5 
Biomechanics of the Spine
Olivier Y. Rolin, William E. Carter III
KEY POINTS
• The primary biomechanical functions of the spinal column are to
support the substantial loads induced during activities of daily
living and protect the spinal cord while allowing physiologic
mobility.
• This chapter presents a framework for understanding these
biomechanical functions of the spine by first discussing the
stability of the osteoligamentous spinal column and the role
SPINAL ORTHOSES
Spinal orthoses protect the spine in cases of instability related to
degenerative changes that result from aging and in postoperative situ-
ations to facilitate healing of surgical constructs used to stabilize gross
spinal instability. The orthosis should restrict the gross flexion or
extension, lateral bending, and axial rotation of the trunk to limit
compressive loading, straining, and shear stresses on the unstable spine
until healing is achieved. Understanding how movement and force
loading stresses the spinal column, how the spinal column is stabilized
under stress, and when stabilizing mechanisms are vulnerable to failure
is essential for using orthoses to treat spinal disorders.
SPINAL STABILITY UNDER STRESS
A spinal motion segment is the smallest functional unit of the osteo-
ligamentous spine and exhibits the generic characteristics of the spine.
The functional spinal unit (FSU) consists of a three-joint complex;
anteriorly vertebral bodies articulate with an intervertebral disc (a
fibro-cartilaginous joint), and posteriorly two facet joints (synovial
joints) articulate on either side of the spinal canal. The three-joint
complex moves in three planes: sagittal flexion and extension (F/E),
lateral bending (LB), and axial rotation (AR) (Fig. 5.1A). Coupling of
these movements allows multidirectional motion of the trunk in three
dimensions. Trunk movements produce compressive loading forces
directed axially through the three-joint complex, strain forces on discs
and ligaments placed under stretch, and shear forces directed horizontally
between discs and vertebral endplates4 (Fig. 5.1B).
Loading Forces
Axial compressive loads across the three-joint complex are produced
by (1) gravitational forces due to the mass of body segments, (2) external
forces and moments generated by a physical activity, and (3) muscle
tension. The greatest forces are produced by muscle tension. Displacement
of the gravitational force by flexion or bending produces a torque that
must be balanced by an equal and opposite torque. In the example of
bending and lifting tasks, an object carried at a distance from the axis
64
played by the muscles. The chapter progresses to a discussion of
the stability of a healthy spinal segment, followed by the effects of
injuries, degeneration, and surgical procedures on load sharing
between components of a spinal segment.
• The chapter presents a brief discussion of the
biomechanics of surgical decompression and spinal
fusion implants.
of rotation of the spine creates significant torque. Dorsal paraspinal
muscles that are relatively close to the spinal axis must generate high-
tension forces to generate a matching torque to maintain stability of
the segment. Thus muscle tension forces can amplify the compressive
load across intervertebral segments generated by mass and gravity alone
(Fig. 5.2).
Compressive forces across the spine during common physical activities
are estimated by kinematic and electromyographic data in conjunction
with three-dimensional biomechanical models and validated by in vivo
measurements range from 200 to 300 N during supine and recumbent
postures to 1400 N during relaxed standing. Forward flexion doubles
intradiscal pressure and increases by fourfold to fivefold when lifting
a 20-kg weight in flexed posture.8 Loads can increase substantially in
more extreme activities such as contact sports and weightlifting. The
human cervical spine also withstands substantial compressive preloads
in vivo. Cervical preload approaches three times the weight of the head
because of muscle coactivation forces in balancing the head in the
neutral posture. The compressive preload on the cervical spine increases
during F/E and may reach an estimated 1200 N in activities involving
maximal isometric muscle efforts.5
The intervertebral disc is the major anterior compressive load-bearing
element. The disc consists of an annulus fibrosus, 10 to 20 circumferential
concentric lamellae, surrounding a central gelatinous fluid, the nucleus
pulposus. Under direct axial compression the annulus fibrosis bulges
out radially in all directions, generating tension. Even tension around
the annulus directs the fluid nucleus pulposus centrally within the disc,
permitting load transmission from vertebra to vertebra to be distributed
evenly across the inferior vertebral endplate2 (Fig. 5.3A). If a load is
applied with the FSU in flexion, the superior endplate transmits compres-
sion to the anterior annulus. The anterior annulus bulges under compres-
sion while the posterior annulus undergoes stretching, creating a pressure
differential. The nucleus pulposus flows posteriorly, balancing the pressure
between the compression and tension sides, maintaining even pressure
across the inferior endplate despite uneven loading forces from the
superior endplate2 (Fig. 5.3B).
Facet joints provide a posterior load path and determine the limits
of motion in the FSU. Facets in the lumbar spine carry 10% to 20% of
 CHAPTER 5  Biomechanics of the Spine 65

