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

Skin-Integrated wearable systems and implantable biosensors: a comprehensive review

Biosensors devices have attracted the attention of many researchers across the world. They have the capability to solve a large number of analytical problems and challenges. They are future ubiquitous devices for disease diagnosis, monitoring, treatment and health management. This review presents an overview of the biosensors field, highlighting the current research and development of bio-integrated and implanted biosensors. These devices are micro- and nano-fabricated, according to numerous techniques that are adapted in order to offer a suitable mechanical match of the biosensor to the surrounding tissue, and therefore decrease the body’s biological response. For this, most of the skin-integrated and implanted biosensors use a polymer layer as a versatile and flexible structural support, combined with a functional/active material, to generate, transmit and process the obtained signal. A few challenging issues of implantable biosensor devices, as well as strategies to overcome them, are also discussed in this review, including biological response, power supply, and data communication.This research was funded by FCT- FUNDAÇÃO PARA A CIÊNCIA E TECNOLOGIA, grant numbers: PTDC/EMD-EMD/31590/2017 and PTDC/BTM-ORG/28168/2017

Proceedings of the Conference on Progress in Electrically Active Implants - Tissue and Functional Regeneration (ELAINE 2020)

The conference on Progress in Electrically Active Implants - Tissue and Functional Regeneration (ELAINE 2020) focused on novel methods in the electric stimulation of bio-material compounds of living cells and implantable electric stimulation devices. ELAINE 2020 provided international scientists a virtual platform to discuss the latest achievements in the form of invited presentations, selected talks from abstract submissions, and virtual poster sessions. In addition, we particularly invited critical reviews and contributions with negative results or unsuccessful replications to foster the scientific discussion and explicitly encourage young scientists to contribute and submit their work

Transdermal wires for improved integration in vivo.

Alternative engineering approaches have led the design of implants with controlled physical features to minimize adverse effects in biological tissues. Similar efforts have focused on optimizing the design features of percutaneous VAD drivelines with the aim to prevent infection, omitting however a thorough look on the implant-skin interactions that govern local tissue reactions. Here, we utilized an integrated approach for the biophysical modification of transdermal implants and their evaluation by chronic sheep implantation in comparison to the standard of care VAD drivelines. We developed a novel method for the transfer of breath topographical features on thin wires with modular size. We examined the impact of implant's diameter, surface topography, and chemistry on macroscopic, histological, and physical markers of inflammation, fibrosis, and mechanical adhesion. All implants demonstrated infection-free performance. The fibrotic response was enhanced by the increasing diameter of implants but not influenced by their surface properties. The implants of small diameter promoted mild inflammatory responses with improved mechanical adhesion and restricted epidermal downgrowth, in both silicone and polyurethane coated transdermal wires. On the contrary, the VAD drivelines with larger diameter triggered severe inflammatory reactions with frequent epidermal downgrowth. We validated these effects by quantifying the infiltration of macrophages and the level of vascularization in the fibrotic zone, highlighting the critical role of size reduction for the benign integration of transdermal implants with skin. This insight on how the biophysical properties of implants impact local tissue reactions could enable new solutions on the transdermal transmission of power, signal, and mass in a broad range of medical devices

Sensor capacitivo para a monitorização da interface osso-implante

Mestrado em Engenharia MecânicaOs implantes ósseos usados atualmente não são capazes de substituir integralmente a articulação onde são aplicadas. A redistribuição da carga no osso origina o efeito stress-shielding, o que pode provocar perda de massa óssea e migração do implante. O desgaste das componentes integrais do implante também causa alterações na interface ossoimplante. Os pacientes com estas complicações, podem ser submetidos a operações de revisão, onde o risco de insucesso e infeções é elevado. Para prevenir tais casos, recentemente foi proposto o conceito de Implante Instrumentado para dotar esta tecnologia com: sistemas de atuação (sobre a interface osso-implante), monitorização da integração osso-implante, sistemas de comunicação implante-exterior e sistemas de geração autónoma de energia. No entanto, uma revisão da literatura mostrou que os sistemas de monitorização propostos não são viáveis para serem incorporados em implantes instrumentados. Este é um estudo preliminar que visa propor um sistema de monitorização capacitivo com configuração em co-superfície listrado integrado num circuito ressonante RLC. Foi desenvolvido um aparato experimental para o teste do sistema in vitro usando estruturas de osso porcino. Observaram-se variações de 0,2 fF da capacitância por cada μm de deslocamento relativo entre a estrutura óssea e o sistema de monitorização. Embora preliminar, este estudo apresenta resultados promissores para a monitorização de diferentes interfaces osso-implante usando em sistemas capacitivos em co-superfície.The prostheses currently used, are not able to fully replace the joint where they are applied. The redistribution of the load in the bone causes stressshielding, which origins loss of bone mass, and migration of the implant. Also, the wear of the integral components of the prosthesis causes changes between the interface of the bone and the implant. Patients with these complications can be submitted to review surgeries, where the risk of failure and infection is high. To prevent such cases, instrumented prosthesis have been recently proposed, to enhance this technology with: actuation systems (over the bone-implant interface), osseointegration monitoring, communication systems between implant-exterior and systems capable of generating energy autonomously. However, a review over these technologies showed that the proposed monitoring systems are not feasible to be incorporated into instrumented implants. This is a preliminary study which aims to advocate a monitoring capacitive system with a cosurface stripe pattern integrated in a RLC resonant circuit. An experimental apparatus was developed to test the system in vitro using a porcine bone. Variations of 0,2 fF in the capacitance were observed, for each ìm of relative movement between the bone and the monitoring system. Although preliminary, this study presents promising result for monitoring different bone-implant interfaces using a cosurface capacitive system

