Views: 0 Author: Site Editor Publish Time: 2026-10-22 Origin: Site
Introduction
Osteoporosis is an increasingly important health concern among older adults. As bone mineral density decreases, vertebral compression fractures can occur after minor trauma or even during routine daily activities. These fractures may cause severe back pain, reduced mobility, progressive spinal deformity, and a decline in quality of life.
Global estimates have suggested that osteoporosis is associated with approximately 8.9 million fractures annually, with vertebral fractures accounting for a substantial proportion of osteoporotic fractures. The actual incidence varies by population, age, diagnostic criteria, and whether asymptomatic vertebral fractures are included.
Percutaneous vertebroplasty (PVP) and percutaneous balloon kyphoplasty (PKP) are minimally invasive vertebral augmentation procedures used in selected patients with painful vertebral compression fractures. Both procedures involve injecting bone cement into the vertebral body to improve mechanical stability. Balloon kyphoplasty additionally uses an inflatable balloon to create an intravertebral cavity and may help restore some lost vertebral height.
This article reviews patient selection, procedural preparation, access routes, fluoroscopic positioning, balloon expansion, bone cement injection, and postoperative management. It is intended for professional education and should be applied alongside current clinical guidelines, device instructions for use (IFUs), and the judgment of appropriately trained clinicians.
An osteoporotic vertebral compression fracture (OVCF) occurs when weakened vertebral bone collapses under axial loading or relatively low-energy trauma. A fracture can produce a wedge-shaped vertebral body, biconcave deformity, or more extensive collapse.
Pain and progressive vertebral deformity may contribute to a cycle of reduced activity, muscle weakness, worsening functional independence, and increased fracture risk. Multiple vertebral fractures can also increase thoracic kyphosis and alter spinal biomechanics, potentially placing additional stress on adjacent vertebral levels.
Treatment aims to relieve pain, restore mobility, prevent further collapse where possible, and address the underlying osteoporosis.
PVP and PKP are established minimally invasive options for carefully selected patients with painful vertebral compression fractures. Compared with open reconstructive surgery, these procedures generally require smaller access incisions and less extensive tissue dissection.
Potential benefits include:
Pain reduction: Vertebral cement augmentation may reduce fracture-related pain in appropriately selected patients.
Mechanical stabilization: Bone cement reinforces the fractured vertebral body.
Minimally invasive access: Percutaneous techniques reduce the need for extensive surgical exposure.
Potential vertebral height restoration: Balloon kyphoplasty may restore part of the lost vertebral height when the fracture remains reducible.
Functional recovery: Effective pain control may help patients resume mobility and daily activities earlier.
These benefits are not guaranteed. Clinical outcomes depend on fracture characteristics, symptom severity, fracture age, patient selection, procedural technique, and complications. PVP and PKP should not be described as universally superior to conservative treatment or as risk-free procedures.
PVP involves direct injection of bone cement into the vertebral body through a working cannula. PKP adds balloon inflation before cement injection, creating a cavity that can accommodate cement and potentially restore some vertebral height.
The two procedures have different technical requirements and risk profiles. Balloon expansion does not eliminate cement leakage, and the choice between PVP, PKP, and nonoperative treatment should be based on the individual clinical situation.
Vertebral augmentation may be considered in selected patients with:
Painful osteoporotic vertebral compression fractures that remain symptomatic despite appropriate conservative management.
Imaging-confirmed fractures that correspond to the patient's pain location and clinical findings.
Painful vertebral lesions caused by benign or malignant tumors, when augmentation is appropriate as part of the overall treatment plan.
Selected fractures with delayed healing, an intravertebral cleft, or cystic changes, including some cases of Kümmell disease.
The decision should take into account fracture stability, neurological status, imaging findings, symptom duration, and alternative treatment options. An asymptomatic fracture or a fracture that is improving satisfactorily with conservative care is not, by itself, an indication for vertebral augmentation.
Conditions that may contraindicate the procedure or require additional assessment include:
Active vertebral infection, osteomyelitis, discitis, or systemic infection.
Uncorrectable coagulation disorders.
Allergy to bone cement or relevant procedural materials.
Significant posterior vertebral wall disruption, retropulsed fragments, or spinal canal compromise that increases the risk of cement leakage and neurological injury.
Spinal instability or neurological compression requiring a different surgical strategy.
Severe cardiopulmonary disease that makes the procedure or potential complications unacceptably hazardous.
