Surgical techniques for unilateral percutaneous vertebroplasty of high thoracic vertebrae determined by the shape of the ribs under X-ray fluoroscopyunder X-Ray Fluoroscopy

Surgical techniques for unilateral percutaneous vertebroplasty of high thoracic vertebrae determined by the shape of the ribs under X-ray fluoroscopyunder X-Ray Fluoroscopy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Surgical techniques for unilateral percutaneous vertebroplasty of high thoracic vertebrae determined by the shape of the ribs under X-ray fluoroscopyunder X-Ray Fluoroscopy Yongdong Zhou, Hongyi Kang, Bangjian Zhou, Shanzhi Li, Wenping Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6843510/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Percutaneous vertebroplasty is a very common method for the treatment of thoracolumbar osteoporotic vertebral compression fractures. However, when it comes to cases of high thoracic vertebrae, there exist challenging difficulties such as the risk of high puncture ,a steep learning curve of the procedure and multiple complications.As a result, Many doctors are not confident or reluctant to perform percutaneous vertebroplasty on high thoracic vertebrae In order to solve the aforementioned challenges, this article elaborates on the surgical techniques for unilateral vertebroplasty for high thoracic vertebral compression fractures determined by the course of the ribs under X-ray fluoroscopy Purpose : Explore a safe and effective method of percutaneous vertebroplasty for high thoracic vertebrae, which can reduce bone cement leakage make the distribution of bone cement more uniform avoid complications such as intercostal nerve injury Materials and Methods : Retrospectively selected 28 patients (including 29 high thoracic vertebrae) , and all of them were treated with unilateral percutaneous vertebroplasty for high thoracic vertebrae determined by the course of the ribs under X-ray fluoroscopy Results : The hardness of all 29 fractured vertebrae was enhanced after the procedure. The pain of all patients was significantly relieved 24 hours after the procedure. 23 cases (79.31%) with type I and type II distribution of bone cement after the procedure. Only 1 patient (3.45%) had right intercostal pain, and 2 patients (6.90%) had bone cement leakage The complication incidence rate of the new procedure was much lower than traditional percutaneous vertebroplasty, and there were no occurrences of other serious complications. Conclusions : The high thoracic vertebroplasty designed according to the shape of the ribs under X-ray fluoroscopyhas a good therapeutic effect, with better distribution of bone cement, a lower incidence of postoperative complications and higher safety. It is worthy of clinical reference and application. Health sciences/Diseases Health sciences/Medical research Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction With the development of population aging, there are an increasing number of patients with osteoporotic vertebral compression fractures (a.k.a. OVCF). Studies have shown[ 1 ] that 25% of postmenopausal women will experience vertebral compression fractures, and 40% of women over 80 years old will have vertebral compression fractures. Moreover, men over 65 years old also have a relatively high risk of developing vertebral compression fractures. Percutaneous vertebroplasty (PVP) is currently an important method for treating thoracic and lumbar vertebral compression fractures. It can relieve pain quickly and effectively, accelerate patients' recovery and improve their life quality[ 2 ]. However, as the vertebral segment is located higher, the risk of the PVP operation becomes greater. Among them, the puncture risk of the high thoracic vertebrae (T3-T8) is relatively higher than that of the lumbar vertebrae and the low thoracic vertebrae (T12-T9). Moreover, its learning cycle of the procedure is longer, and it is often accompanied by complications such as bone cement leakage, uneven distribution of bone cement and intercostal nerve injury[ 3 ]. Some studies have shown that the risk of bone cement leakage in PVP surgery is as high as 39.3%[ 4 ]. If there is severe leakage of bone cement, it will lead to serious complications such as pulmonary embolism and neurological dysfunction [ 5 ]. These difficulties make many doctors reluctant to perform percutaneous vertebroplasty on high thoracic vertebrae. Based on this, this article