Axial rotaion

Supraspinous ligament Compression

Y
Superior vertebra
Endplate Shear
Flexion/extension

Nucleus Strain
Disc annulus
Z Endplate
Interspinous ligament
Inferior vertbra
X
Facet joint
Lateral bending
A B
Figure 5.1  (A) The functional spinal unit (FSU) rotates around three cardinal axes: the X-axis creating sagittal
flexion and extension, the Y-axis creating axial rotation, and the Z-axis creating lateral bending. Coupling of
these movements allows multidirectional motion of the trunk in three dimensions. (B) Anteriorly vertebral
bodies articulate with a fibrocartilaginous intervertebral disc and posteriorly with two facets. Trunk movements
produce compressive loading forces directed axially through the three-joint complex, strain forces stretching
the elastic fibers within connective tissue, and shear forces directed horizontally at the interface of articulating
surfaces. (A, From Manfrè L, editor: Spinal instability, 2015, Springer International Publishing, Switzerland.
B, From Stellman JM, Chapter 6, Encyclopedia of Occupational Health and Safety, 4th Edition, International
Labor Office, Geneva Swizterland, 1998.)

Axial loading T = F x R (Sinθ)

force
sion

Weight
θ
le ten

R1 R2
Musc

F
F1 Sinθ x R1 = F2 x R2

F1

Figure 5.2  Muscle tension balances torque forces and generates large compressive loads. F1, Force vector from
muscle tension forces; F2, force vector from mass carrier at a distance anterior to the spine; R1, distance from
paraspinal muscles to axis of rotation; R2, distance from the carried weight to the axis of rotation; t, tension.

the compressive load in a neutral upright position. Load transmission
through the articular facet surfaces as well as through the tips
of the inferior facets in extension relieves some of the load on the
intervertebral disc, whereas flexion increases disc loading and offloads
the facets.3
Strain
The physiologic range of motion (ROM) of intervertebral joints is
maintained by elastic restraints. Within the initial part of ROM, a neutral
zone exists where motion encounters minimal resistance because joint
capsules, ligaments, fascias, and tendons remain slack. With further
deviation from neutral in all planes of F/E, LB, and AR, the joint restraints
become strained by tension, creating an elastic zone. Within the elastic
zone, the effort required to generate movement of the FSU increases
linearly with increasing distance from the neutral posture3,7 (Fig. 5.4).
A key elastic restraint to spinal motion is the annulus fibrosus. The
concentrically arranged lamellae crisscross relative to each other at
30-degree angles. This alternating orientation of the lamellae allows
for one half of the layers to resist strain from torsion in one direction
while the other half engage in response to torsion in the opposite
direction.4 During F/E and LB, the collagen fibers of the annulus fibrosus
opposite to the compression side are placed under vertical tension strain.
The angular arrangement enables simultaneous resistance to torsion
strain in the horizontal and from vertical tensile forces. A combination
of lateral bending and flexion generates maximal shear and strain forces
on the posterior inferior vertebral endplate and posterolateral discs,
respectively. The posterolateral disc and inferior vertebral endplate are
the most common sites of disc injury.6
66 SECTION 2  Spinal Orthoses

P1 P

Nucleus Bulge
pulposus

n
Tensio
Compres
P P Tensile
P P
Bulge Bulge Annulus
fibrosus

A B Bending Compression

Figure 5.3  (A) Direct axial compression causes the disc fibers to bulge radially, generating even tension
that restrains the nucleus pulposus (NP) centrally and maintains even load transmission (thick arrows) from
one vertebral body (VB) to the next. (B) Under unbalanced axial loading the posterior annulus undergoes
compression while the anterior annulus stretches, creating a pressure differential. The NP flows from the
compression side to the stretch side, balancing the pressure throughout the disc and across inferior endplate.
(B, From Zahaf S, Mansouri B, Belarbi A, et al. The effects induced by a backpack eccentric load on the spine
of children. J Biomed Sci Eng. 2016;4:6-22.)

