A New Technique for Measuring Lumbar amber 2, pp 156-166 Raven Painher Segmental Motion In Vivo Method, Accuracy, and Preliminary Results Thomas Steffen, MD, Rick K. Rubin, BEng, Hani G. Baramki, MD, John Antoniou, MD, Dante Marchesi, MD, and Max Aebi, MD Study Design. A direct method for three-dimensional in vivo spine kinematic studies was developed and used {to measure segmental motion patterns in healthy sub- 9s. To validate the new method, and to study the L3-L4 segmental motion patterns for complex: dynamic movements. ‘Summary of Background Data, Conventional two dimensional and three-dimensional radiographic meth- ‘ods have been used in the past to study spine kinemat jes. Few studies provided a direct approach to study segmental kinematics. No dynamic recordings of three: dimensional segmental motion patterns have been re ported previously. ‘Methods. In 16 healthy men, Kirschner wires were inserted in the spinous processes of L3 and Lé. Electro: magnetic tracking sensors were attached to the pins. Motion data recorded during ranging exercises were uused with biplanar radiographs to calculate L3-L4 seg: mental motion patterns. Errors resulting from pin defor Imation and the dynamic accuracy of the tracking sys: tem were investigated thoroughly Results. The average range of motion for flexion extension was 16.9", for one side lateral bending 63°, ‘and for one side axial rotation 1.1°. Large intersubject, variation was found in flexion-extension with values ranging from 7.1 t0 29.9°, Coupled motion patterns were found to be consistent among subjects in active lateral bending and inconsistent for active axial rotation. onclusions. This new method offers dynamic re cording capabilities and a measurement error compara ble with stereo radiographic methods. Repetitive rang- ing experiments are highly reproducible. The range of ‘motion for axial rotation seems overestimated in prev ‘ous cadaveric studies. Coupling patterns show large variations between individuals. [Key words: coupled motion, electromagnetic tracking, in vivo kinematics, lumbar motion segment, ranges of motion] Spine 1997; 22:156-166 From the Orthopaedic Research Laboratory, Division of Orthopaedic Surgery, Mell University, Montreal, Canada, Supported by Medical Research Council of Canada, Grant # MA. Acknowledgment date: June 28, 1995 First revision date: January 22, 1996, Second revision date: July 22, 1996, Acceptance dite: July 29, 1996 Device status category: 1 aes Spinal abnormalities commonly are associated with mor- phologic changes or mechanical dysfunction of the spine, Technical advances in the fields of radiology and imaging have led to a precise description of morphologic changes that produce or accompany spinal disorders. Missing are comprehensive methods to evaluate the mechanical be- havior of the normal and abnormal spine ft vivo. This mechanical behavior can be described with joint kine- matics and knowledge of the forces acting on the struc: tures involved. As forces are dificult to measure i vit, clinical studies of spinal biomechanics focus primarily on. joint kinematics ‘The morphology of the spine dictates its mechanical behavior. Pathologic changes or surgical alteration of the spine’s normal morphology inevitably will change the spine’s mechanical behavior. A comprehensive clinical evaluation of the spine should include tests that describe the spine’s morphology and function. Such an evaluation can help the surgeon choose the most appropriate oper ative procedure toward restoring adequate spinal func= tion. Postoperative evaluation of the spine’s mechanical function can be used to study the immediate and long- term effects of surgery. Along with direct surgical appli cations, comparisons of morphology and kinematics in the healthy and the pathologically affected spine may give further insight into the pathophysiology of many spinal disorders. Methods used for measuring spine kinematics must combine sufficient accuracy with three-dimensional (3D) ‘motion recording capacity. Sufficient accuracy is impor- tant when measuring the small ranges of segmental mo- tion observed in certain directions (e.g., axial rotation, anteroposterior shear). A 3D kinematic analysis is needed to comprehensively describe segmental motion. Because of segmental coupling characteristics, any pos- tural changes not limited to the sagittal plane will have segmental motion components in all three dimensions. Rather than frozen views of end range of motion (ROM) positions produced on radiographs, continuous sam= pling is needed to better analyze segmental motion. A sufficiently high sampling rate should permit evaluation of the dynamics of everyday activities.Methods for mea suring im vivo spinal movements balance noninvasiveness with accuracy and comprehen: siveness; frequent clinical use of simple and noninvasive goniometers**"* provides ready but imprecise da. ta.5°*# Skin-mounted optical." or electromagnet: jcl!21- measuring devices are prone to substantial er rors because of skin motion.*#°"” Standard radiologic methods*”** allow for two-dimensional (2D) segmental motion analysis but are limited by the inaccurate identi fication of the same anatomic landmarks on multiple radiographs."?* These studies were mainly limited to evaluating the subject in a static posture, usually in the end ROM. Only cineradiography**" record dynamic 2D kine can be used to tics. Three-dimensional ra- diologic methods demand stereo radiographic tech niques 22°24? To improve the accuracy of stereo radio graphic methods, mathematical optimization is used when identifying anatomic landmarks’ or small metal halls are inserted into the bone to serve as more reliable markers.*"” Yet, stereo radiographic methods only eval tate subjects in a static posture. Gregerson,'! Lums. used a direct method « study lumbar spine movements: Percutaneously inserting Kirschner wires into the spinous processes and measur sgmental axial rotation for various fixed postures by den,!