Vertebroplasty

In vertebroplasty, a thin needle is passed into the fractured vertebral body under imaging guidance, and a small amount of medical-grade cement is injected to fill and stabilise the fracture. The cement hardens quickly, splinting the broken bone from the inside. Unlike kyphoplasty, vertebroplasty does not use a balloon to restore height first — the cement is injected directly into the fracture. The procedure is minimally invasive, usually done through a tiny skin puncture, and is aimed at reducing the pain of an unstable fracture rather than correcting deformity.

The main use of vertebroplasty is for painful osteoporotic compression fractures that are not settling with time and appropriate non-surgical care, and where the pain is clearly coming from the fracture. It can also play a role in fractures weakened by tumour. The best results appear to be in carefully selected patients — particularly those with severe pain from a relatively recent fracture. It is not a treatment for back pain in general, and patient selection is central to whether it helps.

The evidence on vertebroplasty is genuinely divided, and it would be wrong to pretend otherwise. The VAPOUR trial, which studied patients with severe pain from acute fractures, found a clear benefit over placebo. VERTOS II, an open-label trial, also favoured vertebroplasty. However, two influential sham-controlled trials published in the New England Journal of Medicine in 2009 (Buchbinder and Kallmes/INVEST), and the sham-controlled VERTOS IV trial, found no significant benefit over a placebo procedure, and a Cochrane review concluded the evidence does not support routine use for osteoporotic fractures. The most reasonable reading is that vertebroplasty is not a treatment for everyone, but may help a selected group with severe, recent fracture pain — which is exactly why careful selection and honest discussion matter.

Vertebroplasty is generally well tolerated, but no procedure is without risk. The main technical concern is cement leakage outside the vertebra, which is usually harmless but can occasionally cause problems. Because the underlying bone is weak, new fractures can occur at other levels over time, reflecting the underlying osteoporosis rather than the procedure itself. This is why treating the bone disease — with bone-health assessment and osteoporosis treatment guided by the appropriate specialists — is an essential part of the overall picture, not just the fracture in front of us.

Where vertebroplasty is being considered, the decision is based on the type and age of the fracture, the severity of pain, the imaging, and how things are responding to non-surgical care. The procedure, its realistic benefits and its limitations are discussed honestly and individually, alongside alternatives such as kyphoplasty and continued non-surgical management. Attention to bone health runs alongside any decision about the fracture itself.

• —Clark W, et al. Vertebroplasty for acute painful osteoporotic fractures (VAPOUR): a randomised, double-blind, placebo-controlled trial. Lancet 2016. (PMID 27544377)
• —Buchbinder R, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 2009. (PMID 19657121)
• —Kallmes DF, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures (INVEST). N Engl J Med 2009. (PMID 19657122)
• —Klazen CAH, et al. Vertebroplasty versus conservative treatment (VERTOS II): open-label randomised trial. Lancet 2010. (PMID 20701962)
• —Firanescu CE, et al. Vertebroplasty versus sham for acute osteoporotic vertebral fractures (VERTOS IV): randomised sham-controlled trial. BMJ 2018. (PMID 29743284)
• —Buchbinder R, et al. Percutaneous vertebroplasty for osteoporotic vertebral compression fracture. Cochrane Database Syst Rev 2018. (PMID 29618171)