Effect of Degeneration on the Six Degree of Freedom Mechanical

Properties of Human Lumbar Spine Segments

Dhara B. Amin,1 Dana Sommerfeld,2 Isaac M. Lawless,1 Richard M. Stanley,1 Boyin Ding,3 John J. Costi1
1
Biomechanics and Implants Research Group, The Medical Device Research Institute, School of Computer Science, Engineering and
Mathematics, Flinders University, Bedford Park 5042, South Australia, Australia, 2Institute of Biomechanics, Hamburg University of Technology,
Hamburg, Germany, 3School of Mechanical Engineering, The University of Adelaide, Adelaide, South Australia, Australia
Received 19 January 2016; accepted 5 June 2016
Published online 28 June 2016 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/jor.23334

ABSTRACT: While the effects of disc degeneration on compression and rotation motions have been studied, there is no data for shear
loading. Clinical research has shown that those with low back pain (a potential consequence of degeneration) experience a 75% greater
lateral shear force than those without it. Therefore, the aim was to compare the effect of degeneration on spine segment stiffness and
phase angle in each of six degree of freedom (6DOF) loading directions. Fourteen intact functional spinal units (FSU) were dissected
from human lumbar spines (mean (SD) age 76.2 (11) years, Thompson grades 3 (N ¼ 5, mild), 4 (N ¼ 6, moderate), 5 (N ¼ 3, severe)).
Each FSU was tested in 6DOFs while subjected to a physiological preload, hydration, and temperature (37˚C) conditions in a hexapod
robot. A one-way ANOVA between degenerated groups was performed on stiffness and phase angle for each DOF. Significant
differences in stiffness were found between mild and moderate degenerative groups in lateral shear (p ¼ 0.001), and axial rotation
(p ¼ 0.001), where moderate degeneration had decreased stiffness. For phase angle, significant differences were seen in anterior shear
(p ¼ 0.017), and axial rotation (p ¼ 0.026), where phase angle for mild degeneration was less than moderate. Trends of stiffness and
phase angle changes between degenerative groups were similar within each DOF. Clinically, the identification of the DOFs that are
most affected by degeneration could be used in rehabilitation to improve supplemental stabilization of core muscle groups. ß 2016
Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1399–1409, 2016.

Keywords: disc degeneration; six degree of freedom; biomechanics

Disc degeneration leads to biochemical and mechanical
changes resulting from structural alterations in the
nucleus pulposus, annulus fibrosus, and vertebral
endplate.1,2 The loss of water in the nucleus and
corresponding decrease in disc height places higher
stresses on the annulus,3 theoretically contributing to
greater viscous damping of the solid phase than seen
in normal disc tissue. These increased annular
stresses may lead to the formation of annular tears
and clefts,4,5 calcification of the endplates,6–8 and an
increase in osteophyte formation.9,10 In addition to
structural changes, disc degeneration can lead to
clinical and mechanical instability.11–13
Clinically, the definition of joint instability is when a
patient with back problems transitions from mildly to
severely symptomatic with the least provocation12.
Kirkaldy–Willis and Farfan further characterized the
relationship between degeneration and instability by
defining three clinical and biomechanical stages: Tem-
porary dysfunction, instability, restabilization12. Fur-
thermore, mechanical instability is defined as increased
abnormal motion relative to the load applied in compar-
ison to normal, which does not necessarily always evoke
a clinical response.12 A number of in-vitro studies have
quantified mechanical instability by measuring the
range of motion (ROM) of spinal segments under
rotations about three anatomical axes.14–19 However,
there is no general consensus on trends among these
studies. For example, Mimura et al. found an increase
in ROM with degeneration for lateral bending, while
Grant sponsor: Whitaker International Program.
Correspondence to: John J. Costi (T: þ61 8 8201 3323;
F: þ61 8 8201 2904; E-mail: john.costi@flinders.edu.au)
# 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Krismer et al. saw a decrease. In flexion/extension and
axial rotation, most studies reported an increase in
ROM15,16,20; however, there were studies which found a
decrease with degeneration.17,18 In addition, these
studies did not conduct testing under physiological
conditions, such as the application of a follower load
and hydration of the specimen. Furthermore, many of
the ROM studies were tested under quasi-static step-
wise loading rather than ramp or cyclic loading.
With the continuing improvement of six degree of
freedom (6DOF) testing systems, instability due to
degeneration can be characterized under more physio-
logical conditions and by other mechanical parameters
such as stiffness. The human spine is a complex
structure that allows for multi-directional, 6DOF
movements under dynamic loads during daily activi-
ties. Understanding how the diseased spine responds
to those movements and loads is critical for the
development of new spinal implants and surgical
treatments for disc injuries. A study by Zirbel et al.
investigated the effect of degeneration on ROM and
stiffness under a compressive follower load for axial
rotation, lateral bending, and flexion-extension.19 They
found significant differences in spine segment stiffness
between degenerative grades during axial rotation,
bending, and compression, with a fivefold increase for
grade 5 discs compared to 3. However, there is limited
research on the mechanical response of degenerated
intact functional spinal unit (FSUs—including
posterior elements) under 6DOF loading.
While the effects of degeneration on compression
bending, and rotation motions have been studied, to
our knowledge there is no data for shear loading.
Clinical research has shown that people with lower
back pain experience a 75% greater lateral shear force