elaborates on a advanced technique for unilateral vertebroplasty of high thoracic vertebral compression fractures determined according to the rib alignment. This technique has the advantages of reducing bone cement leakage, enabling more uniform distribution of bone cement, and avoiding injury to the intercostal nerves. Materials and Methods Patient Source Retrospectively, 28 patients with high thoracic vertebral (T8-T5) compression fractures, involving 29 high thoracic vertebrae, who were treated at Chinese Medicine Hospital of Shapingba District in Chong, China, from January 1, 2023, to November 20, 2024, were selected. All patients signed the informed consent forms, and the surgical treatments were initiated only after the approval from the hospital's ethics committee. All diagnoses were made in accordance with the "Guidelines for the Diagnosis and Treatment of Osteoporotic Fractures" released by China in 2017. At the same time, all PVP systems used during the surgery were provided by China Weigao Company, and the bone cement was provided by China Mingde Company Surgery Procedure and key technical points 1. Preparation before the surgery The patient is placed in a prone position on the operating table. A soft pillow is placed under the chest and pelvis respectively to keep the thoracolumbar region in a hyperextended position, and both shoulders are fixed. The local area is disinfected with iodine. A 5-ml syringe needle is temporarily inserted between the spinous processes. The injured vertebra is identified under C-arm fluoroscopy, and the puncture height is determined on the lateral radiograph. Then, draw the posterior midline (the line connecting the spinous processes) on the body surface, and make a perpendicular line to the posterior midline to determine and mark the skin puncture point, which is about 3–4 cm away from the posterior midline, as shown in Fig. 1 . 2. Preliminary positioning using a long needle of a syringe After routine disinfection with iodine and draping, a long syringe needle is used to perform local anesthesia on the skin, subcutaneous tissue, and zygapophyseal joints on the left or right side with 200 mg of 2% lidocaine injection. During this process, the long syringe needle can be re-examined under C-arm fluoroscopy to ensure it is near the pedicle of the vertebral arch, which appears near the "cat's eye" on the image. 3. Determine the optimal anchor point according to the shape of the rib Cut the skin about 1cm, use a puncture needle with a specification of 3.0mm or 3.5mm at the lateral edge of the facet joint on the left or right side of the injured vertebra. At this point, under C-arm fluoroscopy, the needle tip of the puncture needle should be about 0.5cm away from the lateral edge of the cat's eye (visualization of the pedicle of vertebral arch under X-ray fluoroscopy), aiming at the ipsilateral corner of the upper endplate of the vertebral body, the best anchoring point is not to break through the lower edge of the rib. As shown in Fig. 2 . At this moment, the puncture needle handle on the body surface is tilted outward from the posterior median line at an angle of about 30 to 40 degrees, but as the thoracic vertebral segment rises, the angle of inclination towards the head side becomes correspondingly larger. On the image, it is appropriate that the needle tip does not break through the lower edge of the rib, as long as the needle tip does not break through the lower edge of the rib, it is safe. If the needle tip breaks through the lower edge of the rib, there is a risk of damaging the intercostal nerves, as shown in Fig. 3 . 4. Use the puncture needle to perform the puncture gradually After determining the puncture angle, insert the needle slowly. When the needle tip of the puncture needle reaches the posterior edge of the vertebral body on the lateral view under C-arm fluoroscopy, the anteroposterior view should be fluoroscoped. At this point, on the anteroposterior view, the needle tip preferably should not break through the inner edge of the "cat's eye", otherwise there is a risk of entering the spinal canal. 