Load or stress

Physiologic Traumatic
range range
Stress

Neutral zone Elastic zone Plastic zone Failure zone

Deformation or strain
Figure 5.4  Stress-to-strain curve of the vertebral body. In the neutral
and elastic zones the structure deformation of the structure is fully
reversible. The plastic zone is a damaging deformation, and the failure
zone results in subluxation, fracture, or other more traumatic injuries.
The capsular ligament of the facet joints provides additional mul-
tidirectional stability to the FSU under strain. The well-developed joint
capsules of the lumbar facets resist strain from rotation and lateral
bending. In the thoracic spine, facet joints have limited capsular reinforce-
ment, permitting substantial axial rotation.7
Shear Forces
Inclination of the vertebral endplate relative to the disc during F/E and
LB generate shear strain along the joint line (see Fig. 5.1B). Shear forces
are resisted passively by the bonds between the annulus fibrosus and
the vertebral endplates; however, active stabilization by axial musculature
plays a critical role in minimizing shear. Relative to the substantial loads
generated during various activities of daily life, the osteoligamentous
spine buckles under surprisingly little force when specimens are loaded
in the laboratory without active muscular support. The cervical spine
buckles at a vertical load of approximately 10 N, the thoracolumbar
spine at 20 N, and the lumbar spine at 88 N. In a purely osteoligamentous
Kg
Figure 5.5  Axial muscle forces direct the compressive load through
the axis of rotation of each individual motion segment. Kg represents
a mass that places force on a guide wire that directs tension through
the axis of rotation of each individual vertebra.
multisegment spine specimen, vertical compressive loads create segmental
bending moments that changes the specimen’s posture and generate
large shear forces with relatively small loads.5 Experimental models that
consider the activity of paraspinal and abdominal muscles demonstrate
that, in weight-holding tasks, the compressive force on the lumbosacral
disc increases with increasing trunk inclination and the amount of
weight lifted, whereas the maximum anteroposterior shear force remains
small (approximately 20%–25% of the compressive force).6 It is
hypothesized that coactivation of trunk and paraspinal muscles directs
the internal compressive force vector to follow the lordotic and kyphotic
curves of the spine, passing through the instantaneous axis of rotation
of each segment5 (Fig. 5.5). The load vector described is called a follower
 CHAPTER 5  Biomechanics of the Spine
load. Follower load mechanics minimize the segmental bending moments
and shear forces induced by the compressive load, allowing the liga-
mentous spine to support loads that otherwise cause buckling and
provide a margin of safety against both instability and tissue injury.
Application of follower load mechanics to human cadaveric specimens
of lumbar (L1–5), thoracolumbar (T2–sacrum), and cervical spines
(C2–7) and mathematical models have demonstrated that the ligamentous
spine, with its multiple motion segments, can withstand physiologic
compressive loads without tissue injury or instability.5 Applying a follower
preload to spine specimens in vitro does not compromise ROM in F/E,
AR, or LB and enables more faithful experimental reproduction of
physiologic motion in response to external force moments.1 Intradiscal
pressures in human cadaveric lumbar spines under a follower preload
are comparable to those measured in vivo.5 Because maintenance of
follower load mechanics requires balanced coactivation of the trunk
muscles, muscle dysfunction and imbalance or impairment of propriocep-
tion may allow increased shearing forces and compromise segmental
stability.3
SPINAL INSTABILITY
Injuries, degeneration, and surgical procedures alter normal load sharing
between the components of an FSU and cause an abnormal motion
response to physiologic loads. Instability of the FSU is measured by stiffness,
how much load is required to produce a given motion, and is inversely
proportional to the motion produced by a given load. Instability is
quantified in terms of loss of stiffness or increased mobility of an FSU
and can be categorized as microinstability or macroinstability.3
Microinstability
Microinstability refers to degenerative changes that compromise spinal
