The Spine Journal 13 (2013) 1581–1589

Basic Science

Lumbar facet joint and intervertebral disc loading during simulated

pelvic obliquity
John M. Popovich, Jr., PhD, DPT, ATCa,b,*, Judson B. Welcher, PhDb,c,
Thomas P. Hedman, PhDd, Wafa Tawackoli, PhDe,f, Neel Anand, MDg,
Thomas C. Chen, MD, PhDh, Kornelia Kulig, PhD, PTa
a
Division of Biokinesiology and Physical Therapy, University of Southern California, 1540 E. Alcazar St, CHP-155, Los Angeles, CA 90089, USA
b
Spine Biomechanics and Tissue Engineering Laboratory, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Davis Building, 6006,
Los Angeles, CA 90048, USA
c
Department of Biomedical Engineering, University of Southern California, 1042 Downey Way, Denney Research Center 140 Los Angeles, CA 90089, USA
d
Biomedical Engineering and Neurosurgery Departments, University of Kentucky, 1501 Bull Lea Road, Suite 103, Lexington, KY 40511, USA
e
Regenerative Medicine Institute, Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Davis Building, G149C,
Los Angeles, CA 90048, USA
f
Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Davis Building, G149C,
Los Angeles, CA 90048, USA
g
Spine Center, Cedars-Sinai Medical Center, 444 S. San Vicente Blvd., #800, Los Angeles, CA 90048, USA
h
Department of Neurological Surgery, Keck School of Medicine, University of Southern California, USC University Hospital, 1500 San Pablo Street,
Los Angeles, CA 90033, USA
Received 28 December 2011; revised 12 October 2012; accepted 9 April 2013

Abstract BACKGROUND CONTEXT: Intervertebral disc and facet joints are the two primary load-
bearing structures of the lumbar spine, and altered loading to these structures may be associated
with frontal plane spinal deviations.
PURPOSE: To determine the load on the lumbar facet joint and intervertebral disc under simu-
lated frontal plane pelvic obliquity combined loading, an in vitro biomechanical study was
conducted.
STUDY DESIGN/SETTING: An in vitro biomechanical study using a repeated-measures design
was used to compare L4–L5 facet joint and intervertebral disc loading across pure moment and
combined loading conditions.
METHODS: Eight fresh-frozen lumbosacral specimens were tested under five loading conditions:
flexion/extension, lateral bending, axial rotation using pure moment bending (610 Nm), and two
additional tests investigating frontal plane pelvic obliquity and axial rotation (sacrum tilted left
5
and at 10
followed by a 610-Nm rotation moment). Three-dimensional kinematics, facet load,
and intradiscal pressures were recorded from the L4–L5 functional spinal unit.
RESULTS: Sagittal and frontal plane loading resulted in significantly smaller facet joint forces
compared with conditions implementing a rotation moment (p!.05). The facet joint had the highest
peak load during the 10
combined loading condition (124.0630.2 N) and the lowest peak load in
flexion (26.8616.1 N). Intradiscal pressure was high in lateral flexion (495.66280.9 kPa) and

FDA device/drug status: Not applicable.
Author disclosures: JMP: Grant: American Society of Biomechanics
(B, Paid directly to institution/employer). JBW: Nothing to disclose.
TPH: Stock Ownership: Orthopeutics, LP (51%), IntralinkSpine, Inc.
(35%), Ampac Biotechnology, Inc. (100%), Equinext, LLC (25%); Re-
search Support (Investigator Salary). WT: Nothing to disclose. NA: Royal-
ties: Medtronics (D), Globus (C), Nuvasive (C); Stock Ownership: Globus
(E); Private Investments: Medtronics (C); Consulting: Medtronics (B),
Trans 1 (B); Scientific Advisory Board: Globus (B), Trans 1 (B); Other Of-
fice: Globus (B), Trans 1 (B). TCC: Stock Ownership: Pharmacokinesis,
NeOnc Technologies (options only); Consulting: Globus Medical (B);
Board of Directors: Pharmacokinesis (C); Scientific Advisory Board: Ne-
Oncology ($0); Other Office: NeOncology ($0). KK: Nothing to disclose.
