Surgical Therapy: Vertebro-Cifoplastic: – Pros and Cons

  • Umberto Tarantino
  • Giuseppina Resmini
  • Alessando Provenza
  • Eleonora Piccirilli
  • Maurizio Feola
  • Riccardo Iundusi


Vertebral compression fractures (VCFs) are the most common complication of osteoporosis. They result in significant mortality and morbidity and prolonged pain for patients. Vertebroplasty (PVP) and kyphoplasty (PKP) have recently been introduced for the treatment of osteoporotic patients who have prolonged pain following VCFs not responding to conservative treatment. Both procedures are based on the injection of a bone cement, usually polymethyl methacrylate (PMMA), into the fractured vertebra for the mechanical stabilization of VCFs and for pain relief. These procedures may be useful for osteoporotic patients who have prolonged pain following acute vertebral fracture and seem to determine a rapid and sustained pain relief with a better quality of life. Short-term complications, mainly the result of leakage extravasation of cement, include increased pain and damage from heat or pressure to the spinal cord or nerve roots as well as embolism problem. Proper patient selection and good technique should minimize complications, but, rarely, open surgery is needed. Long-term benfits have not yet been shown but potentially include prevention of recurrent pain at the treated level(s) with both procedures and with kyphoplasty restoration of height loss and spinal deformity, an improvement in level of function, and avoidance of chronic pain and restriction of internal organs. Controlled trials are needed to determine both short-term and long-term safety and efficacy of vertebroplasty and kyphoplasty.


Vertebral compression fracture Osteoporosis Vertebroplasty Kyphoplasty 


  1. 1.
    Silverman SL. The clinical consequences of vertebral compression fracture. Bone. 1992;13(Suppl 2):S27–31.CrossRefPubMedGoogle Scholar
  2. 2.
    Consensus development conference: diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med. 1993;94:646–50.Google Scholar
  3. 3.
    Dennison E, Cooper C. Epidemiology of osteoporotic fractures. Horm Res. 2000;54(Suppl 1):58–63.CrossRefPubMedGoogle Scholar
  4. 4.
    Bonnick SL. Osteoporosis in men and women. Clin Cornerstone. 2006;8:28–39.CrossRefPubMedGoogle Scholar
  5. 5.
    Genant HK, Wu CY, van Kuijk C, Nevitt MC. Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res. 1993;8:1137–48.CrossRefPubMedGoogle Scholar
  6. 6.
    Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classifi-cation of thoracic and lumbar injuries. Eur Spine J. 1994;3(4):184–201.CrossRefPubMedGoogle Scholar
  7. 7.
    Miyakoshi N, Itoi E, Kobayashi M, Kodama H. Impact of postural deformities and spinal mobility on quality of life in postmenopausal osteoporosis. Osteoporos Int. 2003;14(12):1007–12.CrossRefPubMedGoogle Scholar
  8. 8.
    David C, Confavreux CB, Mehsen N, Paccou J, Leboime A, Legrand E. Severity of osteoporosis: what is the impact of co-morbidities? Joint Bone Spine. 2010;77(Suppl 2):S103–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Lombardi I Jr, Oliveira LM, Mayer AF, Jardim JR, Natour J. Evaluation of pulmonary function and quality of life in women with osteoporosis. Osteoporos Int. 2005;16(10):1247–53.CrossRefPubMedGoogle Scholar
  10. 10.
    Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, Licata A, Benhamou L, Geusens P, Flowers K, Stracke H, Seeman E. Risk of new vertebral fracture in the year following a fracture. JAMA. 2001;285:320–3.CrossRefPubMedGoogle Scholar
  11. 11.
    Gallacher SJ, Gallagher AP, McQuillian C, Mitchell PJ, Dixon T. The prevalence of vertebral fracture amongst patients presenting with non-vertebral fractures. Osteoporos Int. 2007;18(2):185–92.CrossRefPubMedGoogle Scholar
  12. 12.
