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BackgroundBleb presence in intracranial aneurysms (IAs) is a known indication of instability and vulnerability.ObjectiveTo develop and evaluate predictive models of bleb development in IAs based on hemodynamics, geometry, anatomical location, and patient population.MethodsCross-sectional data (one time point) of 2395 IAs were used for training bleb formation models using machine learning (random forest, support vector machine, logistic regression, k-nearest neighbor, and bagging). Aneurysm hemodynamics and geometry were characterized using image-based computational fluid dynamics. A separate dataset with 266 aneurysms was used for model evaluation. Model performance was quantified by the area under the receiving operating characteristic curve (AUC), true positive rate (TPR), false positive rate (FPR), precision, and balanced accuracy.ResultsThe final model retained 18 variables, including hemodynamic, geometrical, location, multiplicity, and morphology parameters, and patient population. Generally, strong and concentrated inflow jets, high speed, complex and unstable flow patterns, and concentrated, oscillatory, and heterogeneous wall shear stress patterns together with larger, more elongated, and more distorted shapes were associated with bleb formation. The best performance on the validation set was achieved by the random forest model (AUC=0.82, TPR=91%, FPR=36%, misclassification error=27%).ConclusionsBased on the premise that aneurysm characteristics prior to bleb formation resemble those derived from vascular reconstructions with their blebs virtually removed, machine learning models can identify aneurysms prone to bleb development with good accuracy. Pending further validation with longitudinal data, these models may prove valuable for assessing the propensity of IAs to progress to vulnerable states and potentially rupturing.

Poly(ether ether ketone) (PEEK) is a semi-crystalline thermoplastic with excellent mechanical and chemical properties. PEEK exhibits a high degree of resistance to thermal, chemical, and bio-degradation. PEEK is used as biomaterial in the field of orthopaedic and dental implants; however, due to its intrinsic hydrophobicity and inert surface, PEEK does not effectively support bone growth. Therefore, new methods to modify PEEK’s surface to improve osseointegration are key to next generation polymer implant materials. Unfortunately, PEEK is a challenging material to both modify and subsequently characterize thus stymieing efforts to improve PEEK osseointegration. In this manuscript, we demonstrate how surface-initiated atom transfer radical polymerization (SI-ATRP) can be used to modify novel PEEK microparticles (PMP). The hard core-soft shell microparticles were synthesized and characterized by DLS, ATR-IR, XPS and TEM, indicating the grafted materials increased solubility and stability in a range of solvents. The discovered surface grafted PMP can be used as compatibilizers for the polymer-tissue interface.

Background: Implanting hardware into surgical sites increases the rate of infection associated with these sites. Without novel efforts to reduce this rate of infection, we can expect to see an incr...

Due to their capacity to conduct complex organic transformations, enzymes find extensive use in medical and industrial settings. Unfortunately, enzymes are limited by their poor stability when exposed to harsh non-native conditions. While a host of methods have been developed to stabilize enzymes in non-native conditions, recent research into the synthesis of polymer-enzyme biohybrids using reversible deactivation radical polymerization approaches has demonstrated the potential of increased enzymatic activity in both native and non-native environments. In this manuscript, we utilize the enzyme lipase, as a model system, to explore the impact that modulation of grafted polymer molecular weight has on enzyme activity in both aqueous and organic media. We studied the properties of these hybrids using both solution-phase enzyme activity methods and coarse-grain modeling to assess the impact of polymer grafting density and grafted polymer molecular weight on enzyme activity to gain a deeper insight into this understudied property of the biohybrid system.

To investigate the biomechanical changes in the development of scoliosis due to intervertebral disc and facet joint degeneration.We enrolled 39 cases of fresh-frozen lumbar spine specimens and underwent CT scanning and 3D reconstruction. An Osirix Dicom imaging system was to assess the degeneration of the intervertebral disc and facet joints, and mechanical loading was conducted using a spine mechanical instrument with the frequency set at plus/minus 7.5 NM, 0.005 Hz. Range of motion (ROM) and neutral zone (NZ) of 39 cadaveric lumbar spines were tested.Degeneration existed in all 39 cases of the lumbar specimens: the Cobb angle10° in 5 cases (degenerative scoliosis (DS) group), between 3° and 10° in 9 cases (pre-degenerative scoliosis (PS) group) and3° in 25 cases (no scoliosis (NS) group). The axial torsion (AT) range of motion (ROMThe AT correlated with intervertebral disc and facet joint degeneration, which might be a mechanic factor in the occurrence and development of degenerative scoliosis.

Advancements in electrode technologies to both stimulate and record the central nervous system’s electrical activities are enabling significant improvements in both the understanding and treatment of different neurological diseases. However, the current neural recording and stimulating electrodes are metallic, requiring invasive and damaging methods to interface with neural tissue. These electrodes may also degrade, resulting in additional invasive procedures. Furthermore, metal electrodes may cause nerve damage due to their inherent rigidity. This paper demonstrates that novel electrically conductive organic fibers (ECFs) can be used for direct nerve stimulation. The ECFs were prepared using a standard polyester material as the structural base, with a carbon nanotube ink applied to the surface as the electrical conductor. We report on three experiments: the first one to characterize the conductive properties of the ECFs; the second one to investigate the fiber cytotoxic properties in vitro; and the third one to demonstrate the utility of the ECF for direct nerve stimulation in an in vivo rodent model.

