European Journal of Radiology 82 (2013) 118–126

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European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Review

Biomechanics of the spine. Part I: Spinal stability

Roberto Izzo a,∗ , Gianluigi Guarnieri a , Giuseppe Guglielmi b , Mario Muto a
a
Neuroradiology Department, “A. Cardarelli” Hospital, Napoli, Italy
b
Department of Radiology, University of Foggia, Foggia, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Biomechanics, the application of mechanical principles to living organisms, helps us to understand how
Received 3 July 2012 all the bony and soft spinal components contribute individually and together to ensure spinal stability,
Received in revised form 21 July 2012 and how traumas, tumours and degenerative disorders exert destabilizing effects.
Accepted 23 July 2012
Spine stability is the basic requirement to protect nervous structures and prevent the early mechan-
ical deterioration of spinal components. The literature reports a number of biomechanical and clinical
Keywords:
definitions of spinal stability, but a consensus definition is lacking.
Spine
Any vertebra in each spinal motion segment, the smallest functional unit of the spine, can perform
Biomechanics
Spinal stability
various combinations of the main and coupled movements during which a number of bony and soft
CT restraints maintain spine stability.
MR Bones, disks and ligaments contribute by playing a structural role and by acting as transducers through
their mechanoreceptors. Mechanoreceptors send proprioceptive impulses to the central nervous system
which coordinates muscle tone, movement and reflexes. Damage to any spinal structure gives rise to
some degree of instability.
Instability is classically considered as a global increase in the movements associated with the occur-
rence of back and/or nerve root pain.
The assessment of spinal instability remains a major challenge for diagnostic imaging experts.
Knowledge of biomechanics is essential in view of the increasing involvement of radiologists and neu-
roradiologists in spinal interventional procedures and the ongoing development of new techniques and
devices. Bioengineers and surgeons are currently focusing on mobile stabilization systems. These systems
represent a new frontier in the treatment of painful degenerative spine and aim to neutralize noxious
forces, restore the normal function of spinal segments and protect the adjacent segments. This review
discusses the current concepts of spine stability.
© 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
The spine is a complex multi-articular system controlled by the
muscles which supports the head and trunk during posture and
movements and encloses and protects the spinal cord, nerve roots
and, at cervical level, the vertebral arteries.
The normal function of the spine presupposes its stability. Apart
from the protection of nervous structures, spine stability is the basic
requirement for the transfer of power forces between the upper and
lower limbs, the active generation of forces in the trunk, the pre-
vention of early biomechanical deterioration of spine components
and the reduction of the energy expenditure during muscle action
[1,2].
The literature reports a number of biomechanical and clinical
definitions of spinal stability but a consensus definition is lacking.
The loss of stability, the instability, is an important often unknown
cause of back pain particularly at lumbar level.
Mobile stabilization systems aim to neutralize noxious forces,
restore normal function of the spinal segments and protect the
adjacent segments. They represent the new frontier of treatment of
degenerative painful spine on which the attention of bioengineers
and surgeons has focused.

2. Definitions of stability and instability

∗ Corresponding author at: Neuroradiology Department, “A. Cardarelli” Hospital,

Viale Cardarelli 9, 80131 Napoli, Italy. Tel.: +39 0817473116.
E-mail addresses: roberto1766@interfree.it (R. Izzo),
gianluigiguarnieri@hotmail.it (G. Guarnieri), g.gugliemi@unifg.it (G. Guglielmi),
mutomar@tiscali.it (M. Muto).
White et al. defined clinical stability as the spine’s ability under
physiologic loads to limit patterns of displacement in order not to
damage or irritate the spinal cord and nerve roots and to prevent
incapacitating deformity or pain caused by structural changes [3].

0720-048X/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejrad.2012.07.024
 R. Izzo et al. / European Journal of Radiology 82 (2013) 118–126 119