    Ledlie JT, Renfro M. Balloon kyphoplasty: one-year outcomes in vertebral body height restoration, chronic pain, and activity levels. J Neurosurg. 2003;98:36–42.PubMedGoogle Scholar
  13. 13.
    Hansen L, Petersen KD, Eriksen SA, Langdahl BL, Eiken PA, Brixen K, Abrahamsen B, Jensen JE, Harsløf T, Vestergaard P. Subsequent fracture rates in a nationwide population-based cohort study with a 10-year perspective. Osteoporos Int. 2015;26(2):513–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Prather H, Hunt D, Watson JO, Gilula LA. Conservative care for patients with osteoporotic vertebral compression fractures. Phys Med Rehabil Clin North Am. 2007;18:577–91.CrossRefGoogle Scholar
  15. 15.
    Brown CJ, Friedkin RJ, Inouye SK. Prevalence and outcomes of low mobility in hospitalized older patients. J Am Geriatr Soc. 2004;52:1263–70.CrossRefPubMedGoogle Scholar
  16. 16.
    Garfin SR, Yuan HA, Reiley MA. New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine. 2001;26:1511–5.CrossRefPubMedGoogle Scholar
  17. 17.
    Hargunani R, Le Corroller T, Khashoggi K, Murphy KJ, Munk PL. Percutaneous vertebral augmentation: the status of vertebroplasty and current controversies. Semin Musculoskelet Radiol. 2011;15:117–24.CrossRefPubMedGoogle Scholar
  18. 18.
    Galibert P, Deramond H, Rosat P, Le Gars D. Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty. Neurochirurgie. 1987;33:166–8.PubMedGoogle Scholar
  19. 19.
    Lieberman IH, Dudeney S, Reinhardt MK, Bell G. Initial outcome and efficacy of “kyphoplasty” in the treatment of painful osteoporotic vertebral compression fractures. Spine (Phila Pa 1976). 2001;26(14):1631–8.CrossRefGoogle Scholar
  20. 20.
    Belkoff SM, Mathis JM, Fenton DC, Scribner RM, Reiley ME, Talmadge K. An ex vivo biomechanical evaluation of an inflatable bone tamp used in the treatment of compression fracture. Spine (Phila Pa 1976). 2001;26(2):151–6.CrossRefGoogle Scholar
  21. 21.
    Weninger P, Schultz A, Hertz H. Conservative management of thoracolumbar and lumbar spine compression and burst fractures: functional and radiographic outcomes in 136 cases treated by closed reduction and casting. Arch Orthop Trauma Surg. 2009;129:207–19.CrossRefPubMedCentralPubMedGoogle Scholar
  22. 22.
    Chandra RV, Yoo AJ, Hirsch JA. Vertebral augmentation: update on safety, efficacy, cost effectiveness and increased survival? Pain Phys. 2013;16:309–20.Google Scholar
  23. 23.
    Mailli L, Filippiadis DK, Brountzos EN, Alexopoulou E, Kelekis N, Kelekis A. Clinical outcome and safety of multilevel: clinical experience and results. Cardiovasc Intervent Radiol. 2013;36:183–91.CrossRefPubMedCentralPubMedGoogle Scholar
  24. 24.
    Cuénod CA, Laredo JD, Chevret S, Hamze B, Naouri JF, Chapaux X, Bondeville JM, Tubiana JM. Acute vertebral collapse due to osteoporosis or malignancy: appearance on unenhanced and gadolinium-enhanced MR images. Radiology. 1996;199:541–9.CrossRefPubMedCentralPubMedGoogle Scholar
  25. 25.
    Garfin SR, Buckley RA, Ledlie J. Balloon kyphoplasty for symptomatic vertebral body compression fractures results in rapid, significant, and sustained improvements in back pain, function, and quality of life for elderly patients. Spine (Phila Pa 1976). 2006;31:2213–20.CrossRefGoogle Scholar
  26. 26.
