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Indications & Contraindications
Patient selection and absolute/relative contraindications
Indications
- Osteoporotic vertebral compression fracture (VCF) — acute (<6 weeks) preferred; subacute (up to 3 months) acceptable when bone marrow edema confirmed on MRI STIR
- Malignant compression fracture — myeloma, lytic metastases; consider ablation (coblation/RFA) before cement in highly vascular tumors
- Painful vertebral hemangioma — aggressive intraosseous hemangioma with refractory pain
- Traumatic fracture — non-osteoporotic acute fracture with significant pain refractory to conservative management
- First described by Galibert and Deramond in 1984 for cervical hemangiomas; now standard of care for VCF
Contraindications
- Absolute: Stable asymptomatic fracture without pain · Active local or systemic infection (osteomyelitis) · Neurologic deficit from retropulsed bony fragment (kyphoplasty or surgery preferred) · Uncorrectable coagulopathy · Allergy to PMMA
- Relative: Vertebra plana (>75% height loss — technical challenge but feasible) · Posterior wall disruption with canal compromise · Pregnancy · Significant spinal instability requiring surgery
- Note: Myelopathy or neurologic deficit from pure epidural tumor (not retropulsed bone) is a relative contraindication — discuss with spine surgery
Vertebroplasty vs. Conservative Management
- Up to 84% of VCFs have pain lasting ≥4–6 weeks; one-third develop chronic pain, kyphosis, and height loss without treatment
- Vertebral augmentation reduces 12-month all-cause mortality compared to conservative management (Cazzato et al, Eur Radiol 2021)
- Prolonged bed rest causes 2% bone density loss/week and up to 61% DVT risk — early mobilization via vertebroplasty has systemic benefit
- Conservative management for >3 months without MRI-confirmed edema: benefit of vertebroplasty diminishes
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Pre-Procedure Checklist
Imaging, labs, consent
MRI spine with STIR sequence. STIR hyperintensity = bone marrow edema = active/acute fracture that will respond to vertebroplasty. T1 hypointensity corroborates. If MRI contraindicated: bone scan (Tc-99m) to confirm activity. CT alone insufficient to confirm fracture acuity.
CT spine for fracture morphology. Assess posterior wall integrity, degree of height loss (Genant grading: Grade 1 = 20–25%, Grade 2 = 25–40%, Grade 3 = >40%), pedicle width (must be ≥4–5 mm for transpedicular approach), canal compromise, and fragment retropulsion.
Identify fracture level on imaging. Most common: mid-thoracic (T7–T8) and thoracolumbar junction (T12–L1). Confirm symptomatic level correlates with imaging findings — count from C2 or sacrum on sagittal MRI.
Labs. Coagulation studies (INR, platelets) required. SIR Category 2: INR ≤1.5, platelets ≥50K. CBC, BMP. If malignancy: additional staging workup as needed.
Anticoagulation management. Hold oral anticoagulants per SIR guidelines. Warfarin: hold 5 days; DOACs: hold 24–48h; LMWH: hold 24h; heparin infusion: hold 4–6h. Aspirin may be continued.
Anesthesia plan. Most cases: local anesthesia with MAC sedation (midazolam + fentanyl or propofol). Patient must be able to be positioned prone. General anesthesia reserved for multi-level procedures or anxious/uncooperative patients.
Consent. Discuss: cement extravasation (epidural, foraminal, intradiscal, venous), neurologic injury (cord/nerve root compression), pulmonary cement embolism, infection, adjacent vertebral fracture risk, incomplete pain relief, need for repeat procedure.
PMMA cement and mixing system available. Confirm cement brand, mixing supplies, and fluoroscopy capability (biplanar preferred). Bone biopsy equipment available if malignancy suspected and tissue diagnosis needed.
