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Vertebroplasty and kyphoplasty

68 citationsUpdated Sep 2026

Overview

Percutaneous cement augmentation, comprising vertebroplasty and kyphoplasty, is the standard surgical intervention for symptomatic osteoporotic and metastatic vertebral compression fractures when conservative management fails [5, 6]. Vertebroplasty is a faster, less costly procedure that remains useful with no detectable clinical complications [1]. It is recommended as the first-line surgical technique for older patients, while balloon kyphoplasty serves as a second-line option for vertebral fragility fractures [33]. Both procedures achieve good early results in fresh dislocated thoracic and lumbar vertebral compression fractures [8], and satisfactory clinical and radiographic outcomes are observed regardless of whether the operation is performed early or delayed [4]. For stable fractures, percutaneous kyphoplasty alone or combined with other minimally invasive strategies is safe and effective [139]. Conversely, aggressive intervention is recommended for unstable fractures or severe foraminal encroachment [139]. Assessment of underlying osteoporosis is crucial for the management of these fractures [33], and the authors recommend obtaining a vertebral body biopsy prior to every vertebral augmentation procedure [21].

Kyphoplasty demonstrates improved pain reduction and lower complication rates compared to standard vertebroplasty for painful thoracic and lumbar compression fractures [2]. However, the absence of a sham group in available data leaves the placebo effect unaddressed regarding kyphoplasty outcomes [2]. Some trials showed limited effectiveness of vertebroplasty and kyphoplasty over sham treatment [24], and pooled results of vertebroplasty did not provide patients with a clinically important improvement in pain or function [11]. Consequently, pooled results do not support the routine use of vertebroplasty for osteoporotic vertebral fractures [11]. Despite this, a recent meta-analysis cited strong evidence in favor of cement augmentation for symptomatic vertebral compression fractures [24]. Setting aside mostly asymptomatic leakage, the vertebroplasty technique may be considered the surgical procedure of choice [13].

Complications are relatively infrequent, though cement leakage is more common with vertebroplasty and in metastatic disease [3]. The most important factors for new vertebral compression fractures after a percutaneous augmentation procedure are the degree of osteoporosis and resistant kyphosis [19]. There is no indication for prophylactic stabilization of adjacent segments with balloon kyphoplasty [25]. Specific indications and long-term outcomes for percutaneous treatment of vertebral body pathology require further refinement [3]. Differences exist in the indications for vertebroplasty and kyphoplasty [7], and vertebroplasty may limit indications for purely mechanical purposes in the context of anterior spine surgery for recent thoracolumbar fractures [10]. Patients undergoing percutaneous vertebroplasty were encouraged to mobilize on the first day, while conservative patients mobilized two weeks after fracture [29]. Kyphoplasty cost-effectiveness was not a subject of the study regarding percutaneous vertebroplasty versus conservative treatment [29]. Requirements for bone cement in a kyphoplasty setting were excellently fulfilled [9].

Anatomy & Pathophysiology

Bony Anatomy

The vertebral column comprises 33 vertebrae divided into five sections: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal [66]. The sacral and coccygeal vertebrae are fused, which typically allows for 24 mobile segments [66]. A typical vertebra consists of an anterior body and a posterior arch that enclose the vertebral canal [66]. The vertebral body is a fairly cylindrical mass of bone connected by the pedicles to the posterior arch [58]. It functions primarily to bear weight and transfer forces to the pelvis and hips [58]. The posterior arch, composed of the lamina and spinous process, creates the spinal canal through which the spinal cord passes [58]. The neural arch is composed of two pedicles laterally and two laminae posteriorly that are united to form the spinous process [66]. The articular processes articulate with adjacent vertebrae to form synovial joints, with orientation accounting for the degree of flexion, extension, or rotation possible in each segment [66]. The vertebral canal extends throughout the length of the column and provides protection for the spinal cord, conus medullaris, and cauda equina [66].

The thoracic spine represents two transitional zones, from the highly mobile cervical spine into the more rigid thoracic region, then back to the more mobile lumbar spine [60]. It forms a bony “cube” with the ribs and sternum, providing protection to the heart and lungs [60]. Thoracic vertebral bodies are larger than cervical vertebrae but smaller than lumbar vertebrae [60]. Thoracic pedicles arise more superiorly from the posterior vertebral body than in the cervical or lumbar spine and project obliquely from superodorsal to inferoventral [60]. The pedicles of T1 and to a lesser degree T2 have a more medial trajectory, while remaining thoracic pedicles project almost straight forward [60]. The spinal canal is narrowest in the thoracic region [60]. The spinous processes of the midthoracic spine project sharply obliquely, overlapping the lamina and spinous processes inferiorly [60]. The rib heads articulate with the lateral aspect of the vertebral bodies, with a shared articulation at the level of the disk space referred to as a demifacet [60].

The vertebral body is composed of an inner region of cancellous bone surrounded by a thin shell of cortical bone [63]. In general, each mobile vertebral body increases in size when moving from cranial to caudal [66]. The length of the vertebral column averages 72 cm in men and 7 to 10 cm less in women [66].

