PAIN MEDICINE

Volume 9 • Number S1 • 2008

Vertebroplasty and Kyphoplasty: Case Presentation,

Complications, and Their Prevention

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Allen W. Burton, MD
Departments of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas,
USA

ABSTRACT

Objective. To describe vertebroplasty and kyphoplasty, which are relatively new techniques used to
treat painful vertebral compression fractures.
Design Setting Patients. This article briefly reviews the procedural indications, technical aspects of
the procedure, and strategies for complication avoidance.
Results. Percutaneous vertebroplasty is the injection of a vertebral body with bone cement, generally
polymethylmethacrylate. Kyphoplasty is the placement of balloons (called “tamps”) into the verte-
bral body with an inflation/deflation sequence to create a cavity prior to the cement injection. These
procedures are most often performed in a percutaneous fashion on an outpatient (or short stay)
basis. The mechanism of action is unknown, but it is postulated that stabilization of the fracture
leads to analgesia. The procedure is indicated for painful vertebral compression fractures due to
osteoporosis or malignancy, and painful hemangiomas. The procedure has efficacy in painful
vertebral metastasis and traumatic compression fractures. Much evidence favors the use of this
procedure for pain associated with these disorders. The overall risks of the procedure are low but
serious complications can occur. The serious complications include spinal cord compression, nerve
root compression, venous embolism, pulmonary embolism including cardiovascular collapse, and
others. With good patient selection and careful technique, these complications are avoidable,
making the risk-to-benefit ratio highly favorable.
Conclusions. Vertebroplasty and kyphoplasty are effective and safe techniques used to treat painful
spinal fractures.

Key Words. Kyphoplasty; Vertebroplasty; Vertebral Compression Fracture; Osteoporosis; Spinal

Metastasis; Spine Fractures; Spine Interventional Procedures

Case Report was located in the thoracolumbar spine. It was

A 43-year-old physician presented with a
2-month history of severe low back pain after
a fall while playing with his children. The pain
Reprint requests to: Allen W. Burton, MD, Departments of
Anesthesiology and Pain Medicine, UT MD Anderson
Cancer Center, 1400 Holcombe Blvd.-409, Houston TX
77030, USA. Tel: 713-745-7246; Fax: 713-745-0177;
E-mail: awburton@mdanderson.org.
Disclosure: AWB is the principal investigator on a Kyphon,
Inc.-supported research protocol.
described as nonradiating, worse with movement,
with numerical pain scores ranging from 1–10/10
over the previous 24 hours. The patient was taking
oxycodone-CR 80 mg orally every 8 hours, plus
hydromorphone 8–16 mg orally up to six times
daily for breakthrough pain. The patient was
diagnosed with vertebral compression fractures
(VCFs) at T-11, L1, L2, L3, L4, and L5. He was
diagnosed with multiple myeloma and begun on
chemotherapy 2 weeks prior to consultation. His
magnetic resonance imaging (MRI) scan revealed

© American Academy of Pain Medicine 1526-2375/08/$15.00/S58 S58–S64 doi:10.1111/j.1526-4637.2008.00440.x

Vertebroplasty and Kyphoplasty: Complications and Prevention S59

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Figure 1 Anterior-posterior/lateral ra-
diographs after six-level vertebro-
plasty. Large cement extrusion is seen
at T-11 anteriorly, extrusion into a
small vein at L-1, and into the disk at
L-2.