A posterior wall defect is not managed identically in every patient; its significance depends on the fracture pattern, degree of canal compromise, and planned technique. It should be evaluated carefully rather than treated as a simple yes-or-no rule.
A typical balloon kyphoplasty procedure follows this general sequence:
Establish percutaneous access to the target vertebral body under imaging guidance.
Insert a working cannula and create a channel into the vertebral body.
Introduce the balloon catheter through the working channel.
Inflate the balloon using the specified inflation system while monitoring its position, expansion, and pressure.
Deflate and remove the balloon, leaving an intravertebral cavity.
Inject bone cement into the cavity under continuous or frequent fluoroscopic monitoring, according to the procedural protocol.
Confirm cement distribution, evaluate for leakage, and complete the procedure.
PVP does not include balloon inflation. Cement is injected directly into the vertebral body through the access cannula.
Balloon expansion serves two main purposes.
Creating an intravertebral cavity: The cavity provides space for cement placement. This may help control cement distribution, but it does not eliminate the risk of leakage or guarantee a lower complication rate in every case.
Potentially restoring vertebral height: The balloon can elevate portions of a collapsed vertebral endplate and may improve vertebral body height or kyphotic alignment. The degree of correction depends on fracture reducibility, fracture age, endplate integrity, and the surrounding bone structure.
Before the procedure, prepare the necessary instruments and emergency equipment.
Typical preparation includes:
A C-arm fluoroscopy system or another suitable imaging system.
A compatible access needle, guidewire, working cannula, drill, bone tamps, and cement delivery instruments.
A balloon inflation device and the specified inflation medium.
PMMA bone cement or another approved bone cement indicated for the procedure.
Contrast medium, when required by the device system and procedural technique.
Appropriate analgesia and, when indicated, carefully titrated sedation.
Blood pressure, heart rate, oxygen saturation, and other monitoring appropriate to the patient's condition.
Equipment and trained personnel for managing procedural emergencies.
The source protocol identifies ionic contrast medium, such as diatrizoate, and nonionic contrast medium, such as iohexol. Contrast selection and allergy assessment should follow current institutional protocols and the product's labeling. Do not assume that a particular contrast agent requires no assessment of prior contrast reactions or other relevant risks.
The anesthesia plan should be individualized according to the patient's health, the number of levels treated, procedural complexity, ability to remain still, and the clinician's assessment.
General anesthesia may be appropriate when immobility, airway management, or procedural circumstances make it preferable.
Local anesthesia with monitored analgesia or sedation may be suitable for selected patients, including some single-level procedures. It may allow the patient to report discomfort during the procedure, but patient communication alone cannot reliably detect every complication.
The choice should be made by the treating team. Local anesthetic drugs, concentrations, and doses must be calculated for the individual patient and should not be inferred from an abbreviated drug list.
Three access approaches are commonly described for PKP:
Transpedicular approach.
Extrapedicular approach.
Lateral vertebral access, where anatomically and technically appropriate.
The approach depends on the vertebral level, pedicle dimensions, fracture morphology, surrounding anatomy, and the selected device system.
The transpedicular route is commonly used for lumbar and thoracolumbar vertebral augmentation and may be suitable for selected thoracic levels. Whether it is appropriate depends on the dimensions and orientation of the pedicle, not solely on a fixed vertebral-level cutoff.
The trajectory is planned to provide safe access through the pedicle into the vertebral body while avoiding the spinal canal and surrounding neurovascular structures. Entry point and angulation must be determined from the patient's imaging and confirmed with fluoroscopy.
A fixed clock-face direction or angle should not be applied universally because anatomical orientation and imaging projection vary between patients and levels.
An extrapedicular approach may be used for selected thoracic vertebrae when the pedicle is too narrow or the anatomy makes a transpedicular trajectory unsuitable.
The entry point is planned in relation to the transverse process, superior articular process, rib, and lateral pedicle boundary. Particular attention is required to avoid the pleura, segmental vessels, and other adjacent structures.
A lateral approach may be considered in selected cases according to vertebral anatomy and the access system. It requires careful preoperative planning and appropriate imaging guidance.
Regardless of the approach, access should be performed by a trained clinician with a clear understanding of the local anatomy and the risks associated with cortical breach.
Correct level identification is essential. Preoperative imaging should be reviewed alongside intraoperative fluoroscopy to identify the symptomatic vertebra and distinguish it from adjacent levels.