Intervertebral Disc Anatomy

The intervertebral disc (IVD) separates each successive vertebral body and provides a combination of compressive stiffness and flexibility to support normal spine biomechanics [63]. The IVD is composed of an inner nucleus pulposus (NP) and an outer ring termed the anulus fibrosus (AF) [63]. The nucleus pulposus serves as an osmotic pump to attract water and generate hydraulic pressure when subjected to significant loads [63]. The anulus fibrosus encapsulates the gelatinous nucleus pulposus and provides mechanical support to contain NP pressure and constrain intervertebral rotations [63]. The outer anulus fibrosus is integrated with the vertebral rim via a fibrocartilage enthesis consisting of a thin layer of calcified cartilage, or “tidemark” [63]. The end plate is a bilayer of cartilage and bone that separates the disk from adjacent vertebrae [63]. The end plate must be strong and thick to resist significant loads but also permeable to favor chemical transport and disk cellular vitality [63].

Biomechanics

Normal cervical alignment is approximately 15° of lordosis [62]. The thoracic spine generally ranges from 20° to 40° of kyphosis [62]. The lumbar spine has approximately 40° to 50° of lordosis [62]. Kyphotic segments (thoracic, sacral) are considered “primary” curvatures present in utero and at birth [62]. Lordotic curvatures of the cervical and lumbar spine develop secondarily later in life to allow the growing child to develop an upright posture [62]. The cervical and lumbar segments develop lordosis as an erect posture is acquired [66]. The thoracic and sacral segments maintain kyphotic postures, which are found in utero, and serve as attachment points for the rib cage and pelvic girdle [66]. Changes in sagittal balance that shift the center of gravity too far ventrally can result in significant pain and disability [62].

The functional spinal unit consists of two vertebrae, the disk between them, and the facet joints (and their capsules) [62]. The vertebral bodies bear 70% to 90% of the static axial load of the spine [62]. The facet joints support 10% to 20% of axial load in a standing, neutral alignment [62]. In extension, facet joints may bear up to 30% of the axial load [62]. In flexion, facet joints may be burdened with up to 50% of the anterior shear load [62]. The intervertebral disk absorbs axial loads by deforming the nucleus pulposus, which redistributes axial forces radially [62]. Radial pressure from the nucleus pulposus is resisted by the tensile properties of the alternating bands of fibers within the anulus fibrosus [62]. The spinous processes and transverse processes act as lever arms, providing mechanical advantage for the muscles that insert along their surfaces [62].

Vascular Anatomy

The thoracic and lumbar levels are supplied by paired segmental arteries which originate directly from the aorta along its posterior surface [67]. Branches of the segmental arteries supply the vertebral body, the paraspinal musculature, and the spinal cord [67]. The cervical spine derives its circulation primarily from the vertebral arteries [67]. The vertebral arteries typically enter the transverse foramen at the C6 level and run proximally through the transverse foramina to C1 [67]. The vascular supply of the spinal cord is primarily from the medullary branches of the segmental spinal arteries [67]. The anterior spinal artery is responsible for supplying approximately 80% of the vascular supply to the spinal cord [67]. The arteria medullaris magna (AMM), also known as the artery of Adamkiewicz, typically arises on the left side anywhere between the T8 and L1 level [67]. Ligation or injury to the AMM could have disastrous consequences for planned anterior procedures at the thoracolumbar junction [67].

Pathophysiology

The therapeutic mechanism of percutaneous vertebroplasty involves the reinforcement of vertebral body integrity and stability through the infusion of bone cement [52]. The distribution and quantity of bone cement within the vertebral structure have implications for clinical outcomes [52]. Abnormal mechanical stress may contribute to intervertebral disc degeneration in old thoracolumbar fractures with kyphosis [97]. Correction of traumatic vertebral deformity avoids subsidence and loss of mechanical function in the superior adjacent disc [98]. Traumatic intervertebral disc injury contributes to loss of correction following thoracolumbar fractures and is closely associated with accelerated disc degeneration [115]. Acute multiple osteoporotic vertebral compression fractures are an accelerated form of osteoporotic vertebral fracture cascades showing similar anatomical distribution and distribution pattern in the spine [109]. The thoracolumbar spine has a 2-fold higher risk of osteoporotic vertebral compression fractures than the non-thoracolumbar spine [132].

Classification

Genant et al. Semiquantitative Classification: Fracture type is denominated according to the semiquantitative classification of Genant et al. as either wedge, biconcave, or crush [45]. Fracture severity for osteoporotic vertebral compression fractures is classified by the percentage of vertebral body collapse on plain lateral radiographs as mild (20–25%), moderate (26–40%), and severe (>40%) [45].

Morphological Classification for Chronic Symptomatic Osteoporotic Thoracolumbar Fracture: This system defines five types based on radiological and MRI findings. Type I (dynamic stable type) is characterized by radiological changes such as vertebral vacuum sign, intervertebral cleft, and/or pseudarthrosis, with a D-value of VKA less than 11° [140]. Type II (dynamic unstable type) is defined by a D-value of VKA greater than 11° [140]. Type III (spinal stenosis type) is identified by MRI revealing backward displacement of bone fragments leading to spinal canal stenosis and neurological deficit [140]. Type IV (kyphotic deformity type) is defined by a CKA greater than 30° on both flexion and extension lateral radiography [140]. Type V (mixed type) is defined by the presence of at least two of the morphological changes from types II to IV [140].