* and later Gunzburg' protractor or linked transducer. Dynamic measurements with this method by Kaigle™ were limited to motion in the sagittal plane The purpose of this study was to develop a method for dynamic 3D segmental motion measurement and to quantify the method’s total error. Three-dimensional spinal motion data were recorded from healthy subjects with the goal of establishing a baseline of normal values. In addition, the safety concerns with using an invasive method for measuring segmental motion were thor oughly investigated and specifically addressed. & Materials and Methods Experimental Set-up and Data Processing. Procedure. Un local anesthesia, 2.5-mm diameter pins (AO Kirschner re, 15-mm thread) were threaded percutancously into the A fluc rify the insertion depth (1 processes of L3 and La} ze the pin entry and mm). A holder ‘calibration units were replace Jectromagnetic trackin igure 1). Th n (FASTRAK, Polhemus, Colchester, VT Lumbar Segmental Kinematics + Steffen et al_157 Figure 1. Plexiglas holder and pin assembly with the electromag: netic sensor in place. Sensor Offset Calibration, Assuming sound pin fixation, the spatial relationship of the sensor's CS to the vertebral body's CS would remain constant throughout the experiment, This 1 2. Subject performing lateral bending exercises wi ors attached tothe pin the sen he source of the electromagnetic tracking system is fixed to a harness in the mid-thoracic back region158. Spine + Volume 22 + Number 2 + 1997 Figure 3. Schematic diagrams for the biplanar radiographs showing the two vertebrae with the pins and the calibration unts. The sample points were digitized and used to calculate the following parameters. A, Lateral view: (NM): pin projection length; (NP): distance from sensor end of the pin to the perpendicular intersection of a line passing through the center of the L4 vertebral body’s upper endplate (CVBL4) and the extrapolated line passing through the pin; (p): angle that the line NP forms with the 2 axis ofthe LA's coordinate system {origin at CVBL4}; (, ¢'): angles made by lines connecting the steel ball markers and the perpendicular of NM; (CVBL3): center of the 13 vertebral body's lower endplate. B, Anteroposterior view: (AB, CD): distance between the steel ball markers; (A: angle made by the line AB and the x axis of L's coordinate system, relationship, defined as sensor offset, can be expressed mathe matically (Appendix 1) as a coordinate system transformation (CST), Anteroposterior and lateral radiogeaphs (Figure 3) and stereo radiographic methods established the CST of each vertebral endplate (L3 and 1.4) to its respective sensor (Appendix I) Calculation of L3-L4 Segmental Motions. The recorded data inttially reflected the sensors’ motion relative to the source, These raw data were first filtered using a nonlinear ‘median filter (rank = 1) to remove spurious values while main: taining the high frequency content, Because the two sensors were sampled sequentially (8.3 msec interleave), the second sensor’s position had to be adjusted to reflect its position when the first sensor was sampled. This was done by linearly inter- polating the second sensor’s position using the values sampled immediately before and after the time of each of the first sen- sor’s measurements. The interpolated sensor data were then ‘multiplied by the constant calibration offset CSTs to reflect the motion of the CS of each vertebral body relative to the source The motion of L3 relative to L4 was calculated by transforming the sensor data using the two CSTs (L3-R1 and L4-R2s Ap- pendix 1). Motion of the source and harness is inconsequenti because only the relative motion berween R1 and R2 was cal culated. Once the relative segmental motion was obtained, these data were low pass filtered forward and backward through a sec ‘ond order Butterworth filter (cut-off frequency = 5.4 Hz), result ing ina fourth order Butterworth filter with no phase shit. ‘A computer system (Macintosh Quadra 650, Apple Com: puters, Cupertino, CA) was used for data acquis ware, including the post-processing subroutines, was devel oped in a graphical programming language (LabVIEW, Ver. 3.0.1, National Instruments, Austin, TX). ion. All soft Validation of the Method. Potential errors in our method Were expected to compromise the method's accuracy and reli ability. Accuracy refers to how closely the system can track and motion. Reliability refers to the method's objectivity in measuring true vertebral body motion. Accuracy is governed by the tracking system's technical limitations and the possible error amplification thar may occur during mathe- matical transformation of raw sensor data into L3-L4 segmen: al motion. Reliability can be compromised by changes in the relative position of the sensor and its corresponding vertebra because of unstable spinous process pin fixation, dynamic pin bending, or vertebra deformation, Electromagnetic Tracking System. The electromagnetic tracking system's (ETS) accuracy was evaluated separately for dynamic and static conditions. Root mean square (RMS) error, derived from a large series of sample points, was used to de scribe the system's dynamic accuracy because the dynamic’ measurements did not identify an error pattern correlated with’ the recorded movements. To quantify the dynamic accuracy of the ETS, two sensor-mounted pins were fixed to a wooden block. The subject performed full lumbar spine ROM move: ments with this experimer gion. Experimental conditions wer ing the har using realistic offset values. The transformed data represents al montage worn in the lumbar re- maintained closely by us -s fixation for the source and by calculating CSTs calculated relative motion between two virtual vertebrae in an’ invariant spatial relationship, Any displacement observed in this virtual seem plificatton because of the CSTs, electromagnetic distortion be- ‘cause of the metal pins, oF motion of the source ata frequency would demonstrate ETS error, error am beyond the tracking system’s sampling rate. Error is defined as the deviation of a sample point from the mean. To investigate the static accuracy of the tracking system, the two sensors were mounted to a wooden block as described: previously, and this montage was fastened to a Plexiglas dise \with angular graduations. The disc constrained the sensor motion toa circular path in the field of the source, and static measure ments were obtained at 10° increments, Total movement was 30° and 60? in cach direction. Testing was repeated three times fot ‘each of the three spatial orientations (x,y, and 2), Pin Fixation in the Spinous Process, Our method assumes that the vertebra, the Kirschner wire, and the