Useful anatomical landmarks include:
The ribs and thoracolumbar junction.
The iliac crests and lumbar vertebral landmarks.
Pedicle outlines and spinous processes.
Vertebral body deformity, including wedge-shaped or biconcave collapse.
Anatomical variants, transitional vertebrae, and absent or hypoplastic ribs can make level counting difficult. When the level is uncertain, use additional imaging and a consistent counting method rather than relying on one landmark alone.
With the patient positioned appropriately, obtain anteroposterior and lateral fluoroscopic views. The entry point should be planned in relation to the pedicle and the intended trajectory into the vertebral body.
During needle advancement, assess the tip position in both views. The instrument should remain within the planned osseous corridor, and its progression should be checked before advancing toward the posterior vertebral body wall.
Do not rely on a single fluoroscopic projection to judge the depth or safety of the needle.
Once access has been established according to the chosen system:
Remove the needle core as required and insert the guidewire.
Advance the working cannula over the guidewire using the system's prescribed technique.
Confirm the cannula's position relative to the posterior vertebral body wall.
Create the working channel with the compatible drill or access instrument.
The original procedural protocol describes positioning the working sheath approximately 3–5 mm beyond the posterior vertebral body margin. This measurement must not be interpreted as a universal target for every system or every patient. The actual position should be guided by the device IFU, anatomy, and real-time imaging.
A drill may be used to create a channel for balloon insertion. The instrument's depth and direction should be monitored in both anteroposterior and lateral views.
The source technique describes positioning the drill toward the anterior-middle portion of the vertebral body while keeping its tip within the planned bony boundaries. The precise stopping point depends on the vertebral dimensions and the system being used.
Before balloon insertion, confirm that the channel is adequate and that no unintended cortical breach has occurred.
A compatible bone tamper or curette may be used to clear obstructing bone from the access channel when indicated.
The source protocol also describes a curette-based technique for selected vertebral fractures with sclerosis, chronic fracture surfaces, or intravertebral clefts, including some cases of Kümmell disease. In selected cases, a cavity may be prepared before balloon placement when expansion is difficult.
For pathological fractures, tissue removal or biopsy should only be performed when indicated and with a suitable diagnostic plan. Instrument choice and depth must remain consistent with the device instructions and the patient's anatomy.
Insert the balloon catheter through the established working channel and confirm its position using the specified imaging views. Ensure that the catheter is advanced according to the device instructions; the source protocol describes advancing the gold marker fully into the working sheath.
If a guidewire is used for initial placement, remove it at the stage specified by the device instructions.
Balloon expansion is a controlled process. The operator should monitor balloon volume, pressure, position, and the response of the surrounding vertebral bone under fluoroscopy.
The original source describes the following pressure ranges:
Pre-expansion: approximately 50–70 psi.
Expansion against cancellous bone: approximately 70–300 psi.
Maximum pressure in the source protocol: 300 psi.
These values are source-specific examples, not universal settings. The permissible pressure and volume depend on the exact balloon catheter, inflation device, and manufacturer's instructions. The pressure must never exceed the specified limit for the device.
Increasing resistance may reflect compression of surrounding cancellous bone. Pressure changes alone, however, should not be used to infer fracture reduction or safe expansion.
The source protocol lists the following possible stopping indicators:
Vertebral body height has been restored to the intended extent.
The balloon has expanded to the endplate even though further height restoration is not achieved.
The balloon reaches a cortical boundary.
Balloon pressure no longer decreases during expansion.
The balloon reaches its maximum permitted volume or pressure.
The source specifies a maximum balloon volume of 4 mL and a maximum pressure of 20 atm. These are device-specific parameters and must be checked against the balloon system actually being used. They should not be combined automatically with the separate pressure values above, because different devices may have different operating limits.
Stop expansion if the balloon reaches a device limit or if imaging, pressure behavior, or the anatomical response raises concern. Do not continue inflation simply to achieve a particular vertebral height.
PMMA bone cement must be mixed and delivered according to its instructions for use. Mixing ratio, working time, viscosity, and polymerization behavior vary between formulations and environmental conditions.
The source protocol describes loading mixed cement into the bone delivery instrument and waiting until it reaches an appropriate injectable consistency. It also refers to a string-like appearance, or a “drawing” phase, as a practical indicator of cement consistency.
