Percutaneous Vertebral Augmentation: Vertebroplasty and...

Percutaneous VertebralAugmentation: Vertebroplastyand Kyphoplasty

98

R. David Fessler, Richard L. Lebow, John E. O’Toole,Richard G. Fessler, and Kurt M. Eichholz

ContentsIndications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1129

Natural History and Conservative Management 1130

Patient Evaluation and Selection . . . . . . . . . . . . . . . . . 1131

Vertebroplasty Technique . . . . . . . . . . . . . . . . . . . . . . . . 1132

Kyphoplasty Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . 1136

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1137

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1139

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1140

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1140

Indications

Vertebroplasty was initially described by Galibertet al. in 1987 as a percutaneous technique to treatvertebral angiomas [1]. Since that time, the treat-ment indication for vertebroplasty has expandedto include osteoporotic compression fractures,metastatic spinal lesions, and traumatic vertebralbody fractures [2].

Affecting more than 24 million Americans,osteoporosis is a systemic metabolic bone disor-der characterized by low bone density and theprogressive microarchitectural deterioration ofbone tissue leading to increased bone fragilityand thus an increased risk of fracture [3]. Vertebralfractures are the most common type of osteopo-rotic fracture and are a significant cause of mor-bidity and mortality in the elderly population inthe United States [4]. The incidence of osteopo-rotic vertebral fractures is difficult to accuratelyquantify given that only approximately 30 %come to medical attention [5]. The risk of devel-oping VCF has been shown to increase with age.Slightly less than 25 % of women over the age of50 years are afflicted by osteoporotic bone frac-tures [6]. This number increases only slightly intothe seventies, after which there is an abrupt riseinto the 40–50 % range for female octogenarians[5, 7]. However, this is not solely a women’sdisease, as a review by Olszynskiet al. demonstrated that VCF occurs in approxi-mately 40 % of men surviving into their eighthdecade [8]. Osteoporosis has a significant

R.D. Fessler (*)University of Cincinnati College of Medicine, Cincinnati,OH, USAe-mail: [email protected]

R.L. LebowDepartment of Neurological Surgery, VanderbiltUniversity Medical Center, Nashville, TN, USAe-mail: [email protected]

J.E. O’TooleRush University Medical Center, Chicago, IL, USAe-mail: [email protected]

R.G. FesslerDepartment of Neurosurgery, Rush University MedicalCenter, Chicago, IL, USAe-mail: [email protected]

K.M. EichholzSt. Louis Minimally Invasive Spine Center, St. Louis, MO,USAe-mail: [email protected]

# Springer International Publishing Switzerland 2016G.R. Scuderi, A.J. Tria (eds.), Minimally Invasive Surgery in Orthopedics,DOI 10.1007/978-3-319-34109-5_109

1129

mailto:[email protected]





socioeconomic impact, as the estimated cost ofosteoporotic bone fractures within the United Statesin 1995 was approximately $746 million [3].Considering the increasing life expectancy inthe United States, as well as the growth in thesenior citizen population as the “baby boomergeneration” ages, the prevalence and economicimpact of this disease will continue to magnifyin the near future. Other factors that increase therisk of developing VCF include rheumatoidarthritis, cirrhosis, renal insufficiency, meno-pause, prolonged immobilization or immobility,chronic steroid therapy, diabetes mellitus, andmalnutrition [9].

Metastatic spinal lesions that cause compres-sion fractures have also been treated withvertebroplasty. Metastatic disease commonlyaffects the spine and is symptomatic in morethan a third of patients afflicted with cancer[10, 11]. Spinal metastases are the presentingsymptom in approximately 10 % of cases[12]. The majority of primary lesions are breast,lung, and prostate, which account for approxi-mately 60 % of cases, while gastrointestinal andrenal malignancies are each responsible for 5 %of cases [13]. Metastases are typically osteolyticprocesses, and result in subsequent weakness andfracture of the vertebral bodies. Symptomati-cally, these lesions result in debilitatingpain, deformity, and neurological compromise[10, 11, 13]. These sequelae have a detrimentalimpact on the quality of life for patients whoalready have systematic neoplastic disease.Vertebroplasty has become a useful treatmentfor symptomatic relief for spinal metastatic dis-ease [14–17] as well as multiple myeloma [18],has been used to treat malignant compressionfractures with epidural involvement [19], andhas been combined with radiotherapy [20].

Vertebroplasty has also been employed in thetreatment of burst fractures [2], although thisshould be done with trepidation. Detailed analysisof radiographic images is essential to ensure thatinjection of cement does not cause furtherretropulsion of loose bone fragments into thecanal. It has been shown that balloon vertebroplastymay be used safely in cases where damage to thelongitudinal ligaments is expected [21]. In the

setting of vertebral burst fracture, careful consider-ation must be made in the decision to performcavity creation, and with what method (balloon orarc osteotome).

Natural History and ConservativeManagement

Osteoporosis-induced VCF can be a self-perpetuating cycle. Ross et al. examined howbone mass density and the presence of VCFwere predictive of the development of future frac-tures [22]. After a mean follow-up of 4.7 years,they concluded that patients who had a bone massless than two standard deviations from the meanhave a fivefold increased risk of developing VCF.This increased risk was the same for patients withaverage bone density and a prior single VCF.However, in the presence of two or more VCFs,this risk is magnified to 12-fold. In the rare settingof a patient with a bonemass in the 33rd percentileand two or more fractures, the risk of future frac-tures is increased by 75-fold compared withwomen with bone density above the 67th percen-tile and no prior history of VCF. Although thispopulation is at high risk for the development ofmultiple fractures, only approximately two thirdsof patients with acute symptomatic fracturesimprove despite the management initiated [23].

Traditional conservative treatment includesoral analgesic therapy and bed rest. However,bed rest may accelerate bone loss and increasesthe risk of developing deep venous thromboses[24]. The pain caused by vertebral fractures maylast for months and prove to be severely debilitat-ing. Unfortunately, the use of analgesic medicaltherapy occasionally results in narcotic depen-dence. In a predominantly elderly population,this can alter mood and mental status, thuscompounding the patient’s condition [25].Chronicpain, sleep deprivation, depression, decreasedmobility, and loss of independence are allsequelae of VCF [26, 27]. In addition, both tho-racic and lumbar compression fractures can leadto a decrease in lung capacity [28].