    Gangi A, Sabharwal T, Irani FG, Buy X, Morales JP, Adam A, et al. Quality assurance guidelines for percutaneous vertebroplasty. Cardiovasc Intervent Radiol. 2006;29:173–8.CrossRefPubMedCentralPubMedGoogle Scholar
  27. 27.
    Kamath S, Venkatanarasimha N, Silver DAT. Percutaneous vertebroplasty. CPD J Radiol Update 2007; 6:82–96 and National institute for health and care excellence interventional procedures programme. Interventional procedure overview of percutaneous vertebroplasty (methyl methacrylate). London: NICE; 2003.Google Scholar
  28. 28.
    Blattert TR, Jestaedt L, Weckbach A. Suitability of a calcium phosphate cement in osteoporotic vertebral body fracture augmentation: a controlled, randomized, clinical trial of balloon kyphoplasty comparing calcium phosphate versus polymethylmethacrylate. Spine (Phila Pa 1976). 2009;34:108–14.CrossRefGoogle Scholar
  29. 29.
    Kamath S, Venkatanarasimha N, Silver DAT. Percutaneous vertebroplasty. CPD J Radiol Update. 2007;6:82–96.Google Scholar
  30. 30.
    National Institute for Health and Care Excellence. Interventional procedure guidance 12: percutaneous vertebroplasty. London: NICE; 2003.Google Scholar
  31. 31.
    National Institute for Health and Care Excellence. Interventional procedure guidance 166: Balloon kyphoplasty for vertebral compression fractures. London: NICE; 2006.Google Scholar
  32. 32.
    Grohs JG, Matzner M, Trieb K, Krepler P. Minimal invasive stabilization of osteoporotic vertebral fractures: a prospective nonrandomized comparison of vertebroplasty and balloon kyphoplasty. J Spinal Disord Tech. 2005;18:238–42.PubMedGoogle Scholar
  33. 33.
    Grados F, Depriester C, Cayrolle G, Hardy N, Deramond H, Fardellone P. Long-term observations of vertebral osteoporotic fractures treated by percutaneous vertebroplasty. Rheumatology (Oxford). 2000;39:1410–4.CrossRefGoogle Scholar
  34. 34.
    Lee HM, Park SY, Lee SH, Suh SW, Hong JY. Comparative analysis of clinical outcomes in patients with osteoporotic vertebral compression fractures (OVCFs): conservative treatment versus balloon kyphoplasty. Spine J. 2012;12:998–1005.CrossRefPubMedGoogle Scholar
  35. 35.
    Yang EZ, Xu JG, Huang GZ, Xiao WZ, Liu XK, Zeng BF, Lian XF. Percutaneous vertebroplasty versus conservative treatment in aged patients with acute osteoporotic vertebral compression fractures: a prospective randomized controlled clinical study. Spine (Phila Pa 1976). 2016;41(8):653–60.CrossRefGoogle Scholar
  36. 36.
    Rousing R, Hansen KL, Andersen MO, Jespersen SM, Thomsen K, Lauritsen JM. Twelve-months follow-up in forty-nine patients with acute/semiacute osteoporotic vertebral fractures treated conservatively or with percutaneous vertebroplasty: a clinical randomized study. Spine (PhilaPa 1976). 2010;35:478–82.CrossRefGoogle Scholar
  37. 37.
    Shi-Ming G, Wen-Juan L, Yun-Mei H, et al. Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for osteoporotic vertebral compression fracture: a metaanalysis. Indian J Orthop. 2015;49(4):377–87.CrossRefPubMedCentralPubMedGoogle Scholar
  38. 38.
    Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet. 2002;359:1761–7.CrossRefPubMedGoogle Scholar
  39. 39.
    Wang H, Sribastav SS, Ye F, et al. Comparison of percutaneous vertebroplasty and balloon kyphoplasty for the treatment of single level vertebral compression fractures: a meta-analysis of the literature. Pain Physician. 2015;18(3):209–22.PubMedGoogle Scholar
  40. 40.
