Tag Archives: spine

A Second Chance: Robotic Exoskeletons May Be the Future of Mobility for Patients with Spinal Cord Injuries

No one ever imagines themselves getting seriously injured. Accidents do happen though, like car crashes and unexpected sports injuries. These events can drastically change a person’s life, leaving them unable to perform simple daily tasks without assistance, such as walking. One injury that can radically impact a person’s life is a spinal cord injury. There are approximately a quarter of a million people in the United States with spinal cord injuries, and that number grows by 12,500 each year.

The spine is the center of support in the body. It adds structure and facilitates movement. Its other extremely important job is to protect the spinal cord, which is a column of nerves that runs down the length of the neck and back. The spinal cord is part of the nervous system, and it acts as a messenger, taking orders from the brain and relaying these messages to the rest of the body, telling the muscles what to do. If the spinal cord is injured, the messages can’t be delivered properly. This often results in a loss of mobility.

Diagram of the central and peripheral nervous system showing how the spinal cord connects the brain to nerves that run throughout the body
From OpenStax Anatomy and Physiology on Wikimedia Commons

Most people don’t think about the mechanics involved in the simple act of walking. However, in order to walk, various joints such as the hip, knee, and ankle need to work together, rotating and bearing loads to allow for movement. When your foot hits the ground, the ground imparts a force through the foot which is translated up through the lower extremities to the spine. When a spinal cord injury occurs, the brain is unable to communicate with our muscles which inhibits this load bearing and the resulting movement.

Studies have shown that powered exoskeletons have numerous benefits for patients with spinal cord injuries to help with walking and mobility. These powered exoskeletons are built in various ways to bear loads and encourage movement, and a review of different exoskeletons, along with other rehabilitation devices, discusses differences in design and control of the systems. For example, to allow for control of movement, one exoskeleton was built with motors located at the joints while another was designed with a braking system at the joints.

Photo of the Indego powered exoskeleton
Indego Exoskeleton – From Indego.com

One study researched mobility outcomes for patients with injuries that varied in severity and location on the spine. Some patients were paraplegic, which means their lower extremities were paralyzed, and some patients were tetraplegic/quadriplegic, which means the paralysis affected both their lower and upper extremities. Also, some patients had complete spinal cord injuries, which means all feeling was lost below the injury, while others had incomplete spinal cord injuries, which means they had some feeling and some ability to control movement below the injury. This study showed that powered exoskeletons, specifically the Indego exoskeleton, could help a patient move in both indoor and outdoor settings, and there is potential for patients with paraplegia caused by injuries to the lower spine to use this device to allow greater ease of mobility in public spaces. For patients with more severe injuries, such as those with quadriplegia, the powered exoskeleton allowed for slower movement with supervision and occasional assistance from a therapist. These patients also needed assistance with putting on and removing the device. Therefore, the powered exoskeleton won’t help patients with more severe injuries move on their own in public settings, but it was excellent for exercise and rehabilitation.

These exoskeletons are also proven to be safe and feasible. Patients with complete spinal cord injuries did not report discomfort or injury, and they were able to use a powered exoskeleton more easily than previous rehabilitation technology.

Powered exoskeletons may be the future of movement for those who thought they would never walk again. This further reading contains examples of paraplegics who walked using a powered exoskeleton. Another man even walked marathons using one of these devices:

From Freethink on YouTube

There are limitations on these devices, but the robotics field is swiftly evolving, and the technology is giving patients something they never thought they would have: a second chance.

Top Gun Trauma: the Effects of Ejecting From a Fighter Jet on the Spine

The need for speed places fighter pilots in electrifying yet dangerous situations. When things go wrong during flight, pilots must consider ejecting, a terrifying choice. Ejection is a last resort due to the large compressive forces and the high wind speeds that can cause many different serious injuries, including spinal injuries. Approximately 20-30% of people who survive ejection endure spinal fractures. Understanding the dangers of flight that servicemembers face increases awareness of the military lifestyle within the civilian population and is critical in finding solutions to lessen the severity of injury.

During ejection, the rocket-propelled ejection seat thrusts the pilot upward out of the aircraft. The pilot experiences around 18 g-forces (18 times your bodyweight)! The acceleration from the thrust of the seat, peaking at 140 to 160 m/sec2, compresses the spine vertically, loading the thoracic and lumbar spinal regions seen below. 

Anatomy of the spine
Photo from Patel et al., Pediatric Practice: Sports Medicine, 2009

The large rate of loading causes spinal fractures that can be either unstable and require surgery due to the movement of vertebrae or stable and treated with a brace. Thoracolumbar (lower back) fractures can be modeled using a variety of methods. One study applied axial loads of 5.2 kN (1,169 lbs) on two different spines from cadavers with a peak acceleration of around 20 g to simulate ejection. The resulting fractures for both specimens were on the L1 vertebrae, and one fracture was stable while the other was unstable. Another study constructed a drop tower and subjected 23 lumbar spines (T12-L5) to axial forces between 2.1 (472 lbs) and 7.3 kN (1,641 lbs) and accelerations between 8 and 23 g. Data analysis produced injury probability curves, which showed a 95% chance of injury with an acceleration of 20 g. The larger loads and accelerations also correlated with lower-level injuries (L4 and L5 vertebrae). 

One study modeled ejection using the finite element method, which can mathematically model the spine’s response to forces, and imaging software to investigate the effect of posture on spine injury severity. 

Software model of thoracolumbar spines in normal and relaxed postures.
Modified from Du et al., Int. J. Numer. Meth. Biomed. Engng., 2014

Thoracolumbar spines in normal and relaxed postures shown in the image above were simulated with an acceleration peak of 15 g for 0.2 sec. The relaxed posture correlates with increased stress on the endplate (the region between a vertebrae and an intervertebral disc), as the relaxed posture increases anterior flexion (forward bending) of the spine that is then increased by compression. Sitting straight up could help decrease the chance of injury during ejection. 

