The patient should be positioned prone or oblique prone for thoracic and lumbar procedures. Proper cushion support under the upper chest and lower abdomen maximizes extension promoting kyphosis reduction [24]. The patient’s arms should be placed toward the head to ensure that they are not in the path of the fluoroscope. The majority of vertebroplasty and kyphoplasty can be performed with moderate conscious sedation and local analgesia; in some cases, general anesthesia is required to provide adequate comfort and safety. In all cases, continuous ECG, blood pressure, and pulse oximetry monitoring should be performed in conjunction with certified nursing personnel, nurse anesthetists, or anesthesiologists. Use standard operating-room guidelines for sterile preparation of the skin, draping, operator scrub, and sterile gowns, masks, and gloves, as well as intravenous antibiotic prophylaxis prior to skin incision.

Most often vertebroplasty and kyphoplasty are performed with fluoroscopic guidance. Have a clear understanding of the affected level and appropriate bony landmarks prior to skin incision. Use of biplane fluoroscopy reduces procedure time, and the image dose may be increased if required to help identify bony landmarks in markedly osteopenic patients. The needle may be placed via a transpedicular or parapedicular approach. The transpedicular approach passes through the posterior surface of the pedicle, via the length of the pedicle, and into the vertebral body. This long intraosseous path protects adjacent soft tissues including neural and vascular structures. However, this approach can limit the ability to achieve a midline needle tip position. The alternate parapedicular approach penetrates the pedicle along its path that permits a more central tip placement, facilitating unilateral treatment (Fig. 20.2).

The needle trajectory must be kept lateral to the medial cortex and superior to the inferior cortex of the pedicle (Fig. 20.3). This prevents entry into the spinal canal or the neural foramen. Once the needle has traversed the pedicle, it can be advanced to the anterior aspect of the vertebral body. If a curved vertebroplasty needle is used, different areas of the vertebral body can be targeted (Fig. 20.4). Once in position the needle stylet is removed, and the cannula filled with saline to prevent pressurized injection of air and secondary embolus. Subsequently, cement can be injected through the percutaneous cannula into the bone. For kyphoplasty, after initial positioning the cannula is pulled back slightly into the posterior aspect of the vertebral body to create room to allow for the insertion and inflation of a balloon tamp. The tamp creates a cavity into which cement is injected (Fig. 20.5). The long flexible cement delivery systems minimize radiation exposure to the operator [25]. Careful fluoroscopic monitoring is performed during cement injection. Any extra-osseous cement extravasation should be avoided; in particular posterior or posterolateral leakage could result in irritation or injury to the spinal cord or nerve roots. The optimal volume of cement remains a matter of controversy. Small volumes of cement continue to result in good clinical outcomes after vertebroplasty [26]. Attempting to place a large volume of cement may in turn lead to higher rates of extra-osseous leakage and symptomatic complications; similarly cement fill in the posterior third of the vertebral body close to the basivertebral vein is best avoided. The needle may be reinserted to deliver the final portion of cement, and after allowing the cement to harden, the needle and cannula are removed with a gentle rocking motion to prevent cement migrating along the needle tract.

Afterward, the patient should have a period of observation of vital signs and lower limb neurological function as well as bed rest (for example 2 h). This also allows the cement to fully harden and integrate before axial load of the spine. Most patients can be discharged later on the same day. Any clinical deterioration suspicious for local cement leakage should prompt cross-sectional imaging with CT and/or MRI. Systemic or cardiorespiratory deterioration is suspicious for cement or fat pulmonary embolism, and should prompt chest imaging.

Post-procedure follow-up should reassess previously recorded pain and disability scale scores. These procedures should be performed within a quality improvement program where the clinical effectiveness and safety can be examined. Rates of all major permanent complications should be <2 %, including in neoplasm-related fractures [27]. Greater than 1 % permanent neurological deficit rate for osteoporotic fractures and 5 % for neoplasm-related fractures should prompt additional review of practice [27].