tracking sensor astic or permanent posi tion change within this system would compromise the meth: d's reliability in measuring vertebral motion. constitute a rigid body system, AnyWFO Nee 1, oD ty Figure 4 25 mm diameter Kirschner wires were instrumented with semiconductor strain gauges (arrowheads) to measure pin bending in vivo. The pins’ stable fixation within the spinous processes was verified by comparing kinematic data recorded in a standard neutral position before and after the experiment. A 10-second sequence of relative segmental linear and angular positions was averaged and compared for each subject in this stationary, up. right position. If a change greater than I* in angulation or greater than 1 mm in position was measured in any of the three we changed, and the analysis. Respiratory mo ‘axes, the pin’s fixation was considered to subject was excluded from further tion and subjectivity in reproducing identical body posture le the ertor tolerance necessary. Dynamic Pin Bending. A pilot study based on four consec tive subjects was conducted to measure perpendicular defor mation. Pairs of semiconductor strain gauges (FSB-160-1000, Entran Devices Inc., Fairfield, NJ) were bonded along the pin's Group Ine., Ra mm from the tip axis (610 Adhesive System, Measurement leigh, NC) at a dist (Figure 4). Teflon-insulaced wire a nce of 20.5 mm to ached the strain gauges 0 an external circuit n gauges and the con. To protect the st: nection points during pin insertion, silicon tubing (9555-G69, Dow Corning Canada Inc., Mississauga, ON) encompassed the pin and was secured in place with an adhesive (Dow Corning 355 Medical Adhesive). A laser inscription on the pin defined the vertical orientation of the strain gauge pair during insertion into the spinous process. Strain gauge had an instrumented pin inserted into the [3 vertebra. One subject had an additional instrumented pin inserted into the L4 vertebra, All strain g sure pin bending in the craniocaudal direction. ‘were recorded from all four subjects. All K nted vertically to mea: ge paits were oriente Each instrumented pin was calibrated before and after the experiment. The pin was inserted to an established depth into a wooden block, A micrometer laterally displaced the pin at a fixed height in the plane of the strain gauge pair. After the experiment, the pin was similarly calibrated at an insertior depth identical to the intraoperative insertion depth measured 6m the lateral radiographs. The signal voltage of the strain auges is proportional to the average strain along the bonded region. The pin’s bending radius was estimated at the center of the strain gauge’s 5 mm long active measuring zone. To esti mate the error caused by in vivo pin bending, the voltage signal measured during the experiment was compared with the post experiment calibration voltage signal (Appendix 2 Lumbar Segmental Kinematics * Steffen et al_159 Perpendicular force distribution along the bone-skin dis: tance of the pin is unknown, so two different beam bending models were used to calculate the pin-bending error. One as- sumes a uniform force distribution throughout the bone-skin distance, and the other assumes a point-orce applied at the level of the skin, Both beam bending models (Appendix 2) estimate the resulting kinematic measurement error from the ‘measured pin bending in the eraniocaudal direction. Comparative Studies. To directly compare the ETS's results with those obtained from another independent dynamic mea~ surement method, segmental lateral bending data were re- corded simultaneously with cineradiography (unpublished data) and with the ETS in two subjects. Two independent or thopedic surgeons measured the angular displacements for the lateral bending exercises on identical films. An interclass cor- relation was performed to compare the results obtained from the two methods, L3-L4 Segmental Ranges of Motion. Study Population Sixteen healthy men with an average age of 31.6 years (range, 19-51 years) gave written consent to participate in the study approved by the institution's ethics committee. The subjects were informed of possible complications, including infection, Scarring, hematoma formation, dural tear, spinous process fracture, and neurologic deficit. The follow-up period was 3-9 months, Four subjects formed a pilot study meant to collect Kinematic data and evaluate pin bending, Excluded were can dates witha history of low back pain, previous spine surgery, known spine abnormality, or relevant abnormalities on lumbar spine radiography. Exercises Performed by the Subjects. After the pins were inserted and the ETS was mounted and calibrated, all subjects performed a standard series of exercises. L3-L4 segmental ki hhematic data were recorded for voluntary flexion~extension, ind axial rotation. © recorded in the upright position with the arms lateral. bendin Fall flexion-extension held above the head. The subjects were permitted to bend at the knees to touch the floor in the full flexion position. Lateral bending and axial rotation were performed in the upright po- sition with hands joined behind the head. During the exercises, the subject was strongly encouraged to reach a maximum range ‘of movement. All exercises were repeated five times. Data Postprocessing, The theee angular displacements (flex ion-extension, lateral bending, axial rotation) and the three fincar displacements (anteroposterior shear, lateral shear, axial istraction) for each rangi sxercise and for ‘compression~ each subject were plotted versus time (Figure 5). Maximum and ‘minimum values for all the repetitive tived to calculate the amplitude of the ROMs. The variation between repetitive exercises in the same subject and the varia nging exercises were tion between different subjects for the same ranging exercise were analyzed using ANOVA for all active ROM. wm Results. Side Effects and Complications No infections or complications were observed other than a small, spontaneously resolving, subcutaneous hema: toma in one subject. None of the subjects required pain relief medication after the experiments. All subjects re-160 Spine * Volume 22 + Number 2 + 19 He | Figure 5. Example of L3-L8 segmental motion recorded for one subject during four successive lateral bending exercises. The coupled motion patterns for axial ratation and for flexion are