Alternatively, physical therapy and use of ahardshell brace that appropriately immobilizes

1130 R.D. Fessler et al.

the affected segment may decrease the risks ofcomplications due to bed rest. As noted above,the majority of patients improve regardless of thetreatment prescribed, usually within 4–6 weeks.Several additional medical treatments have beenstudied with mixed results. Bisphosphonates, cal-citonin, parathyroid hormone, or raloxifene havebeen shown to reduce subsequent fracture rates,whereas the results for calcitriol, etidronate, fluo-ride, and pamidronate have been mixed andinconclusive [29]. In comparing conservativetreatment with vertebroplasty, Diamond et al.conducted a prospective, nonrandomized trial ofosteoporotic patients with acute VCF [30]. It wasshown that vertebroplasty provided a rapid andsignificant reduction in pain and an improvementin physical activity scores compared with medicaltreatment and it was concluded that vertebroplastyis a viable treatment option. A more recent studyby Li et al. compared vertebroplasty orkyphoplasty versus conservative treatment inelderly polytrauma patients. This study showed adecreased length of hospital stay as well asdecreased incidence of complications, especiallybed rest complications, in the operative groupcompared to the conservative treatment group.There was no significant difference in mortalitybetween the two groups [31]. It has also beenshown that vertebroplasty and kyphoplasty areassociated with longer patient survival thannonoperative treatment [32]. These data furthersupport vertebroplasty or kyphoplasty as a viabletreatment option for VCF.

Patient Evaluation and Selection

It is important to obtain a thorough medical his-tory with specific attention to risk factors for VCFas well as surgical candidacy. Evaluation con-tinues with a detailed neurological examinationdocumenting any motor or sensory changes, andpaying attention to any existing radiculopathies.Preoperative investigations should include routinelaboratory work and coagulation studies. In addi-tion, if malignancy is suspected, an appropriatework-up is indicated, including the determinationof a tissue diagnosis, if possible. Radiological

evaluation includes anteroposterior (AP) and lat-eral radiographs of the spine as well as a thin-cut,reconstructed computed tomography (CT) scan.The CTscan is scrutinized to evaluate the integrityof the posterior cortex, which may suggest anincreased risk of cement extrusion into the spinalcanal during the procedure, as well as the size ofthe pedicles, should a transpedicular route be con-sidered. In patients with signs of myelopathy, it isessential to obtain a magnetic resonance imaging(MRI) or postmyelogram CT scan (if MRI iscontraindicated) to evaluate for evidence of cordcompression. The presence of bone marrow orendplate edema has been shown to be a positiveprognostic sign for patients undergoingvertebroplasty [33]. Alvarez et al. also showedthat signal changes in the vertebral body on MRIscan as well as 70 % or greater collapse of thevertebral body are both highly predictive of pos-itive outcome [34].

The primary indication for vertebroplasty isfailure of conservative management of a vertebralfracture in which patients continue to have painthat affects their mobility and activities of dailyliving. It is important in determining ifvertebroplasty is indicated to ensure that the painbe localized and attributable to the fracture level.There is minimal evidence available in the medi-cal literature to guide the duration of conservativetherapy before it is deemed a failure. A consensusposition statement published by several profes-sional societies in 2014 stated that patients withpersistent pain precluding ambulation or physicaltherapy or resulting in unacceptable side effectsfrom analgesic therapy after 24 h of analgesictherapy should be considered to have failed con-servative management [35]. Typically, patientsare selected whose duration of pain from fractureis greater than 6 weeks but less than 1 year. Othershave reported successfully treating painful frac-tures of 2-year duration [36]. While completerelief of pain is less likely in older fractures[37, 38], Irani et al. reported symptomaticimprovement in fractures up to 5 years old[39]. Guidelines and reviews have been publishedto aid in the selection of patients, although thedecision to undergo surgery is made by thetreating surgeon [40, 41]. Painful osteoporotic

98 Percutaneous Vertebral Augmentation: Vertebroplasty and Kyphoplasty 1131

and osteolytic fractures without myelopathy con-stitute the vast majority of cases in most practices.Contraindications for vertebroplasty includesevere wedge deformity with loss of greater than90 % of vertebral height (vertebra plana), commi-nuted burst fracture, spinal canal compromise>20 %, epidural tumor extension, myelopathy,inability to lie prone, uncorrected coagulopathy,inability to localize source of pain, allergy tocement or radio-opaque dye, and infection (localor systemic). There has been considerable debateinto the merits of prophylactic vertebroplasty inselected patients [40, 41]; however, it is the prac-tice of the senior authors to only include symp-tomatic patients, because many patients neverdevelop clinical symptoms. It is also prudent tohave the facilities and capability to perform emer-gent decompressive surgery should extravasationof bone cement into the spinal canal occur,resulting in spinal cord compromise.

Kyphoplasty is a modification of thevertebroplasty technique that was developed inthe late 1990s [42, 43]. This technique attemptsto restore vertebral body height with the introduc-tion of cement into a lower-pressure cavity. Theuse of a balloon creates a cavity for placement ofthe cement and may result in a lower incidence ofcement extravasation [44]. Verlaan showed areduced incidence of endplate fractures in balloonvertebroplasty [45]. In addition, recent develop-ments have included the use of an arc osteotome,which creates a cavity for cement placement with-out attempting to restore vertebral body height.The indications for these procedures mirror thosefor vertebroplasty; however, with the goal of frac-ture reduction, the age of the fracture affects thesuccess rate, although the exact timing has yet tobe determined [41, 46]. In addition, technical con-siderations require a minimum of 8 mm of resid-ual vertebral height to introduce thematerials [41].

Vertebroplasty Technique

After obtaining appropriate medical clearance andwritten, informed consent, the patient is broughtto either an interventional radiology suite or

operating room (Fig. 1). Although inmany centersboth a radiologist and a surgeon are present, inother centers, the procedure is performed withonly the surgeon present. The procedure may beperformed under general anesthetic or under localanesthetic with mild sedation.Which type of anes-thetic should be determined based on the patient’sgeneral medical condition, comorbidities, and inconjunction with the anesthesiologist. While thepatient may be monitored for neurological dys-function if the procedure is performed under localanesthetic, this method is typically uncomfortablefor the patient. General anesthetic may be usedsafely, with frequent use of intraoperative fluoros-copy to prevent cement extravasation. The patientis placed in the prone position with their armsabove their head and adequately padded for com-fort and to prevent compressive peripheral neu-ropathies. Awide area of skin overlying the levelof interest is then prepped and draped in strictsterile fashion to minimize the chance of a post-operative infection.

