó la validación del modelo, e incluyó un estudio de las distribuciones de esfuerzo y deformación a las condiciones de carga en compresión, flexión y torsión. Los resultados de todas las simulaciones de carga mostraron que el disco es sometido a grandes deformaciones. En contraste, las vértebras fueron sometidas a mayores esfuerzos pero con deformaciones insignificantes. En compresión, el modelo predijo la formación de una protuberancia radial simétrica, en concordancia con la experimentación. El núcleo pulposo mostró ser el portador principal de carga, con tensiones y deformaciones principales negativas. En flexión y torsión, el anillo fibroso mostró ser el portador principal de carga, con grandes deformaciones y tensiones principales simétricas para la primera carga, y con grandes tensiones cortantes para la segunda carga. El estudio mostró la importancia de las deformaciones de los tejidos blandos, principalmente notados en la degeneración avanzada. Por el contrario, las tensiones mayores en los cuerpos vertebrales sobre aquellas del disco intervertebral mostraron la relevancia de la predisposición a las fracturas óseas. Este tipo de estudio debe contribuir a la comprensión de la biomecánica del disco intervertebral

Ceramic coatings for Cervical Total Disc Replacement

Surgical interventions for the treatment of chronic neck pain, which affects 330 million people globally, include fusion and cervical total disc replacement (CTDR). Most of the currently clinically available CTDRs designs include a metal-on-polymer (MoP) bearing. Numerous studies suggest that MoP CTDRs are associated with issues similar to those affecting other MoP joint replacement devices, including excessive wear and wear particle-related inflammation and osteolysis. The aim of this study was to investigate the biotribology of a novel metal-on-metal (MoM) design of cervical total disc replacement device in its pristine form and coated with chromium nitride or silicon nitride, in order to understand the influence of loading conditions upon the tribological performance of the implant, and to investigate biological effects of the wear debris produced by the implants. To achieve this, a series of studies were carried out. Chromium nitride and silicon nitride coatings have been characterised for their mechanical properties, chemical composition and surface finish. Whilst some of the experiments showed minor differences between the mechanical properties and adhesion of the coatings, there was no indication of significant differences between the chromium nitride and silicon nitride coated samples. Functional testing in the six-station spine wear simulator showed that MoM CTDRs produced wear volumes significantly lower than those of the commercially available MoP devices. The wear volumes were reduced further by three-fold, following testing under altered ISO-18192-1:2011 kinematics, whereby, reduced ranges of motions were applied. Whilst the silicon nitride coated CTDRs failed catastrophically early in the test, chromium nitride coated CTDRs produced an eight-fold reduction in wear volumes, when compared to the pristine devices tested under the same conditions. Investigation of potential biological effects of the particles generated in wear testing showed that that high concentrations (5-50µm3 per cell) of CoCrMo particles resulted in significant reduction of cell viability of the L929 fibroblast cells, but not the dural fibroblasts, which were used in this study. No ceramic coating particles, at any concentrations, caused significant reduction of cell viability. In summary, results presented in this thesis showed that whilst the MoM CTDR device exhibited significantly lower wear rates than those of the commercially available MoP devices, the cytotoxic wear particles could potentially lead to adverse biological reactions, particularly in patients with metal hypersensitivity, and lead to devastating consequences similar to those of failed MoM THRs. Currently, the consequences of similar failure, leading to metalosis or pseudotumour formation in the vicinity of the spinal cord are unknown. During the investigation of the ceramic coatings, it was also found that chromium nitride ceramic coating could not only lower wear rates further, but it also has the potential to reduce the cytotoxic potential of the wear particles

Low Back Pain (LBP)

Low back pain (LBP) is a major public health problem, being the most commonly reported musculoskeletal disorder (MSD) and the leading cause of compromised quality of life and work absenteeism. Indeed, LBP is the leading worldwide cause of years lost to disability, and its burden is growing alongside the increasing and aging population. The etiology, pathogenesis, and occupational risk factors of LBP are still not fully understood. It is crucial to give a stronger focus to reducing the consequences of LBP, as well as preventing its onset. Primary prevention at the occupational level remains important for highly exposed groups. Therefore, it is essential to identify which treatment options and workplace-based intervention strategies are effective in increasing participation at work and encouraging early return-to-work to reduce the consequences of LBP. The present Special Issue offers a unique opportunity to update many of the recent advances and perspectives of this health problem. A number of topics will be covered in order to attract high-quality research papers, including the following major areas: prevalence and epidemiological data, etiology, prevention, assessment and treatment approaches, and health promotion strategies for LBP. We have received a wide range of submissions, including research on the physical, psychosocial, environmental, and occupational perspectives, also focused on workplace interventions

A Virtual Model of the Human Cervical Spine for Physics-based Simulation and Applications