In a similar way the American Academy of Orthopedic Surgeons

defined stability as “the capacity of the vertebrae to remain cohe-
sive and to preserve the normal displacements in all physiological
body movements” [4].
Any vertebra in each spinal motion segment (MS), the smallest
functional unit of the spine (FSU), can perform various combina-
tions of the main and coupled movements during which a number
of bony and soft movement restraints guarantee stability. This
intrinsic complexity contributes to clinical and imaging difficulties
in assessing spinal movement.
The loss of stability, instability, is an important, often unknown,
cause of back pain particularly at lumbar level. Like stability, insta-
bility also lacks a generally accepted definition.
White and Panjabi defined instability as “the loss of the ability
of the spine under physiologic loads to maintain its patterns of dis-
placement so there is no initial or additional neurologic deficit, no
major deformity, and no incapacitating pain” [5]. Pope and Panjabi
qualified instability as a loss of stiffness leading to abnormal and
increased movement in the motion segments [6].
With instability movement can be abnormal in quality (abnor-
mal coupling patterns) and/or quantity (increased motion) [7].
The location of the dominant lesion in the MS determines the
pattern of instability, but as spinal movement is three-dimensional
with coupled movements, tissue derangement tends to cause dys-
functional motions in more than one direction. Fig. 1. Lateral conventional radiograph of the cervical spine in flexion. During
flexion–extension the vertebra moves around a transverse rotation axis placed in
the subjacent vertebral body. Both the endplates and the facet joints perform two
circumference arcs around the same rotation centre whose location changes accord-
3. Normal spinal motion ing to level, being placed two vertebral bodies below in the superior cervical spine
and in the subjacent vertebral body in the inferior cervical, in the dorsal and lumbar
spine.
Pope and Panjabi and other classic definitions of instability refer
to a global increase in spinal movements over the normal limits
associated with the occurrence of back and/or nerve root pain [6].
Unfortunately, the definition of “normal or physiological move- intervertebral motion on either side of the neutral position where
ments” remains a matter of debate as the excessive overlap of the it meets relatively low resistance and the spine exhibits high flexi-
types of movement between symptomatic and asymptomatic sub- bility owing to the laxity status of capsules, ligaments and tendons
jects makes it difficult to define standard references and to correlate (Fig. 2).
clinical and radiological findings [8]. The NZ is followed by the EZ where the resistance to movement
Within each MS, the FSU including two adjacent vertebrae with and the slope of the curve increase linearly when the ligaments,
interposing soft tissues, a vertebra can perform three translations capsules, fascias and tendons are subjected to tension requiring
along and three rotational movements around each of the x-, y-, z- more load per unit displacement [11] (Fig. 2). The EZ represents a
cartesian axes of the space and various combinations of main and zone of high stiffness where spinal motion meets significant resis-
coupled movements, the latter occurring simultaneously along or tance [11].
around an axis different from that of the principal motion [9]. Each of the six degrees of freedom of motion any vertebra can
According to Louis, during flexion–extension the vertebra perform with respect to other vertebrae has its own range of motion
moves around a transverse rotation axis placed not in the subja- (ROM), neutral zone (NZ) and elastic zone (EZ) [12].
cent disc but in the vertebral body below [10]. Both the endplates
and the facet joints perform two circumference arcs around the
same rotation centre whose location changes according to level,
being placed two vertebral bodies below in the superior cervical
spine and in the subjacent vertebral body in the inferior cervical,
in the dorsal and lumbar spine [10] (Fig. 1). The low position of the
rotation centres gives rise to a coupled movement of antelisthesis
which varies from a maximum of 2–3 mm at C2–C3 to a minimum
of 0.5 up to 1.5 mm from D1 to L5 [10].
Axial rotation and lateral bending are always coupled move-
ments because of the oblique orientation of both the facet joints
and muscles. The coupling is most evident at cervical level.
While the centre of lateral bending is always located between
the facets, the centre of axial rotation varies according to level: in
the central body for the dorsal spine, in the spinous processes for
the lumbar segment [10].
The key to proper spinal function is the highly nonlinear
load/displacement ratio of the FSU because the effort required for
Fig. 2. Load/displacement curve. The load/displacement curve of the spine is not
movement changes significantly in its various phases [11] (Fig. 2).
linear. The range of motion of the spinal joints includes an initial neutral zone (NZ)
The physiologic range of motion (ROM) includes a neutral zone with relatively large displacements at low load and an elastic zone (EZ) that requires
(NZ) and an elastic zone (EZ) [11]. The NZ is the initial part of the more load per unit of displacement because of the tension of capsules and ligaments.
