Finite element modeling to compare craniocervical motion in two age-matched pediatric patients without or with Down syndrome: implications for the role of bony geometry in craniocervical junction instability

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  • 1 Departments of Bioengineering, Scientific Computing and Imaging Institute, and
  • 2 Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, Utah
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OBJECTIVE

Instability of the craniocervical junction (CCJ) is a well-known finding in patients with Down syndrome (DS); however, the relative contributions of bony morphology versus ligamentous laxity responsible for abnormal CCJ motion are unknown. Using finite element modeling, the authors of this study attempted to quantify those relative differences.

METHODS

Two CCJ finite element models were created for age-matched pediatric patients, a patient with DS and a control without DS. Soft tissues and ligamentous structures were added based on bony landmarks from the CT scans. Ligament stiffness values were assigned using published adult ligament stiffness properties. Range of motion (ROM) testing determined that model behavior most closely matched pediatric cadaveric data when ligament stiffness values were scaled down to 25% of those found in adults. These values, along with those assigned to the other soft-tissue materials, were identical for each model to ensure that the only variable between the two was the bone morphology. The finite element models were then subjected to three types of simulations to assess ROM, anterior-posterior (AP) translation displacement, and axial tension.

RESULTS

The DS model exhibited more laxity than the normal model at all levels for all of the cardinal ROMs and AP translation. For the CCJ, the flexion-extension, lateral bending, axial rotation, and AP translation values predicted by the DS model were 40.7%, 52.1%, 26.1%, and 39.8% higher, respectively, than those for the normal model. When simulating axial tension, the soft-tissue structural stiffness values predicted by the DS and normal models were nearly identical.

CONCLUSIONS

The increased laxity exhibited by the DS model in the cardinal ROMs and AP translation, along with the nearly identical soft-tissue structural stiffness values exhibited in axial tension, calls into question the previously held notion that ligamentous laxity is the sole explanation for craniocervical instability in DS.

ABBREVIATIONS AAAM = anterior atlantoaxial membrane; AP = anterior-posterior; CCJ = craniocervical junction; DS = Down syndrome; FE = finite element; FEM = FE model; lbf = pounds of force; PAAM = posterior atlantoaxial membrane; ROM = range of motion; TL = transverse ligament; TM = tectorial membrane.

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Contributor Notes

Correspondence Douglas L. Brockmeyer: University of Utah, Primary Children’s Hospital, Salt Lake City, UT. douglas.brockmeyer@hsc.utah.edu.

INCLUDE WHEN CITING Published online November 13, 2020; DOI: 10.3171/2020.6.PEDS20453.

Disclosures Dr. Dailey reports being a consultant for Zimmer, having direct stock ownership in Discgenics, and receiving support of a non–study-related clinical or research effort overseen by the author from Stryker/K2M.

  • 1

    Pueschel SM, Scola FH. Atlantoaxial instability in individuals with Down syndrome: epidemiologic, radiographic, and clinical studies. Pediatrics. 1987;80(4):555560.

    • Search Google Scholar
    • Export Citation
  • 2

    Parfenchuck TA, Bertrand SL, Powers MJ, Posterior occipitoatlantal hypermobility in Down syndrome: an analysis of 199 patients. J Pediatr Orthop. 1994;14(3):304308.

    • Search Google Scholar
    • Export Citation
  • 3

    Caird MS, Wills BP, Dormans JP. Down syndrome in children: the role of the orthopaedic surgeon. J Am Acad Orthop Surg. 2006;14(11):610619.

    • Search Google Scholar
    • Export Citation
  • 4

    Sankar WN, Schoenecker JG, Mayfield ME, Acetabular retroversion in Down syndrome. J Pediatr Orthop. 2012;32(3):277281.

  • 5

    Martel W, Tishler JM. Observations on the spine in mongoloidism. Am J Roentgenol Radium Ther Nucl Med. 1966;97(3):630638.

