TP10PUB42

TECHNICAL PAPER Use of Rapid Prototyping for

Demonstrative and Other Purposes in
Spinal Injury Cases

author

ROBERT R. ZINSER
Doctor of Chiropractic
Peoria, IL

abstract

Rapid prototyping (RP) is a technology used by the manufacturing industry for turning
a CAD model into a tangible prototype. In the past 18 years, software advances in
CT imaging of the spine have made the output of such imaging the equivalent of a
CAD model, and thus suitable for RP. This means the technology can be used in
whiplash injury cases by producing an exact replication of the human spine. The
model can be used as evidence in a courtroom, as an educational aid in a doctor’s
office, or as a model for training physicians.

In the latter application, RP allows for a new training tool for spine surgery residents
and fellows. Surgical techniques can be developed and studied for real-world
application. In forensic venues, RP of the spine can help juries understand the
nature and extent of spinal injuries. The future applications of the technology as an
adjunct to medical imaging are virtually unlimited.

terms

Rapid Prototyping, Prototypes, Medical Applications, Spinal Injuries, Medical Models

conference

RAPID 2010 AND 3D IMAGING CONFERENCES & EXPOSITION

Society of Manufacturing Engineers
May 18–20, 2010
Anaheim, CA

Society of Manufacturing Engineers • One SME Drive • PO Box 930

2010 Dearborn, MI 48121 • Phone (313) 425-3000 • www.sme.org
 SME TECHNICAL PAPERS

This Technical Paper may not be reproduced in whole or in

part in any form without the express written permission of
the Society of Manufacturing Engineers. By publishing this
paper, SME neither endorses any product, service or
information discussed herein, nor offers any technical
advice. SME specifically disclaims any warranty of
reliability or safety of any of the information contained
herein.
 TP10PUB42

Use of Rapid Prototyping for Demonstrative and

Other Purposes in Spinal Injury Cases

Robert R. Zinser, D.C., C.C.S.P., P.C.

ABSTRACT

Rapid prototyping (RP) is a technology used by the manufacturing industry for

turning a CAD model into a tangible prototype. In the past 18 years, software
advances in CT imaging of the spine have made the output of such imaging the
equivalent of a CAD model, and thus suitable for RP. This means the technology
can be used in whiplash injury cases by producing an exact replication of the
human spine, graphically demonstrating osseous injury and instability that results
in malalignment. The process of RP involves constructing physical objects using
solid freeform fabrication. By applying virtual design using computer software, the
image is interpreted as thin horizontal cross sections. Through successive layers
of liquid, plastic, powder, or metal, the 3-D computer image is transformed into a
model that can be used as evidence in a courtroom, as an educational aid in a
doctor’s office, or as a model for training physicians.

In the latter application, RP allows for a new training tool for spine surgery
residents and fellows. Surgical techniques for reduction and fixation of complex
comminuted fractures of the spine, particularly the upper cervical spine, can be
developed and studied for real-world application. In forensic venues, RP of the
spine can help juries understand the nature and extent of spinal injuries and
allow for a hands-on inspection of a victim’s injuries. The future applications of
the technology as an adjunct to medical imaging are virtually unlimited.

INTRODUCTION

Rapid prototyping, as a process, intrigued me. When it comes to injuries of the

spine, I see a need in both the legal and medical fields for an exact replica that
demonstrates the detail needed to determine such injuries. Of this, Rapid
Prototype Anatomicals was born.

It is very difficult for people to assemble in their mind how an injury of the spine
might look. It is far more impressive for a person to have a model they can hold
in their hand. The MRI and CT scan are proven diagnostic methods that have
been used for years. The process of rapid prototyping has also been proven as a
successful method of fabrication. I am proposing that the consolidation of these
processes gives us the recipe for a usable body of evidence.

1
 TP10PUB42

The technology excites me. I have been a practicing chiropractor for more than
40 years. This type of material was never present. I want to use the high-tech
procedures of today’s world to bring current the unknown. When it comes to
litigation, crash analysis, and chiropractic as a discipline, I strive to level the
playing field and show the truth.

PROCESS ANALYSIS

The current steps for creating rapid prototype models of the spine begin with
static X-rays to show bone material, digital motion X-rays (DMX) to demonstrate
range of motion and ligamentous elasticity, and CT or MRI scans to show soft
tissue. A DICOM (digital imaging and communications in medicine) file is then
created from such studies. Mimics® software by Materialise is used to clean up
and put DICOM files together. At this point, the file is translated from a DICOM
file into an STL file (a file format native to the stereolithography CAD software
created by 3D Systems). The STL file will be used to create a rapid prototype
model. The RP process would depend on the customer’s requirements
(SLA/Stereolithography, SLS/Selective Laser Sintering, or ZCorporation). The
model is then delivered to the customer. (Different fabricators are being
investigated for compatibility and future production.)