stability as one ages. Most commonly disc degeneration initiates a series
of changes within the aging FSU.3 In a healthy disc, fluid pressure
generated in the nucleus pulposus (NP) distributes loads evenly across
the endplates when bearing loads. As early as the second decade the
vasculature regresses around the nucleus pulposus, leading to decreased
proteoglycan synthesis and a diminished capacity of the NP to generate
fluid pressure in response to compression.10 With loss of internal fluid
pressure from dehydration of the nucleus, eccentric loading of the disc
transmits loads asymmetrically to the inferior endplate. In the case of
flexion there are high compressive loads on the anterior endplate with
reciprocal straining of the posterior disc placing tension on the posterior
endplates.2 Chronic overcompression of the anterior side can cause
endplate fractures, whereas strain on the posterior endplate is associated
with osteophyte formation.3,4,11 Initial degenerative changes in the disc
expand the neutral zone and decrease the stiffness of the elastic zone,
resulting in increased segmental motion. The neutral zone and elastic
zone mechanics of a healthy spine can be likened to a ball restrained
in a cup, whereas in a degenerated spine it more resembles a ball in a
bowl12,13 (Fig. 5.6).
Facet joint degeneration follows degenerative changes in the disc.
Facet joints bear loads on the posterior column, limiting AR, LB, and
F/E. At terminal flexion the facet joint gaps, placing tension on the
capsule, whereas in terminal extension the lower edge of the inferior
articular process opposes the superior edge of the superior articular
processes. With decreasing disc height and increased mobility of the
degenerated disc, contact pressures between the superior and inferior
facets precipitates erosion of the articular cartilage. Cartilage loss
combined with increased posterior loading forces and may lead to
subluxation of the facet joints. Increased gapping of the facets in flexion
places severe strain on the capsular ligament. Decreased stiffness of the
elements that limit spinal deformation in response to external forces
67
ROM
NZ
ROM
NZ
Figure 5.6  Disc degeneration decreases elastic resistance and allows
segments to move unstably. NZ, Neutral zone; ROM, range of motion.
(From Panjabi MM: Clinical stability and low back pain. J Electromyogr
Kinesiol. 2003;13:371.)
is described as a widening of the neutral zone with decreased elastic
zone activity.3
The hypermobility of the three-joint complex resulting from the
degenerative cascade can eventually restabilize through bony hypertrophy
and osteophyte formation, which may decrease pain symptoms. This
remodeling of the spine mitigates hypermobility; however, it may produce
functional limitation with impingement of the neural elements within
the central canal or the lateral neuroforaminal recesses. Magnetic reso-
nance imaging (MRI) combined with F/E radiographs in patients with
back pain show increased movement with normal or mildly degenerate
discs but reduced movements in the markedly degenerative discs.3,4,11
Macroinstability
Macroinstability implies gross disruption related to fracture or dislocation
of the spinal column causing a severely unstable spine. The three-column
model of load-bearing described by Denis et al. provides a framework
to assess macroinstability9 (Fig. 5.7). The anterior column consists
of the anterior longitudinal ligament and the anterior half of the vertebral
body and annulus fibrosis. The posterior longitudinal ligament
and posterior half of the vertebral body and annulus fibrosis compose
the middle column. The posterior arch, supraspinous and interspinous
ligaments, facet joints, and ligamentum flavum form the posterior
column. When two or more columns are disrupted, the injured
segments undergo excessively large motion in response to loading,
leading to present or imminent neurologic deficit, because any spinal
motion will lead to compression of the neural elements. As discussed
later, macroinstability requires urgent neurosurgical intervention for
restabilization.
BIOMECHANICS OF SURGICAL DECOMPRESSION
AND STABILIZATION
Decompression
Degenerative changes of the spine may result in central stenosis or
neuroforaminal stenosis that can be remediated by surgical decompressive
procedures such as discectomy, facetectomy, foraminotomy, or several
68 SECTION 2  Spinal Orthoses

Ant.

Mid.