shown, sumed their normal activity on the day of the experi ment. Validation of the Method Electromagnetic Tracking System. The RMS errors and the 95% confidence intervals (CI) used to describe the ETS’s dynamic accuracy for each angular and linear component are listed in Table 1 ‘The static error measurements showed moderate de pendency on the absolute angulation of the sensors rela tive to the source. Error measurements were pooled for absolute angulations up to 30° and up to 60° (Table 2), ‘The mean and 95% Cl static error measurements were similar to the mean and 95% Cl dynamic error measure- ments Pin Fixation in the Spinous Process. One subject was ex cluded from data analysis because the relative segmental linear and angular position measured in the standard neutral position before and after the experiment showed changes that exceeded the error tolerance (more than 1° or L mm change) Dynamic Pin Bending. Calibration of the strain gauged pins revealed a highly linear (R® = 0.999) relationship between perpendicular displacement and signal voltage for all pins. Autoclaving had no apparent effect on the strain gauges’ electrical characteristics, The calculated errors from pin bending in craniocaudal direction (Table 3) were pooled forall full ROM exercises and all subjects because there was no obvious relationship between the sured error amplitudes and the performed exercises. ‘The mean relative segmental errors, estimated with beam bending models, were 0.30° (range, 0.07-0.66*) for an. gular displacement and 0.37 mm (range, 0.09=0.83 mm) for linear displacement. Table 1. Dynamic RMS Error Due to the Electrom Tracking System's Inaccuracy for Angular Motion* and for Linear Motiont A AMS Error for Segmental Mation(*), Angular Mation A Mean 96% cl Flexion-extension 2% ow 009-0.20 Lateral bending Py 13 015-023 ‘Axial rotation 2 08 0.06-0.10 8 MS Error for Segmental ‘Motion (mm) Linear Motion n ‘Mean ‘5% cl ‘Anteroposterior shear Py 02 016-025 Lateral shear 4 038 923-048 Compression/distracton 24 a3 025-040 13-L4 Segmental Ranges of Motion The F ratios derived from the analysis of variance (ANOVA) that evaluated variation between repetitive exercises in the subject and variation between the differ- ent subjects for the same ranging exercise were between 22.2 and 132.0, with all exercises showing significant variations between subjects (all P values < 0.0001). The highest variations were found with flexion~extension, Tables 4 and 5 summarize the results of active and coupled ROMs in the study group. Coupled axial rota- tion during active side bending was to the contralateral side in all 15 subjects (ie., lateral bending to the left produced coupled axial rotation toward the right and vice versa). Coupled motion in the sagittal plane during lateral bending was toward flexion in all 11 subjects who demonstrated clear coupled motion in this plane. Cou- pled lateral bending during active axial rotation was ob- served in 14 subjects. Ten of those produced coupled lateral bending toward the contralateral side and four toward the ipsilateral side as the active axial rotation. Eleven subjects showed coupled motion in the sagittal Table 2. Static Measurement Error Due to the Electromagnetic Tracking System's Inaccuracy Angular Erorfor Linear Error for Seomental Segmental Matin (*) ‘Mation (rim) solute Static Measurement Eor on Mean 95% Mean 95% 20° rotation 108 010 op0-034 © 0230008 60° rotation 18 014 000-088 © 030 00-1 4Table 3. Pin Bending in the Crani During Various Ranging Exercises in Four Subjects: Calculated Maximal Angular and Linear Errors for Segmental Motion Measurements Using Two Di Beam-Bending Models Angular Error LUnear Error 0 (nm) Type of Exercise Subject Uniform* Point” Uniform Point Fevion-estension 1 os) 0480888 2 05 otk 087 a 02 «00 4 050 © 043 0gk OST Side bending 1 on 0100s 2 00 = (0070s a 053 6045067080 4 015 015 OBO ‘ial rotation 1 06h = 05078. 2 oi 07 at 3 015 016 018020 4 0 0230s 038 Uniform and pont free datrouton bearvbending models (Append) plane; nine of whom showed coupled motion in flexion ‘and two who showed coupled motion in extension. & Discussion Methodology ‘This is the first report of an invasive direct measurement method studying 3D lumbar segmental kinematics. 4 though similar invasive measurement methods have been suggested,!''2!'* none have combined a six DOF tracking system with a stereo radiographic technique to ‘obtain segmental motion data. This direct measurement method currently provides the most accurate data on dynamic segmental displacements. ‘The methods invasiveness was well tolerated by the participating volunteers. The local anesthesia kept the subject sufficiently pain-free during the experiment. The presence of the pins did not appear to affect their normal Table 4. Coupled Motion During Active Lateral Bending and Active Axial Rotation: Number of Coupling Observations and Their Direction in 16 Subjects Active Lateral Bending ‘tive Axial Rotation Coupled axial rotation Coupled lateral bending Contralateral Ipsilateral Contralateral Ipsilateral” r+ 2 arr 8t Bett . Coupled fexion-extension Coupled flexion-oxtnsion Flexon® Extension” Flexion Emtension 46 0 ++ 83 2 Lumbar Segmental Kinematics + Steffen et al_161 Table 5, Ranges of 13-L4 Active Segmental Motion and Coupled Segmental Motion ‘Active Maton and Mean Range 1 Coupled Mation| (P(t) (Subjects) Fexion-extension® wo 71-996 (with knges sight) Fexion-extension™ re eerez ae (with knees bent) (ne side lateral bending 63 43-88 16 Coupled one side rotation ist 1027 15 Coupled fexen-extension® 21 1452 " One side axial rota it 05-19 18 (Coupled one side lateral bending «1810-38 4 Coupled fexion-extension” M0430 " + Fleson-evtension range expressed as afta amplitude, tated itest P= 00001 motion. In our series, we did not encounter any major complication. A safety protocol was rigorously followed. In an operating room, the pins were placed under fluo- roscopic guidance by an experienced spine surgeon, and appropriate dressing was applied during and after the experiment. In addition, having the same team conduct all the experiments helped reduce the total experimental time to less than 2.5 hours. We believe that by following these precautions, the procedure is safe to use. ‘Compared with radiographic methods obtaining seg- mental kinematics, our subjects’ radiation exposure was, minimal. The effective dose equivalent for 30 seconds of fluoroscopy and two lumbar spine radiographs in men ‘was estimated as 0.14 mSv.!