Vertebroplasty and kyphoplasty relieve pain in 70–90% of osteoporotic compression fractures. Learn the spinal cement protocol, imaging guidance, and safety framework.

Vertebroplasty & Kyphoplasty: 6-Step Spinal Cement Protocol

Introduction

Vertebroplasty and kyphoplasty are minimally invasive image-guided procedures that stabilize painful vertebral compression fractures through percutaneous injection of bone cement (PMMA) [1]. Vertebroplasty involves direct cement injection into the fractured vertebral body, while kyphoplasty introduces a balloon tamp to create a cavity and potentially restore vertebral height before cement deposition [3].

These procedures have transformed the management of osteoporotic and pathologic vertebral fractures, offering rapid pain relief and functional improvement without the morbidity of open spinal surgery [2]. While indications have evolved over the past two decades, vertebral augmentation remains a cornerstone of interventional musculoskeletal practice when performed with meticulous technique and appropriate patient selection [5].

Indications and patient selection

The primary indication for vertebroplasty or kyphoplasty is a painful osteoporotic compression fracture that has failed 6 weeks of conservative management (analgesics, bracing, physical therapy) [1]. Pathologic fractures from metastatic disease, multiple myeloma, or lymphoma are also excellent indications, particularly when palliation is the goal [7].

Patient selection requires confirmation of fracture acuity. MRI with short tau inversion recovery (STIR) or T2-weighted fat-suppressed sequences demonstrates bone marrow edema in acute to subacute fractures [6]. The presence of edema correlates with a higher likelihood of pain relief after cement augmentation [8]. Contraindications include asymptomatic fractures, healed fractures without edema, posterior wall retropulsion with spinal cord compression, active osteomyelitis, and uncorrectable coagulopathy [9].

Imaging evaluation and fracture acuity

Pre-procedure imaging includes standing radiographs to assess kyphotic deformity, MRI to confirm acuity and exclude posterior wall compromise, and CT to evaluate cortical integrity [10]. MRI STIR sequences showing high signal intensity within the vertebral body indicate bone marrow edema and fracture acuity [6].

Biplane fluoroscopy is the imaging modality of choice during the procedure, providing simultaneous anteroposterior and lateral visualization of needle trajectory and cement flow [11]. CT guidance is reserved for difficult anatomy, severe scoliosis, or cervical vertebral levels where fluoroscopic visualization is limited [12]. Post-procedure CT is obtained if cement extravasation is suspected or if the patient develops new neurological symptoms [13].

Equipment and cement selection

Vertebroplasty needles are typically 11–13G with beveled or diamond tips to facilitate cortical penetration [11]. Kyphoplasty requires an 8–11G bone access needle to accommodate the balloon tamp and cement delivery cannula [3]. The balloon is inflated with radiopaque contrast under fluoroscopic monitoring to create a controlled cavity within the vertebral body [3].

PMMA cement is available in low-viscosity and high-viscosity formulations. High-viscosity cement is increasingly preferred because it allows slower, more controlled injection with significantly lower rates of venous and disc space extravasation [4]. Modern cements include barium sulfate or tantalum powder for radiopacity, enabling real-time visualization during injection [14].

Step-by-step vertebroplasty protocol

Step 1: Patient positioning and preparation

Place the patient prone on a radiolucent table. Ensure adequate padding for pressure points. Administer local anesthesia at the entry site and moderate sedation for patient comfort [11]. Verify the target level with fluoroscopy before skin preparation and draping.

Step 2: Needle trajectory and access

The transpedicular approach is standard for T10–L5 levels. Advance the needle through the pedicle under biplane fluoroscopy, maintaining a lateral-to-medial trajectory on the AP view and ensuring the needle remains posterior to the anterior cortex on the lateral view [11]. For wider pedicles or upper thoracic levels, a parapedicular approach may be used [15].

Step 3: Needle tip confirmation

On the AP view, the needle tip should cross the midline before cement injection to ensure adequate medial fill. On the lateral view, the tip should reach the anterior one-third of the vertebral body [11]. For unipedicular approaches, confirm that the needle trajectory allows cross-midline fill.

Step 4: Cement preparation and injection

Mix PMMA cement to a toothpaste-like consistency (high-viscosity) or thinner consistency (low-viscosity) per manufacturer instructions. Connect the cement delivery system and inject slowly under continuous biplane fluoroscopy at a rate of 0.5–1 mL per minute [4].

Step 5: Real-time monitoring and stopping rules

Stop injection immediately if cement reaches the posterior one-third of the vertebral body on the lateral view, if venous filling is observed, or if extravasation into the disc space, paravertebral soft tissues, or epidural space occurs [13]. High-viscosity cement allows more time to react before significant leakage occurs [4].