120 R. Izzo et al. / European Journal of Radiology 82 (2013) 118–126
Fig. 3. Three subsystems control the stability of the spine: the spinal column, the
muscles, and the central nervous system. They are strictly related so any acute or
chronic damage to one subsystem requires more compensatory work by the others.
The biphasic nonlinear behaviour of the spinal joints probably
meets two opposed needs: to allow movements near the neutral
posture with as little muscle effort as possible and to ensure stabil-
ity at the end of joint excursion [11].
To depict the load–displacement curve of the spinal motion
segments, Panjabi created the analogy of the ball in a bowl and
compared the NZ to the bottom of a glass in which a ball can move
quite freely, and the extremities of the movement, the EZ, to the
steeper walls of a cup on whose inclination the ball climbs meet-
ing an increasing resistance [13] (Fig. 2a). A stable column would
have the shape of a narrow wine glass, whereas an unstable column
could be compared to a large soup bowl [13].
According to a mechanistic hypothesis of spinal pain in asymp-
tomatic subjects, the NZ and ROM are normal and contained within
the limits of the pain free zone (PFZ) [13]. The NZ is thought to
increase over the PFZ limits in an unstable spine [13]. Severe disc
collapse, osteophytosis, surgical fusion and muscular training all
improve spinal stiffness reducing the NZ and freeing the spine from
pain.
4. Spine stabilization
Stability implies a suitable relationship between the NZ and EZ
[11]. NZ size, particularly, although a small portion of the ROM,
proved to be the most sensitive parameter to define both traumatic
and degenerative spinal instability as it increases earlier and more
than the ROM and EZ [11,14].
Given the key function of the NZ observed in tests on cadav-
eric specimens and in animals, Panjabi re-defined instability as the
reduced ability by the stabilizing systems of the spine to maintain
the neutral zones of the FSUs within physiological limits so that
deformity, neurological deficit or disabling pain do not occur [11].
In this definition the quality of movement becomes more significant
than the global increase in joint excursion in diagnosing instability.
Spinal stability is ensured by a stabilization system consisting
of three closely interconnected subsystems [12] (Fig. 3):
(1) the column or passive subsystem,
(2) the muscles and tendons or active subsystem,
(3) the unit of central nervous control.
In the passive subsystem bones, disks and ligaments fulfil an
intrinsic structural role and directly control the EZ near the extreme
parts of normal movement [12]. Bone, disks, ligaments and joint
capsules also contain mechanoreceptors which act as transducers,
sending a continuous flow of proprioceptive information on loads,
motions and posture from each FSU to the central nervous sys-
tem (CNS) that, in turn, replies via an appropriate and coordinated
feedback muscular action [12,15,16] (Fig. 4).
Fig. 4. The subsystems controlling spinal stability are functionally related.
A continuous stream of proprioceptive information starting from the spinal
mechanoreceptors muscle and tendons inform the CNS on the position, load and
movement of each FSU. The CNS, in turn, answers through an appropriate and
coordinated muscular activity.
The active subsystem and the CNS essentially control the neutral
zone of FSU movement where resistance is low [12].
Degeneration or any traumatic lesion to the bony and soft com-
ponents of the spine tend to expand the ROM and the NZ putting
a greater demand on the muscles and nervous systems in order to
preserve or restrict the segmental instability [12].
5. Passive stabilization
During ordinary daily activities the spine normally supports ver-
tical loads of 500–1000 N, over twice the body weight, and with
lifting, up to 5000 N, near 50% of final failure load [17].
The intrinsic structural role and passive stabilization of the spine
depend on:
- vertebral architecture and bone mineral density,
- disc-intervertebral joints,
- facet joints,
- ligaments,
- physiological curves.
5.1. Vertebral architecture and mineral density
The load-bearing ability of the vertebral body depends on its size
and shape, the integrity of the trabecular system and bone density.
The vertebral body mainly consists of spongy bone with a three-
dimensional honeycomb structure similar to airplane wings that
yields the best strength/weight ratio [10].
The progressive increase in body size downward in the spine
is the only physiological answer to increasing weight loads with
average strength ranging from 2000 N in the cervical segment up
to 8000 N in the lumbar spine [18].
The cancellous bone of any vertebral body has four main trabec-
ular systems with a constant orientation [10]:
- a vertical system extending between the endplates which accepts
and transmit vertical loads;
- a horizontal system travelling in the posterior arch and joining
the transverse processes;
- two curved oblique systems, superior and inferior, start from the
endplates and cross in the peduncles to end in the spinous and
 R. Izzo et al. / European Journal of Radiology 82 (2013) 118–126
Fig. 5. (a and b) The vertical compressive loads are first accepted by vertical trabec-
ular columns which transmit forces between the endplates. However the vertical
struts alone would tend to bow (a). Their bowing is restrained by the presence of