Bone Cement Distribution: Bone cement distribution within the vertebral body can be classified morphologically into a blocky group, characterized by compact and solid distribution, and a spongy group, characterized by diffuse, fibril-like, and sponge-like distribution [44].

Kanchiku Classification: The Kanchiku classification categorizes vertebral fractures into three types: superior, middle, and inferior fractures [23].

Other Considerations: Fractures are classified according to the Magerl classification in prospective studies evaluating percutaneous techniques for thoracolumbar junction fractures [143]. Fractures are categorized using both the AO thoracolumbar classification and the Osteoporotic Fracture (OF) classification systems in studies evaluating kyphoplasty combined with posterior dynamic stabilization [145]. A reliable classification for assessing the stability of a healed vertebra after posterior short-segment fixation for thoracolumbar burst fractures was developed [125].

Clinical Presentation

Vertebroplasty and kyphoplasty are indicated for the treatment of painful thoracic and lumbar compression fractures [2]. In patients with osteoporotic fractures, vertebroplasty provides quick pain relief in approximately 90% of cases [131]. Conversely, vertebroplasty is associated with less predictable pain relief in patients with osteolytic fractures [131]. Compared to conventional conservative medical treatment, percutaneous vertebroplasty and balloon kyphoplasty provide quicker pain relief and mobility recovery in the short term [28]. Vertebroplasty prevents the progression of kyphosis and spinal deformity more effectively than conservative treatment [12].

Comparative Efficacy and Guidelines

Kyphoplasty is associated with improved pain reduction compared to standard vertebroplasty [2]. However, kyphoplasty and vertebroplasty are equally effective in the clinical outcomes of osteoporotic vertebral compression fractures, with no significant difference observed in VAS scores and ODI scores [15]. Recent meta-analyses have shown that kyphoplasty had a superior capability for intermediate-term functional improvement while vertebroplasty was more effective in the short-term relief of pain [43]. There is no difference in long-term function or pain relief between kyphoplasty and vertebroplasty [43]. The AAOS recommendations include a Strong recommendation against vertebroplasty and a Weak recommendation for kyphoplasty in patients not improving with nonsurgical management [18]. Percutaneous vertebroplasty is recommended as the first-line surgical technique for older people, while balloon kyphoplasty is a second-line option [33].

Cement Distribution and Complications

Spongy distribution of bone cement provides better pain relief and functional outcomes than blocky distribution [44]. Spongy distribution of bone cement reduces the risk of postoperative adjacent vertebral body fractures compared to blocky distribution [44]. The lower incidence of adjacent vertebral body fractures in the spongy cement group may be due to a more even distribution of stress throughout the vertebral body [44]. Cement leakage is more common with vertebroplasty than with kyphoplasty [3]. Cement leakage is more common in metastatic disease [3]. Kyphoplasty was associated with a decreased overall risk of cement leakage with a risk ratio of 0.65 compared with vertebroplasty [43]. Cement leakage in the 'at-risk' disc space was no different between kyphoplasty and vertebroplasty [43]. Cement leakage in the 'safe' paravertebral space showed reduction in kyphoplasty compared to vertebroplasty [43].

Neurological Risks and Fracture Patterns

Serious neurological complications can occur with vertebroplasty unless careful attention is paid to technical details, including the use of appropriate imaging and cement consistency [47]. Delayed-onset radiculopathy can be caused by a retropulsed bone fragment after percutaneous kyphoplasty [23]. Preoperative radiculopathy is a relative contraindication for kyphoplasty [23]. Inferior-type vertebral fractures are more related to the development of radiculopathy [23]. A disrupted posterior vertebral rim on preoperative MRI is associated with the risk of fragment retropulsion during kyphoplasty [23]. Vertebroplasty may be associated with a low risk of fragment retropulsion because a balloon tamp is not used [23]. Recollapse of the treated vertebral body was found relatively frequently alongside the correction loss of local kyphotic angle in patients with rheumatoid arthritis [26]. The incidence rates of local kyphosis, adjacent vertebral fracture and vertebral recollapse in the percutaneous vertebroplasty group were significantly lower than those in the percutaneous kyphoplasty group at 3 years postoperatively [35].

Investigations

MRI: Magnetic resonance imaging is the standard for advanced spinal imaging, offering superior visualization of neural structures and the spinal cord compared to CT [79]. It is particularly effective for identifying infections, tumors, and degenerative changes within discs [79]. MRI is recommended for patients with a Glasgow Coma Scale of less than 15 and midline tenderness with neurological symptoms to evaluate for possible ligamentous injury [88]. Preoperative MRI can identify a disrupted posterior vertebral rim, which is associated with the risk of bone fragment retropulsion during kyphoplasty [23].