JOURNAL OF ORTHOPAEDIC RESEARCH AUGUST 2016 1399

1400 AMIN ET AL.
than those without it,21 indicating the importance of
shear loading and its mechanical response.22–24 Fur-
thermore, while stiffness has been reported in few
studies, there is limited data on the phase angle (a
measure of energy absorption) behavior of the spine
segment in 6DOF. To the authors’ knowledge, there is
only one study that measured phase angle of primarily
grades 1 and 3 isolated disc segments.25 Phase angle
can give insight into the viscoelasticity of the disc,
which is important when developing medical devices
for degenerated spine segments.
Therefore, the aim of this study was to determine
the effect of degeneration on the stiffness and phase
angle of intact FSUs in each of 6DOF loading direc-
tions. Intact FSUs were chosen to ensure clinical
relevance. Based on the Thompson macroscopic assess-
ment criteria,26 a significant loss of nucleus pressuri-
zation occurs between grades 3 and 4 degenerated
discs, which may correlate with the instability phase
described by Kirkaldy–Willis and Farfan. This loss of
pressurization results in a reversal of the outward
bulging annulus fibrosus, which would also cause a
decrease in tensile hoop stresses and a corresponding
decrease in shear stiffness of the tissue. However, it is
possible that during compressive and bending loading,
consolidation of the fibrotic nucleus tissue may pro-
duce an increase in hoop stresses compared to during
shear loading, and therefore an increase in stiffness in
these DOFs. During the re-stabilization phase, which
we suggest corresponds to grade 5 degenerated discs,
we hypothesize that the stiffness during shear loading
will increase compared to grade 4 discs by a larger
relative magnitude than for compression and bending
loading. For energy absorption, we hypothesize that
the phase angle will increase between grades 3 and 4
due to the presence of clefts and tears in the annulus
and nucleus. However, for grade 5 discs, which have a
dramatic reduction in disc height, and often very little
remaining tissue, as well as the presence of significant
osteophytes and endplate sclerosis, we hypothesize
that there will be a decrease in phase angle between
grades 4 and 5.
JOURNAL OF ORTHOPAEDIC RESEARCH AUGUST 2016
METHODS
Specimen Preparation
Fourteen vertebra-disc-vertebra functional spinal units
(FSUs), including the posterior elements, were dissected
from 10 freshly frozen human lumbar spines (Levels:
4  L1–2, 4  L2–3, 4  L3–4, 2  L4–5, mean (SD) age: 76.2
(11) years, age range: 64–93 years). This study was approved
by the Southern Adelaide Clinical Health Human Research
Ethics Committee (August 2013). Lumbar spines were stored
at 30˚C (22˚F) and then thawed at room temperature for
at least 3 h, after which careful dissection of soft tissue
surrounding the vertebrae (inferior and superior) and disc
was performed, keeping both the anterior and posterior
longitudinal ligaments intact, as well as the facet joint
capsules. The superior and inferior vertebral surfaces were
then cut parallel to the mid-transverse plane of the disc
using an alignment device in a bandsaw. Specimens were re-
frozen until the day prior to testing, thawed overnight in the
refrigerator, followed by a minimum of 3 h at room tempera-
ture. Axial and lateral radiographs were taken of all speci-
mens to determine the instantaneous axis of rotation of the
disc relative to the cups, which was used as the center of
rotation for the rotational tests.27 The vertebral bodies were
then embedded in fixation tooling using Wood’s Metal28 after
which the FSU underwent a comprehensive sequence of
6DOF mechanical testing (described below). The potting
fixtures consisted of two 316 grade stainless steel cups for
each vertebra. A potting alignment device was used to ensure
that the cups were parallel to each other and therefore with
the mid-transverse plane of the disc.
6DOF Testing System: Hexapod Robot
The embedded FSU was coupled to a custom developed
6DOF hexapod robot and aligned with the hexapod’s axes
(þx ¼ right lateral, þy ¼ anterior, þz ¼ superior). Briefly, the
hexapod robot was based on the concept of the Stewart
platform and employs six servocontrolled ball screw driven
actuators that precisely position a mobile upper plate with
respect to a fixed base plate (Fig. 1). Specimens were bolted
between the fixed base and the mobile upper plate. Displace-
ments and rotations of the specimen were directly measured
by six linear optical incremental encoders with a resolution
of 0.5 mm (B366784180185; LDM54, MicroE Systems, Inc.,
Billerica, MA) that were positioned independently to the
loading frame (i.e., actuators and their ball joint mounting
Figure 1. (a) Photograph showing the six degree
of freedom hexapod robot testing system. A bone is
shown installed in the hexapod for illustration
purposes only. The specimen was inserted between
the rigid base and mobile upper plate (arrow). A
six axis load cell (indicated in photo behind actua-
tor frame) is connected between the mobile upper
plate and actuator frame. Six ball screw actuators
produce the required displacement or rotation.
Displacements and rotations of the specimen were
directly measured by six linear optical encoders
(arrow) that were positioned independently to the
loading frame. Therefore, system compliance was
eliminated from the measurement of specimen
behaviour. (b) Testing setup inside of the Hexapod
robot, showing the stainless steel cups with water
bath, and load cell.
 EFFECT OF DEGENERATION ON MECHANICAL PROPERTIES 1401

points) and load cell. The encoders measure the position of

each of the hexapod’s six actuators, which are then used
together with the robot kinematics to calculate the displace-
ments/rotations of the upper vertebrae relative to the fixed
lower vertebrae about the center of rotation of the disc.
Therefore, the measurement accuracy is highly dependent on
the robot stiffness. The novel design of the hexapod effectively
addressed this and ensured the accuracy of the measurement
even under high loading.29 This configuration eliminated
system compliance from the measurement of specimen behav-
ior. Forces and moments were measured by a six axis load cell
(MC3A-6-1000, AMTI, Watertown, MA), having a maximum
axial compressive force capacity of 4,400 N and 110 Nm of
axial torque. A novel adaptive velocity-based 6DOF load
control scheme allowed for the application of dynamic loading
either as pure forces/moments with real-time minimization of
all off-axis forces/moments, or a hybrid position/load control
strategy.30 The displacement measurements were indepen-
dently validated prior to this study to National Association of
Testing Authorities (NATA) standards (ISO 2009), and the
load accuracies were based on NATA calibrations provided by
the manufacturer. The accuracy of the measured compressive
force and axial torque were 9 N and 0.2 Nm, respectively,
with displacement and rotation angle accuracy being
0.01 mm and 0.006˚, respectively.