When dealing with something as delicate as the cervical spine, the intricacies
make it difficult for a rapid prototype model to be considered durable. I prefer
pressurized plaster in glue for modeling. However, there are improvements in RP
fabrication all the time. The RP spine can be a 1:1 scale model. It is extremely
precise. With micron-scale layer thickness, the human detail can be represented
in astonishingly good quality.

DISCUSSION

The law has not treated the chiropractic profession favorably. Reliability of
information when faced with adversity is of the utmost importance. The rapid
prototype model of the human spine is the answer. Legally, the primary
advantage of the model is education of a jury. Rather than a jury accepting a
doctor’s or insurance company’s testimony regarding the interpretation of an X-
ray or MRI, they are able to view a tangible model—which is far more impressive
and accurate. Both parties in such litigation should worry that a juror may rule out
what he or she does not understand. In this instance, the model commands
attention because it brings sight, touch, and understanding to injuries. This
should level the playing field and slow discrepancies when it comes to evidence,
eventually freeing the court systems of lengthy and expensive arguments. People
should be able to comprehend evidence, allowing them to talk things out and
reach settlements by means that are more reasonable. Such models could be
requested, and used, by both the plaintiff and the defense to demonstrate injury
and/or non-injury in a case.

2
 TP10PUB42

The application to the surgical field is also relevant and exciting. The idea of
using the technology at the pre-surgery stage could allow physicians to prepare
for precise incisions to increase accuracy and decrease error. Malpractice issues
can also be physically shown with possible comparisons of pre- and post-surgical
models. Surgeons that refer to X-rays and MRI while operating potentially could
be referring to an exact model of their patient, thus decreasing risk of damage.

In the cervical spine model, one might look for shrinking disc height. This is
evident by the position of the vertebrae. The intervertebral foramen (openings for
nerves to leave the spine) on either side of the vertebrae are also visible.
Possible narrowing or compression of these openings due to trauma or reaction
to trauma would compromise the transmission of spinal nerves and vessels in a
patient. When looking at calcification and osteophytes (commonly known as bone
spurs), the model can demonstrate the severity of such issues. These bony
matters invade the areas the body reserves for nerve transmission. The
symptoms a patient experiences and the corrective procedures they seek can
only benefit from the anatomical model. Pain, blame, and cost of care begin to
overcome a patient, stifling their quality of life. Hands-on proof can begin to
reverse the cycle and open doors of opportunity for a once-invisible problem.

I have to presume that if the rapid prototype spines were of suitable cost, the
insurance companies would actually embrace the idea to decrease exposure and
insulate themselves from frivolous lawsuits.

People, who do not always understand what they are being told, can now hold in
their hand an exact medical model of something right or something wrong,
allowing for more informed and fair decisions.

CASE STUDY

On April 1, 2004, Michel B. was the seat-belted driver of a 2001 Honda Odyssey
minivan in Miami, Florida, where he was employed as a federal officer. At
approximately 9:00 p.m., he was traveling between 25-35 mph in his own lane
toward a tollbooth. As he was entering the toll area, a 2003 Honda Civic made an
abrupt lane change ahead of Michel B., cutting into his lane of travel. He
slammed on his brakes but was unable to avoid collision with the Honda Civic,
crashing into the rear of the car. His minivan could not be driven after the
collision.

Michel B. reported no symptoms immediately after impact. Approximately two

hours after the crash, he felt soreness in his chest, neck, and back. He took
himself to the emergency room of the nearest hospital, where a cervical CT scan
and low back X-rays were performed. They failed to reveal any fracture. He was
released from the emergency room with ibuprofen and instructions to follow up
with his primary care physician.

3
 TP10PUB42

Two to three weeks post-crash, Michel B. developed paresthesias (tingling) in his

hands, prompting him to wear wrist braces for support. He reported pain starting
behind his right shoulder and radiating across and up the back of the left side of
his neck. He stated that such pain sometimes led to numbness in his left arm. He
also wore a lumbar support during that time for low back pain. For a six-month
period, he underwent massage therapy and electrical stimulation to help reduce
symptoms. For the next year and a half, the symptoms continued periodically,
with the paresthesias also affecting both legs and feet. In January 2005, his left
arm went numb for four hours. He occasionally awoke during that time with
numbness in both arms. He was treated with neurontin (prescription drug used
for the reduction of chronic neuropathic pain) and underwent several trigger point
injections with no relief. His complaints included left grip weakness, constant
neck stiffness, occasional neck pain, headaches that radiated over the scalp and
frontal areas of his head, and paresthesias of the hands, fingers, feet, and toes.
Michel B. also complained that when he turned his neck to the left it triggered
spasms in the left supraspinatus muscle (one of the four rotator cuff muscles).