Objective: Intraoperative neurophysiological monitoring (IONM) is the use of electrophysiological methods during certain high-risk surgeries to assess the functional integrity of nerves in real time and alert the surgeon to prevent damage. However, the efficiency of IONM in current practice is limited by latency of verbal communications, inter-rater variability, and the subjective manner in which electrophysiological signals are described. Methods: In an attempt to address these shortcomings, we investigate automated classification of free-running electromyogram (EMG) waveforms during IONM. We propose a hybrid model with a convolutional neural network (CNN) component and a long short-term memory (LSTM) component to better capture complicated EMG patterns under conditions of both electrical noise and movement artifacts. Moreover, a preprocessing pipeline based on data normalization is used to handle classification of data from multiple subjects. To investigate model robustness, we also analyze models under different methods for processing of artifacts. Results: Compared with several benchmark modeling methods, CNN-LSTM performs best in classification, achieving accuracy of 89.54% and sensitivity of 94.23% in cross-patient evaluation. Conclusion: The CNN-LSTM model shows promise for automated classification of continuous EMG in IONM. Significance: This technique has potential to improve surgical safety by reducing cognitive load and inter-rater variability.

Background: Expandable cages that allow for bidirectional expansion, in both height and width, may offer benefits over traditional expandable cages or static cages. Effective stiffness must also be considered, as implants with exceedingly high stiffness may increase subsidence risk and reduce graft loading. Methods: A retrospective case series of 7 patients were assessed with computed tomography (CT) scan at the final 1-year follow-up to evaluate the interbody fusion and configuration of the expandable cage related to the endplates within the intervertebral space. CT scans were reformatted using cage9s tantalum markers as fiducials for single-plane orientation for each intervertebral cage. Device height and width at maximum in situ expansion was measured at its anterior and posterior aspects to evaluate implant deformation. The new bone volume within each cage was measured from the same CT scan data sets and by the Bridwell classification of interbody fusion. Results: The average difference between medial and lateral height measurements was 1.82 mm (±1.08) at the device9s anterior aspect and 1.41 mm (±0.98) at the posterior aspect. The average difference between medial and lateral heights was 18.55% (±9.34) anteriorly and 15.49% (±9.24) posteriorly. There was a successful fusion in all 7 patients, as evidenced by measurable bone volume in the center of each interbody cage with an average of 586.42 mm3 (±237.06). Conclusion: The authors demonstrated the feasibility of successfully using bidirectionally expandable multimaterial cages to achieve interbody fusion. These composite open-architecture cages were found to conform to each patient9s endplate configuration. The authors9 observations support the concept of material selection impacting the effective construct stiffness. The design investigated by the authors provided sufficient anterior column support and successful fusion in all patients. Level of Evidence: 4.

BACKGROUND: Expandable devices for transforaminal or posterior lumbar interbody fusion (TLIF and PLIF, respectively) may enable greater restoration of disc height, foraminal height, and stability within the interbody space than static spacers. Medial-lateral expansion may also increase stability and resistance to subsidence. This study evaluates the clinical and radiographic outcomes from early experience with a bidirectional expandable device. METHODS: This was a retrospective analysis of a continuous series of patients across 3 sites who had previously undergone TLIF or PLIF surgery with a bidirectional expandable interbody fusion device (FlareHawk, Integrity Implants, Inc) at 1 or 2 contiguous levels between L2 and S1. Outcomes included the Oswestry Disability Index (ODI), a visual analog scale (VAS) for back pain or leg pain, radiographic fusion by 1 year of follow-up, subsidence, device migration, and adverse events (AE). RESULTS: There were 58 eligible patients with radiographs for 1-year fusion assessments and 45 patients with ODI, VAS back pain, or VAS leg pain data at baseline and a mean follow-up of 4.5 months. The ODI, VAS back pain, and VAS leg pain scores improved significantly from baseline to final follow-up, with mean improvements of 14.6 ± 19.1, 3.4 ± 2.6, and 3.9 ± 3.4 points (P < .001 for each), respectively. In addition, 58% of patients achieved clinically significant improvements in ODI, 76% in VAS back pain, and 71% in VAS leg pain. By 1 year, 96.6% of patients and 97.4% of levels were considered fused. There were zero cases of device subsidence and 1 case of device migration (1.7%). There were zero device-related AEs, 1 intraoperative dural tear, and 3 subsequent surgical interventions. CONCLUSIONS: The fusion rate, improvements in patient-reported outcomes, and the AEs observed are consistent with those of other devices. The bidirectional expansion mechanism may provide other important clinical value, but further studies will be required to elucidate the unique advantages. LEVEL OF EVIDENCE: 4.

Background: Bidirectional expandable designs for lumbar interbody fusion cages are the latest iteration of expandable spacers employed to address some of the common problems inherent to static interbody fusion cages. Objective: To describe the rationales for contemporary bidirectional, multimaterial expandable lumbar interbody fusion cage designs to achieve in situ expansion for maximum anterior column support while decreasing insertion size during minimal-access surgeries. Methods: The authors summarize the current concepts behind expandable spinal fusion open architecture cage designs focusing on advanced minimally invasive spinal surgery techniques, such as endoscopy. A cage capable of bidirectional expansion in both height and width to address constrained surgical access problems was of particular interest to the authors while they analyzed the relationship between implant material stiffness and geometric design regarding the risk of subsidence and reduced graft loading. Conclusions: Biomechanical advantages of new bidirectional, multimaterial expandable interbody fusion cages allow insertion through minimal surgical access and combine the advantages of proven device configurations and advanced material selection. The final construct stiffness is sufficient to provide immediate anterior column support while accommodating reduced sizes required for minimally invasive surgery applications. Level of Evidence: 7.