* Validation of Method ‘The ETS's RMS error in measuring angles and distances has been reported as approximately 0.2° and 0.3 mm20213°3) These values were based solely on static position measurements of one sensor relative to the source. Respecting that our experiment relies on the sys~ tem’s accuracy in measuring motion of one sensor rela tive to the other, we performed extensive static and dy namic tests under realistic experimental conditions. Error estimates derived from the dynamic testing set-up (Table 1) were similar to those obtained from static test- ing, Because dynamic testing reflects true experimental conditions, these values were selected and summed to calculate the methods total error. The static error in measuring two sensors’ relative displacement depends somewhat on the absolute angle ‘change between sensor and source. Measurements were analyzed separately for up to + 30° and + 60° absolute angulation (Table 2). Because the source was carried on the lower thoracic back, the maximum absolute angula- tion was no more than the lumbar spine’s ROM above [3-L4. In axial rotation and lateral bending, the abso- Jute angulation between sensor and source was always less than 30°, and in flexion-extension, it never exceeded 60 Muscle, fascia, and skin traction exerted perpendicu: forces on the pins during the experiments. Quantifi- I162__ Spine + Volume 22 + Number 2 + 1997 cation of pin bending and the resulting measurement er- ror during postural changes was crucial. Measurements were limited to craniocaudal-directed deformation of the pin inserted in the L3 vertebra. Two reasons led us to believe thar elastic pin deformation would be greatest in the craniocaudal direction: The skin shift would be larg est in this direction, and the quasistrict vertical orienta~ tion of the muscles and ligaments in this region would exerta perpendicular force on the pin in the craniocaudal direction. The upper pin was selected for instrumenta- tion because the amount of skin shift increases in the cranial direction. ‘Two different force distribution models were used in calculating the effective pin bending error because the exact distribution of the perpendicular force within soft tissue is largely unknown. Although the two models as- sume extreme situations, there was little variation in the calculated error. In the four subjects studied, no specific full ROM exercise consistently showed higher error val: The greater of the two values derived from each model (Table 3) was selected for each subject and exercise, and the results were pooled. The mean relative segmental error resulting from pin bending was estimated at 0.30° and 0.37 mm. This error value was calculated assuming, that only one of the two pins bends, whereas the other remains perfectly rigid. Testing this assumption with data from a subject with two strain gauge mounted pins showed that the pins deform in phase (ie., both pins bend up or down together). With coordinated bending, amplitudes and directions, the relative error for segmen tal motion would be less than estimated. Bone deformation of the posterior elements relative to the vertebral body also was considered asa possible error source. Rolander** measured the segmental mobility in cadaveric specimens for single motion segments with fixed posterior elements simulating posterior fusion. The remaining mobility in the sagittal and frontal plane un- der physiologic axial loads applied to the upper vertebral body was below 1°. Shirazi” studied segmental mobility in a one motion segment finite element model with dif- ferent bone compliance characteristics. Segmental ROMs were compared for rigid vertebrae and for flexi- ble vertebrae having elastic material properties. The dif- ference in segmental angulations fora moment of 20 Nm, in the main direction was approximately 2° for flexion extension and 0.4° for axial rotation. As suggested by Shirazi,*” the actual values for a multisegmental testing, condition are expected to be smaller because forces ap- plied to the posterior elements will be counterbalanced by the adjacent segments. The error resulting from i vivo bone deformation remains difficult to quantify, but, it does not seem likely to exceed the other error sources, being studied. Each RMS error value for each of the six direction components obtained during dynamic testing of the tracking system’s accuracy was added to the correspond: ing angular or linear displacement error value estimated for pin bending. For flexion-extension, side bending, and axial rotation measurements, the method's total es- timated errors are 0.44°, 0.49°, and 0.38°. The total es- timated errors for anteroposterior shear, lateral shear, and axial compression measurements are 0.57 mm, 0.75 mm, and 0.69 mm. These estimates are conservative, especially for the error contribution from pin bending, However, no error contribution could be included for bone deformation. The angular displacement error val= ues for our method are much lower than the 3° measure ment error reported by Panjabi et al”? for plane radio~ graphic methods and typical marker configurations. The urement error for i vivo stereophotogrammetry on biplanar radiographs not using invasive procedures was reported’? as ranging from 1.2° to 2.6° for angular measurements and from 0.8 mm to 2.0 mm for linear ‘measurements. Studies using small radio-dense markers placed invasively before radiologic evaluation®'” re ported lower error values, ranging from 0.1° to 0.2° for angular measurements and from 0.1. mm to 0.4 mm for linear measurements. Our method’s measurement errors. are smaller than the measurement errors reported for noninvasive stereo radiographic methods. The use of vasive stereo radiographic methods appears to provide better accuracy, but our method offers dynamic motion analysis that is not provided by any of the stereo radiog- raphy When we compared the ETS’s results with those obtained simultaneously from cineradiography, the lim- itations of the latter were apparent. The interobserver difference (mean, 1.01°) was higher than the overall an- gular error (mean, 0.42°) calculated for the ETS. When calculating the interclass correlation coefficient (ICC) for the two observers and two methods, the agreement be- tween the two methods (ICC = 0.81) was slightly higher than the agreement between the two observers (ICC = 0.74). methods. 