Once the patient is satisfactorily positioned,the fracture site is identified using biplanar fluo-roscopy. Although some authors have advocatedCT scanning to facilitate needle placement [36,47], it is our experience that CT guidance is nec-essary only in a few rare instances when anatom-ical constraints prohibit easy identification of anappropriate trajectory and placement of the nee-dle. A mark is placed on the skin overlying thepedicle of interest. The skin is infiltrated with abuffered anesthetic solution containing 0.5 % or0.25 % Marcaine, 1:200,000 epinephrine (AbbotLabs, Chicago, IL), and Na bicarbonate (Ameri-can Pharmaceutical Partners, Los Angeles, CA)down to the level of the periosteum over thepedicle.

Currently, there is a wide selection of needlesand cement from several vendors that can be usedfor percutaneous vertebroplasty. Alternatively, theprocedure can be completed using routinely avail-able surgical equipment such as that shown inFig. 1b. In addition, there is no standardized tech-nique for needle placement. The senior authorsuse either a transpedicular or a parapedicularapproach (Fig. 2). Biplanar fluoroscopy is usedto confirm the appropriate trajectory regardless of


which approach is used (Fig. 3). A 2-mm stabincision is created with a #11 scalpel blade lateralto the midline at the point previously marked toidentify the pedicle. A #11 Jamshidi needle withthe trocar in place is introduced. In thetranspedicular approach (Fig. 4), the needle isadvanced until it docks onto the pedicle. Thepreferred entry point is at the upper and outerquadrant of the pedicle, because perforation atthis location has few consequences comparedwith the inferomedial quadrant, which places theexiting nerve root at risk. In this “bull’s eye”approach, the needle forms the center, while thecortex of the pedicle is the outer ring. The location

and trajectory are again confirmed with fluoros-copy, and the needle is advanced into the vertebralbody. An identical procedure is then repeated forthe contralateral pedicle.

When utilizing the parapedicular approach(Fig. 5), only a unilateral cannulation is necessarybecause the more lateral approach allows for amore centrally directed needle. The Jamshidi nee-dle is docked on the transverse process andadvanced immediately caudal to the transverseprocess. The appropriate entry point is at the lat-eral vertebral body on the AP projection and at, orimmediately ventral to, the posterior cortex onthe lateral fluoroscopic image. The biplanar

Fig. 1 Patient positioningand angiography suite setup(a) with biplanar fluoroscopyis shown. Basic surgicalsupplies needed to performpercutaneous vertebroplastyare pictured (b)


fluoroscopic images are used to help guide theneedle trajectory, keeping the needle tip equidis-tant from the vertebral body on both AP andlateral views. Once the vertebral body is encoun-tered, the needle is advanced toward the center ofthe body. While there is a theoretical increasedrisk of pneumothorax and bleeding with thisapproach [48], it has been our experience thatthe complication rates are similar between thetwo approaches.

Regardless of which approach is used, the tar-get of the needle tip should be in the anterior halfof the vertebral body on the lateral views and themedial third in the AP views. The bevel of theneedle can be directed in the most optimal direc-tion for cement placement for each given patient.Given the frequency of fluoroscopic image

acquisition, a clamp may be used to stabilize theneedle during imaging to minimize the exposureof the operator’s hand. Intraosseous venographyhad been advocated in some centers, particularlywithin the United States, prior to injection ofcement [49–51]. However, as more centers haveincreased their experience with this technique, ithas become apparent that there is no increase insafety afforded by venography [52–54]. In mostcenters, venography is typically no longer usedprior to cement injection. To avoid the introduc-tion of air during the injections, the needle is filledwith sterile saline after adequate placement hasbeen confirmed.

There are a number of cement products andsuppliers available and the choice is left to thesurgeon performing the procedure based on their

Fig. 2 Model illustrations depicting the entry points and needle trajectories for both the transpedicular (a and b) andparapedicular (c and d) approaches


experience and training. The increased applica-tion of percutaneous vertebroplasty has led toadvances in the mixing and administrationdevices so that one can achieve a uniform, con-sistent product and minimize exposure to vapors.PMMA is provided in two separate components, amethylmethacrylate polymer in powder form anda liquid methylmethacrylate monomer. Whencombined, an exothermic polymerization reactionoccurs and the resulting compound progressesfrom a liquid to solid state. The ideal time for

injection is when the consistency of the polymerapproximates that of toothpaste. The timing willvary depending upon the specific product used.Most commercially available products come withan aliquot of a radio-opaque marker, which iscombined with the PMMA to facilitate visualiza-tion during the injection process. If not available,sterile barium sulfate powder can be added to themethylmethacrylate polymer and mixed thor-oughly with the compound. The thickenedPMMA solution is poured into a 10-cm3 syringeor one of the many commercial delivery devicesavailable. Some vertebroplasty applicationdevices require placement of a guidewire throughthe Jamshidi needle, removal of the Jamshidi nee-dle, and placement of a larger working cannula.The delivery device is then attached to the hub ofthe Jamshidi needle or working cannula and,under intermittent fluoroscopic monitoring, thePMMA is injected slowly under a consistent pres-sure (Fig. 5). In general, it is typically possible toinject 5–10 cm3 of PMMA into each treated ver-tebral body; the thoracic spine accepts less vol-ume than the lumbar spine due to their relativesizes. Extravasation of cement beyond the con-fines of the vertebral body is an indication to stopthe injection. It is not clear what volume of cementis necessary to reliably produce pain relief, nor isit known by what mechanism the pain relief isachieved. Possible proposed mechanisms includemechanical stabilization of the fracture site [48]and neural thermal necrosis secondary to the heatgenerated during the curing process [55].

Once the operator is satisfied with the injection,the inner cannula is replaced and the needle isremoved with a twisting motion. Closure of thewound is usually unnecessary. Occasional bleedingis controlled with direct pressure. Patients are keptrecumbent for 2 h and are then allowed to sit andambulate with assistance. A postoperative CT scanof the region treated to assess the degree of vertebralbody filling and to rule out any occult spinal cordcompression and X-rays are obtained as a baselinefor later comparison. Patients are then dischargedhome on nonsteroidal anti-inflammatory drugs(NSAIDS) and muscle relaxants later the sameday. Ambulation is encouraged and participationin routine activities of daily living is emphasized.

Fig. 3 Percutaneous access to both pedicles with11-gauge biopsy needles is depicted (a); radiographic con-firmation of adequate placement of the needles is obtainedon lateral fluoroscopy (b)


Kyphoplasty Technique

Kyphoplasty is a procedure whereby a cavity iscreated in the vertebral body for cement injectionwith an inflatable bone tamp or balloon.