Step 6: Post-procedure care

Remove the needle after cement polymerization (typically 10–15 minutes). Apply manual pressure to the skin entry site. Observe the patient for 2–4 hours, monitoring vital signs and neurological status [11]. Most patients can be discharged the same day.

Radiation dose reduction and personnel safety

Vertebroplasty and kyphoplasty rely heavily on biplane fluoroscopy, with operators standing close to the patient during needle manipulation and cement injection [16]. Studies have shown that spinal cement augmentation procedures can deliver operator eye doses of 5–20 μSv per case, with hand doses reaching 50–150 μSv depending on case complexity and fluoroscopy time [17].

ALARA principles for spinal procedures include minimizing fluoroscopy time through meticulous pre-procedure planning, using last-image hold instead of live fluoroscopy for needle position checks, and employing pulsed fluoroscopy at the lowest acceptable frame rate [18]. Collimate tightly to the vertebral level of interest to reduce scatter [19].

SATPro 0.5 mm Pb leaded gloves are essential for operators performing spinal cement procedures, reducing hand dose by up to 60% during needle manipulation and cement delivery under fluoroscopy [20]. SATPro wraparound thyroid shields with 0.5 mm Pb equivalent protection attenuate thyroid dose by over 90% during AP projections [21].

SATPro ceiling-mounted scatter-shield systems positioned over the procedure table block upward scatter from the X-ray tube, reducing ambient exposure for the primary operator by approximately 70% [22]. For kyphoplasty cases requiring additional staff for balloon inflation and cement mixing, SATPro mobile lead barriers provide flexible protection for nurses and technologists working at the side of the table [23].

SATPro 0.75 mm Pb leaded eyewear with side shields protects the operator’s eyes from lateral scatter during lateral fluoroscopy projections, which are used continuously during cement injection to monitor posterior wall integrity [24]. Institutions should mandate personal dosimetry for all staff involved in spinal augmentation cases and review cumulative exposure data quarterly [25].

Outcomes and height restoration

Pain relief after vertebroplasty for osteoporotic VCF is reported in 70–90% of patients within 1–2 weeks [2]. Functional improvement is significant during the first 3 months, with patients demonstrating improved mobility and reduced opioid requirements [1]. Height restoration is minimal with vertebroplasty alone; kyphoplasty achieves 2–5 mm of height restoration on average, though the clinical significance of this difference remains debated [3].

For malignant pathologic fractures, pain palliation is achieved in 60–80% of patients, with stabilization preventing further vertebral collapse [7]. Quality of life improvements are most pronounced in the first 3 months following the procedure [26]. Adjacent-level fracture occurs in 10–20% of patients within 1 year, though the causal relationship to cement augmentation remains controversial [27].

Complications and avoidance strategies

Cement extravasation is the most common complication, occurring in 10–20% of low-viscosity vertebroplasties and <5% of high-viscosity procedures [4]. Most extravasation into the disc space or paravertebral soft tissues is asymptomatic and requires no intervention [13]. However, epidural cement leak can cause spinal cord compression and neurological deficit, requiring emergent decompression [9].

Pulmonary cement embolism occurs when cement enters the basivertebral venous plexus and migrates to the lungs [13]. The incidence is low (<1%) with high-viscosity cement and meticulous injection technique [4]. Infection is rare (<1%) but catastrophic when it occurs; prophylactic antibiotics are recommended for immunocompromised patients or those with metastatic disease [11].

Follow-up and fracture prevention

Clinical assessment at 1–2 weeks, 1, 3, and 6 months is standard [11]. Radiographs are obtained if new symptoms develop. MRI is indicated for new neurological deficits or persistent severe pain suggestive of untreated fracture levels [6].

Osteoporosis evaluation and treatment are essential to prevent future fractures. Initiate bisphosphonates, denosumab, or anabolic agents (teriparatide, romosozumab) as appropriate [28]. Calcium and vitamin D supplementation should be optimized. Falls risk assessment and physical therapy referral reduce the likelihood of recurrent injury [27].

Conclusion

Vertebroplasty and kyphoplasty remain essential interventions for patients suffering from painful osteoporotic and pathologic vertebral compression fractures. When performed with careful patient selection, biplane fluoroscopic guidance, and high-viscosity cement, these procedures deliver rapid, durable pain relief with an acceptable safety profile. The reliance on prolonged fluoroscopy during spinal cement augmentation makes radiation protection a non-negotiable priority. SATPro’s specialized shielding solutions—from ceiling-mounted scatter shields to leaded gloves and mobile barriers—enable operators and ancillary staff to perform these life-improving procedures while maintaining the lowest possible radiation exposure. As populations age and the burden of osteoporotic fracture grows, proficiency in vertebral augmentation will remain a vital skill for interventional radiologists and musculoskeletal specialists.