Post. Post. column

Posterior elements
Ant. column - Pedicle
Ant. longit lig. Middle column - Facet joints
Ant. annulus Post. 1/3 of vert. body - Lamina
Ant. 2/3 vert. body Post. annulus - Sinous process
Post. longit. lig. Posterior ligaments
Figure 5.7  Axial (A) and sagittal (B) views of the vertebral column according to the three-column concept
by Denis. Anterior (Ant.) column: Anterior longitudinal ligament (longit. lig.) and anterior two thirds of the
vertebral body and disc. Middle column: Posterior (Post.) longitudinal ligament and posterior third of the
vertebral body and disc. Posterior column: Pedicles, facet joints, laminae, spinous processes, and posterior
ligaments. (A, From Izzo R, et al. Stability and Instability of the Spine. Manfre, L., Spinal Instability, New
Procedures in Spinal Interventional Neuroradiology,Switzerland:Springer International Publishing DOI 10.1007/978-
3-319-12901-3. B, From –Physiopedia: Lumbar spine fracture, 2016. http://www.physio-pedia.com/Lumbar_Spine
_Fracture.)

others. Decompressive procedures eliminate the homeostatic changes

that compensate for decreased stiffness, thus increasing segmental
mobility and susceptibility of the FSU to further degenerative changes.14 No bone
Fusion success

Whereas remodeling in spinal degeneration shifts loading onto the
posterior columns, spinal loading after laminectomy is shifted back to
the anterior column. Spinal segments with advanced disc degeneration
will therefore have very low shear stiffness, and if there is low bone
mineral density or lack of stabilizing osteophytes, the vertebral column
becomes susceptible to postoperative spondylolysis or spondylolisthesis.14
Partial discectomy or removal of the annulus pulposus, often used to
remediate disc herniation, will affect the FSU similarly to natural disc
degeneration, though much more prominently, increasing angular motion
of the FSU in all planes of motion (but particularly in axial rotation)
and placing increased compression and strain forces on the posterior
elements. Nonphysiologic motion of the segment and decreased load-
bearing of the posterior elements after such procedures can accelerate
degenerative changes of the anterior elements.15
Spinal fusion: If severe segmental instability is present or there is
concern for neurologic deficit, fusion may be indicated. Fusion may be
used in conjunction with decompressive surgeries to prevent associated
instability or spinal traumas wherein multiple columns are disrupted.
The goal of fusion is to restore the stability of the anterior or posterior
column by replacement of an unstable joint complex with a rigid
construct. Common fusion techniques include posterolateral fusion,
interbody fusion, and circumferential fusion. Posterolateral fusion (PLF)
targets the posterior elements. After decortication of the facets, autologous
bone graft is packed into the posterolateral recesses to promote fusion.
Interbody fusion techniques target the anterior column. Interbody
devices replace the intervertebral disc to restore compressive load-bearing
and interbody segment height, which may offload the posterior columns
and indirectly decompress posterior neural elements. The interbody
device consists of either a cage (typically manufactured from poly-
etheretherketone [PEEK] and carbon fiber) or a bone graft spacer.14
Too much stimulation
motion
Construct stiffness
Figure 5.8  The theoretical impact of construct stiffness on surgical
fusion success.
Fusion is a time-dependent process that requires bony healing; thus
fused vertebrae are unstable in the perioperative period. Perioperative
instability thus may be managed with bracing and/or hardware to
compensate. Bracing can reduce segmental loading and shearing from
F/E or bending and prevent strain from axial rotation. Spinal instrumenta-
tion increases the rigidity of segments at the fusion site, reducing the
relative motion between the vertebrae during the biologic healing process.
Immobilization of adjacent vertebrae enhances the chances of obtaining
a solid bony fusion, but too much stiffness also impedes bony fusion
(Fig. 5.8), limits function, and is an infection risk.15 Posterior instrumenta-
tion for stabilization consists of two longitudinal plates or rods with
segmental attachments to the vertebrae to form a solid construct. The
rigidity of the construct depends on the size and shape of the longitudinal
components, the number of vertebrae spanned by the implant, the
method of their attachment to the vertebrae, and the cross-links between
the longitudinal components.14
A complete reference list can be found online at ExpertConsult.com.
 CHAPTER 5  Biomechanics of the Spine
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Surgical Decompression and Stabilization
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