Skip to main content
SpringerLink
Log in

Biomechanics of Lumbar Disk Arthroplasty

  • Chapter
Advanced Concepts in Lumbar Degenerative Disk Disease

  • 2171 Accesses

Abstract

Conceptually, nucleus replacement offers the promise of a novel technology to add to the spectrum of surgical techniques to treat a variety of degenerative spine pathologies. Specifically, nucleus replacement has the potential to address degenerative pathologies more complex than simple disc herniation but less advanced than severe degenerative disc disease (DDD). Therefore, nucleus replacement may fill a surgical niche between simple discectomy and total disc replacement or spinal fusion. However, the potential success of nucleus replacement must also be tempered by the lack of long-term clinical results. Today, new technologies for spine surgery are judged on the basis of their safety and efficacy as well as cost-effectiveness. Several nucleus replacement devices are entering or completing pilot feasibility studies. Further clinical investigation with well-designed prospective, randomized pivotal trials is needed to ultimately determine the ideal indications and efficacy of nucleus replacement in the treatment of lumbar DDD.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 129.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 169.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 219.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Rawlinson JJ, Punga KP, Gunsallus KL, Bartel DL, Wright TM. Wear simulation of the ProDisc-L disc replacement using adaptive finite element analysis. J Neurosurg Spine. 2007;7(2):165–73.

    Article  PubMed  Google Scholar 

  2. Ray CD. Lumbar interbody threaded prosthesis. In: Brock M, Mayer HM, Weigel K, editors. The artificial disc. Berlin: Springer; 1991. p. 53–67.

    Chapter  Google Scholar 

  3. Bono CM, Lee CK. Critical analysis of trends in fusion for degenerative disc disease over the past 20 years: influence of technique on fusion rate and clinical outcome. Spine. 2004;29(4):455–63.

    Article  PubMed  Google Scholar 

  4. Jackson RK, Boston DA, Edge AJ. Lateral mass fusion. A prospective study of a consecutive series with long-term follow-up. Spine. 1985;10:828–32.

    Article  CAS  PubMed  Google Scholar 

  5. Kiviluoto O, Santavirta S, Salenius P, Morri P, Pylkkanen P. Posterolateral spine fusion. A 1–4-year follow-up of 80 consecutive patients. Acta Orthop Scand. 1985;56:152–4.

    Article  CAS  PubMed  Google Scholar 

  6. O’Beirne J, O’Neill D, Gallagher J, Williams DH. Spinal fusion for back pain: a clinical and radiological review. J Spinal Disord. 1992;5:32–8.

    Article  PubMed  Google Scholar 

  7. Stauffer RN, Coventry MB. Posterolateral lumbar-spine fusion. Analysis of Mayo Clinic series. J Bone Joint Surg Am. 1972;54:1195–204.

    CAS  PubMed  Google Scholar 

  8. Carragee EJ. The surgical treatment of disc degeneration: is the race not to the swift? Spine J. 2005;5:587–8.

    Article  PubMed  Google Scholar 

  9. Deyo RA, Nachemson A, Mirza SK. Spinal-fusion surgery-the case for restraint. N Engl J Med. 2004;350:722–6.

    Article  CAS  PubMed  Google Scholar 

  10. Errico TJ, Gatchel RJ, Schofferman K, Benzel EC, Faciszewski T, Eskay-Auerbach M, Wang JC. A fair and balanced view of spine fusion surgery. Spine J. 2004;4:129S–42.

    Article  Google Scholar 

  11. Sheehan JM, Shaffrey CI, Jane JA. Degenerative lumbar stenosis: the neurosurgical perspective. Clin Orthop Relat Res. 2001;384:61–74.

    Article  PubMed  Google Scholar 

  12. Eck JC, Humphreys SC, Hodges SD. Adjacent-segment degeneration after lumbar fusion: a review of clinical, biomechanical, and radiology studies. Am J Orthop. 1999;28:336–40.

