Percutaneous vertebroplasty is a needle procedure in which bone cement is injected into a fractured vertebral body. It goes in through a small skin puncture, guided by live X-ray, to stabilize a painful vertebral compression fracture. It is also one of the most disputed procedures in spine care. Several strong placebo-controlled trials found no real advantage over a sham procedure. A later trial limited to very recent, severely painful fractures did find one.
What a vertebral compression fracture is
A vertebral body is the squat, load-bearing block at the front of each spinal segment. When bone density falls far enough, that block can fail under everyday loads. Bending to lift a bag. A hard sneeze. Stepping off a curb. The front collapses while the back stays closer to its first height. That makes the wedge shape seen on a side-view X-ray.
The Rochester, Minnesota population study looked at clinically diagnosed vertebral fractures. Adjusted for age and sex, the rate was 117 per 100,000 person-years. It was about twice as high in women as in men. And 83% of those fractures followed moderate or no trauma.1 A fracture without a fall is a signal about bone quality. Many compression fractures are never diagnosed at all, because they hurt for a few weeks and then stop. That matters a great deal when reading the treatment studies.
What the procedure actually involves
Vertebroplasty is not open surgery, even though people often say “vertebroplasty surgery”. Nothing is cut open, no bone is removed, and no hardware is implanted.
The patient lies face down. The skin and the periosteum — the sensitive lining of the bone — are numbed with local anesthetic. Practice on sedation varies between centers: some perform the procedure on local anesthetic alone, while others add light intravenous sedation, as the VAPOUR trial did.5 Under fluoroscopy (live X-ray imaging), a wide needle is pushed through the pedicle. The pedicle is the bony bridge that joins the back of the vertebra to the body at the front. The needle goes until the tip sits inside the fractured vertebral body. Some doctors use one pedicle, others both. Some centers add CT guidance.
Polymethylmethacrylate (PMMA) bone cement is then mixed. It is thick enough that it will not run. It is made to show up on X-ray. It is injected slowly while the doctor watches it spread. Above all, the doctor watches for cement going where it should not. That means the spinal canal, the disc space, or a vein. If it starts to, the injection stops.
The cement hardens in a few minutes. It does not restore the vertebra’s first height. It fills the broken bone and splints it from the inside.
What recovery looks like
Most patients lie flat for a short watch period, often a couple of hours. Then they go home the same day. The logic of recovery is simple. There is no cut to heal and no implanted hardware to protect. The cement is already at full strength before the patient leaves. What limits activity afterward is the fracture and the underlying bone, not the procedure.
Soreness where the needle went in is common for a few days. It is separate from the fracture pain the procedure was meant to treat. Whether pain relief comes at all, and how fast, is the disputed question the trials below test. The recovery timeline does not settle it.
How vertebroplasty differs from kyphoplasty
Kyphoplasty adds a step. Before cement goes in, a balloon is inflated inside the vertebral body. It packs down the spongy inner bone and makes a cavity. Then the balloon comes out, and cement is injected into that cavity at lower pressure. There are two reasons. One is to partly restore the vertebra’s height. The other is to cut leakage by filling a ready-made space rather than forcing cement through intact bone.
A meta-analysis of 16 comparative studies found kyphoplasty did three things better than vertebroplasty. It reduced the forward wedge angle. It increased vertebral body height after the procedure. And it lowered the risk of cement leakage (relative risk 0.62, 95% CI 0.47–0.80). But it produced no significant difference in pain or Oswestry Disability Index scores.9 The X-ray pictures differ. In that analysis, the outcomes patients reported did not.
What the evidence actually shows
In 2009 two placebo-controlled trials appeared in the same issue of the New England Journal of Medicine, and they reshaped the field.