horizontal lamellae which join the vertical struts and by tension favour the radial
dispersion of forces conferring resilience to the vertebral body (b).
joint processes. Their function is to withstand the horizontal shear
stresses ensuring the neural arch to the body.
Axial loads are initially accepted by vertical trabecular struts
whose bowing is restrained by the tension of the horizontal lamel-
lae which thereby favour the horizontal dispersion of the vertical
loads conferring resilience to the cancellous bone (Fig. 5).
With respect to spongy bone the body cortical shell, although
highly resistant, has much lower elasticity.
The resistance of spongy bone also strongly depends on mineral
density (BMD). Bone loss in osteoporosis results in a disproportion-
ate exponential reduction of resistance: a bone loss of 25% leads to
a reduction of resistance of about 50% [19].
In the mechanical model of cancellous vertebral bone consisting
of vertical columns joined by horizontal lamellae (Fig. 6a), the resis-
tance of the columns decreases by the square of increasing length
and by the square of decreasing cross section.
During the early stages of osteoporosis the resorption of the
horizontal lamellae causes a progressive relative elongation of
the vertical columns (Fig. 6b) while the thinning of the columns
121
themselves in more advanced stages leads to a summation of the
two processes (Fig. 6c).
A strong and continuous correlation between spinal BMD and
fracture risk has been established, without a defined threshold
value for BMD under which vertebral failure will occur [19].
A vertebra can be affected by fatigue after repetitive loading
forces individually less than would be required in case of a single
load application.
Vertebral fatigue begins as focal osseous microdamage which
extends until final failure.
Bone resorption in osteoporosis is not homogeneous but mainly
involves the anterior half of vertebral bodies [20].
In the elderly, because of degenerative disc collapse, the forces
are no longer evenly distributed on the endplates and the posterior
facets assume much more of the load during erect standing pos-
ture. This relative stress-shielding of the anterior bodies is thought
to favour local bone loss and weakening as, according to Wolff’s
law, bones adapt their mass and architecture in response to the
magnitude and direction of forces habitually applied to them [21].
According to the “mechanostat” theory bones weaken when
peaks strain and dynamic deformations fall below a given threshold
[22]. When the relative off-loading standing posture is followed by
spinal flexion a very high increase in stresses (up to 300%) occurs
on the weakened anterior bodies [21]. The very high loading dis-
parity could favour the collapse of anterior bodies with wedging
and explains why this region is frequently the site of osteoporotic
fracture, and how forward bending movements often precipitate
the injury [21].
The regional alterations of trabecular architecture by limiting
the variation in global bone density could reduce the capacity of
dual-energy X-ray absorptiometry (DEXA) of whole bodies to eval-
uate fracture risk. One study of intact spines found that the best way
to predict the strength of lumbar vertebral bodies and to identify
vertebrae at risk of osteopenic fracture in a wide age range (19–79
years) was the product of BMD and the endplate area using CT data
[23].
Vertebral body fractures modify the mechanical properties of
the injured vertebra as well as the adjacent disc and vertebra.
Endplate deflection provokes depressurization of the adjacent disc
nucleus with a secondary shift of compressive stresses both on the
annulus, mainly posterior to the nucleus, and the neural arch.
Vertebral augmentation by percutaneous vertebroplasty aims
to reverse these effects restoring the stiffness and strength of an
injured painful vertebral body, normal pressure in the adjacent disc
and load-sharing between vertebral body and arch [24].
Stabilization and pain relief are greatest in case of macro-
scopic intravertebral instability (vacuum cleft phenomenon and its
changes during flexion–extension) [25].
Luo et al. determined how the volume of cement injected affects
stress distribution inside the fractured vertebra and between the
affected vertebra, adjacent vertebra and disc in cadaveric motion
segments [26]. While just a small volume of cement (13% of volu-
metric body filling) was sufficient to reduce the abnormal endplate
deflection and normalize intradiscal pressure distribution under
load, larger quantities of cement (25% of averaged filling) were
needed to fully stabilize the injured trabecular bone and equal-
ize stress distribution between vertebral body and neural arch
[26]. Nevertheless, the altered biomechanics of load transfer to the
adjacent vertebra can increase the risk of new adjacent fractures
perhaps through a “stress-riser” effect.
A retrospective analysis of a cohort of 147 patients treated
with vertebroplasty or kyphoplasty found that the most predic-
tive factors among all of possible risk factors for adjacent refracture
such as age, gender, BMD, location of treated vertebra, amount of
bone cement injected, collapse degree, pattern of cement distribu-
tion, treatment modality, cement leakage into the disc space, were
122 R. Izzo et al. / European Journal of Radiology 82 (2013) 118–126

