Prospective surgical solutions in degenerative spine: Spinal simulation for optimal choice of implant and targeted device development

Abstract

Objectives: The most important goal of surgical treatment for spinal degeneration, in addition to eliminating the underlying pathology, is to preserve the biomechanically relevant structures. If degeneration destroys biomechanics, the single segment must either be surgically stabilized or functionally replaced by prosthetic restoration. This study examines how software-based presurgical simulation affects device selection and device development. Methods: Based on videofluoroscopic motion recordings and pixel-precise processing of the segmental motion patterns, a software-based surrogate functional model was validated. It characterizes the individualmovement of spinal segments relative to corresponding cervical or lumbar spine sections. The single segment-based motion of cervical or lumbar spine of individual patients can be simulated, if sizecalibrated functional X-rays of the relevant spine section are available. The software plug-in "biokinemetric triangle" has been then integrated into this software to perform comparative segmental motion analyses before and after treatment in two cervical device studies: The correlation of implantinduced changes in the movement geometry and patientrelated outcome was examined to investigate, whether this surrogate model could provide a guideline for implant selection and future implant development. Results: For its validation in 253 randomly selected patients requiring single-level cervical (n=122) or lumbar (n=131) implant-supported restoration, the biokinemetric triangle provided significant pattern recognition in comparable investigations (p<0.05) and the software detected device-specific changes after implant-treatment (p<0.01). Subsequently, 104 patients, who underwent cervical discectomy, showed a correlation of the neck disability index with implant-specific changes in their segmental movement geometry: The preoperative simulation supported the best choice of surgical implants, since the best outcome resulted from restricting the extent of the movement of adjacent segments influenced by the technical mechanism of the respective device (p<0.05). Conclusions: The implant restoration resulted in best outcome which modified intersegmental communication in a way that the segments adjacent to the implanted segment undergo less change in their own movement geometry. Based on our software-surrogate, individualized devices could be created that slow down further degeneration of adjacent segments by influencing the intersegmental communication of the motion segments.