    CAS  PubMed  Google Scholar 

  13. Lee CK, Langrana NA. A review of spinal fusion for degenerative disc disease: need for alternative treatment approach of disc arthroplasty? Spine J. 2004;4:173S–6.

    Article  PubMed  Google Scholar 

  14. Lehmann TR, Spratt KF, Tozzi JE, Weinstein JN, Reinarz SJ, el-Khoury GY, Colby H. Long-term follow-up of lower lumbar fusion patients. Spine. 1987;12:97–104.

    Article  CAS  PubMed  Google Scholar 

  15. Ozgur BM, Aryan HE, Pimenta L, Taylor WR. Extreme lateral interbody fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J. 2006;6:435–43.

    Article  PubMed  Google Scholar 

  16. Fernstrom U. Arthroplasty with intercorporal endoprosthesis in herniated disc and in painful disc. Acta Chir Scand Suppl. 1966;357:154–9.

    CAS  PubMed  Google Scholar 

  17. Hitchon PW, Eichholz K, Barry C, et al. Biomechanical studies of an artificial disc implant in the human cadaveric spine. J Neurosurg Spine. 2005;2:339–43.

    Article  PubMed  Google Scholar 

  18. Anderson PA, Rouleau JP, Bryan VE, et al. Wear analysis of the Bryan cervical disc prosthesis. Spine. 2003;28:S186–94.

    Article  PubMed  Google Scholar 

  19. Bao QB, Yuan HA. Pioneer surgical technology NUBAC artificial nucleus. In: Kim DH, Cammisa FP, Fessler RG, editors. Dynamic reconstruction of the spine. New York: Thieme; 2006. p. 128–36.

    Google Scholar 

  20. Bao QB, Yuan HA. New technologies in spine: nucleus pulposus replacement. Spine. 2002;27:1245–7.

    Article  PubMed  Google Scholar 

  21. Bao QB, Yuan HA. Prosthetic disc replacement: the future? Clin Orthop. 2002;394:139–45.

    Article  PubMed  Google Scholar 

  22. Bertagnoli R, Schonmayr R. Surgical and clinical results with the PDN prosthetic disc nucleus. Eur Spine J. 2002;11:S143–8.

    PubMed Central  PubMed  Google Scholar 

  23. Bertagnoli R, Vazquez RJ. The anterolateral transpsoatic approach (ALPHA): a new technique for implanting prosthetic disc-nucleus devices. J Spine Dis. 2003;16:398–404.

    Google Scholar 

  24. Bertagnoli R, Karg A, Voigt S. Lumbar partial disc replacement. Orthop Clin N Am. 2005;36:341–7.

    Article  Google Scholar 

  25. Goins ML, Wimberley DW, Yuan PS, Fitzhenry LN, Vaccaro AR. Nucleus pulposus replacement: an emerging technology. Spine J. 2005;5:317S–24.

    Article  PubMed  Google Scholar 

  26. Lemaire JP, Skalli W, Lavaste F, et al. Intervertebral disc prosthesis: results and prospects for the year 2000. Clin Orthop. 1997;337:64–76.

    Article  PubMed  Google Scholar 

  27. Martino AD, Vaccaro AR, Lee JY, Denaro V, Lim MR. Nucleus pulposus replacement: basic science and indications for clinical use. Spine. 2005;30:S16–22.

    Article  PubMed  Google Scholar 

  28. Frymoyer JW, Durrett CL. The economics of spinal disorders. In: Frymoyer JW, editor. The adult spine: principles and practice. Philadelphia: Lippincott-Raven; 1997. p. 143–50.

    Google Scholar 

  29. Lee CK, Goel VK. Artificial disc prosthesis: design concepts and criteria. Spine J. 2004;4:209S–18.

    Article  PubMed  Google Scholar 

  30. Rahm MD, Hall BB. Adjacent-segment degeneration after lumbar fusion with instrumentation: a retrospective study. J Spinal Disord. 1996;9:392–400.