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Relevant Anatomy
Spinal levels, pedicle dimensions, approach planning
Transpedicular Approach
- Most common approach — viable when pedicle width ≥4–5 mm (standard for T4–L5)
- Needle trajectory along the dorsal aspect of the posterior element into the vertebral body via the pedicle
- Target: anteromedial one-third of the vertebral body (anterior 1/3 on lateral view, midline on AP)
- Benefits: overlying soft tissue compression after needle removal promotes hemostasis; shorter working length
- Bilateral bipedicular approach most common; unipedicular can achieve adequate midline fill for osteoporotic fractures
Extrapedicular / Parapedicular Approach
- Used when pedicles are too small — typically above T8 where pedicle width narrows
- Needle passes lateral to the pedicle, through the costovertebral junction (thoracic) or posterolateral (lumbar)
- Harder to achieve hemostasis after needle removal; greater risk of pneumothorax at upper thoracic levels
- Mandatory if pedicle width <4 mm — do not force transpedicular access through a narrow pedicle
Critical Structures at Risk
- Posterior cortex / spinal canal: Cement leak into epidural space can cause cord or cauda equina compression
- Neural foramina: Lateral cement leak can compress exiting nerve root
- Intervertebral disc: Intradiscal injection can accelerate adjacent disc degeneration
- Basivertebral veins: Prominent in vertebral body — venous filling visible on live fluoro; risk of pulmonary embolism
- Aorta / IVC: Paramedian extravasation at lumbar levels can enter great vessels (rare)
Pedicle Width Reference
- Cervical: Small — rarely treated with transpedicular (cervical VP described but uncommon)
- Upper thoracic (T1–T4): 4–6 mm — borderline; extrapedicular often safer
- Mid-thoracic (T5–T10): 5–8 mm — transpedicular feasible; confirm on pre-procedure CT
- Thoracolumbar (T11–L2): 8–14 mm — comfortable transpedicular access
- Lumbar (L3–L5): 12–20 mm — widest; easiest transpedicular access
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Technique
Default RadCall approach · share your own below
Supplies
Biplanar fluoroscopy (C-arm)
11G bone trocar (transpedicular)
13G trocar (alternative)
PMMA cement system (Confidence, Vertas, or equivalent)
Cement mixing bowl + spatula
1 mL Luer-lock syringes (cement injection)
ChloraPrep
Sterile drapes
1% lidocaine
18G spinal needle (local / level marking)
Mallet
Bone biopsy needle (if tissue needed)
Steps
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Position & localize
Patient prone on radiolucent table. Arms alongside head in prone position cushion. Biplanar fluoroscopy configured (AP + lateral). Use marking needle (18G spinal needle) at skin to confirm correct vertebral level — count ribs on AP or use lateral scout. Prep and drape a wide sterile field.
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Local anesthesia & skin nick
Infiltrate skin, subcutaneous tissue, and periosteum of the pedicle with 1% lidocaine under fluoroscopic guidance. Make a 3–5 mm skin incision with #11 blade. Confirm intended approach: transpedicular vs. extrapedicular based on pre-procedure CT pedicle measurements.
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Pedicle entry — "Owl Eye" technique
On AP fluoroscopy, the pedicle appears as an oval shadow ("owl eye"). Position trocar tip at the upper outer margin of the pedicle. Advance trocar in AP plane, keeping the tip within the pedicle oval until it pierces the posterior cortex. Confirm on lateral: trocar should not cross the posterior wall of the vertebral body on lateral view until it has passed through the pedicle on AP view.
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Advance to anterior one-third
Once through the pedicle cortex, advance trocar toward the anterior one-third of the vertebral body. Redirect medially if needed. On lateral view: tip should reach the junction of the anterior and middle thirds of the vertebral body. On AP: tip should cross midline for complete unilateral fill. Tilt bevel caudally (toward fracture cleft).
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Cement preparation
Mix PMMA per manufacturer instructions. Allow to reach "toothpaste" or "paste" consistency — neither too runny (high leak risk) nor too stiff (injection difficult). This typically occurs 3–5 minutes post-mixing depending on room temperature. Test consistency by pulling a small amount with a 1 mL syringe — it should flow slowly with resistance.
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Cement injection under live fluoroscopy
Inject cement slowly with 1 mL Luer-lock syringes under continuous biplanar fluoroscopy. Watch lateral view primarily for posterior wall encroachment. Watch AP for midline crossing. Standard volumes: 2.5–3 mL upper thoracic; 3–4 mL thoracolumbar; 6–8 mL lumbar. STOP IMMEDIATELY if any posterior/epidural filling, foraminal leak, or venous runoff seen.
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Bilateral fill (if unilateral inadequate)
For osteoporotic fractures, unilateral fill often crosses the midline adequately. For malignant fractures or poor fill: repeat transpedicular access on contralateral side. Same technique, same cement phase. Total bilateral volumes per level: thoracic 4–6 mL, lumbar 8–12 mL.