The procedure attempts to restore the vertebralbody back to its original height. In doing so, it isthought that a low-pressure cavity is createdwithin the bone that may then be filled withcement [43, 56]. However, restoration of verte-bral body height does not correlate with pain

Fig. 4 Illustration of the transpedicular approach. A46-year-old man suffered a traumatic compression frac-tures at L1 and L3. He complained of chronic back painfor several months after the injury, which was localizable tothe L3 level. Lateral lumbosacral X-ray (a) and axial CT

scan (b) demonstrate the L3 fracture. He underwentvertebroplasty with bipedicular injection of PMMA. Lat-eral X-ray (c) and axial CT scan (d) show good placementof cement in the anterior third of the vertebral body


relief or improvement in quality of life[57, 58]. Expansion of the vertebral body isfollowed radiographically by placing contrastmedium in the balloon. Alternatively, an arcosteotome may be used to create a cavity. How-ever, this form of cavity creation does not resultin restoration of vertebral body height.

The kyphoplasty procedure was first describedby Garfin et al. [43]. The bone tamp is placedusing either the transpedicular or parapedicularapproach. This is accomplished with the aid of aguide pin and biplanar fluoroscopy. Once cannu-lation of the vertebral body has occurred, an obtu-rator is passed over the guidewire and insertedinto the vertebral body. A working cannula isthen passed over the obturator until the cannulatip is in the posterior portion of the vertebral body.The inflatable tamp is passed through a corridorcreated by drilling along the cannula path. Once inplace, the device is inflated under fluoroscopicguidance to a pressure of no more than 220 psi.An inline pressure gauge allows for constant pres-sure monitoring within the balloon. Once a suffi-ciently sized cavity has been created and anappropriate reduction has been obtained, thePMMA cement is prepared. At this point, smallercannulas filled with cement are inserted into theworking cannula. The cement-filled cannula isinserted into the working cannula, with subse-quent passage into the vertebral body. Aplunger-like effect is obtained by using a stainlesssteel stylet to extrude the cement into its targetlocation. Filling the cavity with cement continuesunder lateral fluoroscopic guidance and ceaseswhen the mantle of cement reaches approximatelytwo thirds of the way to the posterior cortex of thevertebral body.

When utilizing an arc osteotome system suchas the Arcuate XP system (Medtronic SofamorDanek, Memphis, TN), vertebral body access isobtained as described above through either theparapedicular or transpedicular approach. Aguidewire is then placed through the Jamshidineedle, and the Jamshidi needle is removed. Aworking channel with a port in the lateral aspectof the anterior aspect of the channel is then placedinto the vertebral body. A flexible metal arcosteotome is then placed and deployed through

the port. The surgeon will feel variable resistancedepending on the degree of osteoporosis present.The port is turned to allow deployment of theosteotome superiorly, medially, and inferiorly,allowing creation of a cavity. Once the cavity iscreated, the osteotome is removed, an inner can-nula is placed that occludes the side port, andPMMA is injected through the tip of the workingchannel. Closure proceeds as described above.

Complications

The overall complication rates for vertebroplastyand kyphoplasty are in the range of 1–2 % forosteoporotic fractures and 5–10 % for metastaticlesions [40, 48]. The most common complicationafter vertebroplasty is a transient increase in painat the injected level. This is readily treated withNSAIDs and typically resolves within 48–72 h[48]. Acute radiculopathy has been reported tooccur in up to 5 % of cases. The symptoms areoften transient and a short course of steroids maybe of benefit; however, in some cases surgicaldecompression is necessary. The relatively highercomplication rate in malignancy is now well rec-ognized and documented [40]. Chiraset al. reported on a series of vertebroplasty casesand documented a complication rate of 1.3 % inosteoporotic compression fractures, while highercomplication rates were noted with more destruc-tive bone lesions such as hemangiomas (2.5 %)and vertebral malignancies (10 %) [59]. Cementleakage is a common problem, particularly in lyticlesions [48], and has been reported in up to30–70 % of cases; fortunately, most of theseoccurrences are asymptomatic [60]. Some havereported cement leakage necessitating surgicalintervention, with surgical findings consistentwith thermal injury due to the exothermic reactionof the PMMA [61]. Other reported complicationsinclude fractures of the rib or pedicle, pneumotho-rax, spinal cord compression, and infection. Therehave been reports of embolic complications suchas pulmonary embolism [13, 62–67], emboliza-tion of cement into the vena cava and pulmonaryarteries [68] and into the renal vasculature[69, 70], and death [50, 71] occurring during or


Fig. 5 (continued)


shortly after vertebroplasty. The cause of theseevents has not been delineated; however, it hasbeen postulated that cement with low viscosityand a large number of levels treated concurrentlymay play a role [48]. Other rare but reportedcomplications include acute pericarditis [72],osteomyelitis treated successfully with antibiotics[73] and necessitating subsequent corpectomy[74, 75], cardiac perforation [76], and fat andbone marrow embolization [77].

Fracture of adjacent vertebral levels aftervertebroplasty has been known to occur. Thecause is most likely multifactorial and mayinclude the diffuse nature of the osteoporotic dis-ease, relief of pain with a subsequent return tohigher levels of physical activity, and increasedstrength in vertebrae that are subject to increasedloads from kyphotic deformity. In 2005, Syedperformed a retrospective analysis of 253 femalepatients who were treated with vertebroplasty. Ofthese patients, 21.7 % experienced a new symp-tomatic VCF within 1 year [78]. Tanigawashowed that one third of patients who underwentvertebroplasty had a new compression fracture,half of which occurred at the adjacent level within3 months of the procedure [79]. Kimet al. reported an increased incidence of new com-pression fractures after percutaneousvertebroplasty when treatment was performed atthe thoracolumbar junction, and when a greaterdegree of height was restored [80]. Linet al. reviewed their series of patients treatedwith vertebroplasty for compression fractures,concluding that cement leakage into adjacentdisk spaces was related to an increased rate ofadjacent level fracture [81]. Gradual increase inactivity and continued use of orthotic devices (for6 weeks after vertebroplasty) may help preventadjacent level fracture in those at high risk.

There have been no reported complicationsrelated to balloon tamps during kyphoplasty

procedures [43, 56]. Several complications relatedin some way to needle insertion have beendocumented. During Phase 1 testing of an inflat-able bone tamp, Lieberman et al. found thatkyphoplasty was a safe procedure, with no signif-icant complications related to their device.Cement extravasation was the most commonproblem occurring in 8.6 % of their patients[56]. There were no clinical sequelae resultingfrom cement extravasation. Furthermore, theauthors were encouraged that rates of cementextravasation during their kyphoplasty procedurewere lower than those of published vertebroplastyseries, which may indicate that cavity creationmay prevent cement extravasation.

