title: Preliminary biomechanical evaluation of prophylactic vertebral reinforcement adjacent to vertebroplasty under cyclic loading.
abstract: BACKGROUND
  Percutaneous vertebroplasty has become a favored treatment option for reducing pain in osteoporotic patients with vertebral compression fractures (VCFs). Short-term results are promising, although longer-term complications may arise from accelerated failure of the adjacent vertebral body.
  
  
  OBJECTIVE
  To provide a preliminary biomechanical assessment of prophylactic vertebral reinforcement adjacent to vertebroplasty using a three-vertebra cadaveric segment under dynamic loads that represent increasing activity demands. In addition, the effects of reducing the elastic modulus of the cement used in the intact vertebrae were also assessed.
  
  
  METHODS
  Three-vertebra cadaveric segments were used to evaluate vertebroplasty with adjacent vertebral reinforcement as an intervention for VCFs.
  
  
  METHODS
  Nine human three-vertebra segments (T12-L2) were prepared and a compression fracture was generated in the superior vertebrae. Vertebroplasty was performed on the fractured T12 vertebra. Subsequently, the adjacent intact L1 vertebra was prophylactically augmented with cement of differing elastic moduli (100-12.5% modulus of the base cement value). After subfailure quasi-static compression tests before and after augmentation, these specimens were subjected to an incrementally increasing dynamic load profile in proportion to patient body weight (BW) to assess the fatigue properties of the construct. Quantitative computed tomography assessments were conducted at several stages in the experimental process to evaluate the vertebral condition and quantify the gross dimensions of the segment.
  
  
  RESULTS
  No significant difference in construct stiffness was found pre- or postaugmentation (t=1.4, p=.19). Displacement plots recorded during dynamic loading showed little evidence of fracture under normal physiological loads or moderate activity (1-2.5x BW). A third of the specimens continued to endure increasing load demands and were confirmed to have no fracture after testing. In six specimens, however, greater loads induced 11 fractures: 7 in the augmented vertebra (2xT12, 5xL5) and 4 in the adjacent L2 vertebra. A strong correlation was observed between the subsidence in the segmental unit and the incidence of fracture after testing (r(Spearman's)=-0.88, p=.002). Altering the modulus of cement in the intact vertebra had no effect on level of segmental compromise.
  
  
  CONCLUSIONS
  These preliminary findings suggest that under normal physiological loads associated with moderate physical activity, prophylactic augmentation adjacent to vertebroplasty showed little evidence of inducing fractures, although loads representing more strenuous activities may generate adjacent and peri-augmentation compromise. Reducing the elastic modulus of the cement in the adjacent intact vertebrae appeared to have no significant effect on the incidence or location of the induced fracture or the overall height loss of the vertebral segment.
authors.affiliation: School of Mechanical Engineering, University of Leeds, Leeds, UK.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Oakland
authors.forename: Navin R
authors.initials: NR
authors.lastname: Furtado
authors.forename: Ruth K
authors.initials: RK
authors.lastname: Wilcox
authors.forename: Jake
authors.initials: J
authors.lastname: Timothy
authors.forename: Richard M
authors.initials: RM
authors.lastname: Hall
mesh_terms: D001696:Biomechanical Phenomena; D001843:Bone Cements / Q000627:therapeutic use*; D002102:Cadaver; D055119:Elastic Modulus; D050815:Fractures, Compression / Q000601:surgery; D006801:Humans; D008159:Lumbar Vertebrae / Q000601:surgery*; D019637:Orthopedic Procedures / Q000379:methods*; D013904:Thoracic Vertebrae / Q000601:surgery*; D054854:Vertebroplasty
chemical_list: D001843:Bone Cements