Background A number of minimally invasive sacroiliac (SI) joint fusion solutions for placing implants exist, with reduced post-operative pain and improved outcomes compared to open procedures. The objective of this study was to compare two MIS SI joint fusion approaches that place implants directly across the joint by comparing the ilium and sacrum bone characteristics and SI joint separation along the implant trajectories. Methods Nine cadaveric specimens (n = 9) were CT scanned and the left and right ilium and sacrum were segmented. The bone density, bone volume fraction, and SI joint gap distance were calculated along lateral and posterolateral trajectories and compared using analysis of variance between the two orientations. Results Iliac bone density, indicated by the mean Hounsfield Unit, was significantly greater for each lateral trajectory compared to posterolateral. The volume of cortical bone in the ilium was greater for the middle lateral trajectory compared to all others and for the top and bottom lateral trajectories compared to both posterolateral trajectories. Cortical density was greater in the ilium for all lateral trajectories compared to posterolateral. The bone fraction was significantly greater in all lateral trajectories compared to posterolateral in the ilium. No differences in cortical volume, cortical density, or cancellous density were found between trajectories in the sacrum. The ilium was significantly greater in density compared with the sacrum when compared irrespective of trajectory (p < 0.001). The posterolateral trajectories had a significantly larger SI joint gap than the lateral trajectories (p < 0.001). Conclusion Use of the lateral approach for minimally invasive SI fusion allows the implant to interact with bone across a significantly smaller joint space. This interaction with increased cortical bone volume and density may afford better fixation with a lower risk of pull-out or implant loosening when compared to the posterolateral approach.

Study Design: An in vitro biomechanics study. Objective: To evaluate the efficacy of triangular titanium implants in providing mechanical stabilization to a sacroiliac joint with primary and revision sized implants. Methods: Ten lumbopelvic cadaveric specimens were tested in 4 stages: intact, pubic symphysis sectioned, primary, and simulated revision. Primary treatment was performed using 3 laterally placed triangular titanium implants. To simulate revision conditions before and after bone ingrowth and ongrowth on the implants, 7.5-mm and 10.75-mm implants were randomly assigned to one side of each specimen during the simulated revision stage. A 6 degrees of freedom spinal loading frame was used to load specimens in 4 directions: flexion extension, lateral bending, axial torsion, and axial compression. Biomechanical evaluation was based on measures of sacroiliac joint rotational and translational motion. Results: Both primary and revision implants showed the ability to reduce translational motion to a level significantly lower than the intact condition when loaded in axial compression. Simulated revision conditions showed no statistically significant differences compared with the primary implant condition, with the exception of flexion-extension range of motion where motions associated with the revised condition were significantly lower. Comparison of rotational and translation motions associated with the 7.5- and 10.75-mm implants showed no significant differences between the treatment conditions. Conclusions: These results indicate that implantation of laterally placed triangular titanium implants significantly reduces the motion of a sacroiliac joint using either the primary and revision sized implants. No statistically significant differences were detected when comparing the efficacy of primary, 7.5-mm revision, or 10.75-mm revision implants.

Polyether ether ketone (PEEK, 1) is an important material for the fabrication of implants employed in spinal fusion surgery. Although its radiolucency and favorable elastic modulus have made PEEK an attractive choice for interbody fusion devices, its poor osseointegrative properties prevent the formation of a strong union between implant and surrounding bone structures and remain a major liability. Recent advancements in PEEK surface technology have resulted in improved osseointegration; however, the identification of an ideal implant material has proven challenging. In this manuscript, we describe our preliminary investigation into the realm of PEEK-based fusion devices that has culminated in the discovery of a mild, solution-based process for the preparation of covalently surface modified PEEK biomaterials that display enhanced osteoconductive properties. Surface modification occurred under mild reaction conditions via the acid-mediated addition of various commercially available hydrophilic oxyamine and...

Novel organic electrically conductive organic fibers (ECFs) have been fabricated using a facile, economical and scalable technique by staining nonconductive fibers (both natural and synthetic) with a conductive ink composed of two intrinsically conductive materials, i.e., single walled carbon nanotubes (SWCNTs) and regioregular poly(3-hexylthiophene) (rr-P3HT). These organic ECFs exhibit low resistance of 0.50 kΩ cm–1 with a conductive ink composed of 0.8 mg/mL of SWCNTs and 1.6 mg/mL of P3HT while maintaining the mechanical properties of the original fibers. These organic ECFs were characterized by resistance measurements, Raman spectroscopy, scanning electron microscopy, transmission electron microscopy and stress–strain measurements. Finally, the recording properties of the organic ECFs were examined by both electromyography and electrocardiography in terms of the signal-to-noise ratio, which was found to be similar and/or exceeded the data obtained by standard metal electrodes.

Protein–polymer hybrids are used in a variety of fields including catalysis, detection, and therapeutics. The grafting-from method for the synthesis of these biohybrids has gained popularity due to the ease of synthesis and purification. In this method, an initiator or chain transfer agent (CTA) is ligated onto an amino acid residue, typically lysine or cysteine, and polymers are subsequently grown in situ. In this manuscript, we report the preparation of protein polymer hybrids by grafting-from a previously overlooked acidic amino acid residue (glutamic and aspartic acid) and compare our results to protein polymer hybrids, grafted from the traditional lysine residue. Herein, we conjugated an atom transfer radical polymerization (ATRP) initiator to acidic amino acid residues and lysine residues and grew polymers from Thermomyces lanuginosa lipase (TL). N-[3-(N,N-Dimethylamino)propyl] acrylamide was grafted from the TL initiator, and the enzymatic activity of protein polymer hybrids was compared. We found that the acidic residues are easily modified with multiple ATRP initiators and polymers are readily grown. Additionally, the hybrids grafted from acidic residues demonstrated a 50% increase in enzyme activity compared to those grafted from lysine residues. Moreover, the activity was higher than that of native lipase TL in both cases. The polymers that were grafted-from the acid residues tended to provide the hybrids with a higher activity at elevated temperatures. These results point to a new amino acid ligation strategy for preparing protein polymer hybrids via a grafting-from method.

