Vertebral compression fractures (VCFs) are associated with severe pain even with only minimal movement. In severe cases, pain from a VCF can be debilitating, leaving patients bedridden. The annual incidence of vertebral compression fractures has been reported to be 1.21% in women and 0.68% in men in those 50–79 years old, worsening with age and in women of all age groups [1]. When a VCF is identified, conservative management of pain is first attempted with medication, support braces, and in some cases gentle physical therapy. A normal course for a noncomplicated, stable vertebral compression fracture is gradual decrease of pain with healing of the fracture within 3 months. When pain is debilitating, functional capacity decreases, or when initial conservative measures are ineffective, interventional treatments such as vertebral augmentation procedures are involved earlier after the diagnosis.

The first percutaneous vertebroplasty was performed in France in 1984. The procedure has been improved since then. Although an excellent technique to treat VCF, vertebroplasty has been associated with several complications: adjacent-level fracture, pulmonary embolism, cement leak, systemic toxicity, infection, CSF leak, and epidural hematoma [2]. Recently, the advent of kyphoplasty has decreased the incidence of some of these complications such as cement extravasation [3].

With regard to technique, vertebroplasty and kyphoplasty are similar with a few notable exceptions. During vertebroplasty , fluoroscopic guidance is used to advance a needle into the cancellous bone of a vertebra to inject cement at the site of a fracture. In kyphoplasty, the needle is guided with the same technique, but a balloon is inflated in the vertebral body before injecting cement. Inflation is thought to compress the bone and create a cavity for injecting the cement under low pressure to minimize extravasation [4]. If the working kyphoplasty cannula and balloon are close to a compromised wall of a vertebra, an “egg shell technique” recreates the defected wall. Details of this technique are described later in this chapter.

Currently, polymethylmethacrylate (PMMA) is widely accepted as the standard cement type for both kyphoplasty and vertebroplasty. In some studies that have compared PMMA with calcium phosphate cement (CPC), loss of correction at 6 weeks was found on radiographic images in CPC compared to PMMA. CPC may have lower resistance to flexing, tractive, and sheer forces than PMMA. In burst fractures, CPC had a higher risk of cement failure, and patients’ pain scores approached preoperative levels after 1 year. With PMMA pain levels were lessened 1 year post-procedure [5]. Other studies argue that CPC is equally safe and effective, but because there is no literature to date proving its superiority to PMMA, PMMA remains the standard cement used [6].

Kyphoplasty also may have the added benefit of correcting prevalent kyphosis. A VCF follows an increase of anterior column load in response to hyperflexion forces that ultimately contribute to the progressing kyphosis often present in VCFs. With the added benefit of “fracture reduction” and kyphosis correction, kyphoplasty may offer an advantage over vertebroplasty in select cases [7]. Thus far, kyphoplasty has been successfully utilized by practitioners in thousands of patients who have improvement in short-term pain, quality of life, and function [8]. Improvements in pulmonary function also have been noted with respect to forced vital capacity and maximum voluntary ventilation [9]. Based on a comparison of transcortical and vascular extravasation of contrast, the risk of cement extravasation is lower with kyphoplasty than with vertebroplasty [3].

The two most common causes of vertebral compression fractures are osteoporosis and malignancy. Symptoms are almost indistinguishable between the two forms, but they differ depending on a patient’s medical history. A diagnosis of either osteoporosis or cancer is helpful in determining the type of fracture. Risk factors for osteoporotic fractures include alcohol or tobacco use, early menopause, dementia, frailty, and vitamin D deficiency [10]. Osteoporotic fracture is by far the more common of the two, often presenting after trivial events such as lifting objects, a vigorous sneeze, or turning in bed especially in cases of severe disease [11]. In moderate osteoporosis, trauma after falling off a chair or tripping can precipitate fracture. For patients younger than age 55, undiagnosed malignancy also should be considered [11]. During a vertebral augmentation procedure, the diagnosis is confirmed with an intraoperative bone biopsy. MRI distinguishes an osteoporotic from a malignant compression fracture. Studies of imaging have reported 100% sensitivity and 93% specificity for diagnosing metastatic compression fractures [12]. Lesions on the convex posterior border of vertebral bodies, abnormal signal intensity of the pedicle of the posterior element, epidural extension, encasing epidural mass, focal paraspinal mass, and other spinal metastases suggest a metastatic compression fracture.

Low signal intensity band on T1- and T2-weighted images, spared normal bone marrow signal intensity of vertebral body, retropulsion of posterior bone fragment, and multiple compression fractures suggest an osteoporotic compression fracture [12]. Adding axial diffusion-weighted imaging to standard spine MRI improves diagnostic accuracy in osteoporotic and malignant compression fractures [13]. For patients with osteoporotic VCF, the risk factors for developing more fractures are smoking, female gender, and history of treated or untreated VCF [14]. Indications for treatment of both types of fractures are pain refractory to conservative measures, but some patients with malignant fractures may have a better prognosis with radiation therapy.