5. Bone drill dilation Continue to insert the needle slowly. It can be screwed in by hand or gently tapped in with the help of a bone hammer. When the needle tip of the puncture needle passes through the posterior one-third of the vertebral body and enters the middle one-third, stop inserting the needle. Then, pull out the inner core of the puncture needle and replace it with an expanding bone drill. Rotate it clockwise to continue inserting the needle until the head of the expanding bone drill is located at the anterior one-fifth of the vertebral body on the lateral radiograph, and at this time, the head of the expanding bone drill on the anteroposterior radiograph should be close to the spinous process or just beyond it, as shown in Fig. 4 . 6. Bone cement injection At this time, inject the patient intravenously with 10 mg of dexamethasone sodium phosphate injection or betamethasone injection to suppress the immune function. Then, mix the bone cement and replace the expanding bone drill. Slowly inject the bone cement under the monitoring of the C-arm. At this point, when the angle at which the puncture needle handle tilts outward from the posterior midline is less than 30°-40°, the angle of the handle can be increased outward by hand while injecting the bone cement. When injecting the bone cement, it is necessary to inject while withdrawing under the monitoring of the lateral view of the C-arm. 7. Bone cement injection Complete When the bone cement reaches approximately the anterior one-fourth of the vertebral body, the injection speed should be slow. When it reaches around the anterior two-fourths, the speed can be slightly increased. When it gets to about the anterior three-fourths, the speed should slow down again. Stop the injection until the bone cement is about to reach the posterior one-fourth. Then, take an anteroposterior view under C-arm fluoroscopy to confirm that the bone cement is well-distributed, as shown in Fig. 5 and Fig. 6 . 8. Surgery Complete After the bone cement solidifies, withdraw the puncture needle. Apply pressure to dress the wound with sterile dressing, and then the surgery is completed. Results This article reported the treatment of 28 patients with high thoracic vertebral compression fractures, involving 29 high thoracic vertebrae (T8-T5). Among them, there were 8 cases of T8 vertebra, 12 cases of T7 vertebra, 7 cases of T6 vertebra, and 2 cases of T5 vertebra. All fractured vertebrae were augmented. Post-operation, the distribution of bone cement was as follows: 16 cases of type I, 7 cases of type II, 0 cases of type III, 5 cases of type IV, and 1 case of type V. Twenty-four hours after the operation, the thoracolumbar pain of most patients was significantly alleviated, and the VAS score decreased significantly compared with that before the operation. Only 1 patient experienced minor right intercostal pain, which was significantly relieved after taking painkillers for 1 week. Only 2 patients had bone cement leakage, but no complications occurred, and there were no other serious complications, as shown in Table 1 . Table 1 Treatment Results Patient Information Male 1 Female 27 Total 28 Max Age 90 Min Age 63 Avg Age 75.61 ± 7.38 Fractured Vertebrae Type T5 2 T6 7 T7 12 T8 8 Total 29 Bone Cement Distribution Type Type I 16 (55.17%) Type II 7 (24.14%) Type III 0 (0%) Type IV 5 (17.24%) Type V 1 (3.45%) Complications Cases Bone Cement Leakage 2 (6.90%) Right Intercostal Pain 1 (3.45%) Further Discussion Percutaneous vertebroplasty is currently widely applied in the treatment of osteoporotic compression fractures. Both unilateral and bilateral punctures are very common in clinical practice, and their curative effects are similar[ 6 ]. In recent years, a method of single-curved approach vertebroplasty has been used, which can make the distribution of bone cement more uniform. However, it is more expensive, increasing the financial burden on patients[ 7 ]. The anatomical characteristics of the thoracic vertebrae are that the thoracic vertebral bodies gradually become smaller from bottom to top, the pedicles gradually become thinner, the medial inclination angle of the pedicles and the vertebral bodies gradually becomes smaller, and the inferior inclination angle of the pedicles gradually becomes larger, etc. These characteristics make unilateral vertebroplasty generally used for high-thoracic vertebral compression fractures[ 8 – 10 ]. However, for high-thoracic vertebroplasty, the surgical difficulty gradually increases as the vertebral body level rises. There are often defects such as bone cement leakage and uneven distribution of bone cement. Moreover, complications are likely to occur, such as nerve injury caused by mis-puncture, paravertebral vein injury, pedicle fracture, rib