    Article  CAS  PubMed  Google Scholar 

  31. Putzier M, Funk JF, Schneider SV, Gross C, Tohtz SW, Khodadadyan-Klostermann C, Perka C, Kandziora F. Charite total disc replacement–clinical and radiographical results after an average follow-up of 17 years. Eur Spine J. 2006;15:183–95.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Link HD. History, design and biomechanics of the LINK SB Charité artificial disc. Eur Spine J. 2002;11 Suppl 2:S98–105.

    PubMed Central  PubMed  Google Scholar 

  33. Wang J, Mummaneni PV, Haid RW. Current treatment strategies for the painful lumbar motion segment: posterolateral fusion versus interbody fusion. Spine. 2005;30:S33–43.

    Article  PubMed  Google Scholar 

  34. Guyer RD, McAfee PC, Banco RJ, Bitan FD, Cappuccino A, Geisler FH, Hochschuler SH, Holt RT, Jenis LG, Majd ME, Regan JJ, Tromanhauser SG, Wong DC, Blumenthal SL. Prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: five-year follow-up. Spine J. 2009;9(5):374–86.

    Article  PubMed  Google Scholar 

  35. Zigler JE, Glenn J, Delamarter RB. Five-year adjacent-level degenerative changes in patients with single-level disease treated using lumbar total disc replacement with ProDisc-L versus circumferential fusion. J Neurosurg Spine. 2012;17(6):504–11.

    Article  PubMed  Google Scholar 

  36. Gornet MF, Burkus JK, Dryer RF, Peloza JH. Lumbar disc arthroplasty with Maverick disc versus stand-alone interbody fusion: a prospective, randomized, controlled, multicenter investigational device exemption trial. Spine (Phila Pa 1976). 2011;36(25):E1600–11.

    Article  Google Scholar 

  37. Pettine K, Hersh A. Kineflex lumbar artificial disc versus Charité lumbar total disc replacement for the treatment of degenerative disc disease: a randomized non-inferiority trial with minimum of 2 years’ follow-up. SAS J. 2001;5(4):108–13.

    Article  Google Scholar 

  38. Wang JC, Arnold PM, Hermsmeyer JT, Norvell DC. Do lumbar motion preserving devices reduce the risk of adjacent segment pathology compared with fusion surgery? A systematic review. Spine (Phila Pa 1976). 2012;37(22 Suppl):S133–43.

    Article  Google Scholar 

  39. Gertzbein SD, Seligman J, Holtby R, Chan KH, Kapasouri A, Tile M, Cruickshank B. Centrode patterns and segmental instability in degenerative disc disease. Spine. 1985;10(3):257–61.

    Article  CAS  PubMed  Google Scholar 

  40. Panjabi MM. Centers and angles of rotation of body joints: a study of errors and optimization. J Biomech. 1979;12:911–20.

    Article  CAS  PubMed  Google Scholar 

  41. Panjabi MM, Goel VK, Walter SD. Errors in kinematic parameters of a planar joint: guidelines for optimal experimental design. J Biomech. 1982;15:537–44.

    Article  CAS  PubMed  Google Scholar 

  42. Seligman JV, Gertzbein SD, Tile M, Kapasouri A. Computer analysis of spinal segment motion in degenerative disc disease with and without axial loading. Spine. 1984;9(6):566–73.

    Article  CAS  PubMed  Google Scholar 

  43. Cho SK, Riew KD. Adjacent segment disease following cervical spine surgery. J Am Acad Orthop Surg. 2013;21(1):3–11.

    Article  PubMed  Google Scholar 

  44. Coric D, Mummaneni P. Nucleus replacement technologies. J Neurosurg Spine. 2008;8:115–20.

    Article  PubMed  Google Scholar 

  45. Dooris AP, Goel VK, Grosland NM, Gilbertson LG, Wilder DG. Load-sharing between anterior and posterior elements in a lumbar motion segment implanted with an artificial disc. Spine. 2001;26:E122–9.