13-14 Segmental Ranges of Motion Data from 16 healthy subjects were collected to establish 13-14 se gmesalROMlar coup atte sample size of our study was larger than in any previe ously reported invasive study.!!"1°1 With all subjects, the maximal ranges of motion were highly reproducible. The curve shape and amplitudes were consistent during repetitive exercises (Figure 5). In- tersubject amplitude variation for identical exercises was largest for flexion-extension and smallest for lateral bending. The amplitude for the segmental flexion extension ranged between 7.1° and 29.9°, Although the amplitude’s mean value (16.9°) was similar to what has reported previously,”*7"" its measurement range igher. The position of the knees (flexed or ex- in the end segmental flexion position had no. influence on the achieved ROM (P = 0.67). One side axial rotation ROM (average, 1.1°; range, 0.5-1.9°) was soup ao 19° alco he a ct bub bse had ide ard th ose hn por tor bio, Pan oy Ate oe ln ehsomewhat smaller than expected. Cadaverie studies re- ported L3-L4 segmental motion of 2.6° on average (range, 0.9-4.0°)"*” for one side axial rotation. Sterco radiography studies by Pearcy*”" estimated the average angle for one side axial rotation at 1.5° (range, 0.5-2.5°). This value may be considered comparable, given the es- timated error of our method of 0.38°. Cadaveric studies showed larger values for axial rotation, but this may be a result of ligament dissection when isolating single mo- tion segments or the lack of muscular control in an ex vivo experimental set-up. Our measurements for one side lateral bending ROM (6.3°) are consistent with what has been reported. 778 Consistent coupled motion in opposite directions for axial rotation during active lateral bending (e.g. left ax- ial rotation with right lateral bending) was found in 94% (1S of 16) of the subjects. This is consistent with results reported by Panjabi’ and Pearcy.*' Coupled motion for lateral bending during active axial rotation was less uni- form, with only 56% (nine of 16) ofthe subjects showing consistent coupling, 31% (five of 16) showing coupling with large variations between repetitive tasks, and 13% (two of 16) showing no noticeable coupling. Twenty- nine percent (four of 14) of the coupling for axial rota~ tion was ipsilateral to the active lateral bending. The coupling-to-primary motion amplitude ratio for axial ro~ tation versus lateral bending was different for active axial rotation (1.1°/1.8° = 61%) and active lateral bending, (1.8°/6.3° — 29%). This observation was reported pre viously by Panjabi et al.”* The amplitude of coupled ax ial rotation during active lateral bending was larger than the amplitude of active axial rotation (Table 5). Coupled flexion-extension during active side bending and during active axial rotation was present in 69% (11 of 16) of the subjects for both active tasks. Approximately half of the observed coupled motion patterns in the sagittal plane had large variations for both active tasks. During active side bending, all coupling in the sagittal plane was to- ward flexion. During active axial rotation, the direction of the coupled motion in the sagittal plane toward flex- ion was seen in 82% (nine of 11) of the subjects and toward extension in 18% (two of 11). Our inconsistent observations for the coupling directions for the L3-L4 motion segment may explain previous contradictory re ports?" of the coupling direction at this segmental level for side bending with respect to the axial rotation direc tion and on the pattern of coupled motions in the sagittal plane. © Conclusions [A new method has been developed for in vivo measure ment of 3D, dynamic, segmental motion kinematics. The method's accuracy and reliability in measuring segmen tal motion were validated quantitatively and compared with stereo radiography methods. The measurement er ler than that of noninvasive ater than that of stereo radi- ror of our method is sm: stereo radiography but ¢1 Lumbar Segmental Kinematics * Steffen ct al_163 ography that uses the invasive placement of additional markers. Our method’s capability of recording dynamic motion gives it an advantage over stereo radiographic methods. [3-14 lumbar segmental ROMs have been measured successfully in 16 healthy subjects. On the basis of our data, the amount of axial segmental rotation in the lum- bar spine seems to have been previously overestimated in cadaveric studies. Coupling patterns, although present in most of the subjects, show large and presently inexplica~ ble variations in amplitude and direction. In future studies, our data will be compared with the ‘motion patterns of patients with localized segmental dis- ease (i... localized degenerative intervertebral dise dis- cease) to better understand the kinematic changes that produce or accompany such ailments. ‘Acknowledgments ‘The authors thank Mr. Lorne Beckman and Mr, Acjaz Zahid for their valuable assistance. References 1, Adams MA, Dolan P. A technique for quantifying bending moment acting on the lumbar spine in vivo, J Biomech 1991; 24s117-26. 2. Boocock MG, Jackson JA, Burton AK, Tillotson KM. Con- tinuous measurement of lumbar posture using flexible eleetro- sgoniometers. Engonomics 1994;37:175~85. 3, Brown RH, Burstein AH, Nash CL, Schock CC. Spinal analysis using a three-dimensional radiographic technique. J Biomech 1976;9:355~65. 4. Cholewicki J, McGill SM. Lumbar posterior ligament in- volvement during extremely heavy lifts estimated from fluoro- scopic measurements. J Biomech 1992;25:17-28. 5. Dillaed J, Trafimow J, Andersson GB, Cronin K. Motion of the lumbar spine, Reliability of two measurement techniques, Spine 1991;16:321-4. 6. Dupuis PR, Yong-Hing K, Cassidy JD, Kirkaldy-Wills WH. Radiologic diagnosis of degenerative lumbar spinal insta- bility. Spine 1985;10:262-76. 7. Dvorak J, Panjabi MM, Chang DG, Theiler R, Grob D. Functional radiographic diagnosis of the lumbar spine. Flex- jon-extension and lateral bending. Spine 1991;16:562~71. '8, Egund N, Olsson TH, Schmid H, Selvik G. Movements in the sacroiliac joints demonstrated with roentgen stercophoto igrammetry. Acta Radiol 1978;19:833-46. 