fracture, pneumothorax, and spinal nerve compression caused by bone cement leakage into the spinal canal[ 11 ]. As early as 2014, some researchers suggested that performing thoracic vertebroplasty via the rib approach. However, current literature has not presented the specific operation method and details steps. This article specifically demonstrates the puncture technique of unilateral high-thoracic vertebroplasty, which is designed based on the anatomical structures of the ribs thoracic vertebrae. The intercostal nerve emerges from the lower edge of the rib. In this technique, the initial anchor point does not break through the lower edge of the rib. By using the rib's shape to restrict the position of the initial puncture point, injury to the intercostal nerve is naturally avoided. Different from the conventional initial anchor point which is located at the lateral edge of the pedicle projection, the initial anchor point of this technique is approximately 0.5 cm away from the lateral edge of the pedicle projection, and aims at the ipsilateral angle of the upper endplate of the vertebral body, while not breaking through the lower edge of the rib. This restricts the inclination angle of the puncture needle. After determining the initial anchor point, insert the needle and set the abduction angle at approximately 30°-40°. This can maximize the needle's reach to the middle part of the vertebral body, avoid the puncture needle from breaking through the spinal canal, make the distribution of bone cement more uniform, and prevent serious complications caused by bone cement leakage. Three marker lines, namely the central vertical line and the vertical lines at the inner edges of the bilateral pedicles, are set on the postoperative anteroposterior X-ray film, and the vertebral body is divided into zones 1–4 from left to right. According to the postoperative bone cement distribution, it is classified into five types. If all four zones are filled with bone cement, it is considered the best distribution, and if only one zone is filled, it is regarded as poor distribution. Type I means that all zones 1–4 are filled with bone cement, Type II means that zones 2 and 3 are filled, Type III means that zones 1 and 4 are filled, Type IV means that either zones 1 and 2 or zones 3 and 4 are filled, and Type V means that either zone 1 or zone 4 is filled. The results of this study show that there are 23 vertebral bodies with Type I and Type II distributions in total, accounting for 79.31%, indicating that the bone cement distribution is good with this method. The results of this study show that the thoracolumbar pain of most patients was significantly alleviated 24 hours after the operation, indicating that this method has a good therapeutic effect. Meanwhile, bone cement leakage occurred in only 2 vertebral bodies (6.90%), which is much lower than the conventional rate of 39.3%, and no complications caused by bone cement leakage were observed. This indicates that this method can significantly reduce the incidence of bone cement leakage. In addition, with this method, only 1 patient experienced right intercostal pain after the operation, suggesting a possible intercostal nerve injury. However, the symptoms of this patient were significantly relieved after taking painkillers for 1 week, and no complications such as spinal nerve compression or pneumothorax occurred, indicating that this method is relatively safe. Conclusion The high-thoracic vertebroplasty designed based on the rib shape has a favorable treatment effect, with positive bone cement distribution and relatively high safety, making it worthy of reference and application. However, due to the small sample size, further clinical verification is still required. Declarations Disclosures of Conflicts of Interest There are no conflicts of interest in this article Data availability All data generated or analysed during this study are included in this published article [and its supplementary information files]. Author Contribution All authors contributed to the concept and design of this study. Material preparation, data collection, and analysis will be carried out by authors 2 to 5. The initial draft of the manuscript was written by the authors, and all authors provided comments on previous versions of the manuscript. All authors have read and approved the final manuscript. Acknowledgement We sincerely thank every patient for their participation