Cementoplasty / Vertebroplasty

Background and indications

Vertebroplasty (or vertebral cementoplasty) involves injecting surgical cement (polymethylmethacrylate - PMMA) into a fractured vertebral body to stabilize it and relieve pain. Cementoplasty can also be performed in other bones (pelvis, sacrum, femur) for painful pathological fractures.

Main indications include: painful osteoporotic vertebral fractures resistant to conservative treatment (rest, analgesics, brace) for 4 to 6 weeks, painful vertebral fractures from bone metastases or multiple myeloma, and selected stable traumatic vertebral fractures. Balloon kyphoplasty is a variant that partially restores vertebral height before cement injection.

Pre-procedure assessment

Assessment includes recent spinal MRI (essential to confirm the acute/subacute nature of the fracture by the presence of vertebral edema on STIR sequences, and exclude posterior wall retropulsion or spinal cord compression), CT scan to evaluate fracture morphology and plan the puncture trajectory, and coagulation panel.

Procedure

Under local anesthesia and sedation (or general anesthesia depending on the case), one or two bone biopsy needles (11-13G) are inserted via a posterior transpedicular approach under fluoroscopic or CT guidance. The needle is advanced into the vertebral body. PMMA cement is prepared, then injected under continuous fluoroscopic monitoring, watching for extravertebral leakage. Injection is stopped once satisfactory filling is achieved or in case of leakage. Injected volume is typically 2 to 6 mL per vertebra. The procedure takes 30 to 60 minutes per treated level.

Results and scientific evidence

The randomized VERTOS II trial of 202 patients with osteoporotic vertebral fractures demonstrated significant pain relief after vertebroplasty compared to conservative treatment, with mean VAS score decreasing from 7.8 to 3.0 at 1 month versus 7.5 to 4.9 in the control group (Klazen et al., The Lancet, 2010; DOI: 10.1016/S0140-6736(10)60954-3).

Pain relief is achieved in 80-90% of osteoporotic fractures and 60-80% of metastatic fractures. Improvement is often felt within 24-48 hours after the procedure.

Risks and complications

Asymptomatic cement leakage is common (10-20% of cases, visible on CT) but rarely clinically significant. Symptomatic complications are rare: radiculopathy from foraminal leakage (< 2%), pulmonary cement embolism (< 1%, usually asymptomatic). Infection (spondylodiscitis) is exceptional (< 0.5%). Spinal cord compression from posterior leakage is extremely rare with current technique.

Recovery

The patient can stand and walk within hours of the procedure. Pain relief is often rapid (24-48 hours). Treatment of underlying osteoporosis is essential to prevent new fractures. Follow-up is scheduled at 1 and 3 months.

Practical information

The procedure is performed as an outpatient or short inpatient stay depending on the case. It is performed by an interventional radiologist, in coordination with the rheumatologist, spine surgeon, or oncologist.