Minimally invasive vertebral augmentation for osteoporotic vertebral compression fractures

Abstract

Minimally invasive vertebral augmentation is central to the management of osteoporotic vertebral compression fractures (OVCFs) in selected patients. This evidence review summarizes current concepts in the pathogenesis, clinical evaluation, vertebroplasty, kyphoplasty, complications, long-term outcomes, and emerging technologies in OVCFs. Relevant literature from major databases was narratively reviewed, with emphasis on studies involving adult OVCFs, clinical indications, comparative outcomes, and complication prevention. Percutaneous vertebroplasty and percutaneous kyphoplasty both provide rapid pain relief and facilitate mobilization. Kyphoplasty generally offers better vertebral height restoration and kyphosis correction, whereas vertebroplasty is technically simpler, shorter, and often more suitable when procedural burden must be minimized. Current decision-making should integrate fracture acuity, degree of collapse, pain severity, comorbidity profile, and osteoporosis treatment. Recent advances in high-viscosity cement, navigation, robotics, and artificial intelligence may improve accuracy and safety. Long-term benefit depends not only on procedural success but also on comprehensive anti-osteoporosis management and careful patient selection.

Key Words: Osteoporotic vertebral compression fracture; Vertebroplasty; Kyphoplasty; Vertebral augmentation; Osteoporosis

Core Tip: Osteoporotic vertebral compression fractures are not managed by a single procedure-centered algorithm. Percutaneous vertebroplasty is often favored when rapid, lower-burden stabilization is needed, whereas percutaneous kyphoplasty is more attractive when vertebral collapse or kyphotic deformity is substantial. The best outcomes depend on matching the procedure to fracture acuity, collapse severity, symptoms, comorbidity burden, and ongoing osteoporosis treatment.

INTRODUCTION

Osteoporotic vertebral compression fractures (OVCFs) are among the most common fragility fractures in older adults and are associated with persistent pain, spinal deformity, loss of mobility, and reduced quality of life[1-3]. In severe cases, they may also contribute to frailty-related decline and increased long-term mortality[1,4].

Conservative treatment, including analgesia, bracing, rehabilitation, and activity modification, remains the initial option for many patients, particularly those with tolerable symptoms or limited radiographic progression[5,6]. However, prolonged immobilization may worsen deconditioning and increase the risks of thromboembolism, pneumonia, muscle atrophy, and further functional deterioration[1,5,7].

Over the past three decades, minimally invasive vertebral augmentation has changed the therapeutic landscape. Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) can stabilize the fractured vertebra, rapidly relieve pain, and facilitate earlier mobilization in appropriately selected patients[3,8-12]. However, important clinical questions remain regarding procedure selection, the role of augmentation vs conservative care, prevention of cement-related complications, and the need for structured osteoporosis treatment after the procedure[13-16].

This review summarizes current evidence on the pathogenesis, clinical evaluation, vertebral augmentation techniques, patient selection, outcomes, complications, and future directions of OVCFs, with particular attention to issues raised in routine clinical decision-making (Figures 1 and 2).

Figure 1  Pathogenesis and clinical management pathway of osteoporotic vertebral compression fractures.

Figure 2  Overview of minimally invasive vertebral augmentation techniques for osteoporotic vertebral compression fractures.

LITERATURE SEARCH STRATEGY

This article is an evidence review rather than a formal systematic review. Relevant literature was retrieved through narrative searches of PubMed, EMBASE, and Web of Science using combinations of terms related to OVCFs, vertebroplasty, kyphoplasty, vertebral augmentation, conservative treatment, complications, navigation, robotics, biomaterials, and artificial intelligence.

Studies were considered eligible when they addressed adult patients with OVCFs and provided information on pathophysiology, imaging evaluation, treatment indications, comparative efficacy, complication prevention, or emerging technologies. Priority was given to clinical guidelines, systematic reviews, meta-analyses, randomized trials, and large observational studies.

Studies focusing primarily on traumatic, neoplastic, or infectious vertebral fractures, and purely technical descriptions without clinically relevant outcome data, or duplicate datasets were not emphasized. Reference lists of key articles were also reviewed to identify additional relevant publications.