T-2 signal enhancement at the fractured levels
without canal compromise. The patient was
offered the option of percutaneous vertebroplasty
(PV). The patient underwent PV at L3, L4, and
L5 with slight reduction in pain. Two weeks later
the patient underwent PV at T-11, L1, and L2
with near complete pain relief. The patient had a
polymethylmethacrylate (PMMA) leak anteriorly
from his T-11 and L1, and into the disk at L1–2
during the procedure, but this was asymptomatic.
(Figures 1 and 2). Over the next 4 weeks, the
patient was gradually reconditioned with a low-
impact exercise program, having only mild back
discomfort eased with tramadol on an as-needed
basis. He has undergone bone marrow transplant
and his myeloma is in remission. Thus, although
this patient had a minor PMMA leak, it was
asymptomatic and the clinical outcome was good.
injection. Percutaneous kyphoplasty (PK) may
restore vertebral body height and reduce the
kyphotic angulation of the compression fracture
prior to PMMA injection [5].
Ideal candidates for PV or PK have activity-
related axial pain corresponding to the level of a
recent compression fracture. This pain lessens or
goes away completely with recumbency and/or
sitting still. A complete neurologic exam and
recent radiographic imaging is mandatory to rule
out spinal cord compromise and/or retropulsed
bony fragments in the canal. MRI should show an