    Wardlaw D, Cummings SR, Van Meirhaeghe J, Bastian L, Tillman JB, Ranstam J, Eastell R, Shabe P, Talmadge K, Boonen S. Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. Lancet. 2009;373:1016–24.CrossRefPubMedGoogle Scholar
  41. 41.
    Kasperk C, Grafe IA, Schmitt S, Nöldge G, Weiss C, Da Fonseca K, Hillmeier J, Libicher M, Sommer U, Rudofsky G, Meeder PJ, Nawroth P. Three-year outcomes after kyphoplasty in patients with osteoporosis with painful vertebral fractures. J Vasc Interv Radiol. 2010;21:701–9.CrossRefPubMedGoogle Scholar
  42. 42.
    Röllinghoff M, Siewe J, Zarghooni K, Sobottke R, Alparslan Y, Eysel P, et al. Effectiveness, security and height restoration on fresh compression fractures–a comparative prospective study of vertebroplasty and kyphoplasty. Minim Invasive Neurosurg. 2009;52:233–7.CrossRefPubMedGoogle Scholar
  43. 43.
    Molloy S, Mathis JM, Belkoff SM. The effect of vertebral body percentage fill on mechanical behavior during percutaneous vertebroplasty. Spine (Phila Pa 1976). 2003;28(14):1549–54.Google Scholar
  44. 44.
    Hiwatashi A, Yoshiura T, Yamashita K, Kamano H, Dashjamts T, Honda H. Morphologic change in vertebral body after percutaneous vertebroplasty: follow-up with MDCT. AJR Am J Roentgenol. 2010;195:W207–12.CrossRefPubMedGoogle Scholar
  45. 45.
    Hiwatashi A, Westesson PL, Yoshiura T, Noguchi T, Togao O, Yamashita K, Kamano H, Honda H. Kyphoplasty and vertebroplasty produce the same degree of height restoration. AJNR Am J Neuroradiol. 2009;30:669–73.CrossRefPubMedGoogle Scholar
  46. 46.
    Feltes C, Fountas KN, Machinis T, Nikolakakos LG, Dimopoulos V, Davydov R, Kassam M, Johnston KW, Robinson JS. Immediate and early postoperative pain relief after kyphoplasty without significant restoration of vertebral body height in acute osteoporotic vertebral fractures. Neurosurg Focus. 2005;18:e5.CrossRefPubMedGoogle Scholar
  47. 47.
    Klazen CA, Lohle PN, de Vries J, Jansen FH, Tielbeek AV, Blonk MC, Venmans A, van Rooij WJ, Schoemaker MC, Juttmann JR, Lo TH, Verhaar HJ, van der Graaf Y, van Everdingen KJ, Muller AF, Elgersma OE, Halkema DR, Fransen H, Janssens X, Buskens E, Mali WP. Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial. Lancet. 2010;376(9746):1085–92.CrossRefPubMedGoogle Scholar
  48. 48.
    Huang Z, Wan S, Ning L, Han S. Is unilateral kyphoplasty as effective and safe as bilateral kyphoplasties for osteoporotic vertebral compression fractures? A meta-analysis. Clin Orthop Relat Res. 2014;472:2833–42.CrossRefPubMedCentralPubMedGoogle Scholar
  49. 49.
    Taylor RS, Fritzell P, Taylor RI. Balloon kyphoplasty in the measurement of vertebral compression fractures: an update systematic review and meta-analysis. Eur Spine J. 2007;16(8):1085–100.CrossRefPubMedCentralPubMedGoogle Scholar
  50. 50.
    McGirt MJ, Parker SL, Wolinsky JP, Witham TF, Bydon A, Gokaslan ZL. Vertebroplasty and kyphoplasty for the treatment of vertebral compression fractures: an evidenced based review of the literature. Spine J. 2009;9:501–8.CrossRefPubMedCentralPubMedGoogle Scholar
  51. 51.
