Vertebroplasty — Procedure Guide, Recovery & Risks | MyMedicPlus

Vertebroplasty is a minimally invasive image-guided spinal intervention in which polymethylmethacrylate (PMMA) bone cement — a medical-grade acrylic cement that polymerises rapidly and generates heat during setting — is injected under pressure through one or two large-bore bone-biopsy needles directly into the fractured vertebral body to mechanically stabilise the fracture, relieve acute pain, and restore vertebral height and structural integrity. The procedure is performed under fluoroscopic or CT guidance with the patient prone, using a transpedicular or paracostal needle trajectory to access the vertebral body cancellous bone through the posterior cortical wall. Vertebroplasty is used primarily to treat painful osteoporotic vertebral compression fractures (VCFs) — the most common fragility fracture — and pathological vertebral fractures due to vertebral metastases (breast, lung, prostate, myeloma) or haemangiomas that have not responded to adequate analgesia. Vertebral compression fractures affect approximately 20% of post-menopausal women over age 70, causing severe acute-on-chronic back pain, reduced mobility, progressive spinal deformity (kyphosis), and significantly impaired quality of life. Unlike kyphoplasty — its closely related technique — vertebroplasty does not employ a balloon tamp to create a cavity before cement injection and therefore achieves less vertebral height restoration, though both provide equivalent pain relief in randomised trials. The procedure is performed under local anaesthesia with moderate intravenous sedation as a day-case procedure, typically taking 30-60 minutes per level treated.

Vertebroplasty is indicated for patients with painful osteoporotic vertebral compression fractures that are acutely symptomatic, radiologically active (showing oedema on MRI STIR or T2 sequences indicating acute or sub-acute fracture within approximately 6–8 weeks), and have not responded to a conservative management trial of 4–6 weeks including oral analgesics, bed rest, and spinal bracing. Candidates with intolerable pain who cannot tolerate conservative treatment or who are at high risk from prolonged immobility (elderly patients, pulmonary disease) may be treated earlier. Vertebroplasty is also used for painful pathological vertebral fractures from spinal metastases or multiple myeloma, providing effective palliation of pain and structural reinforcement in the context of systemic oncological disease. Contraindications include spinal cord or nerve root compression requiring surgical decompression, spinal instability, active vertebral osteomyelitis, uncorrectable coagulopathy, allergy to PMMA or opacification agents, and fractures older than 12 months without MRI evidence of residual bone oedema.

The patient lies prone on the fluoroscopy or CT table. Local anaesthesia (lignocaine) is infiltrated down to the periosteum of the pedicle(s) of the target vertebra, and intravenous conscious sedation provides comfort throughout. Under biplanar fluoroscopic (or CT) guidance, a bevelled coaxial trocar needle of 11–13 gauge is advanced percutaneously through the pedicle along a lateral-to-medial trajectory into the posterior third of the vertebral body — the transpedicular approach. Bilateral transpedicular access is preferred for thoracic and upper lumbar levels to ensure adequate cement distribution across the vertebra. The stylet is removed and a curved probe used to create a cavity within the cancellous bone. The PMMA cement is mixed with barium sulphate or tantalum powder to make it radiopaque and visible under fluoroscopy, then allowed to reach an appropriate viscosity. Cement is injected slowly under continuous real-time fluoroscopic monitoring using a 1 mL per pass technique, watching for any leakage toward the posterior cortex, disc space, or epidural veins. Injection is stopped immediately if cement nears the posterior wall or enters the venous system. The trocar is rotated and withdrawn when injection is complete and the cement has set sufficiently. The skin puncture site requires only a small adhesive dressing.

Vertebroplasty provides clinically significant pain relief in approximately 85–90% of carefully selected patients with acute osteoporotic compression fractures, typically evident within 24–72 hours as the cement polymerises and stabilises the fracture. Pain scores (VAS) decrease by an average of 5–6 points on a 10-point scale. Restored spinal stability enables earlier mobilisation, reducing the risks of prolonged bed rest including pneumonia, deep vein thrombosis, pressure sores, and progressive muscle deconditioning in elderly patients. Effective pain control substantially reduces or eliminates dependence on opioid analgesics and their associated side effects including constipation, confusion, and falls risk. For pathological fractures from spinal metastases, vertebroplasty provides effective palliation even in advanced disease, supporting ongoing mobility and independence. The VAPOUR trial (Lancet, 2016) confirmed significant superiority of vertebroplasty over placebo in acute fractures meeting strict inclusion criteria.

Cement leakage outside the vertebral body is the most common technical finding, detected on imaging in 10–40% of procedures, but is clinically significant (causing symptoms) in fewer than 1% of cases with careful technique. Epidural or foraminal cement leakage can cause nerve root compression or spinal cord injury — the most feared serious complication — occurring in under 0.5% with strict fluoroscopic monitoring. Cement pulmonary embolism from venous leakage into the epidural or paravertebral veins is rare but potentially life-threatening if large amounts embolise. Rib fractures from needle placement forces occur in less than 1% of thoracic vertebroplasties. Infection (spondylodiscitis) is very rare (under 0.1%) with sterile technique. Adjacent vertebral fractures at levels above or below the cemented vertebra occur in 10–20% within 12 months — possibly due to altered stress distribution — though the background rate of adjacent fractures in osteoporosis is also high. Concurrent bisphosphonate, calcium, and vitamin D therapy for osteoporosis is essential to reduce further fracture risk.

Following the procedure, patients remain supine for 1–2 hours while the cement fully sets. Neurological status and vital signs are monitored. Most patients are able to stand and walk within 2–4 hours of the procedure, representing a dramatic improvement over their pre-procedure immobility. Discharge is same-day or after overnight observation in elderly patients or those requiring social support. The puncture site typically requires no sutures — only a small adhesive dressing changed daily for 48 hours. Analgesic requirements usually decrease significantly within 24 hours. Normal daily activities including gentle walking, sitting, and self-care resume immediately; heavy lifting and high-impact activities such as running, jumping, and contact sports should be avoided for 6 weeks to allow full cement integration and surrounding tissue healing. Follow-up with the referring physician at 4–6 weeks assesses clinical response, pain scores, and mobility. Long-term management of the underlying osteoporosis with antiresorptive medication (bisphosphonates, denosumab) is essential and must be initiated or continued following the procedure.