Mechanical Testing Protocol

Since viscoelastic tissue properties are temperature and
hydration dependent,31–33 the specimens were immersed in a
0.15 M phosphate buffered saline (PBS) bath at 37˚C
throughout testing.25 To reduce putrefaction and tissue
autolysis, protease inhibitors, antibacterial, and antifungal
agents were added to the bath (Amphotericin B—2 ml
(10 ml/L), Benzamidine—32 mg (1 mM), EDTA—4 ml (1 mM),
Idoacetamide—4 ml (1 mM), Gentamicin—10 mg (10 mg/ml),
Pepstatin A—3 ml (0.3mM), Deionized water—168 ml, and
PBS 10—18 ml (0.15M)).25 Each FSU was subjected to a
12 h axial compressive preload equivalent to a nucleus
pressure of 0.1 MPa that represents the unloaded lumbar
disc during sleeping34 in the temperature controlled bath to
reach hydration equilibrium.35 The relationship between the
applied external FSU compressive stress and nucleus pres-
sure is linear, with nucleus pressure being greater by a
factor of approximately 1.5.35 This factor was used to
calculate the required external compressive force based on
the unloaded disc area, to generate the equivalent nucleus
pressure. The unloaded disc area was estimated based on the
formula 0.84  AP  LAT,36 where AP and LAT were the
largest anteroposterior and lateral dimensions of the inferior
and superior vertebrae, averaged over three measurements
using Vernier callipers. Disc area measurements were taken
before potting the FSU.
After hydration equilibration, an initial reference compres-
sion test was conducted. First, a compressive ramp axial
follower preload, equivalent to a nucleus pressure of 0.5 MPa
was applied under 6DOF load control, where all off-axis forces
and moments were minimized to zero. Second, a compressive
haversine waveform (0.1 Hz for eight cycles), having an
amplitude of 0.6 MPa was performed under 6DOF real-time
load control.30 This loading regime subjected the FSU to a
1.1 MPa equivalent nucleus pressure to approximate the in-
vivo intradiscal pressure recorded during standing.34 Once
the reference compression test was completed, the FSU was
subjected to 6DOF testing (Fig. 2).37
Figure 2. Overall testing order. The above sequence was
repeated for each of 6DOF directions on the intact FSUs.
After each 6DOF test direction (e.g., after left lateral
shear), another reference compression test was performed.
For 6DOF testing, the FSU underwent dynamic haversine
displacements/rotations in each DOF with a hybrid position/
load control protocol that drove the primary axis in position
control while minimizing coupling forces/moments in the
other 5DOF via real-time load control.30 The same 0.5 MPa
follower preload was applied during all 6DOF tests. The
sequence of loading directions was chosen to theoretically
minimize the biphasic effect,25 with shear and axial rotation
tests conducted first, followed by bending and axial compres-
sion tests. Displacement amplitudes were: 0.6 mm for all
shear tests (anterior/posterior/lateral shear); 2˚ for axial
rotation; 3˚ for lateral bending; 5˚ for flexion, and 2˚ for
extension.25,38–40 For the axial compression test, the same
sequence described for the reference compression test was
applied (i.e. 1.1 MPa including 0.5 MPa follower preload).
For each DOF (left and right lateral shear, anterior and
posterior shear, left and right axial rotation, left and right
lateral bending, flexion, extension, combined flexion and
extension and compression), five cycles at 1, 0.1, and 0.01 Hz
were applied, followed by a creep recovery25 at a compressive
0.1 MPa equivalent nucleus pressure for 5 (shears/axial
rotation) or 10 min (bending/compression). After creep recov-
ery, two cycles at 0.001 Hz were applied followed by another
recovery period. After the frequency tests, the disc under-
went stress relaxation (0.6 mm for shears and compression;
2˚ for flexion, extension, and axial rotation; 3˚ for lateral
bending) for 5 min, and creep (300 N for shears; 10 Nm for

JOURNAL OF ORTHOPAEDIC RESEARCH AUGUST 2016

1402 AMIN ET AL.

flexion, extension, and axial rotation; 20 Nm for lateral

bending; 1.1 MPa for Compression) for 5 min in each respec-
tive DOF with a creep recovery period in between. A final
recovery period at a compressive 0.1 MPa equivalent nucleus
pressure for 5 (shears/axial rotation) or 10 min (bending/
compression) was conducted after the creep testing. A final
reference compression test was then conducted. This se-
quence of testing was then repeated for each DOF. The total
duration for equilibration and testing was approximately
32 h for each specimen. After testing, the degenerative grade
for each specimen was determined separately by five
researchers using the Thompson scale based on a mid-
sagittal cut through the disc segment.26 For this study, data
from the 0.1 Hz dynamic tests was analyzed for intact FSUs
and for each DOF.

