Patient-specific computational biomechanics for simulating adolescent scoliosis surgery : predicted vs clinical correction for a preliminary series of six patients

Scoliosis is a spinal deformity that requires surgical correction in progressive cases. In order to optimize surgical outcomes, patient-specific finite element models are being developed by our group. In this paper, a single rod anterior correction procedure is simulated for a group of six scoliosis patients. For each patient, personalised model geometry was derived from low-dose CT scans, and clinically measured intra-operative corrective forces were applied. However, tissue material properties were not patient-specific, being derived from existing literature. Clinically, the patient group had a mean initial Cobb angle of 47.3 degrees, which was corrected to 17.5 degrees after surgery. The mean simulated post-operative Cobb angle for the group was 18.1 degrees. Although this represents good agreement between clinical and simulated corrections, the discrepancy between clinical and simulated Cobb angle for individual patients varied between -10.3 and +8.6 degrees, with only three of the six patients matching the clinical result to within accepted Cobb measurement error of +-5 degrees. The results of this study suggest that spinal tissue material properties play an important role in governing the correction obtained during surgery, and that patient-specific modelling approaches must address the question of how to prescribe patient-specific soft tissue properties for spine surgery simulation.

Scaffolding large units for small group collaborative learning : a case study.

Undergraduates working in teams can be a problematic endeavour, sometimes exacerbated for the student by poor prior experiences, a predisposition to an individual orientation of assessment, and simply the busyness that now typifies the life of a student. But effort in pedagogical design is worthwhile where team work is often a prerequisite in terms of graduate capabilities, robust learning, increased motivation, and indeed in terms of equipping individuals for emergent knowledge-age work practice, often epitomised by collaborative effort in both blended and virtual contexts. Through an iterative approach, based extensively on the established literature, we have developed a successful scaffold which is workable with a large cohort group (n >800), such that it affords students the lived experience of being a part of a learning network. Individuals within teams work together, to develop individual components that are subsequently aggregated and reified to an overall team knowledge artefact. We describe our case and propose a pedagogical model of scaffolding based on three perspectives: conceptual, rule-based and community-driven. This model provides designers with guidelines for producing and refining assessment tasks for team-based learning.

Carbon financing and the Australian emissions trading scheme : less emissions, more opportunities?

The introduction by the Australian federal government of its Carbon Pollution Reduction Scheme was a decisive step in the transformation of Australia into a low carbon economy. Since the release of the Scheme, however, political discourse relating to environmental sustainability and climate change in Australia has focused primarily on political, scientific and economic issues. Insufficient attention has been paid to the financial opportunities which commoditisation of the carbon market may offer, and little emphasis has been placed on the legal implications for the creation of a "new" asset and market. This article seeks to shed some light on the discernable opportunities which the Scheme should provide to participants in the Australian and international debt markets.

Prediction model of the buildup of volatile organic compounds on urban roads

A model to predict the buildup of mainly traffic-generated volatile organic compounds or VOCs (toluene, ethylbenzene, ortho-xylene, meta-xylene, and para-xylene) on urban road surfaces is presented. The model required three traffic parameters, namely average daily traffic (ADT), volume to capacity ratio (V/C), and surface texture depth (STD), and two chemical parameters, namely total suspended solid (TSS) and total organic carbon (TOC), as predictor variables. Principal component analysis and two phase factor analysis were performed to characterize the model calibration parameters. Traffic congestion was found to be the underlying cause of traffic-related VOC buildup on urban roads. The model calibration was optimized using orthogonal experimental design. Partial least squares regression was used for model prediction. It was found that a better optimized orthogonal design could be achieved by including the latent factors of the data matrix into the design. The model performed fairly accurately for three different land uses as well as five different particle size fractions. The relative prediction errors were 10–40% for the different size fractions and 28–40% for the different land uses while the coefficients of variation of the predicted intersite VOC concentrations were in the range of 25–45% for the different size fractions. Considering the sizes of the data matrices, these coefficients of variation were within the acceptable interlaboratory range for analytes at ppb concentration levels.