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Needle removal & post-procedure imaging
Once cement is set (1–2 min), rotate trocar 360° to break any cement-needle interface, then remove with gentle traction. Apply firm pressure at skin. Post-procedure CT of the treated level recommended to document cement distribution and exclude clinically occult canal encroachment. Position patient supine 1 hour post.
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Troubleshooting
Problem
Cement leak — posterior (epidural/foraminal)
Likely cause: Cement too thin (injected too early), injection pressure too high, posterior wall fracture with cortical defect, or direct epidural venous filling.
Next step: STOP injection immediately. Do not remove needle. Wait 1–2 minutes — the leading edge of cement will polymerize and self-seal. Resume cautiously after waiting. If leak persists, reposition needle tip to a more anterior position. Consider abandoning the contralateral side injection if filling is adequate. Post-procedure CT to characterize leak extent.
Problem
Venous cement filling
Likely cause: Cement injected too early (too liquid), basivertebral vein or paravertebral venous plexus filling. Appears as "streaking" on fluoroscopy tracking away from the vertebral body.
Next step: Stop injection. Wait for cement to thicken. Consider repositioning needle tip away from the venous channel. Resume injection slowly. If venous filling continues with thicker cement, likely cement emboli already occurred — obtain post-procedure CT chest if clinical concern for PE.
Problem
Needle in wrong position / failed pedicle entry
Likely cause: Trocar slipping off pedicle cortex, misdirection, or cortical breach laterally.
Next step: If in soft tissue, pull back and redirect under fluoroscopy. Confirm AP "owl eye" technique before re-advancing. If cortical breach noted on CT, assess extent. For extrapedicular redirection: pull needle back to skin entry, reangle. Do not force through resistance — get repeat AP fluoroscopy to re-confirm landmarks.
Problem
Unilateral fill does not cross midline
Likely cause: Dense trabecular bone, loculated fracture cleft, or malignant tissue blocking spread.
Next step: Advance needle tip more anteriorly (toward fracture cleft) and retry injection. If still insufficient, proceed with contralateral transpedicular access. For malignant fractures with tissue resistant to cement flow: consider coblation or ablation before cement to create channels.
Problem
Cement too stiff to inject
Likely cause: Over-mixed or waited too long — cement has polymerized beyond the injectable phase.
Next step: Do not force injection — excessive pressure risks fracture leakage or needle dislodgement. Discard current batch, mix fresh cement, and inject at the appropriate toothpaste phase. Time the next batch carefully — room temperature significantly affects polymerization speed (cold = slower, warm = faster).
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Complications
Cement Extravasation
- Epidural leak: Most feared — cord/cauda equina compression. If asymptomatic: close monitoring. If symptomatic (new neurologic deficit): emergent surgical decompression
- Foraminal leak: Radiculopathy (new onset back/leg pain). Often resolves; rarely requires decompression
- Intradiscal leak: Accelerates disc degeneration; increases risk of adjacent level fracture
- Venous/pulmonary embolism: Asymptomatic PE common (up to 5% on CT); symptomatic PE rare but potentially fatal — anticoagulation if hemodynamically significant
Other Complications
- Adjacent vertebral fracture: "Fracture cascade" — altered biomechanics from stiffened cemented level transfers stress to adjacent segments. Counsel patients at discharge. Risk similar to natural VCF progression rate in most studies
- Infection / osteomyelitis: Rare (<0.1%). Risk increased in immunocompromised patients and malignancy
- Incomplete pain relief: 10–30% of patients have inadequate response. Re-evaluate for alternate pain sources, new fractures, or technical failure (insufficient cement fill)
- Refracture: Can occur with insufficient cement fill or treatment of a highly osteoporotic level
- PMMA allergy: Rare; anaphylaxis reported
Emergent Escalation Triggers
- New neurologic deficit post-procedure (weakness, bowel/bladder dysfunction) → emergent spine surgery consult + CT spine
- Hypoxia or chest pain post-procedure → consider cement PE; CT chest angiography
- Severe unremitting pain escalation post-procedure → CT spine to exclude large epidural cement collection
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Post-Procedure Care
Recovery & Monitoring
- Recover supine 1–2 hours post-procedure; neurologic exam before discharge
- Ambulation typically possible day of procedure (1–2 hours post)
- Pain relief onset: immediate to 24–48 hours; transient pain increase in first 24–72h is common (paraspinal muscle spasm, inflammation)
- 70–90% of patients report significant pain improvement
- Most achieve near-complete improvement by 10–14 days post-procedure
- Significant adverse events occur in 1.0–1.5% of cases
Discharge Instructions & Follow-up
- Pain score documentation at 24–48h (phone follow-up or clinic)
- Counsel on adjacent fracture risk — return to ED for any new acute back pain, new neurologic symptoms
- Resume anticoagulation: 24 hours post-procedure (earlier if high thrombotic risk)
- Osteoporosis management referral: bisphosphonates, RANK-L inhibitors, PTH analogs — treating the underlying disease is critical
- Physical therapy referral for core strengthening and fall prevention
- DEXA scan if not recently performed
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Critical Pearls
✦
MRI STIR edema = treatable fracture: Bone marrow edema on STIR is the single most important predictor of vertebroplasty response. No edema on MRI in a chronic fracture = very low chance of pain relief. Do not treat purely based on radiographic fracture appearance.