9, Gill K, Krag MH, Johnson GB, Haugh LD, Pope MH, Repeatability of four clinical methods for assessment of lumbar spinal motion. Spine 1988;13:50-3. 10. Gracovetsky S, Kary M, Levy S, Ben-Said R, Pitchen 1, Helie J. Analysis of spinal and muscular activity during flexion/ extension and free lifts, Spine 1990;15:1333-9. TL. Gregersen GG, Lucas DB, An in vivo study of the axial rotation of the human thoracolumbar spine. J Bone Joint Surg [Am] 1967;49:247~62. 12. Gunzburg R, Hutton W, Fraser R. Axial rotation of the Jumbar spine and the effect of flexion. An in vitro and in vivo biomechanical study. Spine 1991;16:22-8. 13. Hindle RJ, Pearcy MJ. Rotational mobility of the human back in forward flexion. J Biomed Eng 1989511:219-23.164 Spine + Volume 22 * Number 2 + 1997 14. Kaigle AM, Pope MH, Fleming BC, Hansson T. A method for the intravital measurement of interspinous kinematics J Biomech 1992;25:451-6 15. Kereiakes JG, Rosenstein M. CRC Handbook of Radia tion Doses in Nuclear Medicine and Diagnostic X-ray. Boca Raton, FL: CRC Press, 1980 16. Knutsson F. The instability associated with disc degenera- tion inthe lumbar spine. Acta Radiol 1944;25:293 17. Lee S, Harris KG, Nassif J, Goel VK, Clark CR. In vivo kinematics of the cervical spine. Part I Development ofa roent zen stereophotogrammetric technique using metallic markers and assessment of its accuracy. J Spinal Disord 1993;6:522-34, 18. Lumsden RM, Morris JM. An in vivo study of axial rota- tion and immoblization atthe lumbosacral joint. J Bone Joint Surg [Am] 1968;50:1591-602. 19, MeGill SM. A myoelectrically based dynamic three- dimensional model to predict loads on lumbar spine tissues during lateral bending, J Biomech 1992;25:395—414 20. McGill SM, Brown S. Creep response of the lumbar spine to prolonged ful flexion, Clin Biomech 1992;7:43-6 21. Nelson JN, Walmsley RP, Stevenson JM. Relative lumbar and pelvic motion during loaded spinal flexionlextension, Spine 1995;20:199-204 22. Olsson TH, Selvik G, Willner S. Mobility in the lumbosa- cral spine after fusion studied with the aid of roentgen stereo photogrammetry. Clin Orthop 19775129:81-90. 23, Panjabi M, Chang D, Dvorak J. An analysis of errors in kinematic parameters associated with in vivo functional radio graphs. Spine 1992;17:200-5 24. Panjabi M, Yamamoto I, Oxland , Crisco J. How docs posture affect Coupling in the lumbar spine? Spine 198914 1002-11 25. Panjabi MM, Goel VK, Walter SD. Errors in kit parameters ofa planar joint: guidelines for optimal experimen tal design. | Biomech 1982;15:537-44 26. Panjabi MM, Goel VK, Walter SD, Schick S, Errors in the center and angle of rotation ofa joint: An experimental study J Biomech Eng 198210423 27. Panjabi MM, Oxland TR, Yamamoto f, Crisco JJ. Me chanical behavior ofthe human lumbar and kimbosacral spine as shown by three-dimensional load-displacemen J Bone Joint Surg [Am] 1994;76:413-24, 28. Paquet N, Malouin F, Richards CL, Dionne JP, Comeau F Validity and eeliailty of anew electrogoniometer for the mea surement of sagittal dorsolumbar movements. Spine 1991316: 516-9 29. Pearey MJ. Stereo radiography of lumbar spine motion Acta Orthop Scand 1985;212(Suppl:t-45. 30. Pearcy MJ. Twisting mobility ofthe human back in ened postures. Spine 1993518:114-9. 31. Pearcy MJ, Tibrewel SB. Axial rotation and lateral hend- ‘ng in the normal lumbar spine mi radiography. Spine 1984 32, Pearey MJ, Whittle MW. Movements ofthe lumbar spine measured by threedimensional X-ray analysis, | Biomed Eng 1982;4:107-12 33, Polhemus, 3SPACE User's Manual: Kaiser Aerospace & Hectronics Company, Colchester VT, 1992. 34. Pope MH, Svensson M, Broman H, Andersson GB. Mounting of the transducers in measusement of segmental mo tion ofthe spin. J Biomech 1986;19:675~ 35. Rolander SD. Motion of the Iuimbar spine with special sured by three-dimensional reference co the stabilizing effect of posterior fusion. An exper= imental study on autopsy specimens. Acta Orthop Seand 1966; 901-148, 36. Roozmon P, Gracoversky SA, Gouw G}, Newman N. Ex: mining motion in the cervical spine. I: Imaging systems and measurement techniques. | Biomed Eng 1993)15:5-12, 37. Shirazi-Adl A. Analysis of role of bone compliance on me- chanics ofa lumbar motion segment. J Biomech Eng 1994116: 408-12. 38. Stokes IA, Wilder DG, Frymoyer JW, Pope MH. 1980. Volvo award in clinical sciences. Assessment of patients with low-back pain by biplanae radiographic measurement of inter: vertebral motion. Spine 1981;6:233~40. 39, Stokes IAF, Frymoyer JW. Relationship herween move ments of vertebrae and adjacent skin markers and sections of the back. Annual Report ofthe Oxford Orthopaedic Engineer ing Center: Oxford Orthopaedic Engineering Center, 1977. 40. Suh CH. The fundamentals of computer aided X-ray anab 4sis of the spine. | Biomech 1974;7:161-9. 41, Van Mameren H, Sanchez H, Beursgens J, Drukker J. Cer vical spine motion inthe sagital plane. Il. Position of segmental averaged instantaneous centers of rotation—A cineradion scaphie study. Spine 1992517:467—74 42. Wing P, Tsang I, Gagnon F, Susak L, Gagnon R, Diurnal changes in the profile shape and range of motion of the back Spine 1992;17:761-6. 43. Yamamoto 1, Panjabi MM, Crisco T, Oxland T. Three- dimensional movements of the whole lursbar spine and lum= bosacral joint. Spine 1989514:1256~60. 44. Youdas JW, Carey JR, Garret TR. Reliability of measure= ments of cervical spine range of motion —Comparison of three methods. Phys Ther 1991;71:98 108 Address reprint requests to Royal Victoria Hospital Orthopaedic Research Laboratory 687 Pine Avenue West Suite 14,69 Montreal, Quebec Canada H3A 1AL Thomas Steffen, MD | 1 Appendix 1 Coordinate System Transformations Acoordinate system transformation (CST) describes, in the form of a 4x4 matrix, the position and orientation of one coordinate system (CS) relative to a reference sys- tem. The overall CST is obtained from the matrix: ST(x,y,2,4,6,7) cosa cose cosa sine sin r ~ sin a cos r sin acose sina sine sinr + cos acosr =sine 0 0 ie cl ahi li es f by aly Of de di Py Bap Hey gycosasinecosr+sinasinr x sin a sin ¢ cos r~ cos acos ry ‘ cos @ cos r - ag ° 1 ‘Where x, y, and z are the three linear offsets and a, e, and rare the three Euler angle displacements—azimuth, elevation and roll respectively. The Euler angles define a strict rotation sequence: first about the