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Biomechanical influences on the postnatal modeling and remodeling of intervertebral discs have not been described, but the underlying mechanisms are probably quite different from those in vertebrae.
Wedging of discs in scoliosis may involve asymmetric tissue remodeling or selective concave side degeneration [ 87 ].
This Statement presents an analytical simulation of the evolution of a scoliosis curvature, based on the vicious cycle hypothesis, and employing published quantitative estimates of the key variables in this proposed mechanism of curve progression. Methods Loading of the lumbar spine with scoliosis The magnitude of level-specific spinal loading asymmetry was estimated for a three-dimensional spinal geometry with several different magnitudes of scoliosis, assuming physiologically plausible neuromuscular activation strategies [ 88 ].
The strategy that minimized the sum of cubed muscle stresses a physiologically efficient strategy in terms of energy utilization was compared with strategies that equalized or reversed the loading asymmetry at the curve apex. The presumed strategies were required to solve the 'redundancy' problem more muscles than spinal degrees of freedom in these biomechanical analyses.
Muscle activation and spinal loading were calculated for different static tasks, represented by different magnitudes and directions of an external force or moment generated by the modeled person. Load modulated growth of vertebrae Vertebral and tibial growth plate response to sustained compression was measured in three different animal species with The stresses resulted from forces applied by an external apparatus attached to pins passed through the diaphysis and epiphysis.
Spinal growth and simulation of the vicious cycle The spinal growth during each of the adolescent years from 10 to 16 was estimated from a growth curve generated from spinal length measurements obtained from stereoradiographic studies of adolescent patients with scoliosis [ 83 , 90 ].
The modeled geometry was averaged from stereoradiographic studies of 15 patients with a thoracolumbar Cobb angle in the range 27—43 degrees In the simulations of growth, the initial spinal geometry in two dimensions was defined by a lumbar scoliosis of 26 degrees Cobb angle, averaged and scaled from the 15 patients' radiographs [ 88 ].
The estimates of level-specific spinal loading asymmetry, together with the relationship expressing growth sensitivity to load were included in an analysis that was used to estimate the stress distribution across each vertebral endplate, and the resulting asymmetric vertebral growth. The contribution of the altered growth to the progression of a scoliosis curvature was then calculated. The vertical loading direction corresponded to the modeled spine resisting gravity forces.
Two additional factors were taken into account: First, since the disc wedging contributes about half of the lateral curvature, the curvature increase was considered to be double the increases due to vertebral wedging. Results Spinal loading asymmetry Spinal loading asymmetry was dependent on the neuromuscular activation strategy.
In the strategy that is considered most physiological [ 91 ], the sum of the cubed muscle stresses was minimized. In this case the spine was loaded more on its concave side at the curve apex in most activities external loading directions [ 88 ].
However, if the analyses used minimum spinal loading asymmetry as the 'cost function', then symmetrical spinal loading could be achieved, but with a substantial increase in the physiological energy cost. This finding suggests that different individuals may adopt differing neuromuscular activation strategies, with consequences for the spinal loading that could explain why some individuals have more progressive scoliosis curves than others.
Stress-modulated growth in vertebrae and tibiae Growth rates at axially loaded growth plates tail vertebrae and proximal tibiae were found to be modulated relatively uniformly independent of anatomical location and proportional to stress magnitude.
The subscript m signifies the 'baseline' growth and physiological stress for a spine without scoliosis. The spinal shape changes were averaged over the 11 loading cases, assuming that daily activity consists of an equal amount of time spent in each activity Figure 2. Figure 2 Simulated evolution of the thoracolumbar scoliosis as a result of mechanically modulated asymmetrical growth.
The final geometry filled shapes is averaged from the model-predicted final shapes for all 11 analysed loading directions at age 16 years. Note that only the vertebrae grow asymmetrically and develop progressive wedging in this simulation — the discs do not change shape. Illustrative loading scenario For a single anatomical level at the scoliosis curve apex, the compression force is N, laterally offset 2 mm from the vertebral center.
The associated stresses are calculated as 1. Conclusion The simulations indicate that a substantial component of scoliosis progression during adolescent growth is biomechanically mediated. It is possible that suitable muscle rehabilitation programs could alter the prevailing spinal loading, since the muscle force analyses [ 88 ] indicate that different neuromuscular activation strategies are possible, with differing likelihood of loading the spine asymmetrically.
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