Hardware of vertebroplasty
Rachidian access
Preparation of cement
Injection of cement


Technical hitches


Vertebral angioma
Rachidian metastases
Osteoporotic packings




Percutaneous vertebroplasty is a technique of interventional radiology consisting in injecting acrylic cement by percutaneous way into an affected vertebra, in order to obtain an antalgic effect and consolidation of the vertebra. This treatment is carried out under neuroleptanalgesia.


Vertebroplasty has two combined effects : the stabilization of the vertebral body and an antalgic effect.
Vertebroplasty is considered to be a process of stabilizing  the vertebral bodies.
The injection of cement into the vertebra has an antalgic effect, by consolidating microfractures it thus decreases the mechanical constraints, related to the load ; It is also effective because it destroys the nerve endings of the normal bone by a cytotoxic effect or by the releasing of heat by the cement at the time of the treatment.


Preoperative assessment

Standard full-face and profile radiograph measure the extent of vertebral packing, the level to which the pedicles of the posterior wall are affected, and the existence or the appearance of a modification of the rachidian curves.
The MRI specifies to what point the vertebral body,  the pedicles and the posterior arc are affected. It shows whether the posterior wall is ruptured, and whether epidural spread has occurred or whether spreading into the soft parts has occurred.
The scan of the pathological vertebra is also of fundamental interest, because it is the only way to correctly evaluate the existence of a cortical lysis involving either the external cortical of the vertebral body, or the posterior wall. It also makes it possible to study the total texture of the vertebra, and see whether multiple microgeodes or an area where the pathology is condensed are present or totally absent. These are elements which significantly influence the distribution of cement throughout the vertebral body or its possible spreading outside its limits during the percutaneous injection.

Contra-indication of the transpedicular way

The process allows for evaluation of the possibility of using the transpedicular method.
A biological analysis including blood count, is part of the pre-anaesthetic  assessment because in the large majority of cases, the treatment is carried out under neuroleptanalgesia.

Radiological equipment

X-ray control, by means of a digitized table provided with an arch.
Alternative : Control scanner and mobile digitized amplifier. This technique has the advantage of being more precisely aimed under scanner control than under X-ray control of the vertebral body, in particular for small lesions.

Vertebroplasty equipment


Bevelled needles between 10 and 15 cm in length and with a diameter of 3 mm (10G) allowing for a biopsy by coaxial installation and  a trocar of osseous biopsy (15G) at the same time which makes posible the taking of several samples for histological examination,  if necessary. Needles of  a finer gauge (15G) on the cervical and upper dorsal level  require a finer needle  (18G) to carry out a simultaneous coaxial biopsy.

Rachidian access

This method depends on the level of the vertebra to be treated, the anatomical conditions and in certain cases, on the presence of osteosynthesis equipment.

Cervical Rachis

Anterolateral  on a  patient in decubitus dorsal position, the radiologist's fingers penetrating between the aerodigestive axis on the inside and the vascular axis on the outside.
It is thus possible to locate the last four vertebral bodies, to protect the vascular axis and the aerodigestive tract.
(Acces from the right is usually preferable, taking into account the oesophageal overflow which is generally situated on the left)


This way makes it possible to approach all  the cervical vertebrae from C2 to C7.
Taking into account the size of the cervical vertebra, bilateral access is seldom necessary.

Dorsal and lumbar Rachis

The transpedicular method appears  to be  preferable, because it does not present a risk of  a pleuroparenchymatal complication at the dorsal level or of a haematoma of the psoas at the lumbar level and there are less likely to be leakages outside the body through the puncture hole.  (This method can not be used in the case of pedicular lysis or with osteosynthesis equipment).


Transpédicular, the patient is placed in  strict procubitus position and the puncture is carried out full face, until the trocar is in the vertebral body, then  profile.



This method is also carried out in procubitus. 
The puncture is carried out approximately one hand's breadth apart outside the spina line. The progression of the needle towards the vertebral body is followed under radioscopy on two planes  (face and profile).
In dorsal position, it is imperative to check that the needle is always behind of the line of pleural reflexion.

(Help can be gained by the injection of physiological salt solution or xylocaïne with 0,5% to increase the trocar/pleura safety zone at the time of the progression of the anaesthesia needle and  then  the trocar.

Preparation of cement



Simplex Cement (Howmedica). The mixture must be made of 4 volumes of methylmetacrylate powder to 1 volume of solvent. To this mixture tungsten or tantalum powder is added, in order to opacify the cement (usually 20 ml of powder, 5 ml of solvent and 2 grammes of tungsten powder are prepared).
The mixture is injected when it reached a semi-paste consistency. The cement only needs a few minutes  to set at 18°and is reduced notably at an ambient temperature of 24°.
The volume injected into a vertebra is very variable according to the type of vertebra and the importance of packing. In general, it is between 2 and 8 ml.

Cement injection

Luerlock 2 to 3 ml syringes fitted with gripping handles, under continuous profile scopic control.
The methylmetacrylate injection is stopped as soon as the product arrives at the level of the posterior vertebral wall or as soon as there is a threatening spreading of the cement.  It is sometimes necessary to modify the position of the needle, so as to obtain a better filling of the vertebral body.
Once the vertebra has been satisfactorily filled, the needle is gradually withdrawn from the vertebral body.