For three and a half years post-crash, Michel B. sought relief from at least a half
dozen doctors from different disciplines on the auto-insurance claim. The
responsible insurance company went so far as to video him, without his
knowledge, while fishing from a small boat, scrutinizing his daily activities. He
came to Dr. Zinser’s chiropractic office in Peoria, Illinois, in June 2005 (14
months after the accident). Dr. Zinser worked with Michel B. extensively until
March 2006, studying every detail of his case, including all outside treatments.
The responsible insurance company used the video as proof that he had no
permanent injuries and had resumed his daily activities with no problems. They
wanted to settle with Michel B. for nothing more than cents on the dollar for the
medical bills he had incurred. Dr. Zinser disagreed with the assessment and
initial offer by the insurance company. After careful review of the video in
question, he noticed that throughout the entire fishing excursion, Michel B. was
reacting to his neck injury. While he fished, unloaded the boat, and packed up to
leave, Michel B. repeatedly rubbed the left side of his neck, followed by rotating
his neck in a full range of motion as if to relieve stiffness.

The rapid prototype of Michel B.’s cervical spine yielded answers for Dr. Zinser
when considering all of the symptoms. The solid model showed that between the
5th and 6th cervical vertebrae, the intervertebral foramina visible on both sides of
the spine were very, very narrow. This caused the nerves trying to pass through
these areas to become strangulated and over-sensitized, causing intense
headaches. The model also showed a posterior ponticle on the left side of the
atlas vertebrae, which is a calcification of the atlanto-occiptal ligament that
bridges the posterior aspect of the lateral mass and the posterior arch. The right
side also showed the beginnings of a second posterior ponticle. As these areas
of the ligament harden, or atrophy, the stress and strain in the region caused the
intense headaches to worsen into chronic migraine headaches. While the

4
 TP10PUB42

responsible insurance company did not believe that Michel B. had any arthritic
spurs, the front view of the 5th cervical vertebrae clearly showed an osteophyte
resembling the size of a lima bean. An osteophyte of that size is going to crowd
an already crowded area, causing the stiffness associated with arthritis. The front
view of the 3rd cervical showed a juvenile osteophyte arising from some type of
disruption or injury to the periosteum (lining of the bone), indicating trauma.

At the time the prototype was made, the only trauma Michel B. had suffered was
his crash from April 1, 2004. All of the deformities visible on the prototype shed
credibility on Dr. Zinser’s theory that the cervical spine operates as a unit like a
set of connected train cars on a track. The malformed parts are interruptions to a
perfectly functioning unit. Other parts of the unit begin to absorb duties, possibly
causing damage to them. The entire system is compromised and functions
improperly. The lasting result in the patient is pain.

The introduction of Dr. Zinser’s observations from the surveillance tape, along
with the abnormalities visible on Michel B.’s rapid prototype spine brought about
change with regard to understanding the severity of his injuries. Opposing parties
began to see that the crash precipitated Michel B.’s current medical conditions
and the fact that Michel B. would surely incur medical expenses in the future as a
result. The final settlement in the case respectfully reflected these findings when
compared to the initial offer.

CONCLUSION

Given the fact that the diagnosis of a patient’s condition can be corroborated by
the production of a rapid prototype spine as well as contributing to a more
favorable outcome of litigation, I would speculate that my impressions of the
medical and legal applications are valid. This venture is my opportunity to bring
together multiple disciplines in an effort to show truth.

REFERENCES

1) Croft AC, Freeman MD: Correlating Crash Severity with Injury Risk, Injury
Severity, and Long-Term Symptoms in Low Velocity Motor Vehicle Collisions.
Medical Science Monitor. 2005;11(10):316-21.

2) Ettlin TM, Kischka U, Reichman S, Radii EW, Heim S, Wengen D, Benson DF:
Cerebral Symptoms After Whiplash Injury of the Neck: A Prospective Clinical
and Neuropsychological Study of Whiplash Injury. Journal of Neurology
Neurosurgery & Psychiatry. 1992 October;55(10):943-8.

3) Jonsson H. Jr.,Cesarini K, Sahlstedt B, Rauschning W: Findings and Outcome in

Whiplash-Type Neck Distortions. Spine. 1994;19(24):2733-2743.

5
 TP10PUB42

4) Packard RC, Weaver R, Ham LP: Cognitive Symptoms in Patients With

Posttraumatic Headache. Headache: The Journal of Head and Face Pain. 2005
May;33(7):365-8.

5) Radanov BP, Sturzenegger M, Di Stefano G: Long-Term Outcome After

Whiplash Injury. A 2-Year Follow-up Considering Features of Injury Mechanism
and Somatic, Radiologic, and Psychosocial Findings. Medicine (Baltimore). 1995
September;74(5):281-97.

6) Stemper BD, Yoganandan N, Pinter FA, Rao RD: Anterior Longitudinal

Ligament Injuries in Whiplash May Lead to Cervical Instability. Medical
Engineering & Physics. 2006 July;28(6):515-24.

7) Tucker J: Injury with Low-Speed Collisions. Dynamic Chiropractic. 1995

May;13(11).

8) Yoganandan N, Kumaresan S, Pintar FA: Geometric and Mechanical Properties

of Human Cervical Spine Ligaments. Journal of Biomechanical Engineering.
2000 December;122(6):623-29.