Fig. 6. (a–c) The load-bearing capacity of vertebral bodies heavy depends on the vertical trabecular struts joining the endplates (a). The resistance of a column decreases by
the square of increasing length and by the square of decreasing cross section. During osteoporosis both processes occur with progressive elongation of the columns provoked
by the resorption of the horizontal lamellae (b) and the thinning of the columns themselves (c). It results a disproportionate exponential reduction of bone resistance and
load bearing capacity.

cement leakage into the intervertebral disc space (which highly
concentrates the load stresses) and evolving osteoporosis [27].
5.2. Disc-intervertebral joints
Owing to its peculiar structure, the disc has both the tension-
resisting properties of a ligament and the compression-resisting
properties typical of joint cartilage.
The disc behaves as a ligament allowing for and controlling the
complex three-dimensional movements of the spine: vertical com-
pression and distraction, flexion–extension, lateral bending and
axial rotation.
The outermost fibres of the annulus are the first controller of
the abnormal micro-movements of a normal MS: experimental dis-
cectomies cause a significant increase in movements, especially
flexion–extension [28].
With the nucleus behaving like a pressured cylinder, the disc is
also the main shock absorber of mechanical stresses transmitted
during motions to the skull and brain. When the disc is submit-
ted to symmetric loads the nucleus transmits loads in all direction
pushing away the endplates, while, in case of eccentric loads, tends
to move toward the region of lower pressure, where the annulus
fibres are put under tension. Bending movements induce maximum
tensile and compressive loads on the opposing sides of the outer-
most annulus layers along with bulging on the compression side
and stretching on the tensile side.
During axial rotation the disc experiences torsional shear
stresses with half of the annulus fibres engaged (parallel to rota-
tion direction) until eventual delamination. The biomechanical
behaviour of the normal young nucleus is homogeneous and
isotropic, equal in all its parts and all directions: whatever the
spatial position of the spine the load is transmitted evenly on the
endplates avoiding any focal concentration [29].
By contrast, in the degenerated disc the nucleus loses its normal
fluid-like properties and loads asymmetrically assuming a solid-
like behaviour.
In contrast to the nucleus, the fundamental biomechanical prop-
erty of the annulus is its high anisotropy in tension reaching up to
a 1000-fold increase in the tensile modulus along the alignment of
the collagen fibres [29,30]. The tensile circumferential properties
of the annulus are also inhomogeneous, the anterior annulus being
stiffer than the posterior annulus and the outer annulus stiffer than
the inner ring [31].
When the normal disc is loaded tensile circumferential loads
are generated in the annulus because of the pressurization of the
nucleus and the resistance of its fibres to stretching and bulging
under axial compression. With the degenerative depressurization
of the nucleus, annulus fibres are no longer pushed outwards but
loaded in compression. The changes in tensile properties occurring
with disc aging and degeneration are relatively small in compar-
ison to the morphological changes. The nucleus pulposus mainly
works in the NZ bearing low axial loads while the stiffer annulus
fibrosus accepts a larger proportion of the highest loads [32]. Under
 R. Izzo et al. / European Journal of Radiology 82 (2013) 118–126 123

very high compressive loads the first structure to fail is usually the
endplate rather than the disc [33].
The water content and thickness of the disk continuously change
during normal daily activities under the opposite influences of
hydrostatic and osmotic pressures [34]. Under load the high hydro-
static pressure leads to a gradual release of water out of the disc
whose thickness diminishes until it is counterbalanced by the
osmotic pressure exerted by proteoglycans whose concentration
increases progressively [34]. In the recumbent position the re-
prevailing osmotic pressure again recalls water back into the disc.
In the degenerating disc the reduced hydrostatic pressure of the
nucleus displaces compressive loads on the internal annulus that
folds inward with an increase in shearing stresses which favour the
fissures and delamination for both structural fatigue and impaired
cellular response.
Fracture of the endplate and Schmorl herniation drastically
reduce the disc pressure accelerating the degeneration and destruc-
tion of the annulus.

5.3. Facet joints

Facet joints fulfil two basic functions:

- control of the direction and amplitude of movement,

- sharing of loads.