CT: Computed tomography has largely supplanted plain radiographs as the initial screening study of choice for spine fractures due to its combination of high sensitivity and specificity [80]. It is particularly useful in differentiating compression fractures from burst fractures and identifying features such as facet widening [80]. Multidetector CT (MDCT) has a sensitivity of 97% to 100% for patients with neck tenderness and pain in the acute setting [88]. If a neurological deficit is found after vertebroplasty, a CT scan should be taken to confirm the pattern of cement leakage [150]. The primary disadvantage of CT imaging compared to MRI is that it does not provide as good a visualization of soft tissues [80].

Plain radiography: Radiographs, flexion-distraction, or neutral views have limited utility in the acute setting because of their high false-negative and false-positive rates [88].

Other Considerations: Imaging studies must be concordant with clinical symptoms and signs to be of diagnostic value [76]. An imaging study alone is insufficient to qualify for a DRE category, excepting spinal fractures [76]. The best way to obtain meaningful clinical information from MRI is to have a specific question derived from the patient’s history and physical examination, posed using the parameters of neural compression, instability, and deformity [79]. Failure to interpret an imaging study in a way that correlates findings with clinical categories of neural compression, instability, or deformity would inevitably lead to poor clinical choices and outcomes [79]. MRI evidence of disc degeneration has been reported in the cervical spine in 25% of patients younger than 40 years and in 60% of patients 60 years and older [79]. Lumbar disc degeneration was found in 35% of patients aged 20 to 39 years and in 100% of patients older than 50 [79].

Biopsy: A vertebral body biopsy is recommended prior to every vertebral augmentation procedure [21]. Proper diagnosis of a spine tumor with a biopsy is the critical first step in devising proper treatment for a patient who presents with a spine tumor [37]. Careful identification of the tumor type by direct biopsy decreases the chance of misdiagnosis and performing unnecessary or incorrect surgery [37].

Prognostic Factors: Five imaging-based predictors of vertebral recompression were identified in a retrospective cohort study based on logistic regression analysis [152].

Treatment

Non-Operative

Conservative management serves as the baseline against which percutaneous interventions are evaluated. Vertebroplasty and kyphoplasty provide quicker pain relief, mobility recovery, and in some cases vertebral height restoration than conventional conservative medical treatment, at least in the short term [28]. However, the pooled results of vertebroplasty did not provide patients with a clinically important improvement in pain or function, and therefore do not support the routine use of vertebroplasty for osteoporotic vertebral fractures [11].

Operative

Indications: The AAOS recommendations for the treatment of symptomatic osteoporotic spinal compression fractures range from Inconclusive to Strong, with a Strong recommendation against vertebroplasty and a Weak recommendation for kyphoplasty in patients not improving with nonsurgical management [18]. Vertebroplasty and kyphoplasty both have roles in the treatment of vertebral fractures, but differences exist in the indications for the two percutaneous techniques [7]. The use of vertebroplasty with cement to treat multiple-level osteoporotic spinal compression fractures in the elderly does have value, and brings good results to patients which were previously unimaginable [14].

Surgical Approach / Technique: Kyphoplasty is a popular tool for painful thoracic and lumbar compression fractures showing improved pain reduction and lower complication rates compared to standard vertebroplasty, though the absence of a sham group in available data leaves the placebo effect unaddressed [2]. PKP surgery has a higher efficacy in the treatment of osteoporotic vertebral compression fracture patients, which can reduce the incidence of pain, adverse reactions and promote the recovery of kyphotic Cobb Angle [127]. Jack vertebral dilator kyphoplasty for osteoporotic vertebral compression fracture is safe, feasible, and effective and has the prospect of further broad application in the future [134].

Specific Clinical Scenarios: Percutaneous kyphoplasty is a safe and effective procedure for the treatment of very severe osteoporotic vertebral compression fractures with spinal canal compromise, achieving significant vertebral height restoration and kyphotic angle reduction and leading to a significant pain relief and improvement in function [17]. Kyphoplasty is a safe treatment modality for myeloma-related vertebral compression fractures [130]. Minimally invasive management (osteosynthesis, embolization and kyphoplasty) proved able to treat both the traumatic and the tumoral L1 lesion in a case of L1 burst fracture with associated vertebral angioma [32]. Percutaneous stabilization plus balloon kyphoplasty seems to be a safe and effective technique to manage thoraco-lumbar fractures without neurological impairment [48]. Conversely, the efficacy of percutaneous vertebroplasty alone was not satisfactory, and the rate of complications was high for osteoporotic vertebral compression fracture patients with severe anterior edge compression with kyphosis [46].

Comparative Efficacy and Outcomes: Kyphoplasty and vertebroplasty are equally effective in the clinical outcomes of osteoporotic vertebral compression fractures, as radiographic differences did not significantly influence the clinical results [15]. The two procedures have similar short- and long-term pain relief, functional recovery, local kyphosis correction, and vertebral height maintenance in osteoporotic vertebral compression fractures with intravertebral cleft [22]. The paper reviews conflicting evidence regarding vertebroplasty and kyphoplasty, noting that while some trials showed limited effectiveness over sham treatment, a recent meta-analysis cited strong evidence in favor of cement augmentation for symptomatic vertebral compression fractures [24].