z axis, then about, the y axis and then about the x axis of the displaced CS. Given two systems Cl and C2 described with respect to the reference coordinate system, a CST, T, can be found which describes C1 with respect to C2. T can be calculated by the matrix multiplication {T] = (C2)'1C1} (1.2) where C21 is the matrix inverse of C2 and represents, the CST of the reference system to C2 with respect to C2. By pre-multiplying both sides of equation (1.2) by C2, Cl can be expressed as {C1} = [C2] (1.3) which is useful in our case where T is the constant CST of L4 to its sensor, [L4 > R2} , and C2 is the variable CST of the sensor to the reference system, [R2 — Ref]. The resulting matrix C1 is the CST of L4 to the reference system, [L4 — Ref]. Rewritten with more meaningful terms, equation 3 becomes [L4 — Ref] = [R2 > Refl[L4 > R2] (1.4) Similarly, L3 relative to the reference system is calcu- lated from, [L3 > Ref] = [R1 > Ref[L3 >R1] (1.5) Since we are interested in relative movements between 13 and L4, the following matrix multiplication finally allows the data to reflect this relative motion [L3 > L4] = [L4 > Ref} "[L3 — Ref] (1.6) Obtaining CST of L4 from Radiographic Parameters: The calibration units used for stereophotogrammetric determination of the CSTs were equipped with four ra dio-dense markers defining a plane (38 mm x 38 mm) perpendicular to the pin. Sixteen points on the radio- graphs (Figure 3) were digitized (HP Sketch Pro Tablet, Hewlett-Packard, San Diego, CA). Using these points the CST of L4 with respect to its corresponding sensor was calculated. The CST is defined by a set of six parameters (XY, Z, 2X, ZY, ZZ). Each parameter may be found from the two orthogonal radiographs as follows Translation in the sensor's X direction (X): X is de fined as the distance from the electrical center of the sensor to the CS of L4 along the sensor's x axis. Referring to Figure 3, itis calculated by Lumbar Segmental Kinematics «Steffen et al_ 165 Ea Ty Qa ae : Magn cos of ea where #is the angle that the pin makes with respect to the plane of the radiogeaph and can be found from the two angles and «’ formed by the steel ball markers. The relationship between 6, ¢, and 6 is: 0 = cos "(rant prantb) — 5 ‘Magy is a term used to correct for the magnific the radiographs and is dependent on the depth of an ‘object in the radiographic field. X, is the distance from the sensor-end of the pin to the electrical center of the sensor. ‘Translation in the sensor’s Y & Z direction (Y, Z): The projected tip’s y, and z offset from the center of the vertebral body's endplate is used to calculate the real distance from the electrical center of the sensor to the CS of L4 by Yprojected dy v Mae (2.3) ae oth 24 Magen * Me) where Mag,,), is a term used to compensate for the ra~ diographic magnification in the anteroposterior radio- graph and Y, and Z, are the distances from the sensor~ end of the pin to the electrical center of the sensor. Sensor Angular Displacements (2X, ZY, 22): The angular displacements for 2X, and ZY are measured directly from the radiographs as the angles A and p, re- spectively. The angle the sensor is rotated about its z axis. relative to the CS of L4 is chosen to be zero (0). The difficulty in using landmarks for determining the orien- tation of the endplate along this axis justifies using the assumption that the pin is parallel to the sagittal plane. Calculation of CST of L3 The CS of L3 and L4 have identical orientation, but are separated in the craniocaudal direction by a distance equal to the L3-L4 disc height measured from the radio~ graphs. The CST of L3 to its sensor [L3 > R1] was calculated by multiplying the three CSTs relating L3, L4, R1, and R2: 1) [L3 — 14] is defined previously, 2) [L4 > R2] was, determined from the radiographs, and 3) [R2 — R1] was calculated from data sampled in a neutral position (sub- ject stationary and standing upright) m Appendix 2 Errors Due to Pin Deformation Two models were constructed to calculate the error due to pin bending Point Force Model: The relationship between the net vertical pin deflection (Y in Figure 6A) at the location ofee ee ee oe 166 Spine * Volume 22 » Number 2 + 1997 le i . A B Figure 6. Pin deformation schematic diagrams for (A) the point force model and (B) the unformly distributes force model ® f the position sensor (L) and the radius of curvature (r) at ; the center of the strain gauges (x = z) is given by >= 6KV|aosar Bea) |, = , Land a are constants for each pin, and Kisa | (3-1) Constant found during each calibration. Thus we have h linear relationship between I/r and V which can be sum: where the force (F) is applied at x = a, which is the marized as ‘ distance between the spinous process and the skin, The ? ' angle of deflection (8) is given by tev Gon b 5 G ; (3.2) where C is just the amalgamation of the constants. , fa Experiment: Assuming a “point force” at the skin in Uniformly Distributed Load Model: If we assume a te#face, the experimental angular ersor (8) from equa | uniformly distributed force along the length of the pin tions 12 and 17 is given by ‘ between the spinous process and the skin (Figure 6B), the Ee ; relationship beeween the deflection (Y) and the radius of 6, = 5 CV radians 3.7) Jo curvature (r) is given by eee and the linear error (Y,) from equations 11 and 17 is | aaL a) ey ee T2r(a— 2 sr f ; (a+ 31) a The angle of deflection (6) is given by sere eae aera Gl a where 1, a, and 2 are constants for each pin, and Cis) Oe aaa ae (3-4) found during calibration, and V is the voltage measured t Calibration: During the strain gauge calibration, a force was applied to the pin using a micrometer (i.e., by increasing Y) at x ~ a, and calculations were based on, the “point force’ model. We measured Y with the 1m and, the voltage (V) from the strain gauges, The relationship, between Y and V was found to be linear (i.e. R? = 0.999) for each of the strain gauges. Thus, Y=Kxv (3.5) where K is a constant. Solving equation for Lr and sub sticuting Y = KV (3.5) we have from the strain gauges during the experiment. If the assumption of a uniformly distributed load be- | tween the bone and skin is used, the angular error (83) from equations 13 and 17 is given by 6, = 3p CV radians 69) and the linear error (Y3) from equations 13 and 17 is, sziven by _#GL=9 Y, Desa cl =. (3.10)