  • 6

    Kennelly JM Jr. A report of a case of atlanto-axial dislocation in a mongol. Clin Proc Child Hosp Dist Columbia. 1952;8(6):142145.

  • 7

    Browd S, Healy LJ, Dobie G, Morphometric and qualitative analysis of congenital occipitocervical instability in children: implications for patients with Down syndrome. J Neurosurg. 2006;105(1 Suppl):5054.

    • Search Google Scholar
    • Export Citation
  • 8

    Browd SR, McIntyre JS, Brockmeyer D. Failed age-dependent maturation of the occipital condyle in patients with congenital occipitoatlantal instability and Down syndrome: a preliminary analysis. J Neurosurg Pediatr. 2008;2(5):359364.

    • Search Google Scholar
    • Export Citation
  • 9

    Livingstone B, Hirst P. Orthopedic disorders in school children with Down’s syndrome with special reference to the incidence of joint laxity. Clin Orthop Relat Res. 1986;(207):7476.

    • Search Google Scholar
    • Export Citation
  • 10

    Rebouças Moreira TA, Demange MK, Gobbi RG, Trochlear dysplasia and patellar instability in patients with Down syndrome. Rev Bras Ortop. 2015;50(2):159163.

    • Search Google Scholar
    • Export Citation
  • 11

    Valle MS, Casabona A, Micale M, Cioni M. Relationships between muscle architecture of rectus femoris and functional parameters of knee motion in adults with Down syndrome. BioMed Res Int. 2016;2016:7546179.

    • Search Google Scholar
    • Export Citation
  • 12

    Bakouny Z, Assi A, Yared F, Combining acetabular and femoral morphology improves our understanding of the down syndrome hip. Clin Biomech (Bristol, Avon). 2018;58:96102.

    • Search Google Scholar
    • Export Citation
  • 13

    Duque Orozco MDP, Abousamra O, Chen BP, Knee deformities in children with Down syndrome: a focus on knee malalignment. J Pediatr Orthop. 2018;38(5):266273.

    • Search Google Scholar
    • Export Citation
  • 14

    White AA III, Panjabi MM. Update on the evaluation of instability of the lower cervical spine. Instr Course Lect. 1987;36:513520.

  • 15

    Panjabi MM, Thibodeau LL, Crisco JJ III, White AA III. What constitutes spinal instability? Clin Neurosurg. 1988;34:313339.

  • 16

    Panjabi M, Dvorak J, Duranceau J, Three-dimensional movements of the upper cervical spine. Spine (Phila Pa 1976). 1988;13(7):726730.

  • 17

    Ayturk UM, Puttlitz CM. Parametric convergence sensitivity and validation of a finite element model of the human lumbar spine. Comput Methods Biomech Biomed Engin. 2011;14(8):695705.

    • Search Google Scholar
    • Export Citation
  • 18

    Brolin K, Halldin P. Development of a finite element model of the upper cervical spine and a parameter study of ligament characteristics. Spine (Phila Pa 1976). 2004;29(4):376385.

    • Search Google Scholar
    • Export Citation
  • 19

    Dong L, Li G, Mao H, Development and validation of a 10-year-old child ligamentous cervical spine finite element model. Ann Biomed Eng. 2013;41(12):25382552.

    • Search Google Scholar
    • Export Citation
  • 20

    Ellis BJ, Debski RE, Moore SM, Methodology and sensitivity studies for finite element modeling of the inferior glenohumeral ligament complex. J Biomech. 2007;40(3):603612.

    • Search Google Scholar
    • Export Citation
  • 21

    Maas SA, Ellis BJ, Ateshian GA, Weiss JA. FEBio: finite elements for biomechanics. J Biomech Eng. 2012;134(1):011005.

  • 22

    Phuntsok R, Ellis BJ, Herron MR, The occipitoatlantal capsular ligaments are the primary stabilizers of the occipitoatlantal joint in the craniocervical junction: a finite element analysis. J Neurosurg Spine. 2019;30(5):593601.