Complications and Safety: Complications are relatively infrequent, though cement leakage is more common with vertebroplasty and in metastatic disease, while specific indications and long-term outcomes require further refinement [3]. Patients who had experienced percutaneous vertebroplasty or kyphoplasty were not associated with an increased risk of recompression in new levels [94]. The time interval of recompression after operative procedure was much shorter than that for the conservative comparison group (9.7 ± 17.8 versus 22.4 ± 7.99 months, p = 0.017) [94]. In the PVP/PKP group, the rate of secondary adjacent fractures calculated by vertebral number is significantly higher than non-adjacent levels, but no significant statistical difference was observed in the conservative group [94]. Older age, gender, fracture times, location of original fracture segment, the amount of cement, cement leakage, operation modality (PVP or PKP), and initial number of osteoporotic vertebral compression fractures were not influencing factors for recompression in new levels [94].

Complications

Cement Leakage: Cement leakage is more common in patients with metastatic disease [3].

Adjacent and Secondary Fractures: A fracture at T12 has occurred both following vertebroplasty at L1 and an untreated fracture at L1 [20]. An additional history of fracture is significantly associated with secondary fractures after percutaneous vertebroplasty for osteoporotic vertebral compression fractures (OR 6.37; 95% CI 3.22–12.59; P < 0.05) [54]. Age is significantly associated with secondary fractures after percutaneous vertebroplasty for osteoporotic vertebral compression fractures (OR 1.16; 95% CI 1.03–1.10; P < 0.05) after removing a source of statistical heterogeneity [54].

Recollapse and Height Loss: Recollapse of the treated vertebral body was found relatively frequently alongside the correction loss of local kyphotic angle in patients with rheumatoid arthritis treated with balloon kyphoplasty [26].

General Safety and Complication Rates: Complications are relatively infrequent for percutaneous treatment of vertebral body pathology [3]. Kyphoplasty shows lower complication rates compared to standard vertebroplasty [2]. Vertebroplasty is a procedure that remains useful with no detectable clinical complications in a short-term retrospective review of 127 consecutive patients [1]. Percutaneous kyphoplasty is a safe and effective procedure for the treatment of very severe osteoporotic vertebral compression fractures with spinal canal compromise [17]. Vertebroplasty and balloon kyphoplasty are generally safe procedures that provide quicker pain relief, mobility recovery, and in some cases vertebral height restoration than conventional conservative medical treatment [28]. The rate of complications was high for osteoporotic vertebral compression fracture patients with severe anterior edge compression with kyphosis treated with percutaneous vertebroplasty alone [46].

Recovery

Light activity (weeks): Patients undergoing percutaneous vertebroplasty are encouraged to mobilize on the first day [29]. In contrast, patients managed conservatively typically mobilize two weeks after fracture [29]. Vertebroplasty and balloon kyphoplasty provide quicker mobility recovery than conventional conservative medical treatment [28].

Full activity (months): The provided evidence does not specify a distinct timeline for the return to manual work or sport.

Complete recovery / outcome plateau (months): The provided evidence does not specify a distinct timeline for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: No specific protocol details regarding PT phasing, immobilisation duration, or weight-bearing progression are provided in the evidence.

Functional milestones: Kyphoplasty and vertebroplasty are equally effective in the clinical outcomes of osteoporotic vertebral compression fractures [15]. No significant difference was observed in VAS scores between kyphoplasty and vertebroplasty groups [15]. No significant difference was observed in ODI scores between kyphoplasty and vertebroplasty groups [15]. Radiographic differences between kyphoplasty and vertebroplasty did not significantly influence clinical results [15]. However, the pooled results of vertebroplasty did not provide patients with a clinically important improvement in pain [11]. The pooled results of vertebroplasty did not provide patients with a clinically important improvement in function [11]. Kyphoplasty shows improved pain reduction compared to standard vertebroplasty [2].

Other Considerations: Vertebroplasty is a faster and less costly procedure than kyphoplasty [1]. Vertebroplasty remains useful with no detectable clinical complications [1]. Good short-term results have been reported following vertebroplasty for osteoporotic and metastatic vertebral fractures [6]. Good short-term results have been reported following kyphoplasty for osteoporotic and metastatic vertebral fractures [6]. Kyphoplasty and vertebroplasty make it possible to achieve good early results in the treatment of fresh dislocated thoracic and lumbar vertebral compression fractures [8]. Vertebroplasty prevents the progression of kyphosis more effectively than conservative treatment [12]. Vertebroplasty prevents the progression of spinal deformity more effectively than conservative treatment [12]. The use of vertebroplasty with cement to treat multiple-level osteoporotic spinal compression fractures in the elderly brings good results to patients [14].

