How Percutaneous Vertebroplasty (PVP) is Performed
Percutaneous vertebroplasty is performed by injecting bone cement (polymethylmethacrylate/PMMA) through a large-bore needle into a fractured vertebral body under fluoroscopic guidance, typically using a transpedicular approach with the patient prone under local anesthesia with moderate sedation. 1
Pre-Procedure Setup and Patient Positioning
The procedure requires a suite large enough to accommodate:
- High-quality biplane fluoroscopy (advisable, particularly during cement delivery)
- Patient monitoring equipment (pulse oximetry, blood pressure)
- Cardiopulmonary resuscitation equipment
- Rapid availability of CT and/or MRI for complications 1
Patient positioning: Prone position under local anesthesia combined with moderate sedation in most cases 1. General anesthesia may be used for patients at high risk of airway/respiratory complications with prone positioning or those with significant pre-procedural narcotic requirements 1. However, keeping the patient awake is preferable as it allows real-time feedback about increasing pain or neurologic dysfunction that can alert the operator to potential complications 1.
Needle Placement Technique
Approach Selection
- Transpedicular approach is standard (unilateral or bilateral)
- The choice between unilateral vs. bilateral can be determined by preoperative CT measurements 2
- CT three-dimensional positioning can identify the optimal trajectory for passing through the lateral mass of the lamina and pedicle to reach the vertebral body 3
Needle Insertion
- A 13-gauge needle is typically used 3
- Skin entry point and puncture angles (both transverse and sagittal planes) should be determined using preoperative CT imaging software 2
- Fluoroscopic guidance directs needle placement into the fractured vertebral body 1, 4
- Pre-procedural imaging should be available in the procedure room to ensure correct vertebral levels are treated 1
Cement Injection
- PMMA (polymethylmethacrylate) bone cement is injected through the needle into the vertebral body 4, 5, 6
- Injection is performed under continuous fluoroscopic monitoring to detect cement leakage early 1
- The cement reinforces the compressed vertebral segment 5
Important caveat: CT-guided techniques may offer lower complication risk compared to conventional fluoroscopic approaches due to more precise instrument placement and earlier detection of small cement leakages 5.
Post-Procedure Care
- Patient is placed in supine position for approximately 1 hour while cement hardens 4
- Period of bed rest and observation tailored to clinical circumstances 1
- Vital signs and lower limb neurological function assessed at regular intervals 1
- Supervised ambulation after appropriate observation period 1
Critical Technical Points
Monitoring during the procedure:
- Vital signs monitoring is essential
- Pulse oximetry and blood pressure measurement during sedation delivery
- Drug delivery and monitoring by certified nursing personnel, nurse anesthetists, or anesthesiologists 1
Patient identity verification: Follow local hospital practices for confirmation of patient identity, procedure to be performed, procedural site, and consent 1
Common Pitfalls
Cement leakage is the most frequent complication—small amounts are common (72% of treated vertebrae in one study showed leaks on post-procedural CT, though most remained asymptomatic) 1. Continuous fluoroscopic monitoring during injection is critical to minimize symptomatic leakage that could cause nerve compression or pulmonary embolism 1, 4.