The synthesis of novel fentanyl acrylate derivatives via bromo-fentanyl using Heck coupling is described. The synthesis is concise and represents an efficient and useful method for functionalizing fentanyl for medicinal chemistry investigations. The agonistic and analgesic activities are evaluated by Mu opioid receptor activation and hot plate assays in mice.

Titanium (Ti) and its alloys are used in orthopedic and dental implants due to their excellent physical properties and biocompatibility. Although Ti exhibits superior osteoconductive properties compared to those of polymer-based implants, improved bone-on growth properties are required for enhanced surgical outcomes and improved recovery surgical interventions. Herein, we demonstrate a novel surface modification strategy to enhance the osteoconductivity of Ti surfaces through the grafting-from procedure of a reactive copolymer via surface-initiated atom transfer radical polymerization (SI-ATRP). Then, postpolymerization conjugation of the P15 peptide, an osteoblast binding motif, was successfully carried out. Subsequent in vitro studies revealed that the surface modification promoted osteoblast attachment on the Ti discs at 6 and 24 h. Moreover, mineral matrix deposition by osteoblasts was greater for the surface-modified Ti than for plain Ti and P15 randomly absorbed onto the Ti surface. These results suggest that the strategy for postpolymerization incorporation of P15 onto a Ti surface with a polymer interface may provide improved osseointegration outcomes, leading to enhanced quality of life for patients.

Background Polyetheretherketone (PEEK), and more recently titanium-coated PEEK, have been given serious consideration as biomaterial design choices for spinal interbody implants. Shortcomings in these materials necessitate further innovation into materials research, for example, on polyetherketoneketone (PEKK). Common complications such as surface delamination (as with titanium coating) and lack of bone apposition (as with PEEK) indicate the need for a new material that inherently displays preferable bone growth characteristics without sacrificing structural integrity. Purpose To compare three biomaterials with respect to their osseointegrative capacity. Study Design Evaluate the in vivo material characteristics of three separate biomaterials in an ovine bone defect model: PEEK, titanium-coated PEEK (Ti-coated PEEK), and 3D printed PEKK. Biomechanical, histological and radiographic testing was the basis for evaluation and material characterization. Methods Eight ovine specimens were implanted with one of each of the three types of biomaterials tested in both left and right epicondyles using a femoral bone defect model, and were sacrificed at 8 and 16 weeks. Implants were then analyzed using a push-out method, histological staining, and various radiographic tests. Industry funding was provided for the completion of this research study, followed by an independent third party review of all relevant data for publication. Results PEKK implants demonstrated bone ingrowth, no radiographic interference, no fibrotic tissue membrane formation, significant increase in bony apposition over time, and significantly higher push-out strength compared to standard PEEK. The PEKK implant displayed bone growth characteristics comparable to Ti-coated PEEK with significant improvements in implant integrity and radiographic properties. Conclusion This study found that PEKK displayed preferable characteristics when compared to PEEK and Ti-coated PEEK, and is therefore a potential alternative to their use.

Background: Effective triage - directing patients with low back pain to appropriate treatment or correct referral - is fundamental to quality care. Without guidelines, a physician's initial decision may lead to unnecessary investigation, unneeded intervention or unwarranted consultation.Methods: To compare the functional outcomes of patients triaged by a classification based on clinical presentation with those of patients selected at the clinicians’ discretion, an insurance-owned hospital network employed forty-seven specially-trained physical therapists, working within participating primary care practices, to classify low back pain patients into specific Patterns of Pain. Between October 2017 and April 2019, the primary care physicians used this classification, derived entirely from the patient's history and physical examination, to direct subsequent treatment for 260 consecutive low back pain patients. Patients with systemic symptoms, recent substantial trauma or non-mechanical diagnoses indicative of spinal infections or possible malignancy were excluded. Functional outcome measures were spinal imaging, opioid use, length of treatment and number of visits, back-related unplanned care, frequency of spinal surgery and back-related episode cost. These were compared with a control group of 256 propensity-matched patients and, for assessing the financial impact, with a historic cohort of 111 previously treated, non-classified patients.Results: Spinal imaging: study group 24.5%; controls 42.2% (P< .001). Narcotic use: study group 4.6%; controls 13.3% (P< .001). Treatment length: study group 62.2 days; controls 74.5 days (P=.10). Treatment visits: study group 1528 visits; controls 2,046 visits (P=.003). Unplanned care: study group 1.9%; controls 12.8% (P< .001). Spine surgery: study group 15.4%; controls 26.2% (P=.005). Episode cost: study group $1453; controls $2334 (P=.005).Conclusions: A well-defined clinically-based triage system produced meaningful reductions in imaging, opioid use, treatment duration, unplanned interventions, surgery and cost of care.