Both early and delayed operations of kyphoplasty achieve satisfactory clinical outcomes for osteoporotic vertebral compression fractures [4]. Both early and delayed operations of kyphoplasty achieve satisfactory radiographic outcomes for osteoporotic vertebral compression fractures [4]. Percutaneous kyphoplasty achieves significant vertebral height restoration for very severe osteoporotic vertebral compression fractures with spinal canal compromise [17]. Percutaneous kyphoplasty achieves significant kyphotic angle reduction for very severe osteoporotic vertebral compression fractures with spinal canal compromise [17]. Percutaneous kyphoplasty leads to significant pain relief for very severe osteoporotic vertebral compression fractures with spinal canal compromise [17]. Percutaneous kyphoplasty leads to improvement in function for very severe osteoporotic vertebral compression fractures with spinal canal compromise [17]. Short-segment cement-augmented pedicle screw fixation combined with vertebroplasty provides significant correction of spinal kyphosis for stage III Kummell’s disease [116]. Short-segment cement-augmented pedicle screw fixation combined with vertebroplasty provides restoration of vertebral height for stage III Kummell’s disease [116]. Short-segment cement-augmented pedicle screw fixation combined with vertebroplasty provides improvement in neurological function for stage III Kummell’s disease [116]. Short-segment cement-augmented pedicle screw fixation combined with vertebroplasty provides maintenance of long-term spinal stability for stage III Kummell’s disease [116].

Cement leakage is more common in metastatic disease than in osteoporotic disease [3]. A fracture at T12 has occurred following vertebroplasty at L1 [20]. A fracture at T12 has occurred following an untreated fracture at L1 [20]. Inferior-type fractures are more related to the development of radiculopathy after kyphoplasty [23]. A disrupted posterior vertebral rim was found in all patients who developed delayed-onset radiculopathy after percutaneous kyphoplasty [23]. Bone fragments might have been pushed backwards by balloon inflation during percutaneous kyphoplasty, causing nerve root or spinal canal compression [23]. Recollapse of the treated vertebral body was found relatively frequently after balloon kyphoplasty in patients with rheumatoid arthritis [26]. Correction loss of local kyphotic angle was found relatively frequently after balloon kyphoplasty in patients with rheumatoid arthritis [26].

Kyphoplasty and vertebroplasty have similar short-term pain relief in osteoporotic vertebral compression fractures with intravertebral cleft [22]. Kyphoplasty and vertebroplasty have similar long-term pain relief in osteoporotic vertebral compression fractures with intravertebral cleft [22]. Kyphoplasty and vertebroplasty have similar short-term functional recovery in osteoporotic vertebral compression fractures with intravertebral cleft [22]. Kyphoplasty and vertebroplasty have similar long-term functional recovery in osteoporotic vertebral compression fractures with intravertebral cleft [22]. Kyphoplasty and vertebroplasty have similar local kyphosis correction in osteoporotic vertebral compression fractures with intravertebral cleft [22]. Kyphoplasty and vertebroplasty have similar vertebral height maintenance in osteoporotic vertebral compression fractures with intravertebral cleft [22].

The incidence rate of local kyphosis in the percutaneous vertebroplasty group was significantly lower than in the percutaneous kyphoplasty group at 3 years postoperatively [35]. The incidence rate of adjacent vertebral fracture in the percutaneous vertebroplasty group was significantly lower than in the percutaneous kyphoplasty group at 3 years postoperatively [35]. The incidence rate of vertebral recollapse in the percutaneous vertebroplasty group was significantly lower than in the percutaneous kyphoplasty group at 3 years postoperatively [35]. A directional cement delivery device in unilateral percutaneous kyphoplasty has a low incidence of kyphosis recurrence [50].