Radiological control

Standard or digitized radiograph full- face and profile, but also by computerized axial scanning with coronal and sagittal rebuildings.


Technical hitches

Puncture incidents

Transpedicular method: the major risk of the transpedicular method is the lesion of the intern cortical of the pedicle.
Posterolateral method : at the dorsal level, the risk is primarily a pleural puncture with risk of hemothorax.

At the lumbar level, the theoretical risks are the puncture of the renal capsula, hematoma of the psoas and especially cement leakage through the puncture hole.


If the first posterolateral approach does not allow  for a satisfactory positioning of the vertebroplasty needle, it is necessary to leave the first trocar in position and to carry out a second puncture to avoid  cement leakage through the first cortical puncture hole. 

Cement leakage into the soft parts

This risk necessitates a permanent close scopic monitoring of the injection, in particular when the cortical rupture affects the pedicle or the posterior wall.
On the level of the cervical rachis, anterior leakages through the puncture hole are commonplace, usually of small volume and only responsible for a transitory dysphagia in the very large majority of  cases.

Cement leakage into the venous system

This passage into the venous appears during the course of the injection and means that the injection must be stopped and that the repositioning of the needle might be necessary in order to be able to continue to fill the vertebral body.


(the early risk of cement passage into the veins explains why it is desirable to carry out a transosseous phlebography trough, the vertebroplasty trocar, when the lesion appears very vascularized (metastasis of  the thyroid or cancer of the kidney, vertebral angioma).

Leakage into the intervertebral discs

In the cases of rachidian metastases or osteoporotic packings, there is a direct communication between the intervertebral disc and the vertebral body. This incident does not involve a real complication.


Compared with the frequency of these technical hitches, complications occur rarely.

Local complications

They can be of 3 types : local painful exacerbation, radiculalgia, neurological deficit.

Increase in local pains

They yield in a few days under  non-steroidian anti-inflammatory drugs or corticosteroids.

Radicular complications

The specific treatment can be a surgical operation for ablation of the migrated cement fragment or marcaïnisation under scanographic control.
In all these cases a cure without after-effects can be obtained.

Neurological deficiency complications

They are exceptional.
Emergency surgical intervention relieves the compression and leads to neurological recovery.

Infectious complications

The theoretical risk of spondylitis justifies draconian asepsis precautions, but probably also the pre-operatory injection of  delayed action antibiotics or methylmetacrylate containing antibiotics.

It is worth remembering that complications are  much more frequent in metastatic cases where the rate of occurence is about 10%.


Acrylic vertebroplasty makes it possible to obtain an antalgic effect in the majority of  painful lesions of the rachis of tumoral or degenerative origin, which are responsible for an increased fragility of the vertebral bodies. 
The principal indications are metastases and  rachidian localizations of hemopathies, vertebral angioma and osteoporotic or osteopenic packings.

Vertebral Angioma

In a patient presenting a brutal neurological or rapidly progressive symptomatology and in whom a vertebral angioma associated with a significant and compressive epidural component has been diagnosed, it is necessary to combine vertebroplasty and surgery.


In a patient presenting a progressive neurological symptomatology or intense rachialgia without signs of nervous compression and radiologically speaking an " aggressive " angioma with epidural component, the vertebroplasty will be carried out by injection of acrylic cement and supplemented at the same time by an injection of pure alcohol after puncture of the posterior angioma arc or a angioma compartment of the vertebral body not injected with cement. 
This association allows for vertebral stabilization and the total sclerosis of the angiome which stops developing and whose epidural component subsides.

Rachidian metastases

In the case of  a metastasis which is only slightly radio-sensitive (cancer of the kidney, cancer of the thyroid, malignant pheochromocytome), vertebroplasty also provides a simple means of obtaining a consolidation of the vertebral body.
On the other hand, the goal of the vertebroplasty is to consolidate the body of a vertebra.


If the presence of an epidurite is not in itself a countra-indication of vertebroplasty, this treatment being able to relieve  the local pain  relating to the attack on the vertebral body, it will not have any effect on the clinical signs in connection with the epidurite.
Thus in metastases with neurological signs, the vertebroplasty is used only as an extra to stabilizing radiotherapy and/or surgical treatment.


This allows for a consolidation of the anterior rachidian segment, whilst avoiding resorting to a corporectomy which often seems to be out of proportion in polymetastatic patients or those   whose general condition is very poor.
A lesion primarily affecting the posterior arc or the pedicle of the vertebra is not an indication for vertebroplasty.
In the same way, a very significant extension into the soft parts or a complete destruction of the vertebral body and its cortical must lead to  vertebroplasty  being used only with the most extreme prudence.

Osteoporotic Packings

Vertebroplasty is a therapeutic weapon of choice when medical treatment is insufficient to calm  pain.
The antalgic effect is excellent in more than 90% of cases and is very rapid since a resumption of the support is as often  possible within  48 hours.