According to the three-column model of Louis, the weight of the

head and trunk is transmitted first on two columns placed on the
same frontal plane, the atlantooccipital lateral joints, then, from
C2 to L5, on three columns arranged like a triangle with an anterior
vertex [10]. The anterior column is composed of the superimposing
bodies and discs, the two posterior columns of the vertical succes-
sion of the facet joints.
Normally between the three columns there exists a balanced
and modular action for which the posterior facets accept from
0% up to 33% of the load depending on posture, but in case of
hyperlordosis, high and prolonged weight loading and disc degen-
eration the percentage can rise to 70% [35]. Like the vertebral bodies
the increasing size of the facet joints downward compensates the
increasing functional demand.
The spatial symmetry of the facets is an essential requirement
for correct functioning: every significant asymmetry predisposes
to instability and premature degeneration of the facets and discs.
Long-standing remodelling and destabilization of the facet joints
along with degenerative changes in posterior ligaments lead to
degenerative spondylolisthesis with sagittal orientation of the facet
joints acting as a predisposing factor [36].
Patients showing narrow inferior articular processes and facet
joint spaces visible on AP radiographs or with narrow facet joint
angles on axial MR-CT scans are likely to develop degenerative
spondylolisthesis [37]. Facet joint angles greater than 45◦ relative to
the coronal plane were found to have a 25 times greater likelihood
of developing degenerative slippage [38].
An estimated 15–40% cases of chronic low back pain cases are
thought to be caused by lumbar facet joints due to joint capsule
mechanical stresses and deformation with activation of nocicep-
tors [39]. Pain induced by pressure originating in the facets and/or
posterior annulus of the lumbar spine may be relieved by using
interspinous processes spacers.
5.4. Ligaments
The ligaments are the passive stabilizers of the spine. The stabi-
lizing action of a ligament depends not only on its intrinsic strength,
but also and to a greater extent on the length of the lever arm
through which it acts, the distance between the bony insertion,
Fig. 7. Owing to kyphosis the vertebrae of the dorsal spine are located distant from
the body sagittal balance vertical axis which joins the external auditory canals and
the centre of femoral heads passing through the C7–D1 and L5–S1 interspaces.
Eccentric ventral and lateral axial loads and bending moments create which con-
centrate the stresses on the anterior parts of the bodies favouring their collapse and
wedging. The larger the kyphosis, the greater the distance between vertebral bodies
and the body balance axis and the greater the ventral concentration of stresses.
the point of force application, and the IAR of the vertebral body, the
fulcrum located in the posterior body around which the vertebra
rotates without moving at any given moment during any move-
ment. A very strong ligament with a short lever arm may contribute
to stability less than a less strong ligament working by a longer lever
arm that gives it a mechanical advantage (Fig. 7). The interspinous
and supraspinous ligaments being located far away from the IAR
and working with a long lever arm oppose spinal flexion more
than the flava ligaments having a shorter lever arm [40]. Being very
close to the spinal IAR and intrinsically less resistant, the posterior
longitudinal ligament has a dual mechanical disadvantage.
5.5. Physiological curves
Sagittal curves are acquired and represent the evolutionary
response to the needs of the standing position and biped gait with
little energy expenditure [41]. Dorsal kyphosis is the only sagittal
spinal curve present at birth. Cervical and lumbar lordoses develop
with head rising and standing and walking, respectively.
Both in normal individuals and in pathologic conditions sagittal
spine curves are regulated by pelvic geometry expressed by differ-
ent parameters, namely pelvic incidence (PI), sacral slope (SS) and
pelvic tilt [41,42].
PI is a fixed morphologic parameter which after birth remains
unchanged in each subject: any sagittal balance change is obtained
because of the adaption of other positional parameters [42]. After
lumbar or thoracolumbar burst fractures local kyphosis can be com-
pensated by hyperlordosis caudad and, if necessary, hypokyphosis
124 R. Izzo et al. / European Journal of Radiology 82 (2013) 118–126
cephalad, but within the limits dictated by pelvic geometry. In order
to maintain the trunk centered over the femoral heads, an increased
SS leads to increased lumbar lordosis and dorsal kyphosis in both
normal and pathologic conditions. The concept of maintenance of
global spinal balance is helpful in guiding treatment choices in
spinal traumas.
Sagittal spinal curves also increase the resistance to vertical
loads up to 17 times by directing deformations into pre-ordered
directions which can be quickly controlled by the fast intervention
of muscle contraction.
The physiological curves of the spine also affect the response to
traumatic forces. Owing to the kyphosis, the vertebrae in the tho-
racic spine are distant from the body’s anterior–posterior balance
axis (passing through the external auditory canals, the interspaces
C7-D1 and L5-S1 and the centre of the femoral heads) and are sub-
jected to eccentric loads. Eccentric axial loads, anterior to vertebral