The disclosure key can be found on the Table of Contents and at www.
TheSpineJournalOnline.com.
Institutional review board approval was not required as de-identified
anatomic specimens are exempt according to US Code of Federal Regula-
tions (45 CFR 46.101(b)).
* Corresponding author. Center for Orthopedic Research, Department
of Osteopathic Surgical Specialties, College of Osteopathic Medicine,
Michigan State University, West Fee Hall, 909 West Fee Road, East Lans-
ing, MI 48824, USA. Tel.: (517) 975-3318; fax: (517) 975-3305.
E-mail address: popovi16@msu.edu (J.M. Popovich)

1529-9430/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.spinee.2013.04.011
1582 J.M. Popovich et al. / The Spine Journal 13 (2013) 1581–1589

flexion (429.06212.9 kPa), whereas intradiscal pressures measured in rotation (253.26135.0 kPa)
and 5
and 10
combined loading conditions were low (255.56132.7 and 267.16127.1 kPa,
respectively).
CONCLUSIONS: Facet loading increased during simulated pelvic obliquity in frontal and trans-
verse planes, whereas intradiscal pressures were decreased compared with sagittal and frontal plane
motions alone. Altered spinopelvic alignment may increase the loads experienced by spinal tissue,
especially the facet joints. Ó 2013 Elsevier Inc. All rights reserved.
Keywords: Spinopelvic alignment; Pelvic obliquity; Facet joint; Disc pressure; Biomechanics

Introduction In vitro testing under simulated altered alignment may

The intervertebral disc and facet joints are the two pri-
mary lumbar spine load-bearing structures. Because of
their unique morphology and function, these structures play
a significant role in load sharing [1–3]. Excessive load
(magnitude or frequency) may lead to degenerative and ir-
reversible changes to either of these structures. This has
been, in part, substantiated through epidemiologic studies
showing that greater levels of exposure to environmental
workloads may lead to low back dysfunction [4–9], labora-
tory studies confirming the causal components of mechan-
ical load on biologic tissue [10–15], and cadaver studies
linking degenerative changes with loading history [16–20].
Both the intervertebral disc and facet joints rely on the
health of one another for the transmission of loads placed
on the lumbar spine. The facet joints increase their load-
bearing role as intervertebral disc height decreases as seen
with degeneration [21–23]. Similarly, the disc benefits from
the role of facet joints in limiting motion and thereby de-
creasing the strain on the annular fibers [24–26]. In an up-
right normal posture, the intervertebral discs carry the
majority of the load, whereas the facet joints bear the re-
maining load [3,27–29]. However, the load-sharing rela-
tionship between the disc and the facet joints varies
depending on spinal posture [1,30] or the direction of spinal
movement [31–33].
Frontal plane pelvic deviations develop from structural
(eg, pelvic asymmetry, leg-length discrepancy, and so forth)
or functional (eg, hip weakness) factors. Regardless of the
cause of pelvic deviations, spinal compensations and the
associated altered loading should be considered when man-
aging this patient population. Lumbar spine structural
changes, suggestive of increased or altered loading, have
been documented in individuals with leg-length discrep-
ancy and postural scoliosis [34–37]. Moreover, altered lum-
bar facet joint and the intervertebral disc loading have been
associated with scoliosis [38–40]. To decrease the loads
placed on spinal structures, treatment aims in correcting
spinopelvic alignment, as the underlying premise of proper
spinopelvic alignment is to decrease the load subjected to
spinal tissues. Despite the clinical evidence in support of
decreased symptoms with correction of spinopelvic align-
ment, little is known about the biomechanical response to
the lumbar spine load-bearing structures when alignment
is less than ideal.
provide biomechanical information regarding lumbar facet
joint and intervertebral disc loading profiles, thereby en-
hancing the clinical understanding of the consequences re-
sulting from altered spinopelvic alignment. Pure moment
loading is recommended for in vitro biomechanical testing
and may be especially useful when comparing the effects of
different surgical implants or constructs as the load on each
spinal segment is considered to be uniform along the entire
spine [41–44]. However, most daily activities require si-
multaneous movement in all three planes, thereby resulting
in combined intervertebral motion. Whereas it has been
shown that pure moment testing does correspond to
in vivo loading [45], combined loading is likely to occur
in the presence of altered spinopelvic alignment. Thus, im-
plementing combined loading to in vitro experimentation
may be necessary.