Procedural Overview

Vertebroplasty and kyphoplasty are relatively new

techniques used to treat painful VCFs. Vertebro-
plasty is the percutaneous injection of a vertebral
body with bone cement, generally PMMA.
PMMA has been used in orthopedics since the late
1960s [1]. PV was first reported by a French group
in 1987 for the treatment of painful hemangiomas
[2]. Since then, the indications for PV have
expanded to include osteoporotic compression
fractures, traumatic compression fractures, and
painful vertebral metastasis [3,4]. Kyphoplasty is a
modification of PV. It involves the percutaneous
placement of balloons (called “tamps”) into the Figure 2 Axial computed tomography of T-11 showing
vertebral body with an inflation/deflation polymethylmethacrylate anterior to the vertebral body
sequence to create a cavity prior to the cement adjacent to the vascular structures in the area.
S60
increased T-2-weighted signal due to bone edema
at the level with a recent fracture. Bone scan has
also been used to target the most recent fracture(s)
in patients with multiple fractures [6]. Cord com-
pression on MRI (in the absence of neurologic
findings) is a relative contraindication. If on MRI
there is a suspicion of a posterior cortical fracture,
a computed tomography (CT) scan will reveal the
bony architecture more precisely.
Potential Complications
Complications are rare, but can be serious. The
exact incidence is unknown. Most case series
report asymptomatic PMMA extravasation rates of
around 10–15% [5,7]. The Society for Interven-
tional Radiology (SIR) divides up complications
for these techniques into minor and major. Minor
complications are those considered to require no
therapy and having no consequence, such as
PMMA extravasation into the disk. Major compli-
cations are those requiring therapy, including an
unplanned increase in the level of care needed, or
having ongoing permanent sequelae (i.e., PMMA
into the spinal canal with neurological deficit). SIR
noted published complication rates for major com-
plications to be less than 1%, except in those with
neoplastic involvement of the vertebrae, where the
reported level of major complications is less than
5% [8].
PMMA can flow out of the vertebral body pos-
teriorly into the spinal canal and neural foramina,
or anteriorly into the paraspinous veins with sys-
temic consequences. There are case reports of
nerve root and spinal cord compression from
extravertebral PMMA [9,10]. Several minimally
symptomatic pulmonary emboli—one case of car-
diovascular collapse requiring pulmonary embo-
lectomy, one case of lethal pulmonary embolus,
and one case of paradoxical cerebral arterial
PMMA emboli—have been reported [11–14].
There is a suggestion in the literature of less
PMMA leak with PK vs PV [15].
Infectious complications are rare, but reported.
There are several reports of osteomyelitis requir-
ing corpectomy [16]. Meticulous attention to
sterile technique is warranted, including preopera-
tive intravenous antibiotic administration. Most
have abandoned the older technique of adding
tobramycin powder to the PMMA due to uncer-
tainty over both the efficacy and potential impact
on the PMMA properties.
Complications have been reported with both
procedures (vertebroplasty and kyphoplasty),
Burton
with a review of Food and Drug Administration
safety data revealing 58 reported complications
from 1999 through 2003 out of approximately
200,000 procedures performed. These were
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approximately evenly divided among PV and PK,
with more cases of pedicle fracture and cord
compression from PK than PV [17]. It must be
noted that this voluntary reporting system is
almost certainly flawed and most likely underre-
ports the overall incidence of complications. As
further studies are completed, a more complete
risk–benefit ratio can be defined.
Procedural Technical
Aspects/Complication Avoidance
Standards for the safe practice of these techniques
have been published by the Society of Interven-
tional Radiologists in 2003 and recently updated
by the Cardiovascular and Interventional Radio-
logical Society of Europe; the highlights of this
document are in Table 1 [18,19].
Prior to the procedure, the patient should be off
of all anticoagulants and his/her coagulation
profile should be normal. Platelet count should be
at least 50,000 at the time of the procedure,
although no data exists to clearly define a “cut-off”
platelet count. There may be instances when the
Table 1 Overview of guidelines from Society of Interven-
tional Radiologists and Cardiovascular and Interventional
Radiological Society of Europe. Please see the refer-
ences for the complete documents (modified from [17]
and [18])
Indications
Painful osteoporotic VCF refractory to 3 weeks of analgesic
therapy
Painful vertebrae due to benign or malignant primary or
secondary bone tumors
Painful VCF with osteonecrosis (Kummel’s disease)
Reinforcement of vertebral body prior to surgical procedure*
Chronic traumatic VCF with nonunion*
Absolute contraindications
Asymptomatic VCF
Patient improving on medical therapy
Ongoing infection
Prophylaxis in steoporotic patient
Uncorrectable coagulopathy
Myelopathy due to retropulsion of bone/canal compromise
Allergy to PMMA or opacification agent
Relative contraindications
Radicular pain
VCF >70% height loss*
Severe spinal stenosis, asymptomatic retropulsion of bony
fragment
Tumor extension into canal/epidural space
Lack of surgical backup*
* Recommendations from the more recent update [18].