PATHOGENESIS AND CLINICAL EVALUATION

Pathogenesis

OVCF develops via the interaction of reduced bone strength and relatively low mechanical stress[1,2]. Age-related bone loss, postmenopausal estrogen deficiency, impaired bone remodeling, and deterioration of trabecular microarchitecture progressively reduce vertebral load-bearing capacity[1,2]. Under these conditions, minor daily stresses such as coughing, bending, or a low-impact fall may precipitate vertebral collapse[1,17]. Secondary contributors, including long-term glucocorticoid exposure, endocrine disorders, malnutrition, smoking, and physical inactivity, further accelerate skeletal fragility[1,2]. As many OVCFs occur without obvious trauma, early recognition of high-risk patients remains important.

Clinical classification and imaging evaluation

Treatment selection requires integration of fracture morphology, fracture acuity, symptom severity, neurologic status, spinal alignment, and baseline functional status[14,18,19]. The Genant semiquantitative classification remains a practical method for grading vertebral compression severity according to height loss: Mild, moderate, and severe[20]. Magnetic resonance imaging is particularly useful when fracture acuity is uncertain, as marrow edema can help distinguish acute or subacute lesions from chronic deformities and alternative diagnoses[19]. Computed tomography is helpful when posterior wall involvement or cortical disruption raises concern for cement leakage risk during augmentation.

MINIMALLY INVASIVE VERTEBRAL AUGMENTATION TECHNIQUES

PVP

PVP consists of percutaneous injection of polymethylmethacrylate cement into the fractured vertebral body under fluoroscopic or computed tomography guidance[9,17]. Pain relief is thought to result from stabilization of microfractures, increased vertebral stiffness, and thermal or chemical effects on intraosseous nociceptors[8,9,17]. PVP is technically straightforward, usually requires a shorter operative time, and may be especially attractive in frail older patients, those with substantial medical comorbidity, or those in whom minimizing anesthesia time and procedural burden is a priority[7,12]. It is generally most suitable when the primary goal is pain control and stabilization rather than meaningful restoration of vertebral height. PVP may also be reasonable in patients with acute or subacute symptomatic fractures without major kyphotic deformity or marked vertebral body collapse. By contrast, in mild and stable fractures with improving pain, optimized conservative treatment may still be preferred as first-line management.

PKP

PKP was developed to address some limitations of vertebroplasty. A balloon tamp is introduced into the vertebral body to create a cavity and partially restore vertebral height before cement injection[8,10,21]. This maneuver may improve sagittal alignment and reduce kyphotic deformity. Compared with PVP, PKP is generally associated with lower-pressure injection, better restoration of vertebral height, and better correction of local kyphosis, although it is more expensive and may prolong operative time[8,10,21,22]. Accordingly, PKP is often favored in acute or subacute fractures with more substantial collapse, progressive wedge deformity, or clinically relevant sagittal imbalance. PKP may be less compelling in chronic, mechanically stable fractures with limited edema on magnetic resonance imaging, in patients whose symptoms are already controlled, or in patients for whom the added procedural complexity is unlikely to translate into meaningful functional benefit. The major differences between PVP and PKP are summarized in Table 1.

Table 1 Comparison of percutaneous vertebroplasty and percutaneous kyphoplasty.

Parameter	Percutaneous vertebroplasty	Percutaneous kyphoplasty
Main principle	Direct cement injection	Balloon-assisted cavity creation followed by cement filling
Operative burden	Lower	Higher
Height restoration	Limited	Better
Kyphosis correction	Limited	Better
Leakage control	Depends heavily on injection control	Potential advantage as injection usually involves lower pressure
Typical clinical use	Rapid stabilization in frail patients or those with less deformity	Acute/subacute fracture with greater collapse or deformity
Cost	Lower	Higher

Emerging augmentation techniques

Additional augmentation strategies continue to evolve. Stent-assisted kyphoplasty aims to better preserve cavity height and structural support during cement delivery[23]. High-viscosity cement may improve handling and reduce extravasation tendency[11,16,24]. Navigation systems, robotic assistance, and digital planning tools may increase puncture precision, improve cement distribution, and reduce radiation exposure, particularly in anatomically difficult cases or revision procedures[25-29].