The evidence supporting the biomechanical effects of
pelvic frontal plane postural changes on spinal loading is
limited; however, combined loading, as expected in this
posture, has been shown to influence disc and facet loading
[24–26,46]. Therefore, the purpose of this investigation was
to determine the effect of frontal plane pelvic obliquity on
facet joint loads and intradiscal pressures. Our hypothesis
was that combined loading conditions would generate
greater spinal loading than when the spine was subjected
to pure moment loading in the anatomic planes.
Methods
Eight fresh-frozen human lumbosacral cadaver spines
(seven L1–sacrum and one L3–sacrum, mean age 58.66
22.2 years) were used for biomechanical testing. Specimens
were excluded based on visual gross morphologic defor-
mity or pathology (eg, scoliosis, osteoporotic, or metastatic
lesions) and under fluoroscopic inspection to determine any
major degenerative disease (osteoporosis, osteoarthritis,
and so forth) that would influence testing.
Specimens were meticulously dissected of surrounding
neuromuscular tissue, leaving the osteoligamentous lumbo-
sacral spine. Specimens were submerged into two-part
polyurethane (BJB Enterprises, Inc., Tustin, CA, USA) at
the vertebrae midline, parallel to the superior end plate of
the L4, allowing for the superior end plate of L4 to be ori-
ented horizontally in the erect position. Specimens were
 J.M. Popovich et al. / The Spine Journal 13 (2013) 1581–1589
individually wrapped in isotonic saline-soaked gauze to
allow for adequate hydration until mechanical testing was
performed.
Each vertebral body was instrumented with an array of
four infrared light-emitting diodes that were used to monitor
intervertebral kinematics (Optotrak 3020; Northern Digital,
Inc., Waterloo, Ontario, Canada). Three needle pressure sen-
sors (Model 6376; R.A. Denton, Inc., Rochester Hills, MI,
USA), each consisting of a 15-gauge needle embedded with
three individual pressure sensors along the distal portion of
the needle, were inserted to the L4 intervertebral disc (essen-
tially providing a 33 matrix of pressure sensors) to measure
intradiscal pressure (Fig. 1). The L4–L5 bilateral facet joint
capsules were incised allowing for placement of a piezoresis-
tive force sensor (FlexiForce A-201; Tekscan, Inc., South
Boston, MA, USA). This force sensor was overlaid with
pressure-sensitive film (Prescale Measurement Film; Fuji-
film Corporation, Valhalla, NY, USA) and secured by adhe-
sive tape (Kapton; Dupont, Wilmington, DE, USA).
Pressure-sensitive film was used as a qualitative indication
of sensor placement and was inspected after each testing con-
dition. A similar version of this sensor has been previously
used to quantify lumbar facet joint forces [47,48]. Facet sen-
sors were calibrated by applying loads to the sensing area of
the sensor using a material testing device, and force values
(Newtons) were linearly interpolated (StrainSmart; Vishay
Micro-Measurements, Malvern, PA, USA). Despite place-
ment of sensors in each joint, only force from the right facet
joint was recorded (Fig. 2).
Specimens were secured into a Bose Kinematic Spine
Testing Device (Bose Corporation, Minnetonka, MN,
USA) for mechanical testing (Fig. 3). The mechanical test-
ing protocol consisted of five cycles of dynamic pure
moment loading (610 Nm) into flexion/extension, lateral
flexion, and axial rotation to precondition the spine, fol-
lowed by three loading cycles used to record data. The load-
ing rate was 1
/s until a 610-Nm load limit. This loading
profile has been used or recommended when testing similar
Fig. 1. An example of the approximate placement of the three needle pressure transducers in the intervertebral disc (Left) and a needle pressure transducer
position confirmed in the L4 disc under fluoroscopy (Right).
