title: Restoring geometric and loading alignment of the thoracic spine with a vertebral compression fracture: effects of balloon (bone tamp) inflation and spinal extension.
abstract: BACKGROUND
  In patients with osteoporosis, changes in spinal alignment after a vertebral compression fracture (VCF) are believed to increase the risk of fracture of the adjacent vertebrae. The alterations in spinal biomechanics as a result of osteoporotic VCF and the effects of deformity correction on the loads in the adjacent vertebral bodies are not fully understood.
  
  
  OBJECTIVE
  To measure 1) the effect of thoracic VCFs on kyphosis (geometric alignment) and the shift of the physiologic compressive load path (loading alignment), 2) the effect of fracture reduction by balloon (bone tamp) inflation in restoring normal geometric and loading alignment and 3) the effect of spinal extension alone on fracture reduction and restoration of normal geometric and loading alignment.
  
  
  METHODS
  A biomechanical study using six fresh human thoracic specimens, each consisting of three adjacent vertebrae with all soft tissues and bony structures intact.
  
  
  METHODS
  In order to reliably create fracture, cancellous bone in the middle vertebral body was disrupted by inflation of bone tamps. After removal of the bone tamps, the specimen was compressed using bilateral loading cables until a fracture was observed with anterior vertebral body height loss of >/=25%. Fracture reduction was performed under a compressive preload of 250 N first under the application of extension moments, and then using inflatable bone tamps. The vertebral body heights, kyphotic deformity of the fractured vertebra and adjacent segments and location of compressive load (cable) path in the fractured and adjacent vertebral bodies were measured on video-fluoroscopic images.
  
  
  RESULTS
  The VCF caused anterior wall height loss of 37+/-15%, middle-height loss of 34+/-16%, segmental kyphosis increase of 14+/-7.0 degrees and vertebral kyphosis increase of 13+/-5.5 degrees (p<.05). The compressive load path shifted anteriorly by about 20% of anteroposterior end plate width in the fractured and adjacent vertebrae (p=.008). Bone tamp inflation restored the anterior wall height to 91+/-8.9%, middle-height to 91+/-14% and segmental kyphosis to within 5.6+/-5.9 degrees of prefracture values. The compressive load path returned posteriorly relative to the postfracture location in all three vertebrae (p=.004): the load path remained anterior to the prefracture location by about 9% to 11% of the anteroposterior end plate width. With application of extension moment (6.3+/-2.2 Nm) until segmental kyphosis and compressive load path were fully restored, anterior vertebral body heights were improved to 85+/-8.6% of prefracture values. However, the middle vertebral body height was not restored and vertebral kyphotic deformity remained significantly larger than the prefracture values (p<.05).
  
  
  CONCLUSIONS
  The anterior shift of the compressive load path in vertebral bodies adjacent to VCF can induce additional flexion moments on these vertebrae. This eccentric loading may contribute to the increased risk of new fractures in osteoporotic vertebrae adjacent to an uncorrected VCF deformity. Bone tamp inflation under a physiologic preload significantly reduced the VCF deformity (anterior and middle vertebral body heights, segmental and vertebral kyphosis) and returned the compressive load path posteriorly, approaching the prefracture alignment. Application of extension moments also was effective in restoring the prefracture geometric and loading alignment of adjacent segments, but the middle height of the fractured vertebra and vertebral kyphotic deformity were not restored with spinal extension alone.
authors.affiliation: Department of Veterans Affairs, Edward Hines Jr. Veterans Affairs Hospital, 5th Avenue & Roosevelt Road, P.O. Box 5000 (151), Hines, IL 60141, USA.
authors.forename: Ioannis N
authors.initials: IN
authors.lastname: Gaitanis
authors.forename: Gerard
authors.initials: G
authors.lastname: Carandang
authors.forename: Frank M
authors.initials: FM
authors.lastname: Phillips
authors.forename: Brian
authors.initials: B
authors.lastname: Magovern
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Ghanayem
authors.forename: Leonard I
authors.initials: LI
authors.lastname: Voronov
authors.forename: Robert M
authors.initials: RM
authors.lastname: Havey
authors.forename: Michael R
authors.initials: MR
authors.lastname: Zindrick
authors.forename: Alexander G
authors.initials: AG
authors.lastname: Hadjipavlou
authors.forename: Avinash G
authors.initials: AG
authors.lastname: Patwardhan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001696:Biomechanical Phenomena; D002102:Cadaver; D019299:Decompression, Surgical / Q000295:instrumentation / Q000379:methods*; D005260:Female; D005598:Fractures, Spontaneous / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D016268:Internal Fixators; D007738:Kyphosis / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D008297:Male; D010024:Osteoporosis / Q000150:complications; D019736:Prostheses and Implants; D011859:Radiography; D012680:Sensitivity and Specificity; D016103:Spinal Fractures / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D013314:Stress, Mechanical; D013904:Thoracic Vertebrae / Q000601:surgery*; D016474:Weight-Bearing