and contribution, as well as every author for their hard work. We also appreciate the editors and experts who took the time to review our article despite their busy schedules, and thank everyone who has been helpful to us! References ALSOOF, D. et al. Diagnosis and management of vertebral compression fracture [J]. Am. J. Med. 135 (7), 815–821 (2022). BUCHBINDER, R. et al. Percutaneous vertebroplasty for osteoporotic vertebral compression fracture [J]. Cochrane Database of Systematic Reviews, (11). (2018). LIU, J. et al. Percutaneous Vertebral Augmentation for Osteoporotic Vertebral Compression Fracture in the Midthoracic Vertebrae (T5-8): A Retrospective Study of 101 Patients with 111 Fractured Segments [J]. World Neurosurg. 122 , e1381–e7 (2019). ROSE, L. & BATEMAN, G. Clinical significance of cement leakage in kyphoplasty and vertebroplasty: a systematic review [J]. Eur. Spine J. 33 (4), 1484–1489 (2024). HSIEH M-K et al. Risk factors of neurological deficit and pulmonary cement embolism after percutaneous vertebroplasty [J]. J. Orthop. Surg, Res. 14 , 1–8 (2019). YAN, L. et al. A comparison between unilateral transverse process-pedicle and bilateral puncture techniques in percutaneous kyphoplasty [J]. Spine 39 (26B), B19–B26 (2014). HU, B. & ZHANG, X. Comparison of the efficacy and safety of vertebroplasty with different pedicle approaches for osteoporotic vertebral [J]. Eur. Spine J. 33 (8), 3191–3212 (2024). BOGDUK N. Functional anatomy of the spine [J]. Handb. Clin. Neurol. 136 , 675–688 (2016). SCHUPFNER, R. et al. An anatomical study of transpedicular vs. extrapedicular approach for kyphoplasty and vertebroplasty in the thoracic spine [J]. Injury 52 , S63–S9 (2021). DING, Y. et al. Vertebral augmentation via the rib approach: Surgical essentials and therapeutic effects [J]. Neurochirurgie 68 (4), 386–392 (2022). ZHONG, R. et al. Unilateral curved versus bipedicular vertebroplasty in the treatment of osteoporotic vertebral compression fractures [J]. BMC Surg. 19 , 1–9 (2019). Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterialsforsurgicalprocedure.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6843510","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":476188469,"identity":"add7930f-8f2b-4e29-bfcc-e5a768fde113","order_by":0,"name":"Yongdong Zhou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwklEQVRIiWNgGAWjYBACNmb2AwcSKmyYGdubDxCnhY+dJ/HAgzNp7Mw9xxKI0yLHz2B88GHbYX72GTkGxDqMIeFAwpnD0rwNOR9vvGGwk9NtIKiFEeSXdGPJhrObLecwJBubHSDOFutkw8bebdI8DAcStxGhxeBAYhtz/f7DPM9I0uLMzNjGw0asFh6Qw9KYGXvYjC3nGBDhF/n+44c//gBF5fzHD2+8qbCTI6gFBUjwEBk1yFpI1TEKRsEoGAUjAgAAKg9Dkv7w+X8AAAAASUVORK5CYII=","orcid":"","institution":"Shapingba District Hospital of TCM Chongqing","correspondingAuthor":true,"prefix":"","firstName":"Yongdong","middleName":"","lastName":"Zhou","suffix":""},{"id":476188470,"identity":"b5364431-3fe4-4b4f-a4ee-e40ab4baeb4f","order_by":1,"name":"Hongyi Kang","email":"","orcid":"","institution":"Wenjiang District Traditional Chinese Medicine Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hongyi","middleName":"","lastName":"Kang","suffix":""},{"id":476188471,"identity":"b634b463-35ef-4b34-b7cf-53ad34465549","order_by":2,"name":"Bangjian Zhou","email":"","orcid":"","institution":"Shapingba District Hospital of TCM Chongqing","correspondingAuthor":false,"prefix":"","firstName":"Bangjian","middleName":"","lastName":"Zhou","suffix":""},{"id":476188472,"identity":"f48dd643-7546-4def-a795-8be6da0b8423","order_by":3,"name":"Shanzhi Li","email":"","orcid":"","institution":"Shapingba District Hospital of TCM Chongqing","correspondingAuthor":false,"prefix":"","firstName":"Shanzhi","middleName":"","lastName":"Li","suffix":""},{"id":476188473,"identity":"e57add04-0eaa-42bc-82b0-6d919cdfe2fb","order_by":4,"name":"Wenping Liu","email":"","orcid":"","institution":"Shapingba District Hospital of TCM Chongqing","correspondingAuthor":false,"prefix":"","firstName":"Wenping","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2025-06-07 14:53:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6843510/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6843510/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85736294,"identity":"5f19eac4-657d-4219-8b6a-9478b2c9f021","added_by":"auto","created_at":"2025-07-01 08:06:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":268814,"visible":true,"origin":"","legend":"\u003cp\u003ethe puncture point is approximately 3-4 cm away from the posterior midline\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6843510/v1/d7f87b308e10ed5058bdb102.png"},{"id":85737411,"identity":"e8f74f18-30a6-41d9-a9d7-d72b3ba7462b","added_by":"auto","created_at":"2025-07-01 08:14:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":123734,"visible":true,"origin":"","legend":"\u003cp\u003eOn the C-arm image, determine the optimal anchor point. The needle tip of the puncture needle is about 0.5 cm away from the outer edge of the \"cat's eye\", aiming at the ipsilateral angle of the superior endplate of the vertebral body without penetrating the lower edge of the rib.