The exposure to ionizing radiation must beconsidered for both the patient and the treatingteam. Mehdizade et al. evaluated the radiationdose received by operators in a series of 11 cases[82]. They noted significant radiation dosagemea-surements, particularly on the operator’s hands.Kruger and Faciszewski made a similar observa-tion, however they were able to demonstrate thatproper shielding and limiting the radiation usedsignificantly reduced the measured exposure [83].

Outcomes

Several recent clinical trials and meta-analyseshave compared outcomes of vertebroplasty,kyphoplasty, and conservative treatment. Thesestudies have shown similar pain relief effects ofvertebroplasty and kyphoplasty, with diminishedlength of hospital stay and decreased complica-tion rates compared to conservative management[84–86]. A large, multicenter randomized clinicaltrial is required, however, to confirm thesefindings.

Vertebroplasty has been shown to reduce painin 90–95 % of patients suffering osteoporotic

��

Fig. 5 Illustration of the parapedicular approach. A64-year-old woman presented with a complaint of backpain. There was no history of trauma or malignancy. Com-pression fractures of T8 and T10 were identified and bothwere thought to be symptomatic. Lateral thoracic X-ray (a)

demonstrates the fractures. Lateral (b) and AP (c) imagesconfirm the cannulation of T8. Lateral (d) and AP (e)images after injection of T8 and during injection of T10.Postoperative CT scan demonstrates good filling of theanterior portion of the T8 vertebral body (f)


vertebral fractures [48, 60, 87]. Additionally,improvements in mobility and in activities ofdaily living occur. Also of note, patients whohave undergone percutaneous vertebroplastyhave a tendency to decrease their use of narcoticpain medications. Furthermore, the reduction inpain is rapid, usually within 48–72 h [46]. Theanalgesic effect has been shown to persist in acohort of patients followed prospectively for aminimum of 5 years [88]. The success rate isslightly less in patients with metastatic disease,with approximately 65–80 % reporting significantimprovement in pain scores [48, 89].

In 2001, Lieberman et al. reported the results ofa Phase 1 clinical trial examining the efficacy ofkyphoplasty in osteoporotic fractures [56]. Theyreported that, in 70 % of levels operated, a meanrestoration of 47 % of the lost vertebral bodyheight was achieved. In addition, the patientsdemonstrated a significant improvement in mea-sures of pain, activity, and energy. Similar resultshave been reported in patients with multiplemyeloma [90].

Conclusions

Percutaneous vertebroplasty and kyphoplastyprovide minimally invasive options for the man-agement of osteoporotic and osteolytic vertebralbody compression fractures. These techniquesprovide substantial pain relief and support withouthaving to sacrifice mobility, and have been shownto have an acceptable complication rate. Theseprocedures allow stabilization of VCF through ashort procedure, and also allow rapid mobilizationof the patient. However, large-scale clinical trialsneed to be done comparing these variousapproaches for the different indications to whichthey are applied. In this way, surgeons will havebetter information upon which to base the deci-sion to choose vertebroplasty or kyphoplasty. Inaddition, cost-effectiveness of any new treatmentshould be evaluated and scrutinized. Currently,the cost of kyphoplasty is significantly greaterthan vertebroplasty. To justify the additionalcost, kyphoplasty must be shown to be safer

and/or to provide added clinical benefit such asgreater stability, better pain relief, or reducedoperating time. Most published studies demon-strate equivalent results in stability and pain relief,as well as complication rates, though some havesuggested lower rates of cement extravasation. Inaddition, both procedures utilize a similar tech-nique and are roughly equivalent in technical dif-ficulty to perform. Therefore, at this time, it seemsreasonable to question the cost/benefit ratio of thekyphoplasty procedure when compared withvertebroplasty.

Regardless, vertebral augmentation techniquessuch as vertebroplasty and kyphoplasty providepain relief and improvement in quality of life inthe highly selected patient [91–93]. Complicationscan be avoided with careful surgical technique,and good outcomes can be achieved with properpatient selection.

References

1. Galibert P, Deramond H, Rosat P, Le GarsD. Preliminary note on the treatment of vertebral angi-oma by percutaneous acrylic vertebroplasty.Neurochirurgie. 1987;33(2):166–8.

2. Chen JF, Wu CT, Lee ST. Percutaneous vertebroplastyfor the treatment of burst fractures. Case report. JNeurosurg Spine. 2004;1(2):228–31.

3. Ray NF, Chan JK, Thamer M, Melton III LJ. Medicalexpenditures for the treatment of osteoporotic fracturesin the United States in 1995: report from the NationalOsteoporosis Foundation. J Bone Miner Res. 1997;12(1):24–35.

4. Kado DM, Browner WS, Palermo L, Nevitt MC,Genant HK, Cummings SR. Vertebral fractures andmortality in older women: a prospective study. Studyof Osteoporotic Fractures Research Group. Arch InternMed. 1999;159(11):1215–20.

5. Cooper C, Atkinson EJ, O’Fallon WM, Melton IIILJ. Incidence of clinically diagnosed vertebral frac-tures: a population-based study in Rochester, Minne-sota, 1985–1989. J Bone Miner Res. 1992;7(2):221–7.

6. Lyles KW. Management of patients with vertebralcompression fractures. Pharmacotherapy. 1999;19(1 Pt 2):21S–4.

7. Melton III LJ. Epidemiology worldwide. EndocrinolMetab Clin North Am. 2003;32(1):1–13. v.

8. Olszynski WP, Shawn Davison K, Adachi JD,et al. Osteoporosis in men: epidemiology, diagnosis,prevention, and treatment. Clin Ther. 2004;26(1):15–28.


9. Rao RD, Singrakhia MD. Painful osteoporotic verte-bral fracture. Pathogenesis, evaluation, and roles ofvertebroplasty and kyphoplasty in its management. JBone Joint Surg Am. 2003;85-A(10):2010–22.

10. Fourney DR, Schomer DF, Nader R,et al. Percutaneous vertebroplasty and kyphoplastyfor painful vertebral body fractures in cancer patients.J Neurosurg. 2003;98 Suppl 1:21–30.

11. Wise JJ, Fischgrund JS, Herkowitz HN,Montgomery D, Kurz LT. Complication, survivalrates, and risk factors of surgery for metastatic diseaseof the spine. Spine. 1999;24(18):1943–51.

12. Greenlee RT, Murray T, Bolden S, Wingo PA. Cancerstatistics, 2000. CA Cancer J Clin. 2000;50(1):7–33.

13. Aebi M. Spinal metastasis in the elderly. Eur SpineJ. 2003;12 Suppl 2:S202–13.

14. Burton AW, Reddy SK, Shah HN, Tremont-Lukats I,Mendel E. Percutaneous vertebroplasty – a techniqueto treat refractory spinal pain in the setting of advancedmetastatic cancer: a case series. J Pain Symptom Man-age. 2005;30(1):87–95.