PMMA = polymethylmethacrylate; VCF = vertebral compression fracture.
Vertebroplasty and Kyphoplasty: Complications and Prevention
risk–benefit ratio favors doing these procedures in
patients with lower platelet counts. Active infec-
tion and sepsis are contraindications. The author
recommends waiting at least 2 weeks after treat-
ment of an infection to minimize infectious risks.
Informed consent should include lack of pain
relief, osteomyelitis, fracture of the vertebra or
pedicle, extravasation of cement into the spinal
canal or neural foramen, paralysis or nerve root
damage, and venous embolism. Rare but fatal ana-
phylaxis to PMMA has been reported in four cases
[17]. Also, the rare but potential need for open
surgery should be discussed with the patient.
Vertebroplasty and kyphoplasty require the
clinician to be trained in spinal anatomy, fluoro-
scopic imaging, and the use of these techniques
to perform interventional procedures. The pro-
cedure should be performed in a sterile operating
room suite that will allow fluoroscopic imaging
of the thoracolumbar spine. Biplanar or C-arm
fluoroscopy of good quality is mandatory for
maximal procedural safety. A radiolucent table is
mandatory, as is appropriate padding for prone,
slightly flexed positioning. Other procedural
materials needed include local anesthetic solution
(the author uses a 50:50 mixture of 1% lidocaine
with 0.25% bupivacaine), PMMA material, and
barium or other radioopacification material.
Eleven-gauge or 13-gauge bone biopsy needles
with connection tubing and cement injection
syringes are needed; numerous commercial “kits”
are available.
General anesthesia or monitored anesthesia
care (MAC) can be utilized. If MAC is used, the
surgeon must use generous amounts of local anes-
thetic, especially onto the periosteum, where
much nociception occurs. Some patients experi-
ence discomfort with advancement of the trochars
across the posterior cortical margin, with balloon
inflation (in the case of kyphoplasty), and with
PMMA injection. The anesthesiologist must be
prepared to “deepen” the MAC during these
phases of the procedure. Patient selection is
important with consideration to the anesthesia
choice. Very anxious or nervous patients may have
a better experience with a general anesthetic.
Careful consideration must be given to padding
the pressure points of this fragile group of
patients. After uni- or bipedicular vertebral body
access has been obtained, some clinicians proceed
directly with injection of PMMA, whereas others
prefer to do venography prior to cement injection.
In theory, venography provides anatomic knowl-
edge of large venous channels’ proximity to the
S61
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Figure 3 Anterior-posterior radiograph of lumbar vertebro-
plasty after polymethylmethacrylate injection.
trochar. This information is used to more carefully
inject the PMMA. For example, if a small amount
of contrast injection reveals a direct spread into a
venous channel, the operator may move the
trochar prior to injection or carefully inject rela-
tively solidified PMMA to embolize the large vein
prior to injecting more PMMA into the vertebral
body. The literature reveals variable efficacy of the
use of venography [20,21]. The author no longer
uses venography.
PMMA injection into the vertebral body is
undertaken after careful imaging confirming loca-
tion of the trochar or trochars into the anterome-
dial portion of the vertebral body (Figure 3). The
PMMA should be opacified and beginning to
harden to the consistency of toothpaste prior to
injection. Injection can be done by small syringes
filled with PMMA or by one of several commer-
cially available kits. The injection must be done
under live lateral or biplanar fluoroscopic guid-
ance. If PMMA begins to go into a blood vessel or
toward the posterior cortical margin, it must be
halted immediately. The authors halt cement
injection when it spreads to the posterior one-
third of the vertebral body. In order to minimize
PMMA leakage, several groups recommend the
use of high-viscosity cement and relatively small
volume injection [22–24].
Outcomes in Special Circumstances
As experience grows with these techniques,
various groups are pushing the envelope on indi-
S62
cations for the procedure, with the possibility of
seeing more complications in this patient group.
There is some preliminary data/case series on effi-
cacy in patients with radicular pain, traumatic
burst fractures, severe VCF/vertebral plana, cervi-
cal spine pathology, and intra-operative PMMA
augmentation of pedicle screw fixation spinal sta-
bilization [25–29]. In our center, we have pushed
“relative” contraindications in cancer patients
without increased morbidity, even in those with
very advanced cancers [30,31].
Adjacent-Level Fractures
Cortet and colleagues first noted a small increase
in adjacent-level fractures with long-term
follow-up [23]. This phenomenon is similar with
both PV and PK [32]. Subsequent VCFs may
occur at adjacent or remote levels (compared with
the treated “vertebroplastied” level). The reported
rate of new fractures varies from 7% to 20% over
a 1-year follow-up, with sooner refracture occur-
ring at the adjacent levels [33]. This suggests a
local unfavorable biomechanical situation in some
patients who suffer adjacent-level fracturing and
ongoing disease process (usually osteoporosis) in
the nonadjacent fracture group. A recent large
database of 106 patients having undergone 212 PV
procedures was evaluated over a 3-year follow-up
