Vertebroplasty

How it's done

• Restores mechanical strength to the vertebral body, preventing further height loss
• Generates heat during polymerization, which is thought to disrupt local pain nerve endings

Indications

• Painful osteoporotic vertebral compression fractures (the most common indication), ideally treated within 4-6 weeks of symptom onset in patients with severe pain requiring opioids or hospitalization
• Painful vertebral metastases or multiple myeloma
• Kümmell's disease
• Painful vertebral hemangiomas

Effectiveness

Complications (~1% overall serious complication rate, no reported procedural mortality)

• Needle-related: pedicle fracture, needle breakage, pneumothorax, hemorrhage, spinal infection
• Cement-related: nerve root or cord compression, pulmonary cement embolism, cement leakage into epidural/foraminal/paravertebral veins
• Procedure-related: fat embolism, adjacent rib or new vertebral fracture (about 10% of patients develop a new compression fracture, often at an adjacent level)
• Sedation/anesthesia-related: respiratory or cardiac arrest, airway injury
• Drug-related: allergic reaction

Vertebroplasty vs. kyphoplasty

Recent evidence (last 2-3 years)

• A 2025 systematic review/meta-analysis compared newer "curved" (unipedicular, bilateral cement distribution) vertebroplasty techniques against standard unipedicular approaches, generally favoring the curved technique for better cement distribution and pain outcomes (PMID 40342107, 37839572).
• A 2024 meta-analysis of RCTs comparing percutaneous vertebroplasty to nonoperative treatment continues to show mixed results depending on control group design, reinforcing the sham-controlled-trial controversy noted above (PMID 39053849).

Steps of the Vertebroplasty Procedure

• Confirm indication with imaging: plain radiograph shows osteopenia/wedge or crush deformity; MRI (fluid-sensitive, fat-suppressed sequences) confirms an acute fracture by detecting bone marrow edema - this is the key criterion for selecting patients likely to benefit.
• Ensure the patient is on or started on bone-protective/anti-osteoporotic therapy if the fracture is osteoporotic.
• Position the patient prone on the fluoroscopy table.

• Most cases are done under conscious (moderate) sedation with local anesthesia and analgesia at the needle entry site.
• General anesthesia is used in select patients (e.g., those who cannot lie still, significant pain, or multi-level procedures).

• High-quality fluoroscopy is set up in biplane or C-arm configuration (sometimes combined with CT guidance) to allow accurate, real-time visualization of the vertebral body and pedicles.
• A sterile field is established.

• Under fluoroscopic guidance, the pedicle of the target vertebra is identified on the anteroposterior view.
• A trocar/cannula is advanced percutaneously through the pedicle (transpedicular approach) into the anterior third of the vertebral body. This can be done unipedicularly (one side) or bipedicularly (both sides) depending on how well cement can be expected to fill the body from one approach.

• If kyphoplasty is being performed instead of/in addition to vertebroplasty, a balloon (bone tamp) is introduced through the cannula and inflated within the vertebral body to create a cavity and partially restore lost vertebral height before cement injection. This allows use of a thicker, more viscous cement.

• Liquid PMMA (polymethylmethacrylate) bone cement, mixed to a specific viscosity, is injected slowly through the cannula under continuous fluoroscopic monitoring.
• Injection is stopped as soon as cement approaches the posterior vertebral cortex, epidural space, or an intervertebral disc space, or if venous filling is seen, to avoid leakage/embolization.
• Filling the entire vertebral body is not necessary for pain relief - studies show no correlation between cement volume and clinical outcome.

• The cement is allowed to harden in place. As it polymerizes it releases heat, which is thought to help ablate pain nerve endings in addition to mechanically stabilizing the fracture.
• The needle/cannula is withdrawn once the cement has sufficiently hardened (to avoid a cement "tail" tracking back along the needle path).

• The patient is monitored for immediate complications (neurologic changes, hypotension, respiratory issues) and typically observed for a short period before discharge, since the procedure is usually done as an outpatient or short-stay case.
• Follow-up imaging (radiograph or CT) may be done to confirm cement placement and rule out extravasation.

• Patients treated for osteoporotic fractures should remain under the care of a clinician managing their underlying osteoporosis to reduce future fracture risk, since vertebroplasty treats the current fracture's pain but does not address the systemic bone disease.

Key technical notes

• Access route: transpedicular (most common) or parapedicular/posterolateral for levels where the pedicle is too narrow (e.g., mid-thoracic spine).
• Cement is injected slowly and incrementally, with imaging checked between small aliquots - this stepwise approach is the main technique for minimizing leakage, the most common complication.