Data and Statistical Analyzes

Degenerative groups for grades 3, 4, and 5 were labelled as
mild, moderate, and severe degeneration, respectively. To
assess inter-rater reliability and consistency, the Cronbach’s
Alpha was calculated for assessment between multiple
observers. Data from the final cycle of each 0.1 Hz test were
processed and analyzed in MATLAB (2014b, The Math-
works Inc.). Stiffness for each DOF was calculated using
linear regression to determine the slope (MATLAB: POLY-
FIT.m having an order of 1) over a specific range of the
loading portion of the load-displacement curve. The ranges
over which stiffness was calculated for each DOF were:
0.4–0.58 mm for all shear tests, 2˚–2.8˚ for flexion and
lateral bending, 1.25˚–0.85˚ for extension, 1.5˚–1.8˚ for axial
rotation, and 0.77–1 MPa for axial compression. Phase
angles for each DOF were calculated between the input
displacements and measured forces for all cycles using the
cross spectral density estimate function (MATLAB: CSD.
m).25,28 Data from the combined flexion and extension test
were not included in the study, since the individual flexion
and extension tests were analyzed. Figure 3. Example specimen from each degenerative category
Separate ANOVAs were performed on the dependent as grading using the Thompson classification (left-right images:
outcome measures of stiffness and phase angle having an Mild, moderate, and severe degeneration).
independent factor of degenerative grade (mild, moderate,
and severe) for each DOF. Post-hoc multiple comparisons Thompson scale, respectively (Fig. 3). Assessment of
using a Bonferroni correction on alpha were performed when
degenerative grade from five raters did not result in
significant main effects were present. Paired t-tests between
whole number values, which are reported in Table 1.
left and right lateral shear, lateral bending, and axial
rotation were performed to assess symmetry of DOFs. However, for the one-way ANOVA analysis, they were
Significant differences were accepted when p < 0.05 rounded. There was high interobserver reliability on
(2-tailed). Multi-factorial post-hoc power analysis were con- the grade of disc degeneration for each specimen, with
ducted using G POWER, a power analysis software pro- an alpha value of 0.8750. Paired t-tests to analyze
gram,41 using a type II error of 0.2, and a type I error of symmetry found no significant differences between left
0.05, based on the overall effect of the three degenerative and right lateral shear, lateral bending, and axial
groups. rotation (p > 0.05). The means for left and right were
therefore averaged for each of those three DOFs and
RESULTS used in the analysis of the data. Similar load versus
No specimens were excluded from the analysis and displacement behavior was observed for all three
there was no evidence of tissue putrefaction or slip- degenerative groups except in extension and posterior
page of specimens during testing. Mean (SD) disc area shear, where the severely degenerative group exhib-
of grades 3, 4, and 5 specimens were 1811 (348), 1665 ited significant hysteresis (Figs. 4 and 5).
(252), and 1938 (152) mm,2 respectively. Mean (SD)
disc height of grades 3, 4, and 5 specimens were 10.1 Stiffness
(1.0), 8.4 (1.7), and 7.6 (2.7) mm, respectively. Speci- The overall effect of degenerative grade was significant
mens were classified into three categories: Mild, for stiffness in lateral shear (p ¼ 0.001), flexion
moderate, and severe degeneration, which corresponds (p ¼ 0.019), and axial rotation (p ¼ 0.001, Fig. 6).
to grades 3 (N ¼ 5), 4 (N ¼ 6), and 5 (N ¼ 3) on the No significant overall effects were found for anterior

JOURNAL OF ORTHOPAEDIC RESEARCH AUGUST 2016

 EFFECT OF DEGENERATION ON MECHANICAL PROPERTIES 1403

Table 1. The Breakdown of Level, Age, Disc Area, Average Disc Height, and Degenerative Grade for the Present
Study

Specimen Number Level Age Disc Area (mm2) Disc Height (mm) Grade Rounded Grade
1 L1–2 68 1428 10.3 2.7 3
2 L1–2 64 1511 9.4 2.8 3
3 L1–2 72 1857 8.8 3.2 3
4 L1–2 82 2005 5.0 4.3 4
L1–2 Mean (SD) 1701 (275) 8.4 (2.4) 3.3 (0.7)
5 L2–3 93 1765 8.2 4.0 4
6 L2–3 70 1660 8.9 3.8 4
7 L2–3 64 1233 9.5 4.2 4
8 L2–3 84 1790 7.6 4.9 5
L2–3 Mean (SD) 1612 (260) 8.6 (0.9) 4.2 (0.5)
9 L3–4 72 2279 10.6 2.8 3
10 L3–4 82 1977 11.5 2.6 3
11 L3–4 68 1617 9.2 4.0 4
12 L3–4 64 1712 9.4 4.0 4
L3–4 Mean (SD) 1896 (298) 10.2 (1.1) 3.4 (0.8)
13 L4–5 93 1928 4.9 5.0 5
14 L4–5 91 2094 10.4 4.8 5
L4–5 Mean (SD) 2011 (118) 7.6 (3.9) 4.9 (0.1)
Means and standard deviations are provided for each level. Average disc height was calculated as the mean of the anterior, middle and
posterior heights, as measured from lateral radiographs.

Figure 4. Recorded data averaged across all intact FSU specimens in each degenerative group for shear and compression DOFs.
Solid lines indicate average response, dotted lines indicate upper, and lower 95% CI responses. Data taken from the final loading and
unloading curves, each fitted to sixth order polynomials.