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"Toothpaste" consistency test: Cement should be injected at the paste/toothpaste phase — slow flow with resistance. Test by drawing cement into a 1 mL syringe; it should move but require pressure. Too liquid = high leak risk; too stiff = injection impossible and forced pressure can cause blowout.
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STOP at first sign of posterior leak: Any cement appearing to track toward or past the posterior wall on lateral fluoroscopy mandates immediate injection halt. Wait for polymerization plug, then reassess. Never attempt to "push through" a posterior leak.
✦
Unilateral access often sufficient: For osteoporotic fractures, a single well-positioned transpedicular trocar advanced to the midline can achieve adequate bilateral fill. Crossing the midline on AP fluoroscopy is the goal. Bilateral access adds procedure time and risk but is preferred for malignant fractures or when unilateral fill is inadequate.
✦
Malignant fractures: ablate then cement: For highly vascular tumors (e.g., renal cell metastasis, myeloma), consider coblation or RFA ablation before cement injection. This devascularizes tissue, reduces cement leak into tumor vascularity, and provides tumor control.
✦
Biplanar fluoroscopy preferred: AP and lateral views simultaneously are essential. Single-plane fluoroscopy with C-arm toggling increases risk of missing posterior cement migration during injection. If only single-plane available, pause injection to check lateral every 0.5 mL.
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Vertebra plana is not an absolute contraindication: Fractures with >75% height loss (vertebra plana) present technical challenges for needle insertion but are not absolutely contraindicated. Once accessed, cement can restore acceptable vertebral height and provide pain relief. Consider kyphoplasty or SpineJack for significant height loss.
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Related Resources
References, comparison table, related procedures
Vertebral Augmentation Comparison
| Feature | Vertebroplasty | Balloon Kyphoplasty | SpineJack |
|---|---|---|---|
| Mechanism | Direct cement injection | Balloon inflation creates cavity, then cement | Titanium implant expands craniocaudally, then cement |
| Height restoration | Minimal (fracture reduction via cement pressure) | Moderate (balloon inflation before cement) | Superior — up to 40% height gain; durable |
| Cement leak risk | Higher (no cavity — direct injection into cancellous bone) | Lower (contained cavity reduces leak) | Low (implant contains cement) |
| Sedation | MAC / Local | MAC / General | General / MAC |
| Cost | Lowest | Moderate | Highest |
| Implant remains | No | No (balloon removed) | Yes (titanium implant permanent) |
| Best for | Osteoporotic VCF without significant height loss; malignant fractures | Fractures with >15% height loss; intact posterior wall | Acute fractures with significant height loss; young patients; durable restoration desired |
| Antibiotics | Not routine | Not routine | Cefazolin 1g IV (implant) |
Primary Reference
Prologo JD, Ray CE Jr., eds. Advanced Pain Management in Interventional Radiology: A Case-Based Approach. Thieme; 2024. DOI: 10.1055/b000000387
Chapters 16 (Dalili et al — Osteoporotic Fracture I: Vertebroplasty) and 17 (Marshall — Osteoporotic Fracture II: Kyphoplasty)
Additional references: Gangi et al, Radiographics 2003 · ACR Appropriateness Criteria: VCF Management · Cazzato et al, Eur Radiol 2021 (mortality reduction) · FREE trial, Wardlaw et al, Lancet 2009 · SIR Consensus Guidelines for Periprocedural Management