This appearance is not a universal timing rule. The appropriate injection window should be determined by the cement's labeling, its observed viscosity, and the procedural technique.
A controlled injection sequence is essential for monitoring cement distribution.
Confirm the position of the delivery instrument and the cement's readiness for injection.
Begin with a small amount of cement and inspect its distribution under fluoroscopy.
Continue slowly only when the cement pattern is acceptable and no concerning leakage is visible.
Reassess cement distribution frequently during injection.
Monitor the patient's clinical condition and vital signs throughout the procedure.
Stop injection immediately if leakage, unexpected cement migration, or another safety concern is identified.
The source protocol suggests an initial injection of approximately 0.2–0.3 mL followed by fluoroscopic assessment, and further observation at intervals of approximately 0.5 mL. These quantities are examples from the source technique rather than mandatory increments for all cases. Injection volume and interval should be adapted to the cement system, vertebral anatomy, and real-time findings.
The objective is to achieve adequate vertebral body stabilization while minimizing cement leakage. The required amount varies with vertebral size, fracture morphology, cavity formation, and cement distribution.
Do not use a fixed volume or aim to exceed the balloon's final expansion volume as a universal rule. The injected amount should be guided by the intended cement distribution and safety considerations.
Pay particular attention to cement migration toward the spinal canal, neural foramina, endplates, paravertebral tissues, and venous structures. Leakage may occur even when the balloon has created a cavity.
The source technique describes a method intended to reduce cement tailing when the delivery plunger has not completed its full stroke:
Withdraw the unfinished plunger before the cement hardens, when appropriate for the delivery system.
Use the compatible solid push rod to advance the remaining cement in the sheath toward the vertebral body, following the system's instructions.
This maneuver is device-dependent and should only be performed when permitted by the manufacturer's IFU. Do not manipulate a delivery system in a way that increases cement extrusion, disrupts the cement mass, or compromises control of the cannula.
After cement injection, observe the patient closely. The source protocol suggests approximately 10–15 minutes of immediate observation, but this should not be treated as a complete universal monitoring period.
Monitor respiratory status, oxygen saturation, blood pressure, heart rate, pain, and neurological function according to the patient's risk profile and institutional protocol.
Potential complications include pulmonary cement embolism, cement leakage causing neural compression, infection, bleeding, and other procedure-related events. New chest pain, shortness of breath, sudden weakness, progressive numbness, or severe new spinal pain requires prompt clinical assessment.
Evaluate lower-extremity sensation, strength, and other relevant neurological findings. New leg numbness, radiating pain, weakness, or impaired movement may indicate a complication and requires urgent evaluation, including appropriate imaging when indicated.
Do not assume that new symptoms are simply part of routine postoperative recovery.
The timing of mobilization should be determined by the treating team based on procedural findings, the patient's overall condition, pain control, and the stability of the treated fracture.
The source article notes that cement strength develops over time and recommends strict bed rest to prevent loss of vertebral height. However, the exact polymerization timeline varies by cement formulation and conditions, and prolonged bed rest is not appropriate for every patient. Follow the specific cement instructions and the treating clinician's postoperative protocol.
When clinically appropriate, guided mobilization and rehabilitation can help reduce complications associated with immobility and support functional recovery. Activities should be advanced according to pain, balance, fracture status, and clinician guidance.
Patients should be instructed to seek assessment if they develop new or worsening back pain, chest pain, breathing difficulty, or neurological symptoms.
New back pain may indicate a new fracture, progression of the original fracture, or another cause. Chest pain and respiratory symptoms require prompt assessment rather than being attributed automatically to a rib fracture or cement embolism.
Follow-up imaging should be selected according to the patient's symptoms, clinical findings, and treatment plan.
Vertebroplasty and kyphoplasty stabilize a treated vertebra; they do not cure osteoporosis or eliminate the risk of future fractures. Long-term management should therefore include assessment and treatment of the underlying bone disease.
Adequate calcium intake and vitamin D status support bone health. Supplementation should be based on dietary intake, clinical assessment, laboratory findings when indicated, and applicable guidelines.
Depending on the patient's fracture risk and clinical circumstances, treatment may include bisphosphonates, selective estrogen receptor modulators, or other approved antiresorptive medications.
Calcitonin has specific clinical uses but should not be treated as a universal long-term osteoporosis therapy. Estrogen-related treatment requires individualized assessment of benefits, risks, and contraindications.