    McCall T, Cole C, Dailey A. Vertebroplasty and kyphoplasty: a comparative review of efficacy and adverse events. Curr Rev Musculoskelet Med. 2008;1:17–23.CrossRefPubMedCentralPubMedGoogle Scholar
  52. 52.
    Choe DH, Marom EM, Ahrar K, Truong MT, Madewell JE. Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty. AJR Am J Roentgenol. 2004;183(4):1097–102.CrossRefPubMedGoogle Scholar
  53. 53.
    FDA. Class II special controls guidance document: Polymethylmethacrylate (PMMA) bone cement: guidance for industry and FDA. 2011. URL:
  54. 54.
    Kim YY, Rhyu KW. Recompression of vertebral body after balloon kyphoplasty for osteoporotic vertebral compression fracture. Eur Spine J. 2010;19:1907–12.CrossRefPubMedCentralPubMedGoogle Scholar
  55. 55.
    Tanigawa N, Komemushi A, Kariya S, et al. Radiological follow-up of new compression fractures following percutaneous vertebroplasty. Cardiovasc Intervent Radiol. 2006;29:92–6.CrossRefPubMedGoogle Scholar
  56. 56.
    Johannes H, Heiko F, Kerstin Wet al. Incidence of symptomatic vertebral fractures in patients after percutaneous vertebroplasty. Cardiovasc Intervent Radiol. 2006;29:92–6.CrossRefGoogle Scholar
  57. 57.
    Micael NT, Susan MR, Frank MP, et al. Altered disc-pressure profile after an osteoporotic vertebral fracture in a risk factor for adjacent vertebral body fracture. Eur Spine J. 2008;17:1522–430.CrossRefGoogle Scholar
  58. 58.
    Rohlmann A, Zander T, Bergmann G, et al. Spinal loads after osteoporotic vertebral fractures treated by vertebroplasty or kyphoplasty. Eur Spine J. 2006;15:1255–64.CrossRefPubMedGoogle Scholar
  59. 59.
    Eck JC, Nachtigall D, Humphreys SC, Hodges SD. Comparison of vertebroplasty and balloon kyphoplasty for treatment of vertebral compression fractures: a meta-analysis of the literature. Spine J. 2008;8(3):488–97.CrossRefPubMedGoogle Scholar
  60. 60.
    Hiwatashi A, Ohgiya Y, Kakimoto N, Westesson PL. Cement leakage during vertebroplasty can be predicted on preoperative MRI. AJR Am J Roentgenol. 2007;188(4):1089–93.CrossRefPubMedCentralPubMedGoogle Scholar
  61. 61.
    Anselmetti GC, Zoarski G, Manca A, Masala S, Eminefendic H, Russo F, Regge D. Percutaneous vertebroplasty and bone cement leakage: clinical experience with a new high-viscosity bone cement and delivery system for vertebral augmentation in benign and malignant compression fractures. Cardiovasc Intervent Radiol. 2008;31(5):937–47.CrossRefPubMedCentralPubMedGoogle Scholar
  62. 62.
    Hierholzer J, Fuchs H, Westphalen K, Baumann C, Slotosch C, Schulz R. Incidence of symptomatic vertebral fractures in patients after percutaneous vertebroplasty. Cardiovasc Intervent Radiol. 2008;31(6):1178–83.CrossRefPubMedCentralPubMedGoogle Scholar
  63. 63.
    Klazen CA, Venmans A, de Vries J, van Rooij WJ, Jansen FH, Blonk MC, Lohle PN, Juttmann JR, Buskens E, van Everdingen KJ, Muller A, Fransen H, Elgersma OE, Mali WP, Verhaar HJ. Percutaneous vertebroplasty is not a risk factor for new osteoporotic compression fractures: results from VERTOS II. AJNR Am J Neuroradiol. 2010;31(8):1447–50.CrossRefPubMedCentralPubMedGoogle Scholar
  64. 64.