Key Evidence

  • [L4] Vertebroplasty is a faster and less costly procedure that remains useful with no detectable clinical complications. [1] (10.1016/j.otsr.2012.03.018)
  • [L5] Kyphoplasty is a popular tool for painful thoracic and lumbar compression fractures showing improved pain reduction and lower complication rates compared to standard vertebroplasty, though the absence of a sham group in available data leaves the placebo effect unaddressed. [2] (10.1186/1749-799x-6-43)
  • [L5] Complications are relatively infrequent, though cement leakage is more common with vertebroplasty and in metastatic disease, while specific indications and long-term outcomes require further refinement. [3] (10.5435/00124635-200501000-00003)
  • [L3] Both early and delayed operations of kyphoplasty can achieve satisfactory clinical and radiographic outcomes for osteoporotic VCFs. [4] (10.1016/j.injury.2012.06.008)
  • [L4] When surgical intervention is necessary, cement augmentation via kyphoplasty and via vertebroplasty remain the most common options. [5] (10.2106/jbjs.25.00201)
  • [L4] Vertebroplasty and kyphoplasty both have roles in the treatment of vertebral fractures, but differences exist in the indications for the two percutaneous techniques. [7] (10.1007/s00402-010-1083-6)
  • [L3] The minimally invasive procedures of kyphoplasty and vertebroplasty make it possible to achieve good early results in the treatment of fresh dislocated thoracic and lumbar VCF. [8] (10.1007/s00402-009-0901-1)
  • [L4] Requirements for bone cement in a kyphoplasty setting were excellently fulfilled. [9] (10.1186/s13018-019-1200-3)
  • [L4] While its use was historically limited by morbidity, video-assisted techniques and combined staged approaches are increasingly common, though vertebroplasty may limit indications for purely mechanical purposes. [10] (10.1016/j.otsr.2011.06.003)
  • [L1] The pooled results of vertebroplasty did not provide patients with a clinically important improvement in pain or function, and therefore do not support the routine use of vertebroplasty for osteoporotic vertebral fractures. [11] (10.1097/corr.0000000000000430)
  • [L3] However, vertebroplasty prevents the progression of kyphosis and spinal deformity more effectively than conservative treatment. [12] (10.1016/j.injury.2016.01.041)
  • [L1] Setting aside mostly asymptomatic leakage, the vertebroplasty technique may be considered the surgical procedure of choice. [13] (10.1016/j.otsr.2011.11.010)
  • [L4] The use of vertebroplasty with cement to treat multiple-level osteoporotic spinal compression fractures in the elderly does have value, and brings good results to patients which were previously unimaginable. [14] (10.1007/s00402-007-0426-4)
  • [L1] However, radiographic differences did not significantly influence the clinical results (no significant difference was observed in VAS scores and ODI scores between the two groups); thus, kyphoplasty and vertebroplasty are equally effective in the clinical outcomes of OVCF. [15] (10.1186/s13018-018-0952-5)
  • [L4] PKP is a safe and effective procedure for the treatment of vsOVCFs with spinal canal compromise, achieving significant vertebral height restoration and kyphotic angle reduction and leading to a significant pain relief and improvement in function. [17] (10.1186/s13018-018-0719-z)
  • [L1] The AAOS recommendations on the treatment of symptomatic osteoporotic spinal compression fractures range from Inconclusive to Strong, with a Strong recommendation against vertebroplasty and a Weak recommendation for kyphoplasty in patients not improving with nonsurgical management. [18] (10.5435/00124635-201103000-00008)
  • [L2] The most important factors for new VCFs after a percutaneous augmentation procedure are the degree of osteoporosis and resistant kyphosis. [19] (10.1007/s00402-010-1106-3)
  • [L4] A fracture at T12 has occurred both following vertebroplasty at L1 and an untreated fracture at L1. [20] (10.1016/j.injury.2009.07.038)
  • [L4] The authors recommend obtaining a vertebral body biopsy prior to every vertebral augmentation procedure. [21] (10.1016/j.injury.2007.06.019)
  • [L1] The two procedures have similar short- and long-term pain relief, functional recovery, local kyphosis correction, and vertebral height maintenance in OVCFs with IVC. [22] (10.1186/s13018-020-01938-6)
  • [L4] [23] (10.1186/s12891-022-05472-w)
  • [L5] The paper reviews conflicting evidence regarding vertebroplasty and kyphoplasty, noting that while some trials showed limited effectiveness over sham treatment, a recent meta-analysis cited strong evidence in favor of cement augmentation for symptomatic vertebral compression fractures. [24] (10.5435/jaaos-22-10-653)
  • [L2] Based on our data, we believe there is no indication for prophylactic stabilization of adjacent segments with balloon kyphoplasty. [25] (10.1097/blo.0b013e318034032c)
  • [L4] However, recollapse of the treated vertebral body was found relatively frequently alongside the correction loss of local kyphotic angle. [26] (10.1186/s12891-016-1215-4)
  • [L4] Overall, VP and BKP are generally safe procedures that provide quicker pain relief, mobility recovery and in some cases vertebral height restoration than conventional conservative medical treatment, at least in the short term. [28] (10.1007/s00198-011-1639-5)
  • [L5] The authors clarify that patients undergoing percutaneous vertebroplasty were encouraged to mobilize on the first day while conservative patients mobilized two weeks after fracture, and state that kyphoplasty cost-effectiveness was not a subject of the study. [29] (10.1016/j.injury.2016.08.023)
  • [L4] Minimally invasive management (osteosynthesis, embolization and kyphoplasty) proved able to treat both the traumatic and the tumoral L1 lesion. [32] (10.1016/j.otsr.2012.12.016)
  • [L5] Percutaneous vertebroplasty is recommended as the first-line surgical technique for older people, while balloon kyphoplasty is a second-line option, and assessment of underlying osteoporosis is crucial. [33] (10.1016/j.injury.2018.04.018)
  • [L3] The incidence rates of local kyphosis, adjacent vertebral fracture and vertebral recollapse in the PVP group were significantly lower than those in the PKP group at 3 years postoperatively. [35] (10.1186/s12891-026-10050-5)
  • [L5] [43] (10.1302/2058-5241.2.160057)
  • [L4] [44] (10.1186/s13018-025-05868-z)
  • [L3] [45] (10.1186/s12891-021-04685-9)
  • [L3] The efficacy of PVP alone was not satisfactory, and the rate of complications was high for OVCF patients with severe anterior edge compression with kyphosis. [46] (10.1186/s13018-020-1583-1)
  • [L5] The case demonstrates that serious neurological complications can occur with vertebroplasty unless careful attention is paid to technical details, including the use of appropriate imaging and cement consistency. [47] (10.2106/00004623-200107000-00014)
  • [L4] Percutaneous stabilization plus balloon kyphoplasty seems to be a safe and effective technique to manage thoraco-lumbar fractures without neurological impairment. [48] (10.1016/j.otsr.2012.06.004)
  • [L3] It has the advantages of good short- and medium-term effect, excellent bone cement distribution, and low incidence of kyphosis recurrence. [50] (10.1186/s13018-023-03506-0)
  • [L3] [52] (10.1186/s12891-023-06997-4)
  • [L1] [54] (10.1186/s13018-021-02722-w)
  • [L2] [94] (10.1007/s00402-013-1886-3)
  • [L3] Abnormal mechanical stress may contribute to this degeneration, highlighting the importance of managing stress in kyphotic deformities. [97] (10.1186/s12891-024-08157-8)
  • [L4] Correction of traumatic vertebral deformity avoids subsidence and loss of mechanical function in the superior adjacent disc. [98] (10.1016/j.otsr.2015.11.011)
  • [L3] amOVCF are an accelerated form of OVCFcs showing similar anatomical distribution and distribution pattern of OVCF in the spine. [109] (10.1186/s13018-024-05337-z)
  • [L3] Traumatic intervertebral disc injury contributes to loss of correction following thoracolumbar fractures and is closely associated with accelerated disc degeneration. [115] (10.1186/s12891-025-08759-w)
  • [L4] SCAPS fixation combined with vertebroplasty appears to be a safe and effective surgical approach for stage III KD, with significant correction of spinal kyphosis, restoration of vertebral height, improvement in neurological function, and maintenance of long-term spinal stability. [116] (10.1186/s13018-026-06723-5)
  • [L3] A reliable classification for assessing the stability of a healed vertebra was developed. [125] (10.1186/s12891-020-03386-z)
  • [L2] PKP surgery has a higher efficacy in the treatment of OVCF patients, which can reduce the incidence of pain, adverse reactions and promote the recovery of kyphotic Cobb Angle. [127] (10.1186/s12891-022-06125-8)
  • [L4] Kyphoplasty is a safe treatment modality for myeloma-related vertebral compression fractures. [130] (10.1097/01.blo.0000131642.96984.74)
  • [L5] Vertebroplasty provides quick pain relief in approximately 90% of patients with osteoporotic fractures but is associated with an increased rate of cement leak and less predictable pain relief in patients with osteolytic fractures. [131] (10.1097/01.blo.0000093841.72468.a8)
  • [L3] Thoracolumbar spine has 2-folds higher risk of OVCF than non-thoracolumbar spine. [132] (10.1186/s13018-023-04140-6)
  • [L4] Jack vertebral dilator kyphoplasty for osteoporotic vertebral compression fracture is safe, feasible, and effective and has the prospect of further broad application in the future. [134] (10.1186/s13018-016-0371-4)
  • [L4] Percutaneous kyphoplasty alone or combined with other minimally invasive strategies is safe and effective for stable fractures, while aggressive intervention is recommended for unstable fractures or severe foraminal encroachment. [139] (10.1186/s12891-024-07314-3)
  • [L4] [140] (10.1186/s13018-020-01882-5)
  • [L3] [143] (10.1016/j.otsr.2011.08.009)
  • [L4] [145] (10.1186/s13018-025-05891-0)
  • [Case_report] If a neurological deficit is found after vertebroplasty, a CT scan should be taken to confirm the pattern of cement leakage. [150] (10.1186/s12891-021-04625-7)
  • [L3] Five imaging-based predictors of vertebral recompression were identified. [152] (10.1186/s12891-025-08979-0)