15. Chow E, Holden L, Danjoux C, et al. Successful sal-vage using percutaneous vertebroplasty in cancerpatients with painful spinal metastases or osteoporoticcompression fractures. Radiother Oncol. 2004;70(3):265–7.

16. Masala S, Lunardi P, Fiori R, et al. Vertebroplastyand kyphoplasty in the treatment of malignantvertebral fractures. J Chemother. 2004;16 Suppl5:30–3.

17. Yamada K, Matsumoto Y, Kita M, Yamamoto K,Kobayashi T, Takanaka T. Long-term pain relief effectsin four patients undergoing percutaneousvertebroplasty for metastatic vertebral tumor. J Anesth.2004;18(4):292–5.

18. Diamond TH, Hartwell T, Clarke W, ManoharanA. Percutaneous vertebroplasty for acute vertebralbody fracture and deformity in multiple myeloma: ashort report. Br J Haematol. 2004;124(4):485–7.

19. Shimony JS, Gilula LA, Zeller AJ, BrownDB. Percutaneous vertebroplasty for malignant com-pression fractures with epidural involvement. Radiol-ogy. 2004;232(3):846–53.

20. Jang JS, Lee SH. Efficacy of percutaneousvertebroplasty combined with radiotherapy inosteolytic metastatic spinal tumors. J NeurosurgSpine. 2005;2(3):243–8.

21. Verlaan JJ, van de Kraats EB, Oner FC, van Walsum T,NiessenWJ, Dhert WJ. Bone displacement and the roleof longitudinal ligaments during balloonvertebroplasty in traumatic thoracolumbar fractures.Spine. 2005;30(16):1832–9.

22. Ross PD, Davis JW, Epstein RS, WasnichRD. Pre-existing fractures and bone mass predict ver-tebral fracture incidence in women. Ann Intern Med.1991;114(11):919–23.

23. Lieberman I. Vertebral augmentation for osteoporoticand osteolytic vertebral compression fractures:vertebroplasty and kyphoplasty. In: Haid Jr RW,

Subach BR, Rodts Jr GE, editors. Advances in spinalstabilization, vol. 16. Basel: Karge; 2003. p. 240–50.

24. Uhthoff HK, Jaworski ZF. Bone loss in response tolong-term immobilisation. J Bone Joint SurgBr. 1978;60-B(3):420–9.

25. Silverman SL. The clinical consequences ofvertebral compression fracture. Bone. 1992;13 Suppl2:S27–31.

26. Cook DJ, Guyatt GH, Adachi JD, et al. Quality of lifeissues in women with vertebral fractures due to osteo-porosis. Arthritis Rheum. 1993;36(6):750–6.

27. Gold DT. The clinical impact of vertebral fractures:quality of life in women with osteoporosis. Bone.1996;18 Suppl 3:185S–9.

28. Schlaich C, Minne HW, Bruckner T, et al. Reducedpulmonary function in patients with spinal osteoporoticfractures. Osteoporos Int. 1998;8(3):261–7.

29. Lippuner K. Medical treatment of vertebral osteoporo-sis. Eur Spine J. 2003;12 Suppl 2:S132–41.

30. Diamond TH, Champion B, Clark WA. Managementof acute osteoporotic vertebral fractures: anonrandomized trial comparing percutaneousvertebroplasty with conservative therapy. Am J Med.2003;114(4):257–65.

31. Li Y, Hai Y, Li L, Feng Y, Wang M, Cao G. Earlyeffects of vertebroplasty or kyphoplasty versus conser-vative treatment of vertebral compression fractures inelderly polytrauma patients. Arch Orthop TraumaSurg. 2015;135(12):1633–6.

32. Chen AT, Cohen DB, Skolasky RL. Impact ofnonoperative treatment, vertebroplasty, andkyphoplasty on survival and morbidity after vertebralcompression fracture in the medicare population. JBone Joint Surg Am. 2013;95(19):1729–36.

33. Tanigawa N, Komemushi A, Kariya S,et al. Percutaneous vertebroplasty: relationshipbetween vertebral body bone marrow edema patternon MR images and initial clinical response. Radiology.2006;239:195–200.

34. Alvarez L, Perez-Higueras A, Granizo JJ, de Miguel I,Quinones D, Rossi RE. Predictors of outcomes ofpercutaneous vertebroplasty for osteoporotic vertebralfractures. Spine. 2005;30(1):87–92.

35. Barr JD, JensenME, Hirsch JA,McGraw JK, Barr RM,Brook AL, Meyers PM, Munk PL, Murphy KJ,O’Toole JE, Rasmussen PA, Ryken TC, Sanelli PC,SchwartzbergMS, SeidenwurmD, Tutton SM, ZoarskiGH, Kuo MD, Rose SC, Cardella JF. Position state-ment on percutaneous vertebral augmentation: a con-sensus statement developed by the Society ofInterventional Radiology (SIR), American Associationof Neurological Surgeons (AANS) and the Congress ofNeurological Surgeons (CNS), American College ofRadiology (ACR), American Society of Neuroradiol-ogy (ASNR), American Society of Spine Radiology(ASSR), Canadian Interventional Radiology Associa-tion (CIRA), and the Society of NeuroInterventionalSurgery (SNIS). J Vasc Interv Radiol. 2014;25(2):171–81.


36. Barr JD, Barr MS, Lemley TJ, McCannRM. Percutaneous vertebroplasty for pain relief andspinal stabilization. Spine. 2000;25(8):923–8.

37. Brown DB, Gilula LA, Sehgal M, ShimonyJS. Treatment of chronic symptomatic vertebral com-pression fractures with percutaneous vertebroplasty.AJR Am J Roentgenol. 2004;182(2):319–22.

38. Brown DB, Glaiberman CB, Gilula LA, ShimonyJS. Correlation between preprocedural MRI findingsand clinical outcomes in the treatment of chronic symp-tomatic vertebral compression fractures with percuta-neous vertebroplasty. AJR Am J Roentgenol. 2005;184(6):1951–5.

39. Irani FG, Morales JP, Sabharwal T, Dourado R,Gangi A, Adam A. Successful treatment of a chronicpost-traumatic 5-year-old osteoporotic vertebral com-pression fracture by percutaneous vertebroplasty. Br JRadiol. 2005;78(927):261–364.

40. McGraw JK, Cardella J, Barr JD, et al. Society ofInterventional Radiology quality improvement guide-lines for percutaneous vertebroplasty. J Vasc IntervRadiol. 2003;14(7):827–31.