    Article  CAS  PubMed  Google Scholar 

  46. Moumene M, Geisler FH. Comparison of biomechanical function at ideal and varied surgical placement for two lumbar artificial disc implant designs: mobile-core versus fixed core. Spine. 2007;32:1840–51.

    Article  PubMed  Google Scholar 

  47. O’Leary P, Nicolakis M, Lorenz MA, et al. Response of Charite total disc replacement under physiologic loads: prosthesis component motion patterns. Spine J. 2005;5:590–9.

    Article  PubMed  Google Scholar 

  48. Goel VK, Grauer JN, Patel T, et al. Effects of charite artificial disc on the implanted and adjacent spinal segments mechanics using a hybrid testing protocol. Spine. 2005;30:2755–64.

    Article  PubMed  Google Scholar 

  49. Panjabi M, Henderson G, Abjornson C, Yue J. Multidirectional testing of one- and two-level ProDisc-L versus simulated fusions. Spine. 2007;32(12):1311–9.

    Article  PubMed  Google Scholar 

  50. Panjabi M, Malcolmson G, Teng E, et al. Hybrid testing of lumbar CHARITE discs versus fusions. Spine. 2007;32:959–66.

    Article  PubMed  Google Scholar 

  51. Panjabi MM. Hybrid multidirectional test method to evaluate spinal adjacent-level effects. Clin Biomech (Bristol, Avon). 2007;22(3):257–65.

    Article  Google Scholar 

  52. Cunningham BW, et al. Distribution of in vivo and in vitro ROM following 1-level arthroplasty with the CHARITÉ artificial disc compared with fusion. J Neurosurg Spine. 2008;8:7–12.

    Article  PubMed  Google Scholar 

  53. Harrop JS, Youssef JA, Maltenfort M, Vorwald P, Jabbour P, Bono CM, Goldfarb N, Vaccaro AR, Hilibrand AS. Lumbar adjacent segment degeneration and disease after arthrodesis and total disc arthroplasty. Spine. 2008;33(15):1701–7.

    Article  PubMed  Google Scholar 

  54. Etebar S, Cahill DW. Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg. 1999;90:163–9.

    CAS  PubMed  Google Scholar 

  55. Barrey C, Jund J, Noseda O, Roussouly P. Sagittal balance of the pelvis-spine complex and lumbar degenerative diseases. A comparative study about 85 cases. Eur Spine J. 2007;16:1459–67.

    Article  PubMed Central  PubMed  Google Scholar 

  56. Chen WJ, Lai PL, Tai CL, Chen LH, Niu CC. The effect of sagittal alignment on adjacent joint mobility after lumbar instrumentation – a biomechanical study of lumbar vertebrae in a porcine model. Clin Biomech. 2004;19:763–8.

    Article  Google Scholar 

  57. Hioki A, Miyamoto K, Kodama H, Hosoe H, Nishimoto H, Sakaeda H, Shimizu K. Two-level posterior lumbar interbody fusion for degenerative disc disease: improved clinical outcome with restoration of lumbar lordosis. Spine J. 2005;5:600–7.

    Article  PubMed  Google Scholar 

  58. Hresko MT, Labelle H, Roussouly P, Berthonnaud E. Classification of high-grade spondylolistheses based on pelvic version and spine balance. Spine. 2007;32(20):2208–13.

    Article  PubMed  Google Scholar 

  59. Hwang SH, Kayanja M, Milks RA, Benzel EC. Biomechanical comparison of adjacent segmental motion after ventral cervical fixation with varying angles of lordosis. Spine J. 2007;7:216–21.

    Article  PubMed  Google Scholar 

  60. Keorochana G, Taghavi CE, Lee KB, Yoo JH, Liao JC, Fei Z, Wang JC. Effect of sagittal alignment on kinematic changes and degree of disc degeneration in the lumbar spine. Spine. 2011;36(11):893–8.

    Article  PubMed  Google Scholar 

  61. Kolstad F, Nygaard OP, Leivseth G. Segmental motion adjacent to anterior cervical arthrodesis. Spine. 2007;32(5):512–7.