JOURNAL OF ORTHOPAEDIC RESEARCH AUGUST 2016

1404 AMIN ET AL.
Figure 5. Recorded data averaged across all intact FSU specimens in each degenerative group for rotation and bending DOFs. Solid
lines indicate average response, dotted lines indicate upper, and lower 95% CI responses. Data taken from the final loading and
unloading curves, each fitted to sixth order polynomials.
shear (p ¼ 0.299), posterior shear (p ¼ 0.137), compres-
sion (p ¼ 0.262), lateral bending (p ¼ 0.452), and exten-
sion (p ¼ 0.496). Significant post-hoc differences revealed
that there was a significant decrease in stiffness between
mild and moderate degenerated groups in lateral shear
(p ¼ 0.001) and axial rotation (p ¼ 0.001, Fig. 6). In
addition, for axial rotation, severely degenerated intact
FSUs had a significantly larger stiffness compared to
moderate (p ¼ 0.010). For flexion, the severely degener-
ated group had a significantly larger stiffness than mild
degeneration (p ¼ 0.022).
Phase Angle
The overall effect of degenerative grade was significant
for phase angle for anterior shear (p ¼ 0.017) and axial
rotation (p ¼ 0.026, Fig. 7). No significant overall effects
were found for lateral shear (p ¼ 0.082), posterior shear
(p ¼ 0.162), compression (p ¼ 0.223), lateral bending
(p ¼ 0.245), extension (p ¼ 0.073), and flexion (p ¼ 0.476).
Significant post-hoc differences revealed that phase angle
was significantly larger for moderately degenerated
intact FSUs compared to mild for anterior shear
(p ¼ 0.021) and axial rotation (p ¼ 0.027, Fig. 7).
JOURNAL OF ORTHOPAEDIC RESEARCH AUGUST 2016
DISCUSSION
This study aimed to determine the 6DOF mechani-
cal response of degenerated intact FSUs by measur-
ing stiffness and phase angle. Stiffness decreased
and phase angle increased between mild and moder-
ately degenerated groups in axial rotation. A signifi-
cant increase in stiffness was also found between
mild and severely degenerated groups in flexion,
and between moderate and severe degeneration in
axial rotation. The moderately degenerated group
stiffness was significantly larger than the mild
group for lateral shear. Similarly, the moderately
degenerated group phase angle was larger than the
mild group for anterior shear. A trend of increasing
stiffness for severely degenerated FSUs compared to
moderately degenerated was found for lateral shear
and flexion. Overall, for phase angle, the majority of
DOFs had a trend for an increase in energy absorp-
tion for moderately degenerated FSUs compared
to mild.
It was hypothesized that the stiffness under com-
pression and bending would stay relatively similar
between mild to moderately degenerated groups and
 EFFECT OF DEGENERATION ON MECHANICAL PROPERTIES
Figure 6. Mean (95% CI) stiffness in all DOFs for intact FSUs for all three degenerative grades.
between groups (p < 0.05).
then increase from moderate to severe. This hypothe-
sis appears to be consistent, with the general findings
of no significant differences overall between degenera-
tive groups in these directions (apart for flexion), with
a trend of increased stiffness for severe compared to
moderate degeneration for compression and extension.
In these directions, the major stress components are
compressive and tensile, where the solidification of the
nucleus should theoretically lead to an increased
stiffness. However, there was a trend of decreased
stiffness from mild to moderate degenerative groups in
extension. This could be potentially attributed to facet
joint interaction. The results confirmed our hypothesis
for shear and axial rotation DOFs. The initial decrease
in stiffness for shear and rotation directions could be
attributed to an increase in delamination and annular
clefts, which have been observed as degeneration
progresses.1,2 Since the dominant tissue stresses are
shear and tensile, deterioration of the annulus may
cause instability and a decrease in stiffness.3
Phase angle gives insight into the viscoelasticity of
the intervertebral disc. Generally, energy absorption
increased from mild to moderate degeneration, and
although these trends were not significant, they
qualitatively support our hypothesis. We also ob-
served trends for decreasing phase angle between
moderate and severe FSUs for most DOFs, which
1405

Represents significant differences
agree with our hypothesis. Interestingly, there was
little difference in phase angle between moderate
and severe degeneration in compression and anterior
shear, and this may be caused by possible increased
contact pressure in the posterior elements once the
disc becomes moderately degenerated.
Furthermore, the stiffness trends in shears, axial
rotation, and extension trends correspond to the
Kirkaldy–Willis and Farfan instability theory.12 It
could be hypothesized that Thompson grades 3 and 4
discs resemble the temporary dysfunction to instability
phases, and grade 5 discs represent the restabilization
phase. Therefore, the increase in stiffness seen for the
severely degenerative group in comparison to the
moderate group portrays the natural re-stabilization
experienced by the intervertebral disc. In addition, the
stiffness trend in axial rotation was similar to those
found by Zirbel et al.; however, there are magnitude
differences, where the stiffness values are less than
the present study by a factor of two. This could be due
to the fact that the present study measured linear
stiffness instead of neutral zone stiffness, and applied a
normalized preload instead of the same magnitude of
force as preload.19 No other direct comparisons of
stiffness were possible, since previous studies generally
reported ROM at a prescribed moment. In order to
facilitate a qualitative comparison to the present study,
JOURNAL OF ORTHOPAEDIC RESEARCH AUGUST 2016
1406 AMIN ET AL.
Figure 7. Mean (95% CI) phase angle in all DOFs for intact FSUs for all three degenerative grades.
differences between groups (p < 0.05).
corresponding rotations to the moments applied in
these studies14–16,19 were extracted. These rotations
can provide an estimate of the likely ROM, had the
tests in the present study been conducted in a similar
manner.
Comparing ROM data between this present study
and previous studies, it was found that there are
similar trends with differences in magnitude
(Table 2). The trends seen in Fujiwara et al. closely
resembled those seen in the present study, where
there was an increase in ROM from mild to moder-
ate degeneration and a decrease from moderate to
severe degeneration. This trend correlates with the
stiffness trend discussed earlier. The magnitude
differences could be due to various reasons which
include testing control method, grading criteria, and
testing systems. More specifically, this study tested
in position control, while others tested in load
control and used either quasi-static ramp loading or
stepwise loading. Furthermore, previous studies14–16
did not use a compressive follower load, and tested
at room temperature without hydration.
Disc degeneration is known to be related to spinal
level, where higher rates of degeneration occur at lower
lumbar levels. However, this was not consistently the
case for the present study. As expected at the superior
JOURNAL OF ORTHOPAEDIC RESEARCH AUGUST 2016

