Thursday, December 3, 2009, 1:46 1:52 pm CSRS 2009

Paper #18
Validation of a Non-Invasive Technique to Precisely Measure In Vivo
Three-Dimensional Cervical Spine Movement
William J Anderst, MS, Pittsburgh, PA, USA (7- Univ of Pittsburgh, CSRS);
William F Donaldson, III, MD, Pittsburgh, PA, USA (7-Stryker);
Joon Y Lee, MD, Pittsburgh, PA, USA (n);
James D Kang, MD, Pittsburgh, PA, USA (7-Johnson & Johnson, Medtronic Sofamor Danek,
Stryker, Osteotech)

Introduction: It is difficult to accurately determine three-dimensional (3D) spine motion in vivo

during physiological loading due to the inability to directly attach measurement equipment to
individual vertebrae. Previously, cervical spine motion has been measured in vivo under static
conditions using MRI1, CT2, single3,4 and biplane5 x-ray. Two-dimensional fluoroscopic video has
also been used to quantify dynamic sagittal plane motion6. These techniques have significant
limitations, including unreliability, inaccuracy, and the inability to capture true three-dimensional
motion during functional loading. Furthermore, these techniques have not been rigorously
validated using in vivo data and a highly accurate ground truth reference for comparison. The
objective of the present study was to determine the accuracy of a non-invasive model-based
tracking technique that combines subject-specific CT models and high-speed biplane x-ray images
to measure in vivo cervical spine motion.

Methods: Three subjects had 1.0 mm diameter tantalum beads implanted into their fused and
adjacent cervical vertebrae during ACDF surgery (3-5 beads per vertebral body). Subjects were
tested within a biplane x-ray system 6 months after surgery. Biplane x-rays were collected for 2
seconds at 30 to 50 frames per second for 3 trials each of continuous flexion/extension, lateral
bending and axial rotation. A total of 7 flexion/extension trials were analyzed as part of this of this
validation. Implanted beads were tracked within the x-ray images to provide a ground truth for
vertebral movement each trial. Subject-specific bone models derived from CT were placed within
a proportionally identical virtual data collection system (Figure 1) and a computerized matching
process reproduced bone location and orientation in 3D space each x-ray frame. The ability of the
model-based tracking technique to accurately track the position and orientation of individual bones
was quantified by comparing bead-based and model-based tracking results. Additionally, for each
frame of every trial, relative translation and rotation between adjacent vertebrae was calculated
(joint kinematics) using both the bead-based and the model-based tracking results. Accuracy results
were grouped according to motion segment location (above the fusion, fused, or below the fusion)
to investigate variability due to implanted fusion instrumentation.

Results: Implanted beads were tracked with precision of 0.10 mm, with no difference among
fused and adjacent bones, providing a highly accurate ground truth standard. Precision of the
model-based tracking when tracking individual bones was 0.11 mm, 0.21 mm, 0.09 mm for bones
above the fusion site, for fused bones, and for bones below the fusion, respectively. Precision in
measuring 3D joint kinematics in fused and adjacent segments was 0.5 mm or better in translation
and 1.3 degrees or better in rotation (Table 1).

If noted, the author indicates he/she and/or a member of his/her immediate family something of value received. The codes are identified as
7-research or institutional support; 10-miscellaneous non-income support/miscellaneous funding; 3-royalties; 8-stock or stock options;
5a-paid consultant or employee; 5b-unpaid consultant; 4-speakers bureau/paid presentation; n-nothing of value received.
Thursday, December 3, 2009, 1:46 1:52 pm CSRS 2009
Paper #18 (cont.)
Conclusion: 3D cervical spine motion can be precisely measured in vivo with sub-millimeter
accuracy during functional loading without the need for bead implantation. Fusion instrumentation
did not diminish the accuracy of motion segment kinematic results. This technique may now be
applied to assess in vivo vertebral kinematics in asymptomatic and surgical subjects while they
perform functional tasks.

Figure 1. The biplane x-ray technique combines information from two simultaneous
radiographic images to precisely recreate 3D bone locations during dynamic movement. A 3D
CT reconstruction of the bone is placed in a computer-generated simulation of the x-ray system.
Digitally reconstructed radiographs (DRRs) are then created by passing simulated x-rays through
the 3D CT reconstruction. Bone position and orientation is determined by optimizing the
correlation between the DRRs (green bones) and the edge-enhanced radiographs
(red in figure).

Table 1. Precision of the model-based tracking method when measuring in vivo joint kinematics
during flexion/extension. Data from 3 subjects performing 7 trials of flexion/extension.
Translation accuracy in millimeters, rotational accuracy in degrees.

References: 1)Ishii, 2006. 2)Penning, 1987. 3)Dvorak, 1988. 4)Frobin, 2002. 5)Mimura,
1989. 6)Reitman, 2004.

The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being
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