Implantable Electrodes for Upper Limb Prosthetic Control

This thesis describes a study investigating implantable interfaces with muscles and peripheral nerves. Current prostheses for upper limb amputees do not provide intuitive control over hand, wrist and elbow motion. By implanting electrodes for recording and stimulating onto muscles and into nerves in the amputation stump a greater number of control signals may be made available, signals which will be used to control dextrous hand movements. An implantable epimysial interface was developed using a bone-anchored device to hard-wire signals across the skin barrier. In a single ovine model pilot study the bone-anchor was implanted transtibially and the epimysial electrode was place superficially to m. peroneus teritus. Physiological signals were obtained over 12 weeks during treadmill walking. The external connector on the bone-anchor failed at 12 weeks, correlating with a drop in signal quality in an otherwise robust interface integrated with bone and skin tissue. The ovine bone-anchor model was repeated in 6 sheep for 19 weeks, with epimysial recordings made regularly. Increasing signal quality was seen during the study and was significantly greater from implanted electrodes compared with skin surface electrodes at 19 weeks (p = 0.016). Some complications with skin-implant integration were observed in proximally located implants. Crosstalk between muscles was assessed using pre-terminal nerve stimulation, and was found to be dependent upon muscle location and innervation. The ovine m. peroneus teritus model was used to assess recovery following targeted muscle reinnervation. Muscle signal recovery was observed approximately one month after surgery correlating with the start of functional recovery (assessed by force plate analysis). These studies indicate that a suitably modified bone-anchored device may be suitable for signal transmission in human patients, providing a stable, long-term solution to both prosthesis attachment and control. The potential of nerve interfaces for prosthetic control was investigated. The microchannel neural interface (MNI) was chosen because it overcomes limitations with other neural microarray designs: signal strength; cross-talk, and the locations of Nodes of Ranvier. MNIs confine regenerating nerves to small, ∼ 100 µm diameter, insulating tubes, this increases the length within which nerve signals can be recorded and amplifies the recorded signals. However, in vivo MNIs can become occluded by fibrosis that reduces or prevents axon regeneration. Two in vitro studies of neurocompatibility were carried out to investigate strategies for improving axon regeneration within microchannels. The first in vitro study compared the effect of different adsorbed endoneurial basement membrane proteins on PC-12 cell neurite extension on silicone substrates. The optimal protein coating concentrations for poly-D-lysine, collagen-IV and laminin-2,(-4) were determined. The optimal concentrations were compared with mixtures of basement membrane proteins, the effect of mixture coating order and constitution were investigated. It was found that endoneurial BM proteins significantly enhance neurite outgrowth compared with controls. Two coatings were suggested as most suited for improving neural regeneration within microchannels: a single layer coating of 10 µg/cm2 collagen-IV; and a mixed coating of 10 µg/cm2 collagen-IV, 1 µg/cm2 laminin-2,(-4), and 0.175 µg/cm2 nidogen-1. The second in vitro study investigated the effect of grooved, roughened and multi-scale silicone surfaces on on PC-12 cell neurite extension. Deeper, narrower grooves were shown to increase the extent of neurite alignment, while resulting in fewer, longer, neurites. Roughening surfaces was shown to increase the amount of protein (collagen-IV) which adsorbed from solution and increase the number of neurites each cell extended. Surfaces with multiscale topographies synergistically increased the number and length of neurites and guided neurite growth along the groove direction. MNIs were manufactured for in vivo testing. These MNIs were used to determine the effect of adsorbed endoneurial basement membrane proteins on nerve regeneration in vivo, but the multiscale topographies were not applied during manufacturing. Four alternative manufacturing methods were investigated and iterative improvements were made to create a stacked interface with multiple microchannel layers. Microchannel layers were created by laser patterning silicone and metal foil components, followed by plasma bonding to create a 3-dimensional structure with 150 µm deep, 200 µm wide microchannels. Electrode impedances of 27.2 ± 19.8 kΩ at 1kHz were achieved by DC etching. The method overcomes some current limitations on electrode connectivity and microchannel sealing, and may improve recording capabilities over single layer designs by increasing the ratio of electrodes to microchannels. Manufactured MNIs were tested in a rat sciatic nerve transection model. Following implantation nerves were allowed to regenerate for one and two months. First, suture and fibrin glue were compared as MNI fixation methods for one month, the nerve regenerated within the fibrin glue, outside the interface lumen, therefore sutures were chosen as a long term fixation method. The influence of endoneurial basement membrane protein coatings, identified previously, on nerve regeneration with MNIs was investigated. Nerves regenerated through the MNIs over two months and began to reinnervate the distal limb. Improvements in the sciatic function index were observed over two months, with no significant differences between protein coated and control interfaces. Some weak histological evidence for the use of protein coatings was found, with axon diameters increased distal to protein coated MNIs. Electromyographic and electroneurographic recordings demonstrated similar signal amplitudes to previous studies. In order to bring the research described in this thesis to clinical practice further engineering improvements to the design and manufacture of electrodes, which utilise materials or coatings to enhance neurocompatibility, is required. Avenues for further research are discussed and additional experiments and investigations are described. By combining developments in implantable muscle and nerve interfaces with surgical techniques and improvements in neurocompatibility the promise of upper limb prosthetic control may be realised