1583
length lumbar and lumbosacral specimens [41,49–51]. Two
additional loading conditions were implemented to simulate
frontal plane pelvic obliquity consisting of a 5
lateral bend
(tilted left such that the lumbar spine was in a right lateral
bending position) of the sacrum (5
lateral bend and rotation
[LBþROT]) and a 10
lateral bend (tilted left) of the sacrum
(10
LBþROT), both followed by 610 Nm axial rotation
moment. Therefore, a total of five different loading condi-
tions were performed (Fig. 4).
Mechanical testing, motion analysis, and pressure sensor
systems were synchronized and captured data at 50 Hz.
Specimens were preconditioned using pure moment load-
ing before testing. Because of the number of repeated me-
chanical tests, three loading cycles were implemented, and
the second complete loading cycle of each loading condi-
tion was used for data analysis.
Data reduction
Peak facet force represented the loading experienced by
the lumbar facet joints during each loading condition. Mean
peak intradiscal pressure value (mean peak of all nine pres-
sure sensors) was chosen to represent the overall loading
value for the intervertebral disc because the exact place-
ment (annulus or nucleus pulposus) of the sensors was
not confirmed through dissection. There were no significant
differences in mean peak intradiscal pressure between right
and left lateral bending and rotation conditions, and further-
more, during frontal and transverse plane motions, primary
loading on the facet joints occurs during ipsilateral lateral
bending and contralateral rotations, respectively. As such,
comparisons were made among flexion, extension, ipsilat-
eral lateral bending, contralateral axial rotation, and 5

LBþROT and 10
LBþROT conditions.
Data analysis
A one-way analysis of variance (ANOVA) with repeated
measures was performed to compare differences in peak
1584 J.M. Popovich et al. / The Spine Journal 13 (2013) 1581–1589
Fig. 2. Force sensor overlaid with pressure-sensitive film and sealed with Kapton tape (Left) and insertion into the right L4–L5 facet joint (Right).
facet joint force and mean peak intradiscal pressure be-
tween loading conditions. Post hoc testing consisted of
paired samples t tests to determine differences in facet
loads and intervertebral disc pressures among the different
loading conditions. Statistical analyses were conducted us-
ing SPSS statistical software (version 15; SPSS, Inc., Chi-
cago, IL, USA), and statistical significance was set at
p#.05.
Results
The ANOVA showed a significant difference in peak
facet joint force between loading conditions (p!.001).
Lowest peak facet joint force was measured during flexion
(26.8616.1 N) and highest in the 10
LBþROT combined
loading condition (124.0630.2 N). Post hoc tests revealed
significant differences between the 10
LBþROT condition
and flexion (p!.001), extension (p!.001), lateral bending
(p!.001), and rotation (p5.05). There was no significant
difference between 10
LBþROT and 5
LBþROT condi-
tions (p5.12). The 5
LBþROT condition showed similar
statistical results with the exception for when compared
with rotation (p5.13). Rotation was also significantly
greater than flexion (p5.001), extension (p!.001), and lat-
eral bending (p5.02). Peak facet joint forces for all six
loading conditions are presented in Fig. 5.
The ANOVA showed a significant difference in peak in-
tradiscal pressure between loading conditions (p5.003).
High peak intradiscal pressures were measured during lat-
eral bending (495.66280.9 kPa) and flexion (429.06212.9
kPa), and there was no significant post hoc difference be-
tween the two conditions (p5.18). Lowest peak intradiscal
pressures were measured during rotation (253.26135.0
kPa), 5
LBþROT (255.56132.7 kPa), and 10
LBþROT
(267.16127.1 kPa) conditions, in which there were no
significant differences between any of these conditions. Ro-
tation, 5
LB þ ROT, and 10
LB þ ROT had significantly
lower intradiscal pressure than flexion (p5.002, .003, .01,
respectively) and lateral bending (p5.01, .01, .01, respec-
tively). Similarly, rotation and 5
LBþROT had significantly
lower intradiscal pressure than extension (p5.03, .03, re-
spectively), whereas 10
LBþROT was not significant
(p5.07). Mean peak intradiscal pressure for all six loading
conditions are presented in Fig. 6.