Boyle C Cheng,1 Sravanthi Koduri,1 Charles A Wing,2 Natalie Woolery,3 Daniel J Cook,1 Robert C Spiro2,3 1Neuroscience Institute, Allegheny Health Network, Pittsburgh, PA 15212, USA; 2Research and Development, Aesculap Implant Systems, LLC, Breinigsville, PA 18031, USA; 3Research and Development, Aesculap Biologics, LLC, Breinigsville, PA 18031, USA Purpose: Spinal interbody fusion cages are designed to provide immediate stabilization for adjoining vertebrae and ideally enable bony ingrowth to achieve successful integration. For such an implant, cells must be able to attach, move, grow, and differentiate on its surface. These cellular interactions are dependent on how the implant surface enables the coating and binding of blood and tissue fluid proteins that support cell adhesion. The purpose of this study was to evaluate the in vitro and in vivo osteoblast cell–implant surface interactions that result in osseointegration onto a surface composed of plasma-sprayed titanium on a polyetheretherketone (PEEK) substrate or titanium-coated PEEK (Ti-PEEK) (PlasmaporeXP®) as compared to uncoated PEEK implants.Materials and methods: The influence of the Ti-PEEK surface modification on the biochemical, biomechanical, and histological properties at the bone–implant interface is demonstrated both in vitro using simulated bone-forming cell culture experiments and in vivo using a 12- and 24-week ovine implant model.Results: Osteoblast-like cells attached to the Ti-PEEK surface upregulated early bone-forming activity as measured by an increase in transcription and translation of ALP and BMP-2 when compared to cells on PEEK. Similarly, a significant increase in new bone formation, bony apposition, and pullout strength was demonstrated on Ti-PEEK implants when compared to PEEK implants at 12 and 24 weeks in an ovine implant in vivo model.Conclusion: The study shows that the Ti-PEEK surface demonstrated enhanced osseointegrative properties compared to PEEK both in vitro and in vivo. Keywords: porous titanium, implant coating, osteoblast differentiation, osseointegration, pullout test, sheep

Noninvasive ventilator support using bi-level positive airway pressure/continuous positive airway pressure (BiPAP/CPAP) is commonly utilized for chronic medical conditions like sleep apnea and neuromuscular disorders like amyotrophic lateral sclerosis (ALS) that lead to weakness of respiratory muscles. Generic masks come in standard sizes and are often perceived by patients as being uncomfortable, ill-fitting, and leaky. A significant number of patients are unable to tolerate the masks and eventually stop using their devices. The goal of this project is to develop custom-fit masks to increase comfort, decrease air leakage, and thereby improve patient compliance. A single-patient case study of a patient with variant ALS was performed to evaluate the custom-fit masks. His high nose bridge and overbite of lower jaw caused poor fit with generic masks, and he was noncompliant with his machine. Using desktop Stereolithography three-dimensional (3D) printing and magnetic resonance imaging (MRI) data, a generic mask was extended with a rigid interface such that it was complementary to the patient's unique facial contours. Patient or clinicians interactively select a desired mask shape using a newly developed computer program. Subsequently, a compliant silicone layer was applied to the rigid interface. Ten different custom-fit mask designs were made using computer-aided design software. Patient evaluated the comfort, extent of leakage, and satisfaction of each mask via a questionnaire. All custom-fit masks were rated higher than the standard mask except for two. Our results suggest that modifying generic masks with a 3D-printed custom-fit interface is a promising strategy to improve compliance with BiPAP/CPAP machines.

The two most popular models used in anatomical training for residents, clinicians, or surgeons are cadavers and sawbones. The former is extremely costly and difficult to attain due to cost, ethical implications, and availability, while the latter is said to not have the same tactile fidelity or mechanical properties as human bone. This study examined the potential use of 3D-printed phantoms to emulate cadaveric, human vertebrae, in hopes of acting as a future use over cadavers. In so doing, we developed 3D-printed MedPhantom®, with the intended use to offer similar tactile feel, mechanical characteristics, and visual appearance as human bone. In order to quantify tactility, a mechanical test was developed where a 5-mm diameter diamond-coated bur spinning at 75,000 RPM swept across the specimens while continuously recording the resultant forces (N) and moments (N-cm), The bur sweep motion is common in orthopedic surgery and neurosurgery. Since most 3D-prints do not offer internal, trabecular structure similar to bone, an algorithm was written to create a stochastic framework of internal mesh to mimic cancellous bone within an STL (stereolithography) file. The ranges of mesh parameters were chosen after several visits with the neurosurgeons participating in the project. In order to quantify structural combinations of wall thickness, gap sizes, and varying cylindrical radii within a print, 1000 RPM compression test with a 5-mm diamond-coated bur was performed with resultant forces (N). Two sample t-test shows statistical significance that samples are not equal to the vertebrae (p