Represents significant
levels L1–2 were generally mildly degenerated,
however L2–3 were found to be mostly moderately
degenerated. In contrast, the inferior level of L3–4 were
found to be both mildly and moderately degenerated
(Table 1). Furthermore, previous studies have looked at
combined data including all levels when assessing
effects of degeneration. Though this study did not
directly look at the effects of spinal level and age on
mechanical properties, additional one-way ANOVA
analyzes found that spinal level and age did not have a
significant effect on stiffness (p > 0.107, p > 0.106) or
phase angle (p > 0.104, p > 0.079), respectively. Normal-
ization of the data is important to account for geometri-
cal differences between discs, where disc area and
height are taken into account. We performed separate
one way ANOVAs on the dependent outcomes of disc
area and height having an independent factor of
degenerative grade and lumbar level. The statistical
analysis yielded no significant differences between
degenerative grades for the disc area (p ¼ 0.391) and
height (p ¼ 0.152).
There are a number of limitations from this study
that should be acknowledged regarding methodology.
There was a low sample size for the severely
degenerated group (N ¼ 3), which may account for the
generally large standard deviations and lack of
 Table 2. Comparison of Estimated ROM From the Present Study to Other Studies, Broken Down by Degenerative Grade, Based on the Thompson Criteria

5.7 Nm 6.6 Nm 7.5 Nm 8.5 Nm

a b
Moment Present Tanaka Present Fujiwara Present Zirbel Present
b,c
(Nm) Study et al.16 Study et al.14 Study et al.19 Study Krismer et al.15
Lateral Bending
Grade 3 1.04 11.51 1.38 (1.16) 13 (4) 1.51 11.8 (6.07) 2.04 0.3
(0.89) (3.64) (1.13)
Grade 4 1.56 10.85 1.53 (0.36) 12 (3) 2.00 9.17 (4.03) 1.77 0.3
(0.56) (3.13) (0.75)
Grade 5 0.63 8.36 0.75 (0.37) 10 (3) 0.72 4.73 (3.51) 0.85 0.1
(0.34) (3.38) (0.52)
Axial Rotation
Grade 3 0.85 4.68 1.0 (0.22) 5 (2) 1.15 3.78 (2.30) 1.18 1.8
(0.18) (2.18) (0.28)
Grade 4 1.47 7.03 1.79 (0.41) 8 (1) 1.14 4.98 (2.53) 1.73 1.8
(0.23) (1.56) (0.25)
Grade 5 1.10 5.21 1.20 (0.18) 7 (3) 1.52 4.40 (2.15) 1.42 4
(0.15) (2.24) (0.038)
Extension
Grade 3 1.56 3.27 1.48 (0.36) 3 (2) 1.54 - 1.69 0.5
(0.35) (1.44) (0.26)
Grade 4 1.52 3.90 1.66 (0.20) 5 (2) 1.74 - 1.95 0.5
(0.27) (1.75) (1.12)
Grade 5 1.49 3.36 1.57 (0.92) 3.5 (0.5) 1.71 - 1.4 1
(0.93) (1.32) (0.28)
Flexion
Grade 3 4.73 4.91 - 6 (3) - - - 0.2
(0.21) (2.53)
Grade 4 1.98 5.52 2.22 (1.13) 7 (2) 2.41 - 3.56 0.2
(1.51) (1.50) (0.34)
Grade 5 1.93 3.63 2.28 (0.44) 5.5 (1.5) 3.04 - 2.97 0.1
(0.56) (1.97) (0.10)
All studies used intact FSUs with facet joints. aExact values were not reported, estimated values from graphical results were used. bMedian ROM data presented. cNachemson grading
scale converted to Thompson grading scale by comparing the given grading results in the study. All grade 5 (Thompson) were grade 4 (Nachemson) specimen and all grades 3 and 4
(Thompson) were grade 3 (Nachemson).
EFFECT OF DEGENERATION ON MECHANICAL PROPERTIES
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JOURNAL OF ORTHOPAEDIC RESEARCH AUGUST 2016