For selected patients at very high fracture risk, anabolic treatment such as a parathyroid hormone-related agent may be considered under current osteoporosis guidelines.
The source article also lists active vitamin K2, fluoride, and statins among substances related to bone metabolism. These should not be presented as interchangeable or universally recommended osteoporosis treatments. Their roles differ, and treatment decisions should follow current evidence and local guidelines.
Long-term management should also address fall prevention, balance and strength training where appropriate, nutrition, medication review, and home safety. Avoidance of specific activities and restrictions on lifting should be individualized rather than applying a universal three-month prohibition on weight-bearing.
Risk reduction: Use appropriate cement viscosity, controlled injection, and frequent fluoroscopic assessment. Stop injection when leakage or an unsafe cement pattern is suspected.
Risk reduction: Maintain appropriate cement injection technique and monitor the patient's clinical condition. New respiratory symptoms require prompt evaluation.
Risk reduction: Plan access carefully, confirm instrument position in multiple views, and pay particular attention to posterior wall defects, retropulsed fragments, and cement migration toward the spinal canal.
Risk reduction: Assess fracture age, reducibility, endplate integrity, and the degree of collapse before surgery. Balloon inflation cannot reliably restore height in every fracture.
Risk reduction: Treat the underlying osteoporosis, address fall risk, and provide appropriate follow-up. New pain should be evaluated rather than assumed to be a routine consequence of the original procedure.
PVP injects bone cement directly into the vertebral body. PKP uses a balloon to create a cavity before cement injection and may restore some vertebral height. The appropriate procedure depends on fracture characteristics, patient factors, and clinical judgment.
No. Balloon creation may influence cement distribution and vertebral height, but it does not eliminate cement leakage or other complications. Both procedures require appropriate patient selection and careful imaging guidance.
The symptomatic level is determined by correlating the patient's symptoms and examination with preoperative imaging and intraoperative fluoroscopy. Anatomical variants can make level counting difficult, so multiple landmarks and a consistent counting method may be necessary.
The operator should monitor balloon position, volume, pressure, and the vertebral response using the prescribed imaging technique. Device-specific pressure and volume limits must be observed.
Important measures include appropriate cement consistency, controlled injection, careful access planning, continuous or frequent fluoroscopic assessment, and immediate cessation of injection when an unsafe pattern is suspected. No technique can eliminate leakage risk completely.
There is no single timeline suitable for every patient. Mobilization and activity restrictions depend on the treated fracture, procedural findings, pain, overall health, and the treating clinician's instructions.
No. It treats a selected painful vertebral fracture by stabilizing the vertebral body. Long-term osteoporosis management remains necessary to reduce the risk of subsequent fractures.
Percutaneous vertebroplasty and balloon kyphoplasty are minimally invasive options for selected patients with painful vertebral compression fractures. Successful treatment depends on accurate vertebral-level identification, appropriate access planning, controlled balloon expansion when used, careful bone cement injection, and systematic postoperative assessment.
Preventing complications requires more than following a fixed set of numerical parameters. Clinicians must integrate patient anatomy, fracture morphology, imaging findings, cement behavior, and device-specific instructions throughout the procedure. Equally important, long-term osteoporosis treatment and fall prevention are needed to address the underlying risk of future fractures.
For medical-device professionals, reliable access instruments, compatible balloon systems, controlled cement-delivery devices, and clear instructions for use are essential components of a well-planned vertebral augmentation procedure.
Explore CZTOOLMED's orthopedic instrument and vertebral augmentation product range to learn more about available solutions for professional clinical use. Product selection should be based on the intended indication, local regulatory requirements, and the applicable device instructions for use.
National Institute for Health and Care Excellence (NICE). Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for treating osteoporotic vertebral compression fractures. Technology Appraisal Guidance TA279. https://www.nice.org.uk/guidance/ta279
American College of Radiology (ACR). ACR Appropriateness Criteria®: Management of Vertebral Compression Fractures. https://acsearch.acr.org/docs/70545/Narrative/
Vertebral Augmentation: State of the Art. Review article available through PubMed Central. https://pmc.ncbi.nlm.nih.gov/articles/PMC4843078/
Clinical disclaimer: This article is for professional educational and informational purposes. It is not a substitute for formal training, patient-specific assessment, current clinical guidance, or the instructions for use supplied with the relevant medical devices and bone cement products.