A biomechanical investigation of vertebral staples for fusionless scoliosis correction

Background: Fusionless scoliosis surgery is an early-stage treatment for idiopathic scoliosis which claims potential advantages over current fusion-based surgical procedures. Anterior vertebral stapling using a shape memory alloy staple is one such approach. Despite increasing interest in this technique, little is known about the effects on the spine following insertion, or the mechanism of action of the staple. The purpose of this study was to investigate the biomechanical consequences of staple insertion in the anterior thoracic spine, using in vitro experiments on an immature bovine model. Methods: Individual calf spine thoracic motion segments were tested in flexion, extension, lateral bending and axial rotation. Changes in motion segment rotational stiffness following staple insertion were measured on a series of 14 specimens. Strain gauges were attached to three of the staples in the series to measure forces transmitted through the staple during loading. A micro-CT scan of a single specimen was performed after loading to qualitatively examine damage to the vertebral bone caused by the staple. Findings: Small but statistically significant decreases in bending stiffness occurred in flexion,extension, lateral bending away from the staple, and axial rotation away from the staple. Each strain-gauged staple showed a baseline compressive loading following insertion which was seen to gradually decrease during testing. Post-test micro-CT showed substantial bone and growth plate damage near the staple. Interpretation: Based on our findings it is possible that growth modulation following staple insertion is due to tissue damage rather than sustained mechanical compression of the motion segment.

What aspects of the scoliosis correction are most important to the teenager who has keyhole scoliosis correction surgery? A prospective series of 100 patients

Introduction. Surgical treatment of scoliosis is assessed in the spine clinic by the surgeon making numerous measurements on X-Rays as well as the rib hump. But it is important to understand which of these measures correlate with self-reported improvements in patients’ quality of life following surgery. The objective of this study was to examine the relationship between patient satisfaction after thoracoscopic (keyhole) anterior scoliosis surgery and standard deformity correction measures using the Scoliosis Research Society (SRS) adolescent questionnaire. Methods. A series of 100 consecutive adolescent idiopathic scoliosis patients received a single anterior rod via a keyhole approach at the Mater Children’s Hospital, Brisbane. Patients completed SRS outcomes questionnaires before surgery and again at 24 months after surgery. Multiple regression and t-tests were used to investigate the relationship between SRS scores and deformity correction achieved after surgery. Results. There were 94 females and 6 males with a mean age of 16.1 years. The mean Cobb angle improved from 52º pre-operatively to 21º for the instrumented levels post-operatively (59% correction) and the mean rib hump improved from 16º to 8º (51% correction). The mean total SRS score for the cohort was 99.4/120 which indicated a high level of satisfaction with the results of their scoliosis surgery. None of the deformity related parameters in the multiple regressions were significant. However, the twenty patients with the smallest Cobb angles after surgery reported significantly higher SRS scores than the twenty patients with the largest Cobb angles after surgery, but there was no difference on the basis of rib hump correction. Discussion. Patients undergoing thoracoscopic (keyhole) anterior scoliosis correction report good SRS scores which are comparable to those in previous studies. We suggest that the absence of any statistically significant difference in SRS scores between patients with and without rod or screw complications is because these complications are not associated with any clinically significant loss of correction in our patient group. The Cobb angle after surgery was the only significant predictor of patient satisfaction when comparing subgroups of patients with the largest and smallest Cobb angles after surgery.

The measurement of applied forces during anterior single rod surgical correction of adolescent idiopathic scoliosis

INTRODUCTION. Following anterior thoracoscopic instrumentation and fusion for the treatment of thoracic AIS, implant related complications have been reported as high as 20.8%. Currently the magnitudes of the forces applied to the spine during anterior scoliosis surgery are unknown. The aim of this study was to measure the segmental compressive forces applied during anterior single rod instrumentation in a series of adolescent idiopathic scoliosis patients. METHODS. A force transducer was designed, constructed and retrofitted to a surgical cable compression tool, routinely used to apply segmental compression during anterior scoliosis correction. Transducer output was continuously logged during the compression of each spinal joint, the output at completion converted to an applied compression force using calibration data. The angle between adjacent vertebral body screws was also measured on intra-operative frontal plane fluoroscope images taken both before and after each joint compression. The difference in angle between the two images was calculated as an estimate for the achieved correction at each spinal joint. RESULTS. Force measurements were obtained for 15 scoliosis patients (Aged 11-19 years) with single thoracic curves (Cobb angles 47˚- 67˚). In total, 95 spinal joints were instrumented. The average force applied for a single joint was 540 N (± 229 N)ranging between 88 N and 1018 N. Experimental error in the force measurement, determined from transducer calibration was ± 43 N. A trend for higher forces applied at joints close to the apex of the scoliosis was observed. The average joint correction angle measured by fluoroscope imaging was 4.8˚ (±2.6˚, range 0˚-12.6˚). CONCLUSION. This study has quantified in-vivo, the intra-operative correction forces applied by the surgeon during anterior single rod instrumentation. This data provides a useful contribution towards an improved understanding of the biomechanics of scoliosis correction. In particular, this data will be used as input for developing patient-specific finite element simulations of scoliosis correction surgery.