41. Stallmeyer MJ, Zoarski GH, ObuchowskiAM. Optimizing patient selection in percutaneousvertebroplasty. J Vasc Interv Radiol. 2003;14(6):683–96.

42. Garfin SR, Lin G, Lieberman I. Retrospective analysisof the outcomes of balloon kyphoplasty to treat vertebralbody compression fracture (VCF) refractory to medicalmanagement. Eur Spine J. 2001;10 Suppl 1:S7.

43. Garfin SR, Yuan HA, Reiley MA. New technologies inspine: kyphoplasty and vertebroplasty for the treatmentof painful osteoporotic compression fractures. Spine.2001;26(14):1511–5.

44. Togawa D, Kovacic JJ, Bauer TW, Reinhardt MK,Brodke DS, Lieberman IH. Radiographic and histo-logic findings of vertebral augmentation usingpolymethylmethacrylate in the primate spine: percuta-neous vertebroplasty versus kyphoplasty. Spine.2006;31(1):E4–10.

45. Verlaan JJ, van de Kraats EB, Oner FC, van Walsum T,Niessen WJ, Dhert WJ. The reduction of endplatefractures during balloon vertebroplasty: a detailedradiological analysis of the treatment of burst fracturesusing pedicle screws, balloon vertebroplasty, and cal-cium phosphate cement. Spine. 2005;30(16):1840–5.

46. Phillips FM. Minimally invasive treatments of osteo-porotic vertebral compression fractures. Spine.2003;28 Suppl 15:S45–53.

47. Gangi A, Kastler BA, Dietemann JL. Percutaneousvertebroplasty guided by a combination of CT andfluoroscopy. AJNR Am J Neuroradiol. 1994;15(1):83–6.

48. Mathis JM, Wong W. Percutaneous vertebroplasty:technical considerations. J Vasc Interv Radiol.2003;14(8):953–60.

49. Do HM. Intraosseous venography during percutaneousvertebroplasty: is it needed? AJNR Am J Neuroradiol.2002;23(4):508–9.

50. Jensen ME, Evans AJ, Mathis JM, Kallmes DF, CloftHJ, Dion JE. Percutaneous polymethylmethacrylatevertebroplasty in the treatment of osteoporotic verte-bral body compression fractures: technical aspects.AJNR Am J Neuroradiol. 1997;18(10):1897–904.

51. McGraw JK, Heatwole EV, Strnad BT, Silber JS,Patzilk SB, Boorstein JM. Predictive value ofintraosseous venography before percutaneousvertebroplasty. J Vasc Interv Radiol. 2002;13(2 Pt1):149–53.

52. Gaughen Jr JR, Jensen ME, Schweickert PA,Kaufmann TJ, Marx WF, Kallmes DF. Relevance ofantecedent venography in percutaneous vertebroplastyfor the treatment of osteoporotic compression fractures.AJNR Am J Neuroradiol. 2002;23(4):594–600.

53. Vasconcelos C, Gailloud P, Beauchamp NJ, Heck DV,Murphy KJ. Is percutaneous vertebroplasty withoutpretreatment venography safe? Evaluation of 205 con-secutives procedures. AJNR Am J Neuroradiol.2002;23(6):913–7.

54. Wong W, Mathis J. Is intraosseous venography a sig-nificant safety measure in performance ofvertebroplasty? J Vasc Interv Radiol. 2002;13(2 Pt1):137–8.

55. Belkoff SM, Molloy S. Temperature measurement dur-ing polymerization of polymethylmethacrylate cementused for vertebroplasty. Spine. 2003;28(14):1555–9.

56. Lieberman IH, Dudeney S, Reinhardt MK, BellG. Initial outcome and efficacy of “kyphoplasty” inthe treatment of painful osteoporotic vertebral com-pression fractures. Spine. 2001;26(14):1631–8.

57. Dublin AB, Hartman J, Latchaw RE, Hald JK, ReidMH. The vertebral body fracture in osteoporosis: res-toration of height using percutaneous vertebroplasty.AJNR Am J Neuroradiol. 2005;26(3):489–92.

58. McKiernan F, Faciszewski T, Jensen R. Does vertebralheight restoration achieved at vertebroplasty matter? JVasc Interv Radiol. 2005;16(7):973–9.

59. Chiras J, Depriester C, Weill A, Sola-Martinez MT,Deramond H. Percutaneous vertebral surgery. Technicsand indications. J Neuroradiol. 1997;24(1):45–59.

60. Cortet B, Cotten A, Boutry N, et al. Percutaneousvertebroplasty in the treatment of osteoporotic verte-bral compression fractures: an open prospective study.J Rheumatol. 1999;26(10):2222–8.

61. Teng MM, Cheng H, Ho DM, Chang CY. Intraspinalleakage of bone cement after vertebroplasty: a report of3 cases. AJNR Am J Neuroradiol. 2006;27(1):224–9.

62. du Choe H, Marom EM, Ahrar K, Truong MT,Madewell JE. Pulmonary embolism of polymethylmethacrylate during percutaneous vertebroplasty andkyphoplasty. AJR Am J Roentgenol. 2004;183(4):1097–102.


63. Monticelli F, Meyer HJ, Tutsch-Bauer E. Fatal pulmo-nary cement embolism following percutaneousvertebroplasty (PVP). Forensic Sci Int. 2005;149(1):35–8.

64. Pott L, Wippermann B, Hussein S, Gunther T,Brusch U, Fremerey R. PMMA pulmonary embolismand post interventional associated fractures after per-cutaneous vertebroplasty. Orthopade. 2005;34(7):698–700. 702.

65. Righini M, Sekoranja L, Le Gal G, Favre I,Bounameaux H, Janssens JP. Pulmonary cement embo-lism after vertebroplasty. Thromb Haemost. 2006;95(2):388–9.

66. Yoo KY, Jeong SW, Yoon W, Lee J. Acute respiratorydistress syndrome associated with pulmonary cementembolism following percutaneous vertebroplastywith polymethylmethacrylate. Spine. 2004;29(14):E294–7.

67. Padovani B, Kasriel O, Brunner P, Peretti-VitonP. Pulmonary embolism caused by acrylic cement: arare complication of percutaneous vertebroplasty.AJNR Am J Neuroradiol. 1999;20(3):375–7.

68. Baumann A, Tauss J, Baumann G, Tomka M,Hessinger M, Tiesenhausen K. Cement embolizationinto the vena cava and pulmonal arteries aftervertebroplasty: interdisciplinary management. Eur JVasc Endovasc Surg. 2005;31(5):558–61.