IAR, create lever arms and bending moments in a ventral or lateral
direction which concentrate the stresses on the anterior part of the
bodies favouring the occurrence of wedge compression fractures,
while all the elements posterior to the vertebral IAR move away
from each other [43] (Fig. 7).
In the lordotic segments vertical vector forces run near or
through the IAR of the vertebrae, without creating any leverage or
rotation. The forces are more evenly distributed on the endplates:
according to Newton’s third law, equal and opposite forces act on
the endplates favouring central or burst fractures [43].
6. Active stabilization
According to Panjabi, muscles and tendons provide active sta-
bilization of the spine under the control of the nervous system,
ensuring stability primarily in the NZ where the resistance to move-
ment is minimal [12].
Muscle action is needed to stabilize the spine during standing,
lifting and bending activities.
Without the muscles the spine would be highly unstable even
under very light loads [1239].
The muscles may be divided into superficial (rectus abdominis,
sternocleidomastoideus) and deep (psoas) flexors and superficial
(long) and deep (short) extensors.
The function of the superficial, multisegmental muscles differs
from that of deep unisegmental muscles. Being small and located
very close to vertebral rotation axes, the short muscles (inter-
transverse, interspinous, multifidus) globally act primarily as force
transducers sending feedback responses to the CNS on the move-
ment, load and position of the spine [44]. The long superficial
muscles are the main muscles responsible for generating move-
ments.
The lumbar erector spinae and the oblique abdominal muscles
produce most of the power forces required in lifting tasks and rota-
tion movement respectively, having only limited insertions on the
lumbar motion segments, while the multifidus muscle acts as a
dynamic stabilizer of these movements [44].
The oblique and transverse abdominis muscles are mainly flex-
ors and rotators of the lumbar spine but stabilize the spine at the
same time, creating a rigid cylinder around the spine by increasing
intra-abdominal pressure and tensing the lumbodorsal fascia [45].
The complexity of the posterior musculature excludes any possi-
bility of voluntary control upon single units. Out of external forces
(gravity), consistent compressive loads exerted on the spine are
due to muscle activity which has been assessed by electromyo-
graphy and mathematical models. The large number of muscles,
the complex antagonistic activities, the variability of spine inser-
tion sites and related moment arms hamper the determination of
muscle force and its contribution to spinal loading.
Fig. 8. In case of damage to ligaments, discs, joint capsules and to the mechanore-
ceptors they contain, abnormal transducer signals are generated and sent to the CNS
causing an altered motor response which, in turn, increases the mechanical stress
of bony and joint spinal components and elicits an abnormal feedback response
by FSUs and muscles themselves creating a vicious cycle ultimately leading to the
development of inflammation, muscle fatigue, and activation of nociceptors with
acute and chronic pain. CNS: central nervous system.
The CNS receives extensive inputs from all of joints, muscles and
tendons of each MS in order to regulate and coordinate in time and
space muscle activity (Fig. 4) [12].
In case of acute or chronic damage to ligaments, discs, joint
capsules and the mechanoreceptors they contain, abnormal trans-
ducer signals are generated and sent to the CNS causing an altered
motor response with impaired temporal and spatial coordination
[46]. In turn, the altered muscle response increases the mechanical
stress of bony and joint spinal components and elicits an abnormal
feedback response by FSUs and the muscles themselves (starting
from the muscle spindles and Golgi tendon organs) addressed to
the CNS, creating a vicious cycle that ultimately leads to inflamma-
tion, muscle fatigue, and activation of nociceptors with onset and
perpetuation of pain [46] (Fig. 8).
Schleip et al. suggest that, as the thoracolumbar fascia is rich
in Ruffini and Vater-Pacini corpuscles in all its three layers, fascia
damage can be implicated in the genesis of chronic pain through
the abnormal stimulation of the CNS [47]. In fact, patients with
chronic low back pain show a delayed muscle response and offset in
performing voluntary movements, and a reduced postural control
compared to asymptomatic subjects [48].
7. Therapeutic applications and conclusions
The difficulty of assessing spinal instability raises many con-
cerns for its treatment.
Fusion surgery is based on the classical assumption that insta-
bility implies increased motion and if motion is blocked spinal pain
is also relieved.
The main disadvantages of fusion surgery in degenerative insta-
bility remain loss of mobility and curvature with impaired sagittal
balance, instrumentation failure and transfer of increased stresses
to adjacent motion segments referred to as “transition syndrome”
(Fig. 9).
Symptomatic adjacent disease at ten years has been reported in
25% and 36% of patients after cervical and lumbar fusion, respec-
tively [49,50].
These problems have led to the development of new mobile sta-
bilization systems which aim to neutralize abnormal forces, restore
the normal function of the spinal segments and preserve the adja-
