Preoperative planning requires radiographic studies to define fracture anatomy and assess posterior vertebral body wall deficiency (this is mandatory in tumoral lesions the often involve the vertebral wall); magnetic resonance (MR) is a must in all patient candidates for PV, as it provides both functional and anatomical information. T1-, T2-, and STIR-weighted sequences in axial and sagittal planes are required. If there is any doubt regarding the intactness of the posterior vertebral wall, a CT scan through the intended level(s) should be performed. It will also provide information regarding the location and extent of the lytic process, the visibility and degree of involvement of the pedicles, and the tumor extension or retropulsed bone fragment, which can increase the likelihood of major complications. A well-performed pre-procedural study helps to plan the procedure considering if more than one approach and multiple needles are required. When the tumoral lesion such an aggressive hemangioma (Fig. 4.3) is well identified in MR, additional CT scans can precisely evaluate the discontinuity of the cortical bone and the extension of the lesion to the vertebral posterior elements (Fig. 4.4). Digital fluoroscopy integrated with rotational acquisition and 2DMPR may allow precise positioning of three needles trough the pedicles and the spinous process in axial (Fig. 4.5) and sagittal view (Fig. 4.6). Bone cement injection is then performed under continuous digital fluoroscopy monitoring (Fig. 4.7) for early detection of possible cement leakages up to satisfactory bone lesion filling. The injection should be performed using a dedicated injection set (e.g., from Cemento-RE gun Optimed; Allegiance; Cook; Stryker; D-Fine) for a better-graduated control of the injection. Although the use of the injection sets increases the expense of the procedure, it is safer than freehand injection especially in the cervical and upper thoracic spine.

Injection of cement should be done under continuous lateral fluoroscopic control. The lateral view is preferred, as it allows for early detection of epidural leak; in such a case, the injection needs to be immediately stopped, and using the injection set, the pressure can be reversed by unscrewing the injector. Waiting for 1 min allows the cement to harden to seal the leak, changing the needle position or the bevel direction is useful to avoid further leakages, and the injection can be carried out again. If the leak still continues, the injection has to be terminated and the needle removed.

Postprocedural CT (Fig. 4.8) is always useful to evaluate the filling of the lesion and to assess the cement leakage and to detect possible complications; in our experience, postprocedural CT scan is performed in all cases of cervical and upper thoracic spine vertebral augmentation. In neoplastic lesions, we try to fill the lesion fully in order to achieve both bone consolidation and thermal-chemical necrosis; if the aim of vertebroplasty is relief of pain only, smaller volumes (1.5–3 mL) are usually sufficient.