    Article  PubMed  Google Scholar 

  62. Kretzer RM, Hu N, Umekoji H, Sciubba DM, Jallo GI, McAfee PC, Tortolani PJ, Cunningham BW. The effect of spinal instrumentation on kinematics at the cervicothoracic junction: emphasis on soft-tissue response in an in vitro human cadaveric model. J Neurosurg Spine. 2010;13:435–42.

    Article  PubMed  Google Scholar 

  63. Levin DA, Hale JJ, Bendo JA. Adjacent segment degeneration following spinal fusion for degenerative disc disease. Bull NYU Hosp Joint Dis. 2007;65(1):29–36.

    Google Scholar 

  64. Nunley PD, Jawahar A, Cavanaugh DA, Gordon CR, Kerr EJ, Utter PA. Symptomatic adjacent segment disease after cervical total disc replacement: re-examining the clinical and radiological evidence with established criteria. Spine J. 2013;13:5–12.

    Article  PubMed  Google Scholar 

  65. Ozer E, Yucesoy K, Yurtsever C, Secil M. Kyphosis one level above the cervical disc disease. J Spinal Disord Tech. 2007;20(1):14–9.

    Article  PubMed  Google Scholar 

  66. Park JY, Cho YE, Kuh SU, Cho JH, Chin DK, Jin BH, Kim KS. New prognostic factors for adjacent-segment degeneration after one-stage 360° fixation for spondylolytic spondylolisthesis: special reference to the usefulness of pelvic incidence angle. J Neurosurg Spine. 2007;7:139–44.

    Article  PubMed  Google Scholar 

  67. Sudo H, Oda I, Abumi K, Ito M, Kotani Y, Minami A. Biomechanical study on the effect of five different lumbar reconstruction techniques on adjacent-level intradiscal pressure and lamina strain. J Neurosurg Spine. 2006;5:150–5.

    Article  PubMed  Google Scholar 

  68. Vialle R, Ilharreborde B, Dauzac C, Lenoir T, Rillardon L, Guigui P. Is there a sagittal imbalance of the spine in isthmic spondylolisthesis? A correlation study? Eur Spine J. 2007;16:1641–9.

    Article  PubMed Central  PubMed  Google Scholar 

  69. Lemaire JP, Carrier H, el-H S, Skalli W, Lavaste F. Clinical and radiological outcomes with the Charité artificial disc: a 10-year minimum follow-up. J Spinal Disord Tech. 2005;18(4):353–9.

    Article  PubMed  Google Scholar 

  70. Cunningham BW, Dmitriev AE, Hu N, McAfee PC. General principles of total disc replacement arthroplasty: seventeen cases in a nonhuman primate model. Spine. 2003;28(20):S118–24.

    Article  PubMed  Google Scholar 

  71. Cunningham BW, Gordon JD, Dmitriev AE, Hu N, McAfee PC. Biomechanical evaluation of total disc replacement arthroplasty: an in vitro human cadaveric model. Spine. 2003;28(20):S110–7.

    Article  PubMed  Google Scholar 

  72. Denozière G, Ku DN. Biomechanical comparison between fusion of two vertebrae and implantation of an artificial intervertebral disc. J Biomech. 2006;39(4):766–75.

    Article  PubMed  Google Scholar 

  73. Cunningham BW. Basic scientific considerations in total disc arthroplasty. Spine J. 2004;4:S219–30.

    Article  Google Scholar 

  74. LeHuec JC, Kiaer T, Friesem T, Mathews H, Liu M, Eisermann L. Shock absorption in lumbar disc prosthesis: a preliminary mechanical study. J Spinal Disord Tech. 2003;16:346–51.

    Article  CAS  PubMed  Google Scholar 

  75. Kurtz SM, van Ooij A, Ross R, de Waal MJ, Peloza J, Ciccarelli L, Villarraga ML. Polyethylene wear and rim fracture in total disc arthroplasty. Spine J. 2007;7(1):12–21.

