Quantifying the ranges of relative motions of the intervertebral discs and facet joints in the normal cervical spine
Introduction
The cervical spine is prone to injuries and degenerative changes, that can eventually lead to pain, malfunction, and/or neurological complications (Nouri et al., 2015). While the mechanisms of cervical pathology are unclear and assumed to be multifactorial (Akter and Kotter, 2018), biomechanical/iatrogenic changes of the spine are widely considered as a factor causing spinal load changes and initiating disc degeneration (Dai, 1999). Surgical therapies, such as spinal fusion and total disc arthroplasty (TDA), are widely performed to treat severe cervical disc diseases. While TDA is associated with several complications including heterotopic ossification and implant failures (Leven et al., 2017, Nunley et al., 2018), spinal fusion is associated with a higher risk of adjacent segment degeneration (ASD) due to altered segment biomechanics at adjacent levels (Dmitriev et al., 2007, Laratta et al., 2018, Luo et al., 2015, Schwab et al., 2006). An accurate quantification of cervical spine motion could enhance our understanding of the normal, pathological, and surgically treated spines, and help improve surgical techniques and rehabilitation regimens.
Functional cervical motion is achieved by the intervertebral cervical segments with each being composed of an intervertebral disc (IVD) and two facet joints (FJs). Numerous in vitro and in vivo studies have investigated the biomechanical responses of the cervical spine using load transducers (Moroney et al., 1988, Panjabi et al., 2001, Wen et al., 1993, White et al., 1975), motion capture (Black et al., 1996, Henmi et al., 2006), X-ray imaging (Reitman et al., 2004, Wu et al., 2007), computed tomography (CT) (Penning and Wilmink, 1987, Watanabe et al., 2012), and magnetic resonance imaging (MRI) (Ishii et al., 2006, Ishii et al., 2004, Nagamoto et al., 2011). Recently, model based tracking techniques that combined subject-specific vertebral models and bi-plane radiography have been employed to evaluate six-degree-of-freedom (6DOF) intervertebral motions under dynamic physiological loading conditions (Anderst et al., 2013b; Lin et al., 2014, McDonald et al., 2014, Yu et al., 2019). However, most previous studies focused on the kinematics of the intervertebral segments. Fewer in vitro and computational studies have reported on the morphology of FJs (Milne, 1991, Rong et al., 2017) and uncovertebral joints (Panjabi et al., 1991), and on how intact or TDA-treated segment kinematics and load-sharing were affected by FJs (Bauman et al., 2012, Chang et al., 2007, Kang et al., 2010, Patel et al., 2017, Stieber et al., 2011) or uncovertebral joints (Kang et al., 2010, Snyder et al., 2007, Wachowski et al., 2017, Wachowski et al., 2007, Wang et al., 2016). However, little is known on the in vivo kinematics and synergistic function of the IVD and the FJs in the normal human cervical spine. This information is critical for evaluation of the effect of spine pathologies on changes of cervical biomechanics and for improvement of spinal surgeries that can maximally restore the normal spine function.
Previously, we have investigated the intervertebral motion and IVD deformation of the subaxial cervical spine using a dual fluoroscopic imaging system (DFIS) (Yu et al., 2017). In this study, we further investigated the ranges of motion (ROMs) of the IVD joint and FJs of the human cervical spine during functional activities of the neck, including maximal flexion–extension (FE), lateral bending (IB) and axial twisting (AT) motions using the DFIS. Due to the fundamentally different structures of the IVD and FJs, the FJs are commonly recognized to be more mobile than the IVD joints, whereas quantitative comparisons were less reported. The objective of this study is to quantify the differences in the ROMs of both joints in the cervical spines of asymptomatic subjects during various in vivo neck motions. We hypothesized that the segment rotational ROMs and the ratios of IVD to FJ translational ROMs (shortened by the IVD-FJ translation ratio hereafter) are level-dependent, i.e., they vary at different segments.
Section snippets
Subject recruitment
The experiments were performed at two medical centers and approved by their internal review boards (see Supplementary Material). All recruited subjects signed informed consent prior to participation. Each subject was first evaluated in terms of neck pain and other spinal disorders. Then, using magnetic resonance imaging (MRI) or computerized tomography (CT) images of the subjects, the presence of any anatomic abnormalities or early disc degeneration was used as a criterion for exclusion from
The rotational ROMs of cervical segments during three neck motions
During the FE motion of the neck, the ROMs of the primary rotation and coupled LB and AT of the cervical segments were shown in Table 1 and Fig. 4a. From C3/4 to C6/7, the ROMs of the primary rotation were 14.8 ± 4.3°, 17.6 ± 4.5°, 15.9 ± 5.2° and 11.3 ± 4.0°, respectively, with the ROM of C6/7 significantly smaller than those of C4/5 (p < 0.001) and C5/6 (p = 0.016). The mean ROMs of the coupled rotations were between 2.1° to 3.3°.
During neck LB (Table 1 and Fig. 4b), the ROMs of the primary
Discussion
This study investigated the 6DOF (rotational and translational) ROMs of both the intervertebral disc joint and FJs at each subaxial cervical segment during in vivo functional neck motions. During FE of the neck, the dominant segmental rotation was in the sagittal plane (FE rotation) coupled with small out-of-plane rotations (Fig. 4). During both LB and AT of the neck, regardless of primary or coupled rotations, the LB rotation was always larger than the AT and FE rotations at each segment (Fig.
Conclusion
This study quantified the ranges of relative motions of the IVD and FJs in the subaxial cervical spine during various neck motions, and showed that the FJs experienced greater in-plane translations than the IVDs, especially in the AP direction during each neck motion. These data could help understand the normal neck function, and provide valuable references for evaluation of the biomechanical efficacy of cervical surgical treatments. Furthermore, they could be also used to define optimal design
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
We are thankful for the funding supports from National Institutes of Health (1R03AG056897), Shanghai Pujiang Program (17PJ1405000), National Natural Science Foundation of China (31771017), and Shanghai Jiao Tong University (YG2017MS09, ZH2018QNA06, ZXGF082101/050).
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