Buchbinder and colleagues randomized 78 people to vertebroplasty or a sham procedure. Each had one or two painful osteoporotic fractures under 12 months old, confirmed unhealed on MRI. Vertebroplasty produced no significant advantage on any outcome at any time point out to six months. Pain fell a lot in both groups. At three months the adjusted gap between groups was 0.6 points on a 0–10 scale (95% CI −0.7 to 1.8).2
The INVEST trial, led by Kallmes, randomized 131 patients with one to three painful fractures. They got vertebroplasty or a fake procedure without cement. At one month there was no significant difference in disability (0.7 points on the Roland-Morris scale, P=0.49) or pain (0.7 points, P=0.19). Both groups improved right away. By three months, 51% of the control group had crossed over to vertebroplasty versus 13% of the treatment group3 . That signal fits neither side’s argument neatly.
VERTOS IV, published in 2018, randomized 180 patients with acute osteoporotic fractures to vertebroplasty or a sham procedure. It followed them for 12 months. Mean pain fell significantly in both groups at every follow-up point. The difference between groups was never statistically significant. Painkiller use dropped equally in both.6
The 2018 Cochrane review pooled 21 trials. Against placebo, it found high- to moderate-quality evidence of no clinically important benefit. Mean pain was 5 points in the placebo group and 0.7 points better with vertebroplasty (95% CI 0.3 to 1.2). That is an absolute drop of 7%. The smallest change a patient would notice is 15%. The interval excludes zero, so a small average difference was detectable. But it sits well below the point where a patient would notice. Effects did not differ between acute and subacute pain. The review also concluded that open trials comparing vertebroplasty with usual care likely overestimated benefit.7
The counter-evidence, and why timing may matter
VERTOS II, an open-label trial, compared vertebroplasty with conservative treatment in fractures under six weeks old. It found a large edge at one month and one year.4 Because it was unblinded, it carries exactly the bias Cochrane flagged. But one of its numbers stands no matter the blinding. Of 431 patients screened as eligible, 229 — 53% — got pain relief on their own during the screening period. They never entered the trial. More than half got better on their own, without any procedure.
VAPOUR tested vertebroplasty in the patients most likely to benefit. It enrolled 120 patients with osteoporotic fractures less than six weeks old. All had severe pain (7 or higher out of 10 on a number scale). They were randomized to vertebroplasty or a masked placebo procedure. The trial used a deliberate high-volume fill technique. At 14 days, 44% of the vertebroplasty group had pain below 4 out of 10, versus 21% of the placebo group. That is a gap of 23 percentage points (95% CI 6–39; p=0.011).5
A later subgroup analysis suggested the effect was concentrated in fractures under three weeks old. In that group, 51% versus 20% reached mild pain at 14 days.8 That is exploratory and only raises a hypothesis. It is not established. But it is the honest explanation of why VAPOUR differed from earlier trials. Those trials enrolled fractures mostly older than the window VAPOUR targeted.
Put plainly: the evidence does not support vertebroplasty as a routine treatment for compression fracture pain. It leaves open a narrower question. Do patients with a very recent fracture and severe, poorly controlled pain benefit? There, one good trial says yes.
Who is considered a candidate
These features recur across the trials that found benefit. An osteoporotic vertebral compression fracture. Recent onset (weeks, not months). Severe pain that has not responded to care without a procedure. MRI evidence that the fracture is unhealed and is the level causing the pain. And pain that is set off when the doctor presses over that segment.
The trial evidence argues against the procedure when the fracture is already healing. It also argues against it when imaging does not match where the patient hurts. Apart from that, active infection and uncorrected bleeding disorders are reasons not to put a needle into bone at all. Fractures from tumor, myeloma, or trauma are a different clinical problem.
Vertebroplasty treats a mechanical problem in one bone. It does nothing about the disease that broke the bone. Any patient having this procedure for an osteoporotic fracture needs a treatment plan for the osteoporosis itself, running alongside it. Without that, the next fracture is simply waiting.
Risks and honest expectations
Cement leakage is the typical complication. Most leaks show on imaging and cause no symptoms. The ones that matter go into the spinal canal or the veins. Serious adverse events reported in the trials Cochrane included were osteomyelitis (bone infection), cord compression, thecal sac injury, and respiratory failure. These events were few. So the review could not tell whether vertebroplasty meaningfully raises the risk of new symptomatic vertebral fractures (relative risk 1.29, 95% CI 0.46 to 3.62). It also could not tell for other serious adverse events.7 VERTOS IV reported two adverse events in its vertebroplasty arm: one respiratory insufficiency, one vasovagal reaction (a fainting response).6
No honest account of this procedure promises a cure or a set success rate. In the trial that found the largest benefit, fewer than half the treated patients reached mild pain at two weeks.5 Pain also improves a lot without any procedure. That happened in every placebo arm above. The real question is whether waiting is bearable, not whether the procedure is the only path.