BACKGROUND CONTEXT Osteoimmunology, the study of the relationship between the musculoskeletal system and immune system, has emerged as an important consideration in biomaterial research. Based on the current understanding of the immune system, both the innate and adaptive components, a combination of tests on current design materials in spinal implant devices may help understand potential clinical complications and thus reduce the potential adverse events associated with specific design materials. Studies involving macrophages facilitate the understanding behind the mechanism of fibrous capsule formation anecdotally reported with PEEK implants. The cell studies in combination with larger animal studies help understand the importance of appropriate choice in materials. The combination of results from three separate kinds of studies would potentially weave a better understanding of PEEK fibrous encapsulation around retrieved implanted PEEK devices. It was hypothesized that IL-1β, IL-6, and TNF-α cytokine expression levels results would be different for PEEK and a novel zeolite filled PEEK composite (ZFuze, DiFusion Technologies). PURPOSE The objective of this study was to compare the activation state of macrophages, as determined by selected gene and protein expression profiles, following in vitro exposure to PEEK zeolite and PEEK based spinal interbody devices. Similarly, the immune response measured at the local sites in a large animal study was also studied in order to determine the inflammatory response at the local implanted site. STUDY DESIGN/SETTING In vitro cell culture study in combination with a large animal functional cervical spine model. The large animal model included two instrumented levels with one level implanted with a PEEK interbody cervical cage and the alternate level implanted with a PEEK zeolite composite interbody device. OUTCOME MEASURES The levels of inflammatory cytokines interleukin-1 beta (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF-α) were quantified in muscle tissue directly anterior to the index level based on the intensity of fluorescence in each slide. For cell-based study, the presence of cytokines was noted as comparable, increased, or slightly increased compared to macrophages of the M0 phenotype. METHODS Mature macrophages were exposed to the following treatments for 24 hours: complete media (M0 control), 20 ng/ml IFN-γ and 100 ng/mL lipopolysaccharide LPS (M1 control), 20 ng/mL interleukin IL-4 (M2 control). For the cytokine challenge study, cells were exposed for 6 hours to 20 ng/ml IFN-γ and 100 ng/mL LPS, washed and then placed in 10% FBS 1% P/S DMEM for 24 hours. After the incubation period at 37°C, cells were washed with sterile PBS and fixed for 30 minutes with 2% paraformaldehyde (PFA) for immunolabeling, or harvested with TRIzol lysis reagent for RNA assessment, respectively. RNA were isolated from 8 × 106 cells using the RNeasy Mini Kit according to the manufacturer's instructions. Isolated RNA concentration was subsequently determined using a NanoDrop spectrophotometer. Reverse transcription of 500 ng of RNA to cDNA were performed via a high-capacity reverse transcriptase kit according to the manufacturer's instructions. SYBR Green gene expression assays were used to determine the relative expression levels of: gapdh, inos, tnf-α, arg1, fizz1, il1β, il6, and gapdh. Skeletally mature Montadale sheep were implanted with PEEK and PEEK zeolite interbody cages at the C2-C3 and C4-C5 index levels and survived to 12 or 26 weeks, as approved by the IACUC Committee. At the time of sacrifice index level functional spinal units (FSU), major organs, lymph nodes, and muscle tissues were collected. Muscle tissue from the spinal column at the operative level was collected and used for a quantitative analysis of various inflammatory markers using immunohistochemistry techniques. Slides were prepared from these spinal tissue samples as well as positive and negative control tissues. Lymph nodes and muscle tissues distant from the surgical site were collected during necropsy and served as the positive and negative controls respectively. RESULTS In vivo expression was normalized to represent a percentage of intensity measured in the negative control. Independent T-test was performed to compare cytokine expression at both 12 and 26 week time points. Expression of IL1-β was found to be significantly lower in PEEK zeolite samples at 12 weeks (M=0.23, SD=0.28) than standard PEEK samples at 12 weeks (M=1.37, SD=0.49) t(8)=-4.582, p=0.002. PEEK zeolite composite samples were also found to have significantly lower IL1-β expression at 26 weeks (M=0.02, SD=0.009) when compared to standard PEEK samples (M=0.60, SD=0.23) t(11)=-6.667, p CONCLUSIONS The macrophage study in combination with larger animal studies help understand the importance of appropriate choice in design materials. With the above strategies in mind, it was possible to conduct in vitro and/or in vivo studies that comprehensively evaluate the macrophage response to a biomaterial. Results of the macrophage study suggest that PEEK-zeolite, but not PEEK, increases the expression at the translational level of an M2-associated marker, Fizz1. Results of protein expression data support the hypothesis that PEEK zeolite promotes a pro-repair M2-like macrophage phenotype. Similarly, the ovine study showed a novel PEEK zeolite composite elicits reduced pro-inflammatory cytokine excretion when compared to standard PEEK implants. Specifically, the tissues surrounding PEEK-zeolite composite implants had significantly lower levels of IL1-β and IL-6. These results may explain the increased bone growth observed in the pilot rabbit study and suggest the new material is well suited for clinical application including spinal implants that benefit from host bone implant apposition. FDA DEVICE/DRUG STATUS Unavailable from authors at time of publication.

Sacroiliac joint (SIJ) dysfunction and its surgical treatment remain a controversial topic in spine surgery. Determining success after SIJ fusion may be difficult due to preexisting back pain, lumbar fusion (LF), and functional disability. We examine the utility of Oswestry Disability Index (ODI) as a measure of clinical outcomes after minimally invasive SIJ fusion. A retrospective review of 24 patients with at least 12- months follow-up. Patients were divided into two groups based on presence of previous LF. Their post-operative ODI was compared with overall satisfaction, pain reduction, and return to work status. No difference in demographics was found in patients with and without prior LF with 92% of patients reporting lower post-operative pain and 96% being satisfied. Presence of LF did not show any statistically significant differences in pain or satisfaction. However, patient with prior LF reported lower ODI than those without LF at 1-year post-operatively (P=0.015). Postoperative ODI may give a falsely pessimistic impression of outcomes in SIJ fusion patients with prior LF, and its use and limitations should be carefully considered in future studies.

