Implementation of a Virtual Reality Module for Gaining Surgical Access via Planned Oblique Lateral Lumbar Interbody Fusion Khaled El-Monajjed Department of Mechanical Engineering McGill University, Montreal December 2020 A thesis submitted to McGill University in partial fulfillment of the requirements of the degree of Doctor of Philosophy in Mechanical Engineering © Khaled El-Monajjed, 2020 i DEDICATION I dedicate this thesis to my parents, Marwa Al-Zaim and Afif El-Monajjed for their endless support and motivation. Mom and Dad, this is but a minute symbol of gratitude for the sacrifices you have made, the hardships you had to go through and the effort you made to seek a better future for us. I also dedicate this to my wife and life partner, Fatima Bohsali, for never doubting me and always showing her support and endless love. Finally, I dedicate this to my daughter Marwa El-Monajjed, who was born while I was working on my PhD, I love you, Dad. Never let anyone ever tell you that you cannot do something, be strong and stay true to yourself always. ii Life is but a perfect simulator rendering at light speed, bound by the space-time continuum, governed by its flawless laws of physics, dispatching events based on our input as we consciously connect through our physical body peripheral, powered by energy while continuously monitored to conceive a set of metrics whose outcome concludes our void when idle. iii CONTENTS Dedication… .................................................................................................................................. ii Contents….. .................................................................................................................................. iv List of Tables ............................................................................................................................... vii List of Figures ............................................................................................................................... ix List of Equations ........................................................................................................................ xiii List of Symbols and Abbreviations .......................................................................................... xiv Abstract…… ............................................................................................................................. xviii Résumé…… ................................................................................................................................. xx Acknowledgements ................................................................................................................... xxii Authors Contribution .............................................................................................................. xxiii Original Contribution .............................................................................................................. xxiv Introduction ................................................................................................................................... 1 Chapter 1: Literature Review .................................................................................................... 4 1.1. Musculoskeletal Anatomy, Biomechanisms, Mechanical Charactaristics And Its Variation in Spinal Disorders ...................................................................................................................................... 4 1.1.1. Vertebra ...................................................................................................................................... 4 1.1.2 Intervertebral Discs ................................................................................................................... 10 1.1.3. Muscles .................................................................................................................................... 16 1.1.4. Thoracolumbar Fascia .............................................................................................................. 21 1.1.5. Abdominal Cavity .................................................................................................................... 25 1.1.6. Peripheral Nerves ..................................................................................................................... 26 1.1.7. Spinal Stability and Loading .................................................................................................... 27 1.1.8. Mechanical Variations of Tissue in Spinal Disorders .............................................................. 31 1.2. Minimally Invasive Surgery.......................................................................................................... 34 1.2.1. Overview of Low Back Pain .................................................................................................... 34 iv 1.2.2. Surgical Interventions via Lumbar Interbody Fusion ............................................................... 38 1.2.3. Oblique Lateral Lumbar Interbody Fusion ............................................................................... 45 1.3. Virtual Reality-Based Surgical Simulators ................................................................................. 48 1.3.1. History ...................................................................................................................................... 49 1.3.2. Definition ................................................................................................................................. 51 1.3.3. System Types and Components ............................................................................................... 54 1.3.4. Medical Simulators .................................................................................................................. 60 1.3.5. Realtime Computational Techniques and Puncturing Models in Surgical Simulators ............ 68 Chapter 2: Research Rationale, Objectives and Hypothesis ................................................. 79 Chapter 3: Study of the load transmission within the lower spinal structure ..................... 83 3.1. Framework of the First Article .................................................................................................... 83 3.2. Article 1: A Finite Element Analysis of the Intra-Abdominal Pressure and Paraspinal Muscle Compartment Pressure Interaction Through the Thoracolumbar Fascia ...................................... 85 3.2.1. Abstract .................................................................................................................................. 85 3.2.2. Introduction ............................................................................................................................ 86 3.2.3. Method.................................................................................................................................... 87 3.2.4. Results .................................................................................................................................... 90 3.2.5. Discussion .............................................................................................................................. 93 3.2.6. References .............................................................................................................................. 97 3.2.7 Figures and Tables .................................................................................................................... 99 3.3. Additional Studies related to Article 1 ....................................................................................... 105 3D study of Thoracolumbar Fascia .................................................................................................. 105 Chapter 4: Cadaveric experimental study to extract tool-tissue interaction ..................... 116 4.1. Framework of Second Article ..................................................................................................... 116 4.2. Article 2: Analysis of Surgical Forces Required to Gain Access using a Probe for Minimally Invasive Spine Surgery via Cadaveric-Based Experiments toward use in Training Simulators 117 4.2.1. Abstract ................................................................................................................................ 117 4.2.2. Introduction .......................................................................................................................... 118 4.2.3 Methods ................................................................................................................................ 119 4.2.4 Results .................................................................................................................................. 122 4.2.5. Discussion ............................................................................................................................ 125 4.2.6. Conclusion ............................................................................................................................ 131 4.2.7. References ............................................................................................................................ 131 v 4.2.8. Figures and Tables ................................................................................................................ 136 4.3. Additional Studies related to Article 2 ......................................................................................