Discussion
Our study investigated the effects of changing frontal
plane orientation of the sacrum (simulated pelvic obliquity)
on resulting facet joint force and intervertebral disc pres-
sure. The results of this study demonstrate that the load
sharing of these tissues is dependent on the plane and direc-
tion of loading. Facet joint force during combined loading
was higher compared with loading in the three anatomic
planes; however intradiscal pressures did not reveal the
same patterns. These findings support the clinical notion
that pelvic obliquity may play a role in increasing loads
on spinal tissues, particularly the facet joints.
Ipsilateral lateral bending and flexion produced similar
peak intradiscal pressures. Comparing our intradiscal pres-
sure data with other in vitro investigations yields similar
trends during loading in the anatomic planes [52–54]. Test-
ing conditions showed highest intradiscal pressures in lat-
eral bending, followed by flexion, and then axial rotation.
Steffen et al. [55] investigated the spatial intradiscal pres-
sure distribution of the L4 disc using three needle pressure
sensors that were similar to our experimental setup. They
found intradiscal pressure was highest in combined flexion
and axial rotation and reported values of higher magnitude
than presented in our study. Postexperiment location of
 J.M. Popovich et al. / The Spine Journal 13 (2013) 1581–1589
Fig. 3. An example of a lumbosacral spinal specimen setup in the Bose
Kinematic Spine Simulator. Specimen was instrumented with needle pres-
sure transducers and optoelectronic tracking clusters affixed to the anterior
surface of each vertebral body.
each individual sensor showed that a relatively large quan-
tity of sensors were within the annular or intermediate
zones as opposed to the nucleus zone [55]. Although
Fig. 4. An illustration representing the different loading conditions. Flexion and extension are presented together in the sagittal plane testing condition, but
were separated during data analysis allowing for six comparisons.
1585
placement of the intervertebral needle pressure sensors
was confirmed using fluoroscopy in our study, we did not
dissect the discs after biomechanical testing to confirm in-
dividual pressure sensor location (annulus or nucleus pul-
posus); thus, mean peak pressure across all sensors was
used to estimate intervertebral disc load. This, along with
different loading magnitudes and specimen variation, likely
accounts for the higher pressures that were observed in
their study, compared with the peak pressure we measured
during flexion (429.06212.9 kPa). Leaving aside the differ-
ences in magnitude measured among studies, our study did
not show increased intradiscal pressure with simulated pel-
vic obliquity conditions of combined frontal and transverse
plane loadings.
Combined loading in the present study did not show in-
creased averaged peak intradiscal pressure as expected. This
may be partly explained by the majority of loading in the
combined loading conditions being applied through axial ro-
tation, in which the facet joints bear more load while protect-
ing the intervertebral disc. Previous in vitro testing using
porcine intervertebral discs has shown decreased intradiscal
pressure with incremental increases in torsional load [56,57].
This decreasing trend in intradiscal pressure has also been
measured in human cadaveric spines; however, the results
were not statistically significant, indicating that the low
levels of torsional loads minimally affected intradiscal pres-
sure [58]. Although intradiscal pressure has been shown to
decrease with rotation, the annulus fibrosus load has been
shown to increase [56,57].