69. Chung SE, Lee SH, Kim TH, Yoo KH, Jo BJ. Renalcement embolism during percutaneous vertebroplasty.Eur Spine J. 2006;15 Suppl 5:590–4.

70. Freitag M, Gottschalk A, Schuster M, Wenk W,Wiesner L, Standl TG. Pulmonary embolism causedby polymethylmethacrylate during percutaneousvertebroplasty in orthopaedic surgery. ActaAnaesthesiol Scand. 2006;50(2):248–51.

71. Childers Jr JC. Cardiovascular collapse and death dur-ing vertebroplasty. Radiology. 2003;228(3):902.author reply 902–903.

72. Park JH, Choo SJ, Park SW. Images in cardiovascularmedicine. Acute pericarditis caused by acrylic bonecement after percutaneous vertebroplasty. Circulation.2005;111(6):e98.

73. Schmid KE, Boszczyk BM, Bierschneider M, Zarfl A,Robert B, Jaksche H. Spondylitis followingvertebroplasty: a case report. Eur Spine J. 2005;14(9):895–9.

74. Walker DH, Mummaneni P, Rodts Jr GE. Infectedvertebroplasty. Report of two cases and review of theliterature. Neurosurg Focus. 2004;17(6):E6.

75. Yu SW, Chen WJ, Lin WC, Chen YJ, Tu YK. Seriouspyogenic spondylitis following vertebroplasty – a casereport. Spine. 2004;29(10):E209–11.

76. Kim SY, Seo JB, Do KH, Lee JS, Song KS, LimTH. Cardiac perforation caused by acrylic cement: arare complication of percutaneous vertebroplasty. AJRAm J Roentgenol. 2005;185(5):1245–7.

77. Syed MI, Jan S, Patel NA, Shaikh A, Marsh RA,Stewart RV. Fatal fat embolism after vertebroplasty:identification of the high-risk patient. AJNR Am JNeuroradiol. 2006;27(2):343–5.

78. Syed MI, Patel NA, Jan S, Harron MS, Morar K,Shaikh A. New symptomatic vertebral compressionfractures within a year following vertebroplasty inosteoporotic women. AJNR Am J Neuroradiol.2005;26(6):1601–4.

79. Tanigawa N, Komemushi A, Kariya S, Kojima H,Shomura Y, Sawada S. Radiological follow-up ofnew compression fractures following percutaneousvertebroplasty. Cardiovasc Intervent Radiol. 2006;29(1):92–6.

80. Kim SH, Kang HS, Choi JA, Ahn JM. Risk factors ofnew compression fractures in adjacent vertebrae afterpercutaneous vertebroplasty. Acta Radiol. 2004;45(4):440–5.

81. Lin EP, Ekholm S, Hiwatashi A, WestessonPL. Vertebroplasty: cement leakage into the discincreases the risk of new fracture of adjacent verte-bral body. AJNR Am J Neuroradiol. 2004;25(2):175–80.

82. Mehdizade A, Lovblad KO, Wilhelm KE,et al. Radiation dose in vertebroplasty. Neuroradiology.2004;46(3):243–5.

83. Kruger R, Faciszewski T. Radiation dose reduction tomedical staff during vertebroplasty: a review of tech-niques and methods to mitigate occupational dose.Spine. 2003;28(14):1608–13.

84. Evans AJ, Kip KE, Brinjikji W, Layton KF,Jensen ML, Gaughen JR, Kallmes DF. Randomizedcontrolled trial of vertebroplasty versus kyphoplastyin the treatment of vertebral compressionfractures. J Neurointerv Surg. 2015; pii:neurintsurg-2015-011811. doi:10.1136/neurintsurg-2015-011811 (Epub ahead of print)

85. Wang H, Sribastav SS, Ye F, Yang C, Wang J, Liu H,Zheng Z. Comparison of percutaneousvertebroplasty and balloon kyphoplasty for the treat-ment of single level vertebral compression fractures:a meta-analysis of the literature. Pain. 2015;18(3):209–22.

86. Huang Z, Wan S, Ning L, Han S. Is unilateralkyphoplasty as effective and safe as bilateralkyphoplasties for osteoporotic vertebral compressionfractures? A meta-analysis. Clin Orthop Relat Res.2014;472(9):2833–42.

87. Deramond H, Depriester C, Galibert P, Le GarsD. Percutaneous vertebroplasty with polymethyl-methacrylate. Technique, indications, and results.Radiol Clin North Am. 1998;36(3):533–46.

88. Perez-Higueras A, Alvarez L, Rossi RE, Quinones D,Al-Assir I. Percutaneous vertebroplasty: long-termclinical and radiological outcome. Neuroradiology.2002;44(11):950–4.


89. Cortet B, Cotten A, Boutry N, et al. Percutaneousvertebroplasty in patients with osteolytic metastasesor multiple myeloma. Rev Rhum Engl Ed. 1997;64(3):177–83.

90. Dudeney S, Lieberman IH, Reinhardt MK, HusseinM. Kyphoplasty in the treatment of osteolytic vertebralcompression fractures as a result of multiple myeloma.J Clin Oncol. 2002;20(9):2382–7.

91. Kumar K, Verma AK, Wilson J, LaFontaineA. Vertebroplasty in osteoporotic spine fractures: a

quality of life assessment. Can J Neurol Sci. 2005;32(4):487–95.

92. McKiernan F, Faciszewski T, Jensen R. Quality of lifefollowing vertebroplasty. J Bone Joint SurgAm. 2004;86-A(12):2600–6.

93. Winking M, Stahl JP, Oertel M, Schnettler R,Boker DK. Treatment of pain from osteoporotic ver-tebral collapse by percutaneous PMMAvertebroplasty. Acta Neurochir (Wien). 2004;146(5):469–76.


本文献由“学霸图书馆-文献云下载”收集自网络，仅供学习交流使用。

学霸图书馆（www.xuebalib.com）是一个“整合众多图书馆数据库资源，

提供一站式文献检索和下载服务”的24 小时在线不限IP

图书馆。

图书馆致力于便利、促进学习与科研，提供最强文献下载服务。

图书馆导航：

图书馆首页文献云下载图书馆入口外文数据库大全疑难文献辅助工具

http://www.xuebalib.com/cloud/

http://www.xuebalib.com/

http://www.xuebalib.com/cloud/


http://www.xuebalib.com/vip.html

http://www.xuebalib.com/db.php

http://www.xuebalib.com/zixun/2014-08-15/44.html


Percutaneous Vertebral Augmentation: Vertebroplasty and...

Documents

Transcript of Percutaneous Vertebral Augmentation: Vertebroplasty and...