period of time by Kim and colleagues [34]. They
noted 72 new fractures over the 3-year follow-up
(7.9%). One-year fracture-free rate was 93% by
Kaplan–Meier analysis. The mean fracture-free
interval was 32 months, with adjacent fractures
being predicted by location in the thoracolumbar
junction and greater height restoration. There
may be certain anatomical configurations in the
fracture that predispose to adjacent-level fracture,
such as intra-osseous clefts [35]. Also, certain
patient populations may be at higher risk for
future fractures, including those with osteoporo-
sis, previous vertebral fracture, and organ trans-
plant recipients. [36,37]. It must be noted that in
all series examining this phenomenon (including
our own), outcomes of pain relief following PV or
PK for the adjacent level fracture are excellent
(data in submission).
Vertebroplasty vs Kyphoplasty
Both PV and PK have been shown to be effective
to reduce the pain associated with VCFs. These
procedures both have low complication rates and
tend to have islands of supporters, i.e., clinicians
who always favor one over the other regardless of
clinical circumstances. No head-to-head compara-
Burton
Table 2 Vertebroplasty vs kyphoplasty (see text section
for further details and references)
Vertebroplasty
Less expensive
Faster for the operator and patient
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Indicated to treat even older fractures
Kyphoplasty
More anatomic correction of spinal deformity than
vertebroplasty
Greater height restoration in recent fractures, less than 3
months old
Indicated for patients with extensive kyphosis due to multiple
recent VCFs
Less PMMA extravasation
PMMA = polymethylmethacrylate; VCF = vertebral compression fracture.
tive trials have been done to date, but one is in the
planning stages. Currently, we favor the use of PK
in circumstances where the patient has a collapse
of more than 20% of vertebral height and a frac-
ture age of less than 3 months in hopes of restoring
vertebral height and maintaining functional
anatomy when possible. Deramond and colleagues
have stated that PK may be preferrable over PV in
patients with severe or multiple wedge deformity
that has developed in the last 3 weeks. They do
caution that this is speculative until direct com-
parison trials are done [38] (see Table 2).
Key Points
• PV and PK are safe and effective procedures
used in the treatment of painful VCFs.
• Osteoporotic patients need careful positioning
and padding to avoid injury.
• During the performance of PV/PK, careful
needle placement is critical with the use of
omni-planar fluoroscopic imaging.
• Injection of PMMA must be done slowly and
carefully using a viscous opacified cement mixture
to avoid extravasation or halt injection promptly
upon extravasation.
• Over-injection of PMMA should be avoided,
particularly with respect to the posterior corti-
cal wall/spinal canal region.
• Any neurologic abnormality postprocedurally
mandates a careful evaluation, including consid-
eration of prompt CT to define the PMMA
injection in three dimensions and guide poten-
tial therapeutic options including surgical
decompression.
Conclusions
PV and PK are minimally invasive techniques used
to treat painful VCFs. There is a growing body of
Vertebroplasty and Kyphoplasty: Complications and Prevention
evidence, albeit of limited quality—predominately
open case series—which indicates that these pro-
cedures are efficacious in alleviating the pain asso-
ciated with VCF. The results of the procedures
in these numerous reports are uniformly good.
There are, however, a growing number of case
reports of serious complications.
Recent reviews and editorials have called for a
more critical evaluation of these procedures. Watts
and colleagues reviewed the literature, concluding
that controlled multicenter trials are needed to
determine the short- and long-term safety [39].
Garfin and colleagues concluded that there is
a 95% improvement in pain and significant
improvement in function following these proce-
dures [40]. They emphasized that the procedure is
technically demanding, with the potential for sig-
nificant complications. They recommended
further efficacy and safety studies. Jarvik and Deyo
called for randomized controlled trials (RCTs) or
some type of control cohort to compare long term
outcomes carefully [41]. Einhorn calls for careful
monitoring of outcomes and minimal training
standards [42]. Birkmeyer calls for randomized
clinical trials, citing insufficient evidence via
case series to prove safety, efficacy, and cost-
effectiveness [43].
It will be difficult to conduct the RCTs needed to
compare short- and long-term outcomes of PV
and/or PK vs more conservative therapies. These
procedures have gained such widespread popularity
that patients would undoubtedly resist being ran-
domized to the conservative treatment group, and
recent attempts at RCTs for PV have been plagued
by low enrollment. Blinding would be impossible,
as pain relief is usually dramatic and prompt. Other
studies need to be done to compare PV and PK in
various disease states in a randomized fashion.
Early studies are underway to evaluate biologic
materials for spinal injection rather than acrylic
(PMMA). In spite of the need for more research,
PV and PK have shown great promise in the treat-
ment of painful VCFs due to a variety of different
pathologic states. With careful patient selection,
adequate training, and attention to detail during
the procedure, serious complications are rare.
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