    Campbell PG, Harrop JS. Incidence of fracture in adjacent levels in patients treated with balloon kyphoplasty: a review of the literature. Curr Rev Musculoskelet Med. 2008;1(1):61–4.CrossRefPubMedCentralPubMedGoogle Scholar
  65. 65.
    Taylor RS, Taylor RJ, Fritzell P. Balloon kyphoplasty and vertebroplasty for vertebral compression fractures: a comparative systematic review of efficacy and safety. Spine (Phila Pa 1976). 2006;31(23):2747–55.CrossRefGoogle Scholar
  66. 66.
    Frankel BM, Monroe T, Wang C. Percutaneous vertebral augmentation: an elevation in adjacent-level fracture risk in kyphoplasty as compared with vertebroplasty. Spine J. 2007;7(5):575–82.CrossRefPubMedCentralPubMedGoogle Scholar
  67. 67.
    Belkoff SM, Mathis JM, Jasper LE, Deramond H. The biomechanics of vertebroplasty. The effect of cement volume on mechanical behavior. Spine (Phila Pa 1976). 2001;26(14):1537–41.CrossRefGoogle Scholar
  68. 68.
    Kaufmann TJ, Trout AT, Kallmes DF. The effects of cement volume on clinical outcomes of percutaneous vertebroplasty. AJNR Am J Neuroradiol. 2006;27(9):1933–7.PubMedPubMedCentralGoogle Scholar
  69. 69.
    Zheng Z, Luk KD, Kuang G, Li Z, Lin J, Lam WM, Cheung KM, Lu WW. Vertebral augmentation with a novel Vessel-X bone void filling container system and bioactive bone cement. Spine (Phila Pa 1976). 2007;32(19):2076–82.CrossRefGoogle Scholar
  70. 70.
    Bae H, Shen M, Maurer P, Peppelman W, Beutler W, Linovitz R, Westerlund E, Peppers T, Lieberman I, Kim C, Girardi F. Clinical experience using Cortoss for treating vertebral compression fractures with vertebroplasty and kyphoplasty: twenty four-month follow-up. Spine (Phila Pa 1976). 2010;35(20):E1030–6.CrossRefGoogle Scholar
  71. 71.
    Rauschmann M, Vogl T, Verheyden A, Pflugmacher R, Werba T, Schmidt S, Hierholzer J. Bioceramic vertebral augmentation with a calcium sulphate/hydroxyapatite composite (Cerament SpineSupport): in vertebral compression fractures due to osteoporosis. Eur Spine J. 2010;19(6):887–92.CrossRefPubMedCentralPubMedGoogle Scholar
  72. 72.
    Tomita S, Molloy S, Jasper LE, Abe M, Belkoff SM. Biomechanical comparison of kyphoplasty with different bone cements. Spine (Phila Pa 1976). 2004;29(11):1203–7.CrossRefGoogle Scholar
  73. 73.
    Belkoff SM, Mathis JM, Deramond H, Jasper LE. An ex vivo biomechanical evaluation of a hydroxyapatite cement for use with kyphoplasty. AJNR Am J Neuroradiol. 2001;22(6):1212–6.PubMedGoogle Scholar
  74. 74.
    Ekman EF. The role of the orthopaedic surgeon in minimizing mortality and morbidity associated with fragility fractures. J Am Acad Orthop Surg. 2010;18(5):278–85.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Umberto Tarantino
    • 1
  • Giuseppina Resmini
    • 2
  • Alessando Provenza
    • 2
  • Eleonora Piccirilli
    • 1
  • Maurizio Feola
    • 1
  • Riccardo Iundusi
    • 1
  1. 1.Orthopaedic and TraumatologyUniversity of Rome “Tor Vergata”, University Hospital “Policlinico Tor Vergata”RomeItaly
  2. 2.Section of Orthopaedic and TraumatologyASST Bergamo Ovest HospitalTreviglioItaly

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