Bridging the Divide between Neuroprosthetic Design, Tissue Engineering and Neurobiology

Neuroprosthetic devices have made a major impact in the treatment of a variety of disorders such as paralysis and stroke. However, a major impediment in the advancement of this technology is the challenge of maintaining device performance during chronic implantation (months to years) due to complex intrinsic host responses such as gliosis or glial scarring. The objective of this review is to bring together research communities in neurobiology, tissue engineering, and neuroprosthetics to address the major obstacles encountered in the translation of neuroprosthetics technology into long-term clinical use. This article draws connections between specific challenges faced by current neuroprosthetics technology and recent advances in the areas of nerve tissue engineering and neurobiology. Within the context of the device–nervous system interface and central nervous system implants, areas of synergistic opportunity are discussed, including platforms to present cells with multiple cues, controlled delivery of bioactive factors, three-dimensional constructs and in vitro models of gliosis and brain injury, nerve regeneration strategies, and neural stem/progenitor cell biology. Finally, recent insights gained from the fields of developmental neurobiology and cancer biology are discussed as examples of exciting new biological knowledge that may provide fresh inspiration toward novel technologies to address the complexities associated with long-term neuroprosthetic device performance

Developing Biosensor Technology to Monitor Biofilm Formation on Voice Prosthesis in Throat Cancer Patients Following Total Laryngectomy

Voice prostheses (used to replace an excised larynx in laryngectomy patients) are often colonised by the yeast Candida albicans, yet no monitoring technology for C. albicans biofilm growth until these devices fail. With the current interest in smart technology, understanding the electrical properties of C. albicans biofilm formation is necessary. There has been great interest in Passive Radio Frequency Identification (RFID) for use with implantable devices as they provide a cost-effective approach for sensing. The main drawback of RFID sensors is the need to overcome capacitive loading of human tissue and, thus, low efficiency to produce a high read range sensor design. This is further complicated by the size restriction on any RFID design to be implemented within a voice prosthesis as this medical device is limited to less than 3 cm in overall size. In order to develop such a voice prosthesis sensor, we looked at three separate aspects of C. albicans colonisation on medical devices within human tissue. To understand if it is possible to detect changes within a moist environment (such as the mouth), we developed a sensor capable of detecting minute dielectric changes (accuracy of ± 0.83 relative permittivity and ± 0.05 S·m-1 conductivity) within a closed system. Once we understood that detection of dielectric changes within a liquid solution were possible, to overcome human tissue capacitive loading of RFID sensors. Adjusting backing thickness or adding a capacitive shunt into the design could limit this tissue effect and even negate the variability seen between human tissues. Without developing these methods, implementation of any RFID device would be difficult as human tissue variability would not be compensated for properly. Finally, biofilm growth in terms electrical properties. As C. albicans biofilm matures, there is a loss in capacitance (the biofilm becomes increasingly hydrophobic) prior to 24 hours after which the biofilm thickness shifts the resonance leading to a slow gain in capacitance. Understanding all of these aspects allowed us to develop two final voice prosthesis sensors producing read ranges above 60 cm and 10 cm within a tissue phantom. Ultimately, this showed the possibility of developing cost-effective passive RFID sensor technology for monitoring microbial biofilm formation within human tissue, leading to more effective real-time clinical care