Planning

• Localize the painful level in a patient with multiple compression fractures.
  
• Point tenderness on physical exam can be an important localizing sign
  
• Magnetic resonance imaging (MRI) demonstrates vertebral body edema related to acute/subacute unhealed fractures, provides evaluation of the spinal canal and cord, and helps address other causal pathologies of pain.
  
• In patients who cannot undergo MRI (e.g., those with a pacemaker), bone scan allows for the differentiation of healed and unhealed fractures and suggests the diagnosis of metastatic disease.
  
• Computed tomography (CT) is the test of choice for evaluation of the integrity of the posterior vertebral body cortex and can be very helpful in patients with cancer-related compression fractures.

Special Equipment

• Vertebroplasty or kyphoplasty kit: hammer, needle holder, needles, cannulas, inflatable balloon tamps (for kyphoplasty), cement injector system, polymethylmethacrylate cement

Operating Room Set-up

• Fluoroscopy suite with fluoroscopy table: preferably a biplane fluoroscopy unit, although may be performed with single-plane fluoroscopy or CT imaging
  
• Sterile side table with equipment

• In the majority of cases, can be performed with a combination of local analgesics and moderate sedation (e.g., intravenous midazolam and fentanyl)
  
• Intravenous antibiotic such as cefazolin (1 to 2 g) or clindamycin (600 mg)

Positioning

• Prone or oblique prone is ideal, with extension to promote kyphosis reduction
  
• The patient’s arms should be placed sufficiently toward the head to keep them out of the path of the fluoroscope.

Needle Placement