Background Interbody fusion cages with integrated fixation components have become of interest due to their ability to provide enhanced post-operative stability and mitigate device migration. A recently approved anterior lumbar interbody fusion cage with integrated fixation anchors has yet to be compared in vitro to a standard polyetheretherketone cage when used in combination with an interspinous process clamp. Methods Twelve human cadaveric lumbar segments were implanted at L4–L5 with a Solus interbody cage (n = 6) or standard polyetheretherketone cage (n = 6) following Intact testing and discectomy. Each cage was subsequently evaluated in all primary modes of loading after supplementation with the following posterior constructs: interspinous process clamp, bilateral transfacet screws, unilateral transfacet screw with contralateral pedicle screws, and bilateral pedicle screws. Range of motion results were normalized to Intact, and a two-way mixed analysis of variance was utilized to detect statistical differences. Findings The Solus cage in combination with all posterior constructs provided significant fixation compared to Intact in all loading conditions. The polyetheretherketone cage also provided significant fixation when combined with all screw based treatments, however when used with the interspinous process clamp a significant reduction was not observed in lateral bending or axial torsion. Interpretation Interbody cages with integrated fixation components enhance post-operative stability within the intervertebral space, thus affording clinicians the potential to utilize less invasive methods of posterior stabilization when seeking circumferential fusion. Interspinous process clamps, in particular, may reduce peri-operative and post-operative comorbidities compared to screw based constructs. Further study is necessary to corroborate their effectiveness in vivo .

While low back pain is one of the most prevalent, if not the most prevalent reasons for visits to physicians, a majority of patients with low back pain cannot be given a definitive diagnosis. The current standard of care for function assessment of the lumbar spine focuses on uncontrolled patient directed motion which results in increased inter-patient variability and diagnostic misclassifications. The purpose of the current paper is to compare the measurement variability of lumbar spine motion when diagnosed using measurements of intervertebral motion taken from standard flexion extension bending radiographs (FE) between uncontrolled and controlled motion and to assess the rate of diagnostic misclassification errors (false positives and false negatives) in the detection of lumbar instability. 109 patients (57 asymptomatic, 52 symptomatic) were consented in the prospective investigation. The research was designed to compare studies involving FE to controlled motion bending radiographs (CCBR) using the Vertebral Motion Analysis (VMA) within the same patient. Measurement variability was determined by the mean and standard deviation of intervertebral rotation when evaluated by 9 independent observers evaluating each of the 109 patients FE and CCBR. The resulting standard deviation of the intervertebral rotation determinations was used as the measure of variability. Sensitivity (true positive rate) and specificity (true negative rate), were constructed using asymptomatic individuals and symptomatic patients in order to determine true positive (TP) and true negative (TN) appointments. The analysis was compared to known threshold of 25° (IVR) to determine the rates of false negatives (FN) and false positive (FP) rates. Sensitivity and specificity were calculated as TP/(TP/FN) and TN/(FP+TN), respectively. There was statistical greater measurement variability in intervertebral rotation in FE when compared to CCBR (both standing and lying). When comparing measurement variability between FE and CCBR, results indicate between a 26% to 46% decrease in measurement variability under CCBR compared to FE. These findings are consistent across asymptomatic and symptomatic patients. Sensitivity measures were 6.2% (VMA 12.6%, FE 6.4%) greater in the VMA test compared to the FE. Specificity measures were 8.4% (VMA 99.1%, FE 90.7%) greater in the VMA test compared to the FE. The current standard of care for functional testing of the lumbar spine utilizes uncontrolled FE with a manual data evaluation process. Recent developments in using computerized imaging processes has improved, however there remains variability in patient bending due to the self-selected rate and position of the bending. CCBR results in a significant reduction in measurement variability of intervertebral rotation measurements. Reducing measurement variability would be expected to improve the efficacy rates of surgeries indicated for these conditions.

Object Deep brain stimulation (DBS) of the lateral hypothalamic area (LHA) has been suggested as a potential treatment for intractable obesity. The authors present the 2-year safety results as well as early efficacy and metabolic effects in 3 patients undergoing bilateral LHA DBS in the first study of this approach in humans. Methods Three patients meeting strict criteria for intractable obesity, including failed bariatric surgery, underwent bilateral implantation of LHA DBS electrodes as part of an institutional review board– and FDA-approved pilot study. The primary focus of the study was safety; however, the authors also received approval to collect data on early efficacy including weight change and energy metabolism. Results No serious adverse effects, including detrimental psychological consequences, were observed with continuous LHA DBS after a mean follow-up of 35 months (range 30–39 months). Three-dimensional nonlinear transformation of postoperative imaging superimposed onto brain atlas anatomy was used to confirm and study DBS contact proximity to the LHA. No significant weight loss trends were seen when DBS was programmed using standard settings derived from movement disorder DBS surgery. However, promising weight loss trends have been observed when monopolar DBS stimulation has been applied via specific contacts found to increase the resting metabolic rate measured in a respiratory chamber. Conclusions Deep brain stimulation of the LHA may be applied safely to humans with intractable obesity. Early evidence for some weight loss under metabolically optimized settings provides the first “proof of principle” for this novel antiobesity strategy. A larger follow-up study focused on efficacy along with a more rigorous metabolic analysis is planned to further explore the benefits and therapeutic mechanism behind this investigational therapy.