1408 AMIN ET AL.

Table 3. Required Sample Size for Each Degenerative In conclusion, the results suggest that degeneration
Group to Detect Significance for Stiffness and Phase affects 6DOF mechanical properties, which were most
Angle in All Eight Loading Directions notable in axial rotation, lateral shear and flexion for
stiffness, and in anterior shear and axial rotation for
Loading Mechanical Required Sample Size for phase angle. Trends also confirm previous findings in
Direction Parameter Each Degenerative group
axial rotation and suggest that mechanical stability
Lateral Stiffness 3 decreases between grade 3 (mild degeneration) and
shear Phase angle 7 grade 4 (moderate), and increases for grade 5 (severe).
Anterior Stiffness 15 This study gives comprehensive new insights into the
shear Phase angle 5 mechanical response in shear directions of degenerated
Posterior Stiffness 9 intact FSUs, which has not been previously studied.
shear Phase angle 10 Clinically, this study can contribute to improvements in
Compression Stiffness 13 developing and validating finite element models of the
Phase angle 12 intervertebral disc and providing important baseline
Extension Stiffness 25 guidelines for total disc replacements. This research
Phase angle 7 will serve as a basis for future studies, which include
Flexion Stiffness 4 further investigation of normal and degenerated inter-
Phase angle 24
vertebral disc mechanical properties.
Lateral Stiffness 22
bending Phase angle 12
Axial Stiffness 3
AUTHORS’ CONTRIBUTION
Dhara Amin’s contributions included preparation,
rotation Phase angle 5
testing and grading of cadaver specimens, statistical
analysis and interpreting results, writing and editing
the manuscript. Dana Sommerfeld’s contributions
significance. An increased sample size may reveal included preparation and testing of cadaver speci-
further significant differences. According to the power mens and editing the manuscript. Isaac Lawless’
analysis, between 5 and 10 more specimens in each contributions included development of tooling and
group would be required to detect the present differ- techniques for Wood’s metal potting of the specimens,
ences between groups as significant (Table 3). In assisting with the development of the adaptive
addition, there was no comparison to normal discs velocity-based six degree of freedom load control
(grades 1 and 2), which would give insight into the strategy, assistance with testing, disc grading and
magnitude differences between degenerated and nor- editing the manuscript. Richard Stanley’s contribu-
mal discs. Sourcing the required sample size of younger tions included design, development and manufacture
cadaver spines would be time consuming and infeasible. of the hexapod robot, potting alignment device and
Furthermore, degenerated discs have reduced water tooling, and editing the manuscript. Boyin Ding’s
content, which may require a longer time to reach contributions included design and development of the
hydrated equilibrium. It was found that the specimen entire hexapod robot control system hardware, soft-
viscoelastic properties did return to initial conditions ware and graphi graphical user testing interface, and
before each loading direction, with percentage differ- editing the manuscript. John Costi’s contribution
ences relative to the first reference test averaging 12%, included leading the design and development of the
and 9% for stiffness, and phase angle, respectively, over hexapod robot, project conception, development of
the testing sequence. These differences were within the testing protocols, supervision of the project, data and
range of systematic variations found in other studies statistical analysis, interpreting results, and editing
and believed not to be of clinical significance.28 the manuscript. The corresponding author can con-
The comparison of the stiffness’s and phase angles firm that all authors were fully involved in the study
from the present study can be made to a similar study, and preparation of the manuscript and that the
which used a similar testing protocol and 6DOF material within has not been and will not be submit-
hexapod robot.25 However, that study tested isolated ted for publication elsewhere.
vertebra-disc-vertebra segments without the posterior
elements and there were very similar magnitudes of ACKNOWLEDGMENT
stiffness for lateral and posterior shear, compression This project was supported by a scholarship from
and lateral bending. Differences in stiffness were Whitaker International Program administered by the
found for anterior shear (present study stiffer by a Institute of International Education (IIE).
factor of approximately 4), axial rotation (stiffer by a
factor of approximately 2), extension (stiffer by a factor
of approximately 1.7), and flexion (less stiff by a factor REFERENCES
of approximately 0.5). It is highly likely that these 1. Galbusera F, van Rijsbergen M, Ito K, et al. 2014. Ageing
differences were caused by the presence of the poste- and degenerative changes of the intervertebral disc and
rior elements in the present study. their impact on spinal flexibility. Eur Spine J 23:S324–S332.