Clinical application and patient selection

In practice, procedure choice should be individualized rather than based on a simple hierarchy. Important determinants include fracture acuity, severity of vertebral collapse, degree of kyphotic deformity, posterior wall integrity, pain severity despite optimized conservative treatment, mobility loss, baseline frailty, anesthetic tolerance, and treatment goals. When the fracture is acute, pain is severe, and mobility is markedly reduced, then augmentation is more compelling. When symptoms are mild, stable, or improving, conservative treatment may be appropriate, especially if the fracture is chronic and deformity is limited.

CLINICAL OUTCOMES

Pain relief

Rapid pain relief remains one of the most consistent benefits of vertebral augmentation. Many studies report substantial improvement in pain scores within 24-48 hours after both PVP and PKP[8,10,12]. Improved pain control can reduce prolonged opioid use and facilitate earlier mobilization.

Functional recovery

Functional recovery is closely linked to pain reduction. By restoring the ability to sit, stand, and ambulate earlier, vertebral augmentation may reduce complications associated with prolonged bed rest, including thromboembolism, pneumonia, pressure injury, and sarcopenia[5,7]. Functional indices such as the Oswestry Disability Index generally improve after both procedures[10,21,30].

Radiological outcomes

Radiologically, PKP usually provides better vertebral height restoration and kyphosis correction than PVP[8,21,22]. These advantages may matter most in patients with substantial wedge collapse or clinically important sagittal imbalance, whereas they may be less decisive when the main objective is rapid stabilization.

Quality of life and survival

Pain reduction and earlier mobilization can translate into better sleep, mood, independence, and overall quality of life[1,2,19]. Some recent evidence also suggests an association between augmentation and lower mortality compared with prolonged conservative treatment, although causal interpretation remains difficult as observational data are susceptible to selection bias[4,6].

Long-term outcomes

Long-term outcome should not be judged only by immediate pain relief. Durable benefit depends on maintenance of mobility, prevention of subsequent fractures, control of progressive kyphosis, and continued treatment of the underlying osteoporosis. Available long-term studies suggest that many patients maintain symptomatic improvement after augmentation, but heterogeneity in study design, fracture timing, and adjuvant medical therapy makes direct comparison difficult[4,6,31,32]. Accordingly, vertebral augmentation should be viewed as one component of longitudinal fracture care rather than as a stand-alone solution.

COMPLICATIONS AND PREVENTION

Cement leakage

Cement leakage is the most common procedure-related complication and is usually asymptomatic, but symptomatic leakage may cause radicular pain, neural compression, or, rarely, pulmonary embolism[9,16,17]. Risk is increased by severe vertebral collapse, cortical disruption, posterior wall defects, low-viscosity cement, and uncontrolled injection pressure[9,16,24]. Meticulous needle placement, incremental injection, continuous imaging surveillance, and appropriate cement viscosity remain key preventive strategies[11,16,24].

Adjacent vertebral fractures

Adjacent vertebral fractures are controversial. One view is that the treated vertebra becomes relatively stiffer and alters segmental load transfer, thereby increasing stress on adjacent levels[13,33]. The opposing view is that adjacent fractures mainly reflect the natural progression of severe osteoporosis and the patient’s baseline fragility, rather than the augmentation procedure itself[2,15]. The available literature suggests that both biomechanical and disease-related factors probably contribute. For this reason, post-procedural anti-osteoporosis therapy, fall prevention, and long-term bone health management are essential rather than optional adjuncts[2,15].

Other complications

Other complications include infection, hematoma, neural injury, and thromboembolic events[17]. Careful perioperative evaluation, sterile technique, attention to coagulation status, and early mobilization remain important components of risk reduction. Common complications and preventive strategies are summarized in Table 2.

Table 2 Common complications and preventive strategies in vertebral augmentation.