Ejection is a harsh reality that some pilots face. But as dangerous as ejecting is, ejection seats have a 92% survival rate, and sustaining a spinal injury is worth keeping your life. One B-1 Bomber crew member who ejected over the Indian Ocean said, “I lost a full inch in height.” It’s the price service members pay to dominate the skies and fly faster than the speed of sound. 

For more information, check out this retrospective study of French forces and this analysis of accident reports from the Royal Air Force

Pressurized Vessels Supporting the Spine: Structure and Function of Intervertebral Discs

Back in 1989, it was estimated that about 2.5 million U.S. workers suffered from low back pain, and low back pain has even been talked about as one of the largest causes of disability in the world. Intervertebral disc degeneration is one of the most common reasons for low back pain in adults. In order to understand how disc degeneration occurs and causes pain, it is important to examine the structure and function of discs in the back.

Computer generated image of a healthy lumbar spine
Vertebral Column: Obtained from Smart Servier Medical Art

Discs are structures that sit in between vertebrae in the spine (blue in the image). Their consistency has been compared to Jell-O and the seemingly mythical product called the waterbed. This consistency comes about because of the microstructure of the discs. The main structural component is collagen which not only surrounds the discs but also traverses across the fluid-filled center to give support. Collagen is found all over the body in places ranging from bones to eyes. There are many different types of collagen that are able to account for the softness of the cornea and the strength and stiffness of bones. In discs in the back, the collagen that traverses the middle is the same as that found in cartilage, while the collagen that makes up the outer layer is the same collagen found in skin and bones. This gives the discs a strong, thin outer layer surrounding the gel-like center, warranting the comparison to the waterbed.

Because of this structure, intervertebral discs provide support for the spine in compression. The spine can be compressed by activities as simple as carrying a backpack, sitting, or bending over. When these and other activities occur, the vertebrae press in on the discs, causing pressures from about 15 to 300 psi, or pounds per square inch, depending on the activity. For reference, the recommended tire pressure for a car is 30-35 psi and the pressure inside a champagne bottle is 60-90 psi.

As discs degenerate, either with age or trauma, they respond differently to the large compressive stress applied from the spine. With age, this change in response is most commonly attributed to the inside portion of the disc drying up and changing from a gel to a solid. Discs rely heavily on fluid flowing through their pores, and once they dry up, this no longer occurs. As loads are applied, instead of increasing pressure, degenerate discs can expand outward creating a phenomenon known as a bulging disc. While this is just one of the many medical problems a degenerate disc can cause, it is

Computer generated image of a lumbar spine with disc herniation.
Disc Herniation: Obtained from Smart Servier Medical Art

common and typically leads to an increase in pain. When the discs expand outwards, it reduces the space between the vertebrae causing irritation. If the discs expand far enough outward, they can leave the space between the vertebrae, entering the region where many nerves lie, potentially causing pain throughout the body.

Despite their odd consistency, intervertebral discs play an important role in the spine, sometimes pressurizing to more than 3 times that of a champagne bottle. Both injuries and natural degeneration leads to negative changes in the biomechanical properties of discs, causing an increase in back pain. If you are interested in learning how to take care of your discs, worried you have an injured disc, or simply want to learn more, I recommend going here.

The Spinal Fusion that Reignited a Legendary Career

Can you imagine being the best player in the world at a certain sport and one day, aggravating an injury that not only put your athletic career in doubt, but also did not allow you to do normal daily activities? This is the challenge that faced Tiger Woods.

Tiger Woods is one of the greatest golfers to ever play the sport but has been plagued with back issues over the past few years that have prevented him from winning and also playing in golf tournaments. A golf swing applies a significant amount torque to one’s back. Repeating this motion as many times as Tiger has, through practice and tournaments since he began his career, caused him to have chronic back issues that had to be dealt with. In order to deal with these back issues, he had three back surgeries over the course of three years. After these, he was still unable to not only golf but also do daily activities without pain such as get out of bed, or play ball with his kids. Tiger was at a crossroads, and decided to get a spinal fusion surgery.

An image of the spine with the three regions labeled: cervical (upper region), thoracic (middle region), lumbar (lower region)
Taken from Wikimedia Commons

The spine has three regions: cervical, thoracic and lumbar. The cervical region is in the upper spine near the neck, the thoracic region is in the middle of the spine and the lumbar region is in the lower back. The lumbar region takes the majority of force in a golf swing and is where Tiger had his fusion done. In the spine, discs are in between each vertebra. The disc acts as a shock absorber and allows for slight mobility of the spine. Tiger had a severely narrowed disc in between two of his vertebrae in the lumbar region due to the previous three back surgeries he had. In order to be pain free, that disc had to be removed. This brought about the discussion of him receiving spinal fusion surgery.

 

Spinal fusion surgery is a process which removes the problematic disc from the spine and inserts a bone graft in place of the disc. A plate with screws is then placed in the vertebrae above and below the bone graft. The plate helps with the healing process and over time, it will heal as one unit. The essential goal of spinal fusion surgery is to take two vertebrae in your spine and make them act as one. When these two vertebrae become one through the surgery, it eliminates motion in between them and hopefully, removes the pain as well.

This is an image of a spinal fusion surgery with screws helping to hold the vertebrae together
Image taken from Wikimedia Commons

This spinal fusion surgery was a huge success for Tiger and allowed him to keep playing golf at a high level. Through his win at the 2019 Masters tournament, it’s safe to say that he has at least a few more years of winning tournaments and playing competitive golf before calling it a career.

Additional information and sources used can be found here and here.