cent segments. Dynamic stabilizers represent the new frontier of
treatment of degenerative painful spine and have been the focus of
attention of bioengineers and surgeons in the last 10–15 years.
The function of interspinous spacers is to provide a poste-
rior shift of motion segment instantaneous axis of rotation (IAR)
 R. Izzo et al. / European Journal of Radiology 82 (2013) 118–126
Fig. 9. Sagittal midline FSE T2-w scan showing a posterior D12–L1 disc herniation
with light compression of spinal cord. One of main drawbacks of the spinal fixations
by rigid constructs is the transition syndrome caused by abnormal load stresses
converging on motion segments adjacent to fixed segments. Two years after a fix-
ation L1–S1 this middle-aged patient developed dorsal chronic pain. The image is
degraded by susceptibility artefacts due to the construct.
towards the region of increased stiffness and behind the facets,
reducing the compressive loads on the facet joint during standing
posture and extension movements [51]. Among the interspinous
implants classic single-action rigid or deformable spacers essen-
tially control extension, limiting compressive stresses on the facets
and posterior annulus (Fig. 10), while double-action devices cou-
ple a tension band to an interspinous device to control both flexion
and extension movements and also better decompress the anterior
annulus limiting the normal anterior shift of vertebral IAR during
spinal flexion (Fig. 6b) [51].
The best indications for interspinous devices are lumbar canal
and foraminal segmental stenosis, degenerative spondylolisthesis
or retrolisthesis, and Baastrup disease.
The indications for discogenic pain control are less defined,
but Swanson et al. reported a significant reduction of pressure
within the posterior annulus and nucleus of anatomic specimens
after application of interspinous devices. This action is expected
to relieve pain generating from disc nociceptive nerve endings
when stimulated by irregular distribution of internal pressures and
abnormal loads. The preservation of movement is crucial to pro-
mote the exchange of nutrients and waste products to and from
the disc [52].
Dynamic stabilization techniques are globally indicated in the
first stages of degenerative disc and facet diseases to prevent or
delay more invasive and less reversible approaches with the hope of
reversing degenerative processes once they are promptly corrected
[51]. Many of these procedures have been developed by radiol-
ogists: their minimal invasiveness makes them cheap, safe and
reversible [51]. Knowledge of the basic principles of biomechanics
can facilitate our understanding of the aetiology of spine diseases
and how all the bony and soft spinal components contribute indi-
vidually and together to ensure spinal stability. This knowledge is
mandatory in view of the increasing involvement of radiologists
and neuroradiologists in interventional spinal procedures, and the
125
Fig. 10. (a and b) As a consequence of disc degeneration and collapse, higher loads
are supported by vertically slipping neural arcs and facet joints (a). The implant of
interspinous spacers (IS) shifts the instantaneous axis of rotation (IAR) backwards
reducing the pressure between facets and in the posterior annulus, potential sources
of acute and chronic pain (b). In case of listhesis the IS can reduce the anterior
slippage of the vertebra. Vertical red arrows indicate compression; green arrows
tension or distraction. Big red horizontal arrow: degenerative anthelistesis; green
horizontal arrow: vertebral realignment.
ongoing development of new techniques and devices. Mechanical
experiments in human and animal specimens provide much more
quantitative information than can be obtained in vivo. Experimen-
tal data obtained from MS studies vary widely, first because of the
complex structural and material properties of MS substructures
(nonlinearity, viscoelasticity, anisotropy, inhomogeneity), their
interactions and their changes with aging and degeneration. The
key feature of proper spinal MS functioning is the highly nonlinear
load/displacement ratio since the effort required for the movement
significantly changes in its various phases. Spinal stability implies a
suitable relationship between the NZ and EZ [11,13]. Early motion
modifications begin and concentrate in the first phase referred to
as the NZ, nearest to neutral position. Spinal stability is ensured
by a stabilization system consisting of three closely interconnected
subsystems: the column or passive subsystem, the muscles and ten-
dons or active subsystem, and the unit of central nervous control
[12]. The assessment of spinal instability remains a major challenge
for specialists. In an unstable spine movement can be abnormal in
quality (abnormal coupling patterns) and/or in quantity (increased
motion). Fusion surgery leads to loss of mobility and physiologic
curvature and transfer of increased stresses to adjacent motion
segments. Dynamic stabilizers provide an intermediate solution
between conservative treatment and traditional fusion surgery and
often allow a minimally invasive approach and represent a new
frontier in the treatment of degenerative painful spine [51]. With
the contribution of interventional radiology will be soon avail-
able new devices with improved design and with more specific
implementations.
126 R. Izzo et al. / European Journal of Radiology 82 (2013) 118–126
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