As this study is the first to investigate the effects of sim-
ulated frontal plane deviations and spinal loading, compar-
ing the results with other combined loading investigations
may provide additional insight to understanding the effects
of combined loading on spinal tissues. For example,
Schmidt et al. [25] performed a finite element study loading
the lumbar spine in combined loading conditions and
showed minimal changes in intradiscal pressure compared
with loading in the anatomic planes; however, they
1586 J.M. Popovich et al. / The Spine Journal 13 (2013) 1581–1589
Fig. 5. Peak facet force values for each of the six loading condition com-
parisons. Bars represent mean, and error bars represent 61 standard devi-
ation. aSignificantly different from flexion (p#.05); bsignificantly different
from extension (p#.05); csignificantly different from lateral bending
(p#.05); dsignificantly different from rotation (p#.05); esignificantly dif-
ferent from 5
LBþROT (p#.05); and fsignificantly different from 10

LBþROT (p#.05).
demonstrated the highest annular fiber strains under com-
bined lateral bending plus axial rotation conditions. Simi-
larly, Heuer et al. [59] showed axial rotation plus lateral
bending conditions in surgically defected human lumbar
cadaver spines (ligaments and posterior elements removed)
produced relatively smaller outward disc bulge and highest
annular fiber strains than any other complex loading condi-
tion. The loading patterns observed in combined loading
conditions suggest increased loads directly to the facet
joints and annulus fibrosus, which in turn may subject these
spinal tissues to higher risks of injury.
Fig. 6. Mean peak intradiscal pressure values for all sensors for each of
the six loading condition comparisons. Bars represent mean, and error bars
represent 61 standard deviation. aSignificantly different from flexion
(p#.05); bsignificantly different from extension (p#.05); csignificantly dif-
ferent from lateral bending (p#.05); dsignificantly different from rotation
(p#.05); esignificantly different from 5
LBþROT (p#.05); and fsignifi-
cantly different from 10
LBþROT (p#.05).
Although the number of studies directly measuring facet
loads is increasing, technology and methodology used to
quantify facet loads may vary [1–3,21,32,46,60–66]. Re-
sults for anatomic plane loading in the present study were
similar to Rousseau et al. [47] who reported facet joint
loading using similar technology. Facet forces ranged from
20.7 to 68.2 N during flexion/extension and lateral bending
conditions, with highest values occurring during a lateral
bending condition [47]. Facet forces ranging from 10.4 to
116.6 N have also been reported during flexion/extension
and lateral bending conditions, in which different interver-
tebral disc arthroplasty designs were compared [48]. In our
study, facet load was relatively high during all the rotation
conditions, with the highest values measured during the
combined 10
LBþROT condition (124.0630.2 N).
Schmidt et al. [24,46] did not show a significant increase
in facet forces as they hypothesized during combined load-
ing; however, they did show highest facet forces in axial ro-
tation. The fact that forces were highest during simulated
pelvic obliquity conditions, which consisted of combined
loading, suggests that the rotation or combined loading
conditions increased the normal facet joint force, as these
sensors used were only capable of measuring forces per-
pendicular to the sensor surface. The increase in normal
force may induce compressive loading on the cartilage
and thereby may lead to facet joint arthritis and degenera-
tive changes.
Patients with scoliosis have shown increased intradiscal
pressures on the concave side of curvature that demon-
strates asymmetric loading to the disc [38–40]. Similarly,
degenerative changes have been noted to the lumbar inter-
vertebral discs and facet joints suggesting an altered load-
ing environment [67–70]. Degenerative changes have
been associated with individuals with leg-length discrep-
ancies as well [34–37]. Although there are many factors
that may contribute to such changes, the increased facet
joint loads and annular fiber strains associated with rota-
tions and the relatively high intradiscal pressures associated
with lateral bending as seen in this study suggest a possible
biomechanical mechanism for low back dysfunction in this
particular patient population. Identifying the relative mag-
nitudes of loads shared by the spine during the simulated
combined loading tasks provides clinicians with valuable
information pertaining to treatment options. Regardless of
the cause of pelvic or spinal deviations, clinical treatment
options may aim to correct (operative and/or nonoperative)
alignment of the spine or pelvis to optimize the loads expe-
rienced by spinal structures. Perhaps most importantly,
knowledge of the loading associated with spinal deviations
resulting from frontal plane pelvic obliquity may allow for
early assessment and prevention of long-term problems that
may arise from the cumulative trauma or repetitive loading.
Although the results of this biomechanical study provide
insights that may be useful to clinical practice in terms of
altering spinal loads, the clinical implications will require
further controlled investigations in patient populations.
 J.M. Popovich et al. / The Spine Journal 13 (2013) 1581–1589
A limitation of this study was the combined loading con-
ditions only consisted of axial rotation during simulated
frontal plane pelvic obliquity (5
LBþROT and 10

LBþROT) in vitro. Although it would be interesting to de-
termine the effects of other combined motions (eg, flexion
and extension plus simulated frontal plane pelvic obliq-
uity), the combination of the specimen length and con-
straints of the testing device would not allow for these
combined loading condition. Furthermore, it would have
been interesting to simulate multiple ‘‘real-life’’ situations,
which were not performed in this study.
A common limitation of in vitro testing is that the testing
is performed on cadaveric specimens devoid of functioning
muscle tissue, and, therefore, the loads measured may not
replicate in vivo loading. Whether the loads measured or
differences between conditions are clinically relevant can-
not be answered with this study. However, because of the
repeated-measures design, the data presented in this study
do allow for comparisons across conditions. That is, regard-
less of magnitude of loading, relative differences from one
condition to the other are analyzed and can be contributed
to the different conditions. We would hypothesize that the
same pattern of loading would have occurred in vivo.
Simulating the combined loading conditions that may be
experienced in the presence of pelvic obliquity and result-
ing spinal deviations does not allow for the calculation of
the actual segmental loads placed on every spinal level
tested. That is, although pure moment testing assumes that
the segmental load is uniform for each segment, the com-
bined effects of the specimen length, anatomic morphology,
and tissue variability would not allow for calculation of the
segmental loading during the combined loading conditions.
As mentioned, not all segments were the same length,
which may influence the results because of differences in
the ligamentous support placed on the spine (eg, anterior
and posterior longitudinal ligaments). This limitation is
somewhat mitigated in that the effects on the results would
likely be relatively small in magnitude, and the repeated-
measures design of the study compares the conditions
within each lumbosacral specimen. We would expect simi-
lar results within each specimen across the six loading con-
ditions if only segment length was varied.
We used needle pressure sensors that were sensitive to
the direction of load. The needle pressure sensors were in-
serted sensitive side up (facing the superior direction);
however, this may not have captured all loadings in the inter-
vertebral disc. Mcnally and Adams [71] measured stress
distribution across the lumbar intervertebral disc using a sin-
gle pressure transducer mounted in a needle and navigated
across the disc, showing the annulus fibrosus and nucleus
pulposus function differently, especially in the presence of
disc degeneration [71,72]. Although we screened the speci-
mens for disc height and other degenerative changes, we did
not investigate the disc tissue posttesting. Mean specimen
age was 58.5 years; thus, age-related degenerative disc pro-
cesses could have taken place causing aberrant pressure
1587
readings, particularly from sensors in the annulus. Based
on these previous studies, the nucleus pulposus would likely
be best represented by the middle pressure sensor on the
needle that was inserted directly in the middle of the anterior
portion of the disc. These middle sensors yielded similar
trends as the reported mean peak pressure values.
Conclusions
Simulating frontal plane postural deviations during bio-
mechanical in vitro testing of the lumbosacral spine appears
to affect facet joint and intervertebral disc loading behavior.
Incorporating these findings into the cumulative trauma
paradigm may suggest a biomechanical role in spinal load-
ing (particularly the facet joints) in individuals with frontal
plane spine deviations. Further in vivo investigations are
needed to determine whether a compounding or cumulative
effect associated with facet loading is evident in patients
with frontal plane spinal deviations resulting from pelvic
obliquity. Managing the cause of such deviations may in
turn prevent the vicious cycle of injury from occurring
and prevent further damage to spinal tissues.
Acknowledgments
We would like to acknowledge the following entities for
their support of this research: Foundation for Physical Ther-
apy, International Society of Biomechanics, and American
Society of Biomechanics.
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