Vertebroplasty and kyphoplasty

In one minute

Vertebroplasty and kyphoplasty inject bone cement into a broken vertebra (a bone of the spine) through one or two needles placed through the skin of the back under X-ray. Vertebroplasty injects directly; kyphoplasty first inflates a balloon to make a cavity and partly lift the collapsed bone. Both are for a painful osteoporotic compression fracture that has not settled with painkillers, a brace and time, when the fracture is fresh on MRI (magnetic resonance imaging) and the pain is severe. They are usually done under local anaesthetic with sedation, lying face down; one level commonly takes under an hour, and most patients are up within hours and go home the same or the next day. Trials against a sham procedure show a smaller benefit than surgeons once believed, and this page says so. It is not an endoscopic operation.

What the operation is

The names are percutaneous vertebroplasty (PVP), balloon kyphoplasty (BKP) and, for both, vertebral augmentation. Nothing is removed. The cement, polymethylmethacrylate (PMMA), sets within minutes inside the fractured bone and stops the broken trabeculae (the fine struts inside the vertebra) from grinding, which is thought to be why the pain eases. In a 2018 pooled analysis of 16 studies kyphoplasty restored more height and corrected the wedge angle more, with fewer cement leaks, while pain and function scores did not differ. The same procedure is used for painful fractures from myeloma or metastases. It is not for burst fractures with bone in the canal, unstable fractures or fractures with nerve damage, which need decompression or fixation (see the spinal fusion page).

Who it is for

The patient who may benefit has a fracture confirmed on MRI with bone marrow oedema (the sign that it is fresh), at a level that matches the pain, and severe pain despite proper painkillers. The one sham-controlled trial that found a benefit, VAPOUR, enrolled exactly this group: fractures under six weeks old and pain of at least 7 out of 10. At 14 days, 44% of the vertebroplasty group had pain below 4 out of 10 against 21% after placebo. Chronic fractures can qualify: VERTOS V randomised 80 patients with pain for more than three months and oedema still on MRI, and at 12 months the average pain score was 3.9 after vertebroplasty versus 5.1 after an anaesthetic injection alone.

It is not for mild or improving pain: in VERTOS II, 229 of 431 eligible patients (53%) had spontaneous relief during assessment and were never randomised. Nor is it for a healed fracture without oedema, an infected spine (spondylodiscitis), a fracture with fragments in the canal and nerve symptoms, an uncorrectable bleeding disorder, or someone who cannot lie face down.

Two guideline positions belong on the table. The American Academy of Orthopaedic Surgeons (AAOS) guideline, adopted in 2010 and published in summary in 2011, recommends strongly against vertebroplasty and gives kyphoplasty only a weak recommendation, for patients who are neurologically intact. The Cochrane review of 2018 found no clinically important benefit over sham. A patient should hear both, next to VAPOUR and VERTOS V, before deciding.

How it is done

You lie face down on a padded table. Local anaesthetic numbs the skin, the muscles and the surface of the pedicle (the bony bridge from the back of the vertebra into its body), and a sedative keeps you comfortable; VERTOS IV gave both groups this anaesthetic and VAPOUR used conscious sedation. With the X-ray showing the vertebra in two planes, a needle passes through or beside the pedicle into the front half of the vertebral body, checked on both views at each step. For kyphoplasty a balloon is inflated inside the bone until the cavity forms and the endplate lifts, then withdrawn. Cement mixed to a thick paste is injected slowly under continuous X-ray and stopped the moment it moves toward the canal or a vein. It sets in minutes; a dressing covers the puncture.

How it compares with the endoscopic alternative

There is no endoscopic version of cement injection. The endoscope decompresses a nerve when disc or bone presses on it, and it enters this story twice. If an old fracture has narrowed the canal and the leg pain comes from that narrowing, an endoscopic decompression may be the right operation and cement would not help. If a fresh fracture has pushed bone into the canal with nerve symptoms, or the vertebra is unstable, the answer is decompression with percutaneous screws (see the spinal fusion page), not a needle.

The comparison that matters here is against sham and against usual care. Against sham, the Cochrane review pooled five trials and 541 participants: pain was 0.7 points better on a 10-point scale one month after vertebroplasty, below the 15% change the review counts as clinically important. Against usual care, VERTOS II found a 2.6-point greater fall in pain at one month and 2.0 at one year, and FREE found a 5.2-point greater gain in the SF-36 physical component score (a quality-of-life questionnaire) one month after kyphoplasty. Open trials like these are likely to overstate the benefit, as the Cochrane authors note.

Risks and how we reduce them

Cement leakage is the commonest event in published series; most leaks are silent and seen only on imaging. The rare serious ones run into the canal and compress the cord or nerves, or into the veins and travel to the lungs. Kyphoplasty leaked less often than vertebroplasty in the 2018 pooled analysis (relative risk 0.62, from 11 studies and 1,057 patients). The Cochrane review lists the serious adverse events reported after vertebroplasty as osteomyelitis (bone infection), cord compression, injury to the sac around the nerves and respiratory failure, at 34 per 1,000 versus 56 per 1,000 in controls, with wide uncertainty. New symptomatic vertebral fractures occurred in 95 per 1,000 vertebroplasty patients and 73 per 1,000 controls across six trials, a difference the review could neither confirm nor exclude (relative risk 1.29, confidence interval 0.46 to 3.62). Puncture infection, bleeding, a broken pedicle and a brief fall in blood pressure during injection are uncommon; VAPOUR recorded two serious procedure-related events among 61 patients, FREE two among 149.

Surgeons reduce these risks with a thick, slow injection under continuous X-ray in two planes, stopping early rather than filling completely; a balloon cavity when the fracture shape favours it; clotting checked and blood thinners managed beforehand; an antibiotic dose at the start; and a plan for the osteoporosis itself, with the drug class chosen by the treating doctor. Across all the team's operations our complication figure is well below 1%; that is our own figure and not a comparison with anyone else.

Recovery, week by week

What the evidence says

The Cochrane review of 2018 (21 trials, five against sham) found high- to moderate-quality evidence of no important benefit over sham in pain, disability, quality of life or treatment success, and could not settle whether vertebroplasty raises the risk of new fractures. VERTOS IV (2018, 180 patients) found no significant difference from sham at any point over 12 months; VAPOUR (2016, 120 patients with severe pain and fractures under six weeks old) disagrees, and both belong side by side. VERTOS V (2023) favoured vertebroplasty for chronic fractures with oedema; FREE (2009) favoured kyphoplasty over non-surgical care but had no sham group. The AAOS guideline (2010, summary published 2011) recommends strongly against vertebroplasty and gives kyphoplasty a weak recommendation in neurologically intact patients.

How we do it at spine.uz

We are Tashkent's first endoscopic spine team, five surgeons operating as one, with 27,600+ endoscopic and spine operations in total, and we treat the full range of surgical spine pathology, including fractures. Fracture pages are reviewed by Dr. Dilmurod Kandimov, orthopaedic surgeon.

The first step is free: send your MRI on Telegram or WhatsApp and a doctor from the team replies by voice within 48 hours, saying whether the fracture is fresh, whether you match the group the trials describe (severe pain, a fracture under six weeks old or with oedema still on MRI), or whether the evidence suggests that time and a brace will do the same job. After the operation you receive a written conclusion and the team follows you up on Telegram.

Preparing for the operation

Photograph every slice of your MRI and any X-rays and send them ahead. Bring your list of medicines, especially blood thinners and any osteoporosis treatment; the doctor decides what to pause. Tell us about heart or lung disease, since you will lie face down. Fast as the anaesthetist instructs and arrange someone to accompany you home.