See Also

References

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[22] Analysis of two minimally invasive procedures for osteoporotic vertebral compression fractures with intravertebral cleft: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01938-6

[23] Delayed-onset radiculopathy caused by a retropulsed bone fragment after percutaneous kyphoplasty: report of four cases and literature review. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05472-w

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[26] Outcome of balloon kyphoplasty for the treatment of osteoporotic vertebral compression fracture in patients with rheumatoid arthritis. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1215-4

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[35] Percutaneous vertebroplasty and percutaneous kyphoplasty for osteoporotic vertebral compression fractures: medium- and long-term evaluation of clinical outcomes and affecting factors. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-10050-5

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[45] The impact of intravertebral cleft on cement leakage in percutaneous vertebroplasty for osteoporotic vertebral compression fractures: a case-control study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04685-9

[46] Efficacy analysis of percutaneous pedicle screw fixation combined with percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures with kyphosis. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-1583-1

[47] Major Neurological Complications Following Percutaneous Vertebroplasty with Polymethylmethacrylate. The Journal of Bone and Joint Surgery-American Volume. 2001. DOI: 10.2106/00004623-200107000-00014

[48] Minimally invasive management of thoraco-lumbar fractures: Combined percutaneous fixation and balloon kyphoplasty. Orthopaedics & Traumatology: Surgery & Research. 2012. DOI: 10.1016/j.otsr.2012.06.004

[50] Comparison of a directional cement delivery device versus conventional device in unilateral percutaneous kyphoplasty for the therapy of osteoporotic thoracolumbar fracture in the elderly. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03506-0

[52] Effect of different cement distribution in bilateral and unilateral Percutaneous vertebro plasty on the clinical efficacy of vertebral compression fractures. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06997-4

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Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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