JOURNAL OF ORTHOPAEDIC RESEARCH AUGUST 2016

 EFFECT OF DEGENERATION ON MECHANICAL PROPERTIES
2. Adams MA, Roughley PJ. 2006. What is intervertebral disc
degeneration, and what causes it? Spine 31:2151–2161.
3. Adams MA, McNally DS, Dolan P. 1996. ’Stress’ distribu-
tions inside intervertebral discs. The effects of age and
degeneration. J Bone Joint Surg Br 78:965–972.
4. Przybyla A, Pollintine P, Bedzinski R, et al. 2006. Outer
annulus tears have less effect than endplate fracture on stress
distributions inside intervertebral discs: relevance to disc
degeneration. Clin Biomech (Bristol, Avon) 21:1013–1019.
5. Vernon-Roberts B, Moore RJ, Fraser RD. 2007. The natural
history of age-related disc degeneration: the pathology and
sequelae of tears. Spine 32:2797–2804.
6. Wang Y, Videman T, Battie MC. 2012. ISSLS prize winner:
lumbar vertebral endplate lesions: associations with disc
degeneration and back pain history. Spine 37:1490–1496.
7. Benneker LM, Heini PF, Alini M, et al. 2005. 2004 Young
investigator award winner: vertebral endplate marrow con-
tact channel occlusions and intervertebral disc degeneration.
Spine 30:167–173.
8. Rajasekaran S, Vidyadhara S, Subbiah M, et al. 2010. ISSLS
prize winner: a study of effects of in vivo mechanical forces
on human lumbar discs with scoliotic disc as a biological
model: results from serial postcontrast diffusion studies,
histopathology and biochemical analysis of twenty-one hu-
man lumbar scoliotic discs. Spine 35:1930–1943.
9. Lipson SJ, Muir H. 1980. Vertebral osteophyte formation in
experimental disc degeneration. Morphologic and proteogly-
can changes over time. Arthritis Rheum 23:319–324.
10. Al-Rawahi M, Luo J, Pollintine P, et al. 2011. Mechanical
function of vertebral body osteophytes, as revealed by
experiments on cadaveric spines. Spine 36:770–777.
11. Morgan FP, King T. 1957. Primary instability of lumbar
vertebrae as a common cause of low back pain. J Bone Joint
Surg Br 39–b: 6–22.
12. Kirkaldy-Willis WH, Farfan HF. 1982. Instability of the
lumbar spine. Clin Orthop Relat Res 110–123.
13. Knutsson F. 1944. The instability associated with disk
degeneration in the lumbar spine. Acta Radiol 25:593–609.
14. Fujiwara A, Lim TH, An HS, et al. 2000. The effect of disc
degeneration and facet joint osteoarthritis on the segmental
flexibility of the lumbar spine. Spine 25:3036–3044.
15. Krismer M, Haid C, Behensky H, et al. 2000. Motion in
lumbar functional spine units during side bending and axial
rotation moments depending on the degree of degeneration.
Spine 25:2020–2027.
16. Tanaka N, An HS, Lim TH, et al. 2001. The relationship
between disc degeneration and flexibility of the lumbar
spine. Spine J 1:47–56.
17. Mimura M, Panjabi MM, Oxland TR, et al. 1994. Disc
degeneration affects the multidirectional flexibility of the
lumbar spine. Spine 19:1371–1380.
18. Kettler A, Rohlmann F, Ring C, et al. 2011. Do early stages of
lumbar intervertebral disc degeneration really cause instability?
Evaluation of an in vitro database. Eur Spine J 20:578–584.
19. Zirbel SA, Stolworthy DK, Howell LL, et al. 2013. Interver-
tebral disc degeneration alters lumbar spine segmental
stiffness in all modes of loading under a compressive
follower load. Spine J 13:1134–1147.
20. Fujiwara A, An HS, Lim TH, et al. 2001. Morphologic
changes in the lumbar intervertebral foramen due to flexion-
extension, lateral bending, and axial rotation: an in vitro
anatomic and biomechanical study. Spine 26:876–882.
21. Marras WS, Davis KG, Ferguson SA, et al. 2001. Spine
loading characteristics of patients with low back pain com-
pared with asymptomatic individuals. Spine 26:2566–2574.
1409
22. Kim J, Yang SJ, Kim H, et al. 2012. Effect of shear force on
intervertebral disc (IVD) degeneration: an in vivo rat study.
Ann Biomed Eng 40:1996–2004.
23. Norman R, Wells R, Neumann P, et al. 1998. A comparison
of peak vs cumulative physical work exposure risk factors
for the reporting of low back pain in the automotive
industry. Clin Biomech (Bristol, Avon) 13:561–573.
24. McGill SM, Hughson RL, Parks K. 2000. Changes in lumbar
lordosis modify the role of the extensor muscles. Clin
Biomech (Bristol, Avon) 15:777–780.
25. Costi JJ, Stokes IA, Gardner-Morse MG, et al. 2008.
Frequency-dependent behavior of the intervertebral disc in
response to each of six degree of freedom dynamic loading:
solid phase and fluid phase contributions. Spine 33:
1731–1738.
26. Thompson JP, Pearce RH, Schechter MT, et al. 1990. Prelimi-
nary evaluation of a scheme for grading the gross morphology
of the human intervertebral disc. Spine 15:411–415.
27. Pearcy M, Portek I, Shepherd J. 1984. Three-dimensional
x-ray analysis of normal movement in the lumbar spine.
Spine 9:294–297.
28. Amin DB, Lawless IM, Sommerfeld D, et al. 2015. Effect of
potting technique on the measurement of six degree-of-
freedom viscoelastic properties of human lumbar spine seg-
ments. J Biomech Eng 137:054501–054501.
29. Ding B, Cazzolato BS, Stanley RM, et al. 2014. Stiffness
analysis and control of a stewart platform-based manipula-
tor with decoupled sensor—actuator locations for ultrahigh
accuracy positioning under large external loads. J Dyn
Syst Meas Control 136:061008–061008.
30. Lawless IM, Ding B, Cazzolato BS, et al. 2014. Adaptive
velocity-based six degree of freedom load control for real-time
unconstrained biomechanical testing. J Biomech 47:3241–3247.
31. Pflaster DS, Krag MH, Johnson CC, et al. 1997. Effect of test
environment on intervertebral disc hydration. Spine 22:133–139.
32. Race A, Broom ND, Robertson P. 2000. Effect of loading rate
and hydration on the mechanical properties of the disc.
Spine 25:662–669.
33. Costi JJ, Hearn TC, Fazzalari NL. 2002. The effect of
hydration on the stiffness of intervertebral discs in an ovine
model. Clin Biomech (Bristol, Avon) 17:446–455.
34. Wilke HJ, Neef P, Caimi M, et al. 1999. New in vivo
measurements of pressures in the intervertebral disc in
daily life. Spine 24:755–762.
35. Edwards WT, Ordway NR, Zheng Y, et al. 2001. Peak
stresses observed in the posterior lateral anulus. Spine
26:1753–1759.
36. Nachemson A, Morris JM. 1964. In vivo measurements of
intradiscal pressure. Discometry, a method for the determi-
nation of pressure in the lower lumbar discs. J Bone Joint
Surg Am 46:1077–1092.
37. Patwardhan AG, Havey RM, Meade KP, et al. 1999.
A follower load increases the load-carrying capacity of the
lumbar spine in compression. Spine 24:1003–1009.
38. Pearcy MJ, Tibrewal SB. 1984. Axial rotation and lateral
bending in the normal lumbar spine measured by three-
dimensional radiography. Spine 9:582–587.
39. Lu WW, Luk KD, Holmes AD, et al. 2005. Pure shear
properties of lumbar spinal joints and the effect of tissue
sectioning on load sharing. Spine 30:E204–E209.
40. Stokes IA, Frymoyer JW. 1987. Segmental motion and
instability. Spine 12:688–691.
41. Erdfelder E, Faul F, Buchner A. 1996. GPOWER: a
general power analysis program. Behav Res Meth Ins C
28:1–11.
JOURNAL OF ORTHOPAEDIC RESEARCH AUGUST 2016