The safety and the efficacy of those techniques are well established by several studies and trials [14–18], analyzing the outcome of technique about pain’s reduction and kyphosis correction and complications, such as cement leakage, disk leakage, pulmonary embolism, and new vertebral fractures at adjacent or distant vertebral body.

The Fracture Reduction Evaluation (FREE) [19] multicenter randomized controlled trial compared the efficacy and safety of balloon kyphoplasty (149 patients for BKP-group) to nonsurgical management (151 patients for NSM group) over 24 months in patients with painful vertebral compression fractures (VCF). Compared with NSM, the BKP group had greater improvements in SF-36 physical component summary (PCS) scores at 1 month (5.35 points; 95% CI, 3.41–7.30; P < 0.0001) and when averaged across the 24 months (overall treatment effect 2.71 points; 95% CI, 1.34–4.09; P = 0.0001). The BKP group also had greater functionality by assessing timed up and go (overall treatment effect—2.49 s; 95% CI, −0.82 to −4.15; P = 0.0036). At 24 months, the change in index fracture kyphotic angulation was statistically significantly improved in the kyphoplasty group (average 3.13° of correction for kyphoplasty compared with 0.82° in the control, P = 0.003). Number of baseline prevalent fractures (P = 0.0003) and treatment assignment (P = 0.004) are the most predictive variables for PCS improvement; however, in patients who underwent BKP, there may also be a link with kyphotic angulation. In BKP, the highest quart for kyphotic angulation correction had higher PCS improvement (13.4 points) than the quart having lowest correction of angulation (7.40 points, P = 0.0146 for difference). The most common adverse events temporally related to surgery (i.e., within 30 days) were back pain (20 BKP, 11 NSM), new VCF (11 BKP, 7 NSM), nausea/vomiting (12 BKP, 4 NSM), and urinary tract infection (10 BKP, 3 NSM).

The Cancer Patient Fracture Evaluation (CAFE) study [20], a multicenter randomized controlled trial, compared balloon kyphoplasty (70 patients) versus nonsurgical fracture management (64 patients) for treatment of painful VCFs in patients with spine metastasis and one to three painful VCFs. The primary endpoint was back-specific functional status measured by the Roland-Morris Disability Questionnaire (RDQ) score at 1 month. The mean RDQ score in the kyphoplasty group changed from 17.6 at baseline to 9.1 at 1 month (mean change −8.3 points, 95% CI −6.4 to −10.2; P < 0.0001). The mean score in the control group changed from 18.2 to 18.0 (mean change 0.1 points; 95% CI −0.8 to 1.0; P = 0.83). At 1 month, the kyphoplasty treatment effect for RDQ was −8.4 points (95% CI −7.6 to −9.2; P < 0.0001). The most common adverse events within the first month were back pain (4 of 70 in the BK group and 5 of 64 in the control group) and symptomatic vertebral fracture (2 and 3, respectively). This trial showed that BK is an effective and safe treatment that rapidly reduces pain and improves function.

Eight nonrandomized trials of 422 patients and 1 randomized trial of 100 patients compared VP and KP [21]. In all eight studies, VP and KP reduced pain and improved QOL to a similar extent. Only one nonrandomized study suggested that KP is superior at relieving pain and improving QOL, with differences maintained over 1-year follow-up. KP was more effective at reducing the kyphotic wedge and increasing vertebral height. The largest meta-analysis available concluded that BKP decreased pain to a greater degree than VP (5.07 vs. 4.55 points on the VAS) and resulted in significantly better improvement in quality of life than both VP and NSM [21]. This meta-analysis includes all the level I data available on vertebral augmentation, and given this large amount of high-quality data, it is our contention that there is more than adequate information upon which to base treatment decisions. Both procedures are safe, with no reported complications [7].

The risk of cement leakage is certainly lower with AT, thanks to low-pressure condition of cement injection versus VP, while the incidence of new vertebral fractured to adjacent or distant metamer is the same, mostly related to the porotic disease itself [7, 22].

Many studies suggested that AT produces a greater improvement in daily activity, physical function, and pain relief when compared to optimal medical management for osteoporotic VCFs by 6 months after intervention, while there is poor-quality evidence that AT results in greater pain relief for tumor-associated VCFs [23].

No significant difference is demonstrated between VP and KP in short- and long-term pain and disability, complications, and anatomic outcomes [24].

KP and VP are both safe and effective surgical procedures in treating osteoporotic VCF. KP has a similar long-term pain relief, function outcome, and new adjacent VCFs in comparison to VP. KP is superior to VP for the injected cement volume, the short-term pain relief, the improvement of short- and long-term kyphotic angle, and lower cement leakage rate. However, KP has a longer operation time and higher material cost than VP [25].

For traumatic patient, treated by AT, generally pain relief is achieved in the 90–95% of patients affected by A1 and A3 Magerl vertebral fractures, treated within 3 months from the trauma, depending on the type of fracture, and an increase in vertebral body height sufficient to allow early mobilization of the patient and restoration of the physiological distribution of postural forces avoiding bed rest and orthosis devices [7].