Utilizing recent advances in computer technology, Our Biomechanics Laboratory have made an effort to integrate computer animation and engineering analysis software into biomedical research, specifically towards simulation and animation of in vitro experimentation of the human cervical spine in the virtual world. The objectives of this study were to develop a virtual model of the human cervical spine for physics-based simulation and to apply the virtual model to studies of different surgical procedures and instrumentation. A process for creating an accurate virtual model of the human cervical spine was developed. The model consisted of seven vertebrae (C2-T1) connected with soft tissue components: intervertebral joint, facet joints, and ligaments. The soft tissue components were assigned nonlinear viscoelastic properties. The evaluation of the model included the percent contribution of rotation relative to global rotation, coupling behaviors, helical axes of motion pattern, global rotational stiffness curves, and animations of the disc and facet forces. This model was used to evaluate different mounting configurations for axial rotation testing and to identify a set of end constraint conditions that produced physiologic responses during axial rotational loading. This model was also used to simulate the biomechanical responses of single-level cervical fusion. The single-level fusion was found to produce increased motion compensation at the adjacent segments during flexion and extension. Greater increases in the disc forces were found in the spinal level superior to the fusion during flexion and inferior to the fusion during flexion extension. This model was also used to study of the biomechanical effects of different design features for cervical disc arthroplasty. A constrained spherical joint placed at the disc level significantly increased facet loads during extension. Lowering the rotational axis of the spherical joint into the subjacent body also caused a marginal increase in facet loading during flexion, extension, and lateral bending. Un-constraining the spherical joint to a plane at the disc level minimized facet load build up. The virtual model bridges the gap between the cadaveric-based in vitro tests and clinicalbased experimental studies to further the research and educational knowledge of cervical spine biomechanics

Validation and Application of an intervertebral Disc Finite Element Model Utilizing independently Constructed Tissue-Level Constitutive formulations That are Nonlinear, Anisotropic, and Time-Dependent

Finite element models are advantageous in the study of intervertebral disc mechanics as the stress-strain distributions can be determined throughout the tissue and the applied loading and material properties can be controlled and modified. However, the complicated nature of the disc presents a challenge in developing an accurate and predictive disc model, which has led to limitations in finite element geometries, material constitutive models and properties, and model validation. The objective of this dissertation is to develop a new finite element model of the intervertebral disc, to validate the model\u27s nonlinear and time-dependent responses without tuning or calibration, and to evaluate the effect of changes in nucleus pulposus and cartilaginous endplate material properties on the disc mechanical response. This was accomplished through a cohesive series of studies. First, structural hyperelastic constitutive models were used in conjunction with biphasic-swelling theory to obtain material parameters for the disc tissues from recent tissue tests. A new disc finite element model was then constructed utilizing an analytically-based geometry created from the mean shape of human L4/L5 discs, measured from high-resolution 3D MR images and averaged using signed distance functions. The full disc model was then validated against experimental intervertebral disc loading datasets for compressive slow loading ramp, creep, and stress-relaxation simulations, and finally the new disc model was used to investigate the role of each individual disc tissue. The significance of this new disc model is threefold. First, an extensive validation was performed using the full nonlinear response of the intervertebral disc in three different loading modalities. The finite element predictions fit within the experimental range (mean ±95% confidence interval) of the nonlinear response. Second, the validation was predictive; no material parameters were determined using fits to any motion-segment data. All parameters were obtained from fits to the individual tissue responses. Furthermore, the loading mechanisms tested at the tissue level (confined compression, uniaxial tension) were different than those implemented at the full disc scale (quasi-static slow ramp, creep, stress-relaxation). Lastly, model validation was accomplished without any tuning or adjustment of the material parameters in order to force agreement between the FE and experimental responses

Studies on Spinal Fusion from Computational Modelling to ‘Smart’ Implants

Low back pain, the worldwide leading cause of disability, is commonly treated with lumbar interbody fusion surgery to address degeneration, instability, deformity, and trauma of the spine. Following fusion surgery, nearly 20% experience complications requiring reoperation while 1 in 3 do not experience a meaningful improvement in pain. Implant subsidence and pseudarthrosis in particular present a multifaceted challenge in the management of a patient’s painful symptoms. Given the diversity of fusion approaches, materials, and instrumentation, further inputs are required across the treatment spectrum to prevent and manage complications. This thesis comprises biomechanical studies on lumbar spinal fusion that provide new insights into spinal fusion surgery from preoperative planning to postoperative monitoring. A computational model, using the finite element method, is developed to quantify the biomechanical impact of temporal ossification on the spine, examining how the fusion mass stiffness affects loads on the implant and subsequent subsidence risk, while bony growth into the endplates affects load-distribution among the surrounding spinal structures. The computational modelling approach is extended to provide biomechanical inputs to surgical decisions regarding posterior fixation. Where a patient is not clinically pre-disposed to subsidence or pseudarthrosis, the results suggest unilateral fixation is a more economical choice than bilateral fixation to stabilise the joint. While finite element modelling can inform pre-surgical planning, effective postoperative monitoring currently remains a clinical challenge. Periodic radiological follow-up to assess bony fusion is subjective and unreliable. This thesis describes the development of a ‘smart’ interbody cage capable of taking direct measurements from the implant for monitoring fusion progression and complication risk. Biomechanical testing of the ‘smart’ implant demonstrated its ability to distinguish between graft and endplate stiffness states. The device is prepared for wireless actualisation by investigating sensor optimisation and telemetry. The results show that near-field communication is a feasible approach for wireless power and data transfer in this setting, notwithstanding further architectural optimisation required, while a combination of strain and pressure sensors will be more mechanically and clinically informative. Further work in computational modelling of the spine and ‘smart’ implants will enable personalised healthcare for low back pain, and the results presented in this thesis are a step in this direction