Complication	Main mechanism or concern	Key preventive strategy
Cement leakage	High pressure injection, cortical disruption, posterior wall defect	Incremental injection, real-time imaging, appropriate cement viscosity, accurate needle placement
Adjacent vertebral fracture	Baseline osteoporosis with possible additional biomechanical stress	Anti-osteoporosis treatment, fall prevention, balanced correction, longitudinal follow-up
Pulmonary cement embolism	Venous migration of cement	Avoid overly early low-viscosity injection, monitor cement spread continuously
Infection	Contamination or poor perioperative control	Strict sterile technique and perioperative risk optimization
Neurological injury	Malposition or symptomatic leakage	Accurate puncture trajectory and immediate imaging assessment when symptoms occur

DISCUSSION

The role of vertebral augmentation relative to conservative care remains one of the central debates in this field. Some early sham-controlled or conservative-comparator trials questioned whether vertebroplasty provided a large advantage beyond placebo or optimized nonsurgical care[5,12]. Later trials, meta-analyses, and guideline-oriented reviews have generally suggested that augmentation is most beneficial in carefully selected patients with acute symptomatic fractures, severe pain, and inadequate response to conservative treatment[4,6]. These apparently conflicting conclusions are likely explained by differences in patient selection, fracture acuity, baseline symptom severity, timing of intervention, and outcome definitions[6,19,32]. In other words, the controversy is not simply whether augmentation works, but in whom, when, and for what treatment goal.

The comparison between PVP and PKP should be interpreted similarly. As both techniques often achieve comparable pain and disability improvement, selection is not based solely on superiority in a single endpoint. Instead, the choice usually reflects the balance between procedural simplicity, cost, vertebral height restoration, leakage risk, deformity correction, and the patient’s physiologic reserve[8,21,22]. For a very old patient with multiple comorbidities and an acute painful fracture without marked collapse, PVP may be more pragmatic. For a patient with acute symptomatic collapse, progressive wedge deformity, and a realistic need for height restoration, PKP may be more attractive.

RECENT ADVANCES AND FUTURE DIRECTIONS

Recent advances in biomaterials, navigation, robotics, and artificial intelligence are moving vertebral augmentation toward greater procedural precision and more individualized planning[25-29,34,35]. Bioactive or lower-modulus cements may reduce stress concentration, and technology-assisted targeting may improve cement distribution while limiting radiation exposure. Future work should prioritize multicenter randomized studies, standardized definitions of fracture acuity and outcome measures, long-term follow-up, and cost-effectiveness analyses so that treatment algorithms can be more consistently matched to patient subgroups. A summary of minimally invasive treatment strategies is provided in Table 3.

Table 3 Summary of minimally invasive treatments for osteoporotic vertebral compression fractures.

Technique	Principle	Advantages	Limitations	Typical indications
Percutaneous vertebroplasty	Direct polymethylmethacrylate cement injection	Rapid pain relief, shorter operative time, lower cost	Limited height restoration, leakage concern	Acute/subacute painful fracture when stabilization is prioritized and procedural burden should be minimized
Percutaneous kyphoplasty	Balloon cavity creation followed by cement filling	Better height restoration, better kyphosis correction, lower-pressure injection	Higher cost, more procedural steps	Acute/subacute fracture with substantial collapse, deformity, or need for partial height restoration
Stent-assisted kyphoplasty	Expandable stent maintains cavity	Potential structural support and resistance to recollapse	Limited evidence, higher cost	Selected severe collapse cases
Navigation- or robot-assisted augmentation	Technology-guided puncture and cement delivery	Higher accuracy, less radiation, potentially better cement distribution	Equipment cost and limited availability	Complex anatomy, difficult puncture, or revision setting

LIMITATIONS

This review has several limitations. First, it is an evidence review rather than a formal systematic review, and therefore it does not provide quantitative pooled estimates for every outcome. Second, the literature remains heterogeneous with respect to study design, fracture chronicity, imaging definitions, and outcome reporting[8,10,22]. Third, some emerging technologies have encouraging early data but remain supported mainly by limited or selectively reported clinical series[25,27-29,34].

CONCLUSION

Minimally invasive vertebral augmentation has an established role in the treatment of OVCFs, particularly in patients with severe pain, impaired mobilization, and inadequate response to conservative care. PVP and PKP should be regarded as complementary rather than mutually exclusive options. The optimal choice depends on fracture acuity, degree of collapse and deformity, symptom burden, comorbidity profile, and the need to minimize procedural burden. Long-term success further depends on comprehensive osteoporosis management and prevention of subsequent fractures. Additional high-quality comparative studies are still needed to refine indications and long-term treatment pathways.