    • Search Google Scholar
    • Export Citation
  • 23

    Puttlitz CM, Goel VK, Traynelis VC, Clark CR. A finite element investigation of upper cervical instrumentation. Spine (Phila Pa 1976). 2001;26(22):24492455.

    • Search Google Scholar
    • Export Citation
  • 24

    Womack W, Leahy PD, Patel VV, Puttlitz CM. Finite element modeling of kinematic and load transmission alterations due to cervical intervertebral disc replacement. Spine (Phila Pa 1976). 2011;36(17):E1126E1133.

    • Search Google Scholar
    • Export Citation
  • 25

    Phuntsok R, Mazur MD, Ellis BJ, Development and initial evaluation of a finite element model of the pediatric craniocervical junction. J Neurosurg Pediatr. 2016;17(4):497503.

    • Search Google Scholar
    • Export Citation
  • 26

    Leahy PD, Puttlitz CM. The effects of ligamentous injury in the human lower cervical spine. J Biomech. 2012;45(15):26682672.

  • 27

    Dreischarf M, Zander T, Shirazi-Adl A, Comparison of eight published static finite element models of the intact lumbar spine: predictive power of models improves when combined together. J Biomech. 2014;47(8):17571766.

    • Search Google Scholar
    • Export Citation
  • 28

    Maas SA, Ateshian GA, Weiss JA. FEBio: history and advances. Annu Rev Biomed Eng. 2017;19:279299.

  • 29

    Calvy TM, Segall HD, Gilles FH, CT anatomy of the craniovertebral junction in infants and children. AJNR Am J Neuroradiol. 1987;8(3):489494.

    • Search Google Scholar
    • Export Citation
  • 30

    Semine AA, Ertel AN, Goldberg MJ, Bull MJ. Cervical-spine instability in children with Down syndrome (trisomy 21). J Bone Joint Surg Am. 1978;60(5):649652.

    • Search Google Scholar
    • Export Citation
  • 31

    Pueschel SM, Herndon JH, Gelch MM, Symptomatic atlantoaxial subluxation in persons with Down syndrome. J Pediatr Orthop. 1984;4(6):682688.

    • Search Google Scholar
    • Export Citation
  • 32

    Ali FE, Al-Bustan MA, Al-Busairi WA, Cervical spine abnormalities associated with Down syndrome. Int Orthop. 2006;30(4):284289.

  • 33

    Siemionow K, Chou D. To the occiput or not? C1-c2 ligamentous laxity in children with down syndrome. Evid Based Spine Care J. 2014;5(2):112118.

    • Search Google Scholar
    • Export Citation
  • 34

    Carter C, Wilkinson J. Persistent joint laxity and congenital dislocation of the hip. J Bone Joint Surg Br. 1964;46:4045.

  • 35

    Mienaltowski MJ, Birk DE. Structure, physiology, and biochemistry of collagens. Adv Exp Med Biol. 2014;802:529.

  • 36

    Karousou E, Stachtea X, Moretto P, New insights into the pathobiology of Down syndrome—hyaluronan synthase-2 overexpression is regulated by collagen VI α2 chain. FEBS J. 2013;280(10):24182430.

    • Search Google Scholar
    • Export Citation
  • 37

    Marneros AG, Olsen BR. Physiological role of collagen XVIII and endostatin. FASEB J. 2005;19(7):716728.

  • 38

    Dey A, Bhowmik K, Chatterjee A, Down syndrome related muscle hypotonia: association with COL6A3 functional SNP rs2270669. Front Genet. 2013;4:57.

    • Search Google Scholar
    • Export Citation
  • 39

    Luck JF. The Biomechanics of the Perinatal, Neonatal and Pediatric Cervical Spine: Investigation of the Tensile, Bending and Viscoelastic Response. Dissertation. Biomedical Engineering, Duke University; 2012. Accessed July 31, 2020. https://hdl.handle.net/10161/5850

    • Search Google Scholar
    • Export Citation

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