    Article  PubMed  Google Scholar 

  76. Van Ooij A, Oner FC, Verbout AJ. Complications of artificial disc replacement: a report of 27 patients with the SB Charite disc. J Spinal Disord Tech. 2003;16:369–83.

    Article  PubMed  Google Scholar 

  77. Geisler FH, Blumenthal SL, Guyer RD, McAfee PC, Regan JJ, Johnson JP, Mullin B. Neurological complications of lumbar artificial disc replacement and comparison of clinical results with those related to lumbar arthrodesis in the literature: results of a multicenter, prospective, randomized investigational device exemption study of Charite intervertebral disc. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine. 2004;1:143–54.

    Article  PubMed  Google Scholar 

  78. Leary SP, Regan JJ, Lanman TH, Wagner WH. Revision and explantation strategies involving the CHARITE lumbar artificial disc replacement. Spine. 2007;32:1001–11.

    Article  PubMed  Google Scholar 

  79. Siepe CJ, Heider F, Wiechert K, Hitzl W, Ishak B, Mayer MH. Mid- to long-term results of total lumbar disc replacement: a prospective analysis with 5- to 10-year follow-up. Spine J. 2014;14:1417–31. pii: S1529-9430(13)01475-7.

    Article  PubMed  Google Scholar 

  80. Lowell TD, Errico TJ, Fehlings MG, DiBartolo TJ, Ladosi L. Microdiskectomy for lumbar disk herniation: a review of 100 cases. Orthopaedics. 1995;18:985–90.

    CAS  Google Scholar 

  81. Yorimitsu I, Chiba K, Toyama Y, Hirabayashi K. Long-term outcomes of standard discectomy for lumbar disc herniation: a follow-up of more than 10 years. Spine. 2001;26:652–7.

    Article  CAS  PubMed  Google Scholar 

  82. Brinckmann P, Grootenboer H. Change of disc height, radial disc bulge, and intradiscal pressure from discectomy: an in vitro investigation on human lumbar discs. Spine. 1991;16:641–6.

    Article  CAS  PubMed  Google Scholar 

  83. Bertagnoli R, Sabatino CT, Edwards JT, Gontarz GA, Prewett A, Parsons JR. Mechanical testing of a novel hydrogel nucleus replacement implant. Spine J. 2005;5:672–81.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico

    Fanor Saavedra MD

  2. Arizona Neurosurgery and Spine Specialists, Phoenix, AZ, USA

    Christopher A. Iannotti MD, PhD

  3. Lafayette Brain and Spine, Neurological Associates of Louisiana, Lafayette, LA, USA

    Dani Bidros MD

  4. Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, S40, Cleveland, OH, 44195, USA

    Edward C. Benzel MD

Authors
  1. Fanor Saavedra MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christopher A. Iannotti MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dani Bidros MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Edward C. Benzel MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Edward C. Benzel MD .

Editor information

Editors and Affiliations

  1. Neurological and Spine Surgery, Hospital Samaritano, São Paulo, São Paulo, Brazil

    João Luiz Pinheiro-Franco

  2. Rothman Institute, Thomas Jefferson University Medical Center, Philadelphia, Pennsylvania, USA

    Alexander R. Vaccaro

  3. Cleveland Clinic Neurological Surgery, Cleveland, Ohio, USA

    Edward C. Benzel

  4. Schön Klinik München Harlaching FG Wirbelsäulenchirurgie, München, Germany

    H. Michael Mayer

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer-Verlag Berlin Heidelberg

About this chapter

Cite this chapter

Saavedra, F., Iannotti, C.A., Bidros, D., Benzel, E.C. (2016). Biomechanics of Lumbar Disk Arthroplasty. In: Pinheiro-Franco, J., Vaccaro, A., Benzel, E., Mayer, H. (eds) Advanced Concepts in Lumbar Degenerative Disk Disease. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-47756-4_42

Download citation

  • DOI: https://doi.org/10.1007/978-3-662-47756-4_42

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-662-47755-7

  • Online ISBN: 978-3-662-47756-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation