BIOMECHANICS OF SPINE

&
PRACTICAL APPLICATION IN SPINAL
INSTRUMENTATION

Presenter- Dr.Nagaraju Venishetty

Neurosurgery Resident
Moderator- Dr.D.S.Seshadri Sekhar
• SCALAR - This is a quantity defined by only its magnitude and has no direction. It is a
number that only has a magnitude or amount.

• VECTOR- It is a quantity that possesses both magnitude and direction.

• MAGNITUDE- objects size or quantity.

• FORCE OR LOADING VECTOR – Force applied in a particular direction {extension,

vertical compression (axial loading, vertical distraction, lateral flexion or bending, rotation,
shear or combination of these)}, spinal injuries are classificed according to these.

• .
• Strain This is the change in unit length or angle in a body subject to a
force.
• Shear strain is the change in the right angle.
• Normal strain is the change in the length divided by the original length.

• Stiffness - It is the ratio of force to the deformation.

• Coupling- unique property of spine, primary motion associated with

obligatory movements (translational or rotation)

• Hysteresis - This is a lagging or retardation of one of two associated

phenomena or a failure to act in unison of different parts of a body.
 Biomechanical Load Deflection Response

• Physiological loading phase -

Stiffness offered gradually
increased with no structural
damage.
• Traumatic loading phase- micro
failures start occurring and
stiffness starts to decrease.
• Post-traumatic loading phase -
structure has an increase in
the deformation that results in
the decrease in the load.
 Instantaneous Axis of Rotation

• Axis perpendicular to the plane of motion of the

body
• It is also the central point about which the
vertebra rotates.
• This is not a static point but is dynamic and changes
with position, posture and direction of movement.
• Each segment has unique IAR for every movement
and is influenced by spine alignment, anatomy,
muscles and loads exerted
• The IAR is located dorsal to the annulus fibrosis in
the intact spine.
• According to White and
Punjabi,173 the IAR is located
in the ventral portion of the
vertebral body.
• The human body’s centre of
gravity is located approximately
4 cm ventral to the sacrum.
• The cervical IAR is located
ventral to the vertebral bodies.
• In the upper thoracic spine the center
of gravity is anterior to the spine.
Axial loading will result in compressive
forces anteriorly and tensile forces
posteriorly. This will result in flexion-
type of injuries.

• In the lumbar spine due to the

lordosis, the center of gravity is
posteriorly.
• Flexion type of injuries will straigthen
the lumbar spine and result in axial
loading. In this area we will see many
burstfractures
Plumb line

• vertical line drawn from the

middle of the body of the 
C7 vertebral body. 
• This line should pass through the
superior endplate of S1, or more
precisely within 2 cm (some use
1.7 cm) of the posterosuperior
corner of the S1 vertebral body 
 Range of motion

They are the limits of rotational and linear

motion. The spinal cord has six degree of
freedom with three angles and three
displacements of a chosen point along a
coor-dinate axis.

• Extension is a backward bending moment

• Flexion is a forward bending moment
• Subluxation is an anteroposterior or
postero-anterior shear
• Rotation is an axial turning or torsion
• Distraction is stretch or tension.
Elastic deformity-
Reversible deformation of tissue, change in shape of an object
under an applied load from which the object can recover or
return to its original unloaded state when the load is removed.

Plastic Deformation -
Any irreversible deformation of tissues is plastic deformation.
Junghans Motion Segment

• Junghans defined the basic

functional unit of the spine.
This consists of two
vertebral bodies and an
intervening disc with the
ligaments and joints.
• The human spine has 24
motion segments.
 Kyphosis

• Excessive sagittal angular deformity that is beyond the

established normal range
• Thoracic spine curvature is 25–40 degree with a transitional zone
of 40–55 degree.> 60 degree in the thoracic spine is abnormal.
• Thoracolumbar junction, the normal kyphosis is 0 degree and the
lumbar spine is normally lordotic.
• A post-traumatic deformity of greater than 30 degree at the
thoracolumbar junction and a kyphosis of greater than 5 degree in
the lumbar spine are considered abnormal.
• Primary curves - spinal
column in utero has a
thoracic and lumbosacral
kyphosis
• Secondary curves –
develop after birth, cervical
curvature forms due to
head lifting, lumbar due to
walking.
 Vertebral Body

• The trabeculae of the cancellous bone also

resist loads.
• The superior and inferior vertebral body
surfaces are concave and interspersed with the
fibrocartilaginous discs.
• The thoracic and lumbar vertebrae have
transverse processes.
• The cervical vertebrae are smaller and
cylindrical and their spinous processes are
short and bifid.
• vertebral bodies and the intervertebral discs
support 80% of the spinal loading and 20% is by
facet joints and posterior elements.
 Cervical vertebrae

• Bifid spinous process – (except C1 and C7 is

longer than others and may not be bifid)
• Transverse foramina – Vertebral artery
passes from C1-C6
• Triangular vertebral foramen
• Facets from C2 to C7 are oriented at 45
degree and aligned in a coronal orientation.
• Atlas is a bony ring with two lateral masses
with anterior and posterior arches.
• cervical facet joints have a coronal
orientation – do not resist flexion,
extension, lateral bending and rotation,
therefore very mobile.
Thoracic vertebrae –
• Special demi facets on the body
superiorly and inferiorly, articulate
with the ribs on either side.
Lumbar vertebrae-
• large and wider in the transverse
diameter
• Facets are aligned in Saggital plane –
weak at flexion and translational
forces but is able resist rotational
forces.
INTERVERTEBRAL DISC
• Vertebral column has 33 vertebrae and 23
intervertebral discs.
• Avascular structure and has three zones;
the outer annulus fibrosus, the central
nucleus pulposus and the intermediate
transition zone.
• Constituted by collagen, proteoglycans and
glycoproteins.
• three-dimensional deformation allows the
disc to resist great loads like compression,
tension, shear, bending and torsion forces.
• These qualities reduce significantly in an
ageing and degenerated disc.
• Repeated microtrauma causes intervertebral
disc pressure changes and these lead to low
back ache.
 Spinal Canal

• The spinal canal varies in size from the craniovertebral junction

to the sacrum and the dorsal canal has the smallest diameter.
• Canal size may be reduced due to osteophytes, disc, ligamental
hypertrophy or OPLL.
• The sagittal diameter of the canal has long been recognised as
an important cofactor in varied spinal cord pathologies.
• Lumbar canal stenosis is the most common congenital stenosis
followed by cervical canal stenosis.
 LIGAMENTS

• A weak ligament which has a long lever arm may provide more
stability and ligaments that are away from the IAR demonstrate
greater strength. Each ligament resists physiological loads
differently, because of the orientation and location in relationship
to the IAR of each vertebral column.
• Effectiveness of each ligament is related to the strength of the
ligament and also the movement arm through which the ligament
acts.
• A weak ligament with a long lever arm provides more support
to the spine than a very strong ligament with a short
movement arm.
• The incompetence of ligaments, primary - collagen disorders
or secondary-trauma,degeneration, infection and neoplastic
disorders leads to instability and may require surgical
management.
• Forestier’s disease - cause loss of normal elasticity of the
ligaments, reduce the capacity of the spine to bear physiologic
loads.
• Capsular Ligaments - surround the facet joints , resist lateral
bending, axial rotation and flexion.
• CV junction is less stable in children, plane of articulation
between the cranium and atlas is almost horizontal and the
occipital condyles of children are not deeply seated into the
fossa of the superior facet of the atlas.
• Lateral flexion is limited by the alar ligaments.
 Flexion Rotation Lateral
Extension bending
• Head nodding occurs at the occipito-
atlantal joint. occipitocervi 15-20 5 5-10
cal
• Greatest motion in the subaxial
Atlantoaxial 15-20 50 15-20
cervical spine occurs at C4-5 and C5-6 joint
and the least at C2-3. Subaxial 50 50 60
• White and Panjabi – classification on cervical
spine
acute instability, greater than 3.5 mm
of anterolisthesis or more than 11 Thoracic
spine
3-20 2-15 5-10

degree of angulation constitutes

Lumbar 5-25 0-2 3-15
instability in the lower cervical spine. spine
• Cervico dorsal junction - highly mobile
cervical spine and the relatively
immobile thoracic spine.
Thoracolumbar junction-
Commonly involved in severe spine trauma due to change of
stiff thoracic spine to a mobile lumbar spine, absence of the
stabilizing effect of the rib cage and also the change in the
orientation of the facet joints.
Lumbar spine
Pedicle size and morphology permits a comparatively easy
placement of pedicle screws which are biomechanically
superior as they are able to stabilize all three columns.
 Instability

Excessive motion beyond physiological limits of one vertebra upon another in at least one
of the three motion planes (X axis (flexion-extension), Y axis (rotation) and Z axis
(lateral bending).

Benzel system - instability into 4 sub catagories

Acute
a. Overt acute instability
b. Limited acute instability.
Chronic
a. Glacial instability
For example, Spondylolisthesis, trauma, tumour and
infections
b. Dysfunctional segmental motion associated instability.
THEORY OF LOUIS
The spine bears weight principally by sustaining axial loads along the vertebral
body, intervertebral disc and two facet joint complexes at each segmental level.

TWO COLUMN THEORY OF HOLDSWORTH

Anterior column as consisting of the anterior vertebral bodies, the ALL, the
disc and PLL. The posterior column consists of everything posterior to PLL,
including the capsular ligaments, the facet joints, ligamentum flavum and the
interspinous and supraspinous ligaments.

Yilmez et al.177 in a study, found that instability increased with the number of
levels of discectomy and that the excision of the PLL did not increase instability.
 THREE COLUMN THEORY OF DENIS

• Of the three columns, the anterior

and posterior columns are the
principle support structures.
• The anterior column resists
compression and axial loading and the
posterior column maintains the
tension.
• To maintain the correct posture, all
forces and movements must be
balanced about the IAR.
 EVANS FLAGPOLE CONCEPT

• The stability of the spine is

not dependent solely on the
integrity of the spinal
column but also on the
functional capabilities of
the paraspinal muscles and
the ligaments of the spine
 WHITESIDE’S CONSTRUCTION CRANE
ANALOG OF THE SPINE

Anterior column resisted

compressive forces and the posterior
column resisted distraction.
The equilibrium is maintained by
anterior compression vectors against
the posterior tension vectors. The
dorsal ligamentous complex and
paraspinal muscles act as a dorsal
tension band.
The gravitational forces exert an
axial load leading to a ventral angular
vector.
AO classification
 BIOMECHANICS OF SPINE DEFORMITY

• Biomechanically ventral reconstruction and instrumentation

provides superior mechanical stability over an equal number of
spinal segments to compressive loads than the dorsal
instrumentation techniques.
• The removal of the dorsal tension band after trauma with ventral
compression leads to further neurological compromise caused by
the tethering of the neural elements (bow string effect) over
ventral bony components.
GOALS OF SPINAL DEFORMITY
GOALS OF SPINAL
SURGERY
INSTRUMENTATION

• Reasonable correction • Correction of

of deformity deformities
• Prevention of further • correction of misaligned
deformity segments
• Restoration of sagittal • Enhancement of solid
and coronal balance fusion
• Cosmetic optimisation • Maintain anatomic
• Improved neurological alingment
function • Allow early mobilization
• Penning et al . - decreased cross sectional area
of the spinal canal due to the dorsal bulging of
the annulus as well as the in folding of the
ligamentum flavum and the scaffolding of the
lamina, leading to a pincer like action on the cord.
• Irreversible damage occurs when compression
exceeds more than 30% of the initial cord
diameter.
 TYPES OF SPINAL INSTRUMENTATION

• Implantation methods
wiring, hooks, screws
rods vs plates
• Position
anterior or posterior
• Level
thoracolumbar , cervical
 BIOMECHANICS OF BONE GRAFTS

• Remodelling of bone is influenced by level and distribution of

functional strain, thereby bone heals optimally under compression.
• Dynamic implants are implants that prevent stress shielding and
allow a limited and controlled type of deformation.
• Placement of a fusion mass at the maximum distance from the IAR
will be more effective in preventing movement around those axes.
• Instrumentation without structural bone grafts generally fails and
a strong structural graft is required to resist axial loading and
flexion.
• Single rib graft may not provide adequate structural
support, but multiple rib grafts stacked together and
tied, provide excellent support and osteoinduction.

• The instrumentation causes stress shielding, but

generally rigid fixations result in better fusion rates.

• Tricorticate illium, fibular graft and titanium cages

packed with autogenous graft provide good anterior
column support.
 BIOMECHANICS OF SPINAL IMPLANTS

• Dynamic systems, semi-rigid countoured plates and implants that

are lighter and stronger and more similar to biological tissues.

• Instrumentation helps in stability of fusion by load sharing and

preventing graft extrusion and mal-alignment.

• Ventral cervical plating loads the graft in extension and may lead to
graft pistoning and failure in multilevel constructs.

• The dynamic plates share loads more effectively than static plates.
• The application of locking screws to plates has greatly reduced
the incidence of screw pullout.

• Circumferential fixation provides more stability than anterior

instrumentation alone after cervical corpectomy.
• Long circumferential instrumentation provides better stability
than short circumferential fixation, except during axial rotation.
• Circumferential fixation more effectively prevents axial rotation
after corpectomy.
• In comparison to a tricortical iliac crest bone graft and a non-
expandable cage, expandable cages have no biomechanical
advantages. Due to the low extension and rotational stiffness.
None of the implants can be recommended as a stand alone
device.

• Additional anterior plating increased biomechanical stability

adequately. additional posterior stabilisation should only be
considered in cases of severe rotational instability of the
cervical spine.
• The screw angle was the most important parameter that
affected the final stiffness and the coupling behaviour.
• Betz et al.- anterior instrumentation should be put in
place with the axis of the screws aligned as close as
possible with the coronal plane and bi-cortical purchase is
preferable.
• A conservative construct utilising a single screw per
vertebral body and a one-holed plate system appears to
be strong enough to afford stability in both traumatic and
non-traumatic lesions of the sub-axial cervical spine,
comparable to others.