If you are in the St. Louis area
Padda Institute evaluates vertebral compression fractures at its offices in St. Louis and Natural Bridge Road. For local detail on evaluation, imaging, and scheduling, see the vertebroplasty for compression fractures page or the kyphoplasty page.
Frequently asked questions
Is vertebroplasty considered surgery?
No. It is done through a needle under X-ray guidance with local anesthetic. There is no incision, no bone removal, and no implanted hardware. It belongs with image-guided interventional procedures, not open spine surgery, like most options listed under pain treatments.
How long does the pain relief last?
The trials measured outcomes out to six and twelve months, so anything beyond that is not established. When relief does come, it comes from stabilizing that one fractured bone. Nothing in the procedure prevents the next fracture at another level. That is why osteoporosis treatment has to run alongside it. See the vertebroplasty page for how that evaluation is structured.
Should I choose vertebroplasty or kyphoplasty?
Comparative data show kyphoplasty restores more vertebral height and leaks less cement. But it has not been shown to produce better pain or function scores. The choice usually turns on the fracture’s shape and how much height was lost. The kyphoplasty page describes where the balloon step is worth adding.
What happens if I do nothing?
A large share of acute vertebral compression fractures settle on their own. In VERTOS II, 53% of screened patients improved on their own before randomization. Skipping a procedure is a valid option, especially when pain is controllable. See Dr. Gurpreet Singh Padda, MD, MBA, MHP on how treatment decisions are framed.
Why do some doctors say vertebroplasty does not work?
Because several well-designed placebo-controlled trials, and the Cochrane review pooling them, found no clinically important benefit over a sham procedure. That position is based on evidence, not dismissive. The other side rests mainly on VAPOUR, which studied a narrower group. Both readings can be held honestly. Bring the question to your evaluation, starting at the contact page.
What if my pain is not from the fracture?
This is the most common reason vertebroplasty fails to help. Back pain in older adults often comes from facet joints, discs, the sacroiliac joint, or squeezed nerve roots. An old fracture seen on imaging may be a bystander, not the source of the pain. Each of those points to a different treatment. Targeted joint or nerve procedures fit the first three. For a smaller group with lasting nerve-related pain, there are options such as spinal cord stimulation.
Sources
- Cooper C, Atkinson EJ, O’Fallon WM, Melton LJ. Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985-1989. J Bone Miner Res. 1992. PMID 1570766
- Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009. PMID 19657121
- Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med. 2009. PMID 19657122
- Klazen CAH, Lohle PNM, de Vries J, et al. Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial. Lancet. 2010. PMID 20701962
- Clark W, Bird P, Gonski P, et al. Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet. 2016. PMID 27544377
- Firanescu CE, de Vries J, Lodder P, et al. Vertebroplasty versus sham procedure for painful acute osteoporotic vertebral compression fractures (VERTOS IV): randomised sham controlled clinical trial. BMJ. 2018. PMID 29743284
- Buchbinder R, Johnston RV, Rischin KJ, et al. Percutaneous vertebroplasty for osteoporotic vertebral compression fracture. Cochrane Database Syst Rev. 2018. PMID 30399208
- Diamond T, Clark W, Bird P, et al. Early vertebroplasty within 3 weeks of fracture for acute painful vertebral osteoporotic fractures: subgroup analysis of the VAPOUR trial and review of the literature. Eur Spine J. 2020. PMID 32170438
- Wang B, Zhao CP, Song LX, Zhu L. Balloon kyphoplasty versus percutaneous vertebroplasty for osteoporotic vertebral compression fracture: a meta-analysis and systematic review. J Orthop Surg Res. 2018. PMID 30348192
Dr. Gurpreet Singh Padda, MD, MBA, MHP