Background The application of kinematic data acquired during biomechanical testing to specimen-specific, three-dimensional models of the spine has emerged as a useful tool in spine biomechanics research. However, the development of these models is subject to segmentation error because of complex morphology and pathologic changes of the spine. This error has not been previously characterized. Methods Eight cadaveric lumbar spines were prepared and underwent computed tomography (CT) scanning. After disarticulation and soft-tissue removal, 5 individual vertebrae from these specimens were scanned a second time. The CT images of the full lumbar specimens were segmented twice each by 2 operators, and the images of the individual vertebrae with soft tissue removed were segmented as well. The solid models derived from these differing segmentation sessions were registered, and the distribution of distances between nearest neighboring points was calculated to evaluate the accuracy and precision of the segmentation technique. Results Manual segmentation yielded root-mean-square errors below 0.39 mm for accuracy, 0.33 mm for intrauser precision, and 0.35 mm for interuser precision. Furthermore, the 95th percentile of all distances was below 0.75 mm for all analyses of accuracy and precision. Conclusions These findings indicate that such models are highly accurate and that a high level of intrauser and interuser precision can be achieved. The magnitude of the error presented here should inform the design and interpretation of future studies using manual segmentation techniques to derive models of the lumbar spine.

OBJECTIVE Spinal stability is attributed in part to osteoligamentous structures, including the vertebral body, facets, intervertebral discs, and posterior elements. The materials in this study provide an opportunity to augment the degenerated nucleus without removing native disc material, a procedure introduced here as “fortification.” The objective of this study was to determine the effect of nucleus fortification on lumbar disc biomechanics. METHODS The authors performed in vitro analysis of human cadaveric functional spinal units (FSUs), along with characterization and quantification of movement of the units using biomechanical data in intact, disc-only, and fortified specimens. The units underwent removal of all posterior elements and annulus and were fortified by injecting a biogel into the nucleus pulposus. Each specimen was subjected to load testing, range of motion (ROM) quantification, and disc bulge measurements. Optoelectric tracking was used to quantify disc bulge. These criteria were assessed in the intact, disc-only, and fortified treatments. RESULTS Disc-only FSUs resulted in increased ROM when compared with intact and fortified conditions. Fortification of the FSU resulted in partial restoration of normal ROM in the treatment groups. Analysis of hysteresis loops showed more linear response in the fortified groups when compared with the intact and disc-only groups. CONCLUSIONS Disc nucleus fortification increases linearity and decreases ROM.

Efficient load-sharing in the spinal column relies on the proper working of the components of the Functional Spinal Unit (FSU). Due to various reasons such as trauma, ageing and diseases, these components or even the entire FSU can get degenerated or injured during a person’s lifetime. Spinal column reconstruction surgerieswere created with the aimto restore the functioning of the diseased or injured spine. Several spinal implants are available today for the surgeon to aid in this process. There are three major categories of these devices: anterior stabilization devices, posterior stabilization devices and motion preservation devices. This review highlights thein vitro researchdone on these devices,over the past five decades, to evaluate their ability to effectively share loads at the operated level of the spinal column. Some conclusions have been drawn based on this research.Dynamic anterior cervical plates are more successful at maintaining load-sharing after graft subsidence and anterior stabilization devices can be used to provide support to posterior stabilization devices during severe anterior column injuries. Motion preservation devices, specifically cervical disc prostheses and facet replacement systems,show great potential in maintaining physiologicalloads in the spinal column. Further clinical investigation of all these implants would help to identify the contributing factors for their success or failure post-surgery. It would also aid in determining the requirements of an ideal spine stabilization device which perfectly mimics the physiological load-sharing properties of the FSU and its components.

Background Disc protrusion has been proposed to be a possible cause of both pain and stenosis in the lower spine. No previous study has described the amount of disc occlusion of the spinal canal and intervertebral foramen that occurs under different loading conditions. The objective of this study was to quantitatively assess the percent occlusion of the spinal canal and intervertebral foramen by disc bulge under different loading conditions. Methods Spinal canal depth and foraminal width were measured on computed tomography–scanned images of 7 human lumbar spine specimens. In vitro disc bulge measurements were completed by use of a previously described method in which single functional spinal units were subjected to 3 separate load protocols in a spine test machine and disc bulge was recorded with an optoelectric motion system that tracked active light-emitting diodes placed on the posterior and posterolateral aspects of the intervertebral disc. Occlusion was defined as percentage of encroachment into area of interest by maximum measured disc bulge at corresponding point of interest (the spinal canal is at the posterior point; the intervertebral foramen is at the posterolateral point). Results The mean spinal canal depth and mean foraminal width were 19 4 ± mm and 5 ± 2 mm, respectively. Mean spinal canal occlusion under a 250-N axial load, ± 2.5 Nm of flexion/extension, and ± 2.5 Nm of lateral bend was 2.5% ± 1.9%, 2.5% ± 1.6%, and 1.5% ± 0.8%, respectively. Mean intervertebral foramen occlusion under a 250-N axial load, ± 2.5 Nm of flexion/extension, and ± 2.5 Nm of lateral bend was 7.8% ± 4.7%, 9.5% ± 5.7%, and 11.3% ± 6.2%, respectively. Conclusion Percent occlusion of the spinal canal and intervertebral foramen is dependent on magnitude and direction of load. Exiting neural elements at the location of the intervertebral foramen are the most vulnerable to impingement and generation of pain.

The history and rationale of posterior dynamic spinal fusion devices has been derived through the experiences with arthrodesis and devices that serve as adjuncts to such procedures. Dynamic fusion devices provide stabilization through immediate fixation while allowing load sharing. Historically, incorporating these two important concepts in surgical techniques along with the implanted devices facilitates the bone healing process. It stands to reason, spinal fusion techniques that provide immediate stabilization and simultaneously significant graft loading should have the same clinical success seen in other long bone and cervical spine arthrodesis techniques. The load-sharing capability is device-dependent and posterior dynamic constructs theoretically allow dynamic compression of the anterior column higher than that of traditional rigid rod fixation.