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6843510/v1/9c7c511baf9daf3f21dceae9.png"},{"id":85737414,"identity":"de3ab2d7-b1c7-4aa2-91bb-a3ef19718e94","added_by":"auto","created_at":"2025-07-01 08:14:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":298919,"visible":true,"origin":"","legend":"\u003cp\u003eThe puncture needle handle on the body surface is tilted at an angle of approximately 30-40 degrees outward from the posterior midline. The angle of cephalic (head-side) tilt increases correspondingly as the thoracic vertebra segment gets higher. On the image, it is advisable not to penetrate the lower edge of the rib.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6843510/v1/7b828fe7ed8360898835700b.png"},{"id":85737413,"identity":"ada89bb3-5526-4fd8-8e43-6bb4d7b2fd46","added_by":"auto","created_at":"2025-07-01 08:14:45","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":137772,"visible":true,"origin":"","legend":"\u003cp\u003eWhen the head of the expanding bone drill is located at the anterior one-fifth of the vertebral body on the lateral radiograph, it should be close to or just beyond the spinous process on the anteroposterior radiograph.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6843510/v1/a64ac5f52fd5d0072793d2fb.png"},{"id":85736300,"identity":"37aef497-8de6-40d5-afda-dd32a1dd2892","added_by":"auto","created_at":"2025-07-01 08:06:45","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":294989,"visible":true,"origin":"","legend":"\u003cp\u003eStop injecting the bone cement when it is about to reach approximately the posterior 1/4 of the vertebral body.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6843510/v1/8754f73c162c90548e3c8cbc.png"},{"id":87972872,"identity":"2b93a2d2-a299-4d06-a652-b1a25c9ef542","added_by":"auto","created_at":"2025-07-31 03:31:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2049633,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6843510/v1/ef88b6ff-5648-4dc5-a85e-e040665e71f6.pdf"},{"id":85738960,"identity":"c3894e67-769f-4d09-b399-cdccb57bb115","added_by":"auto","created_at":"2025-07-01 08:30:45","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":1136627,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterialsforsurgicalprocedure.docx","url":"https://assets-eu.researchsquare.com/files/rs-6843510/v1/97b3aa7fca48b5053aebe52b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical techniques for unilateral percutaneous vertebroplasty of high thoracic vertebrae determined by the shape of the ribs under X-ray fluoroscopyunder X-Ray Fluoroscopy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith the development of population aging, there are an increasing number of patients with osteoporotic vertebral compression fractures (a.k.a. OVCF). Studies have shown[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] that 25% of postmenopausal women will experience vertebral compression fractures, and 40% of women over 80 years old will have vertebral compression fractures. Moreover, men over 65 years old also have a relatively high risk of developing vertebral compression fractures.\u003c/p\u003e \u003cp\u003ePercutaneous vertebroplasty (PVP) is currently an important method for treating thoracic and lumbar vertebral compression fractures. It can relieve pain quickly and effectively, accelerate patients' recovery and improve their life quality[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, as the vertebral segment is located higher, the risk of the PVP operation becomes greater. Among them, the puncture risk of the high thoracic vertebrae (T3-T8) is relatively higher than that of the lumbar vertebrae and the low thoracic vertebrae (T12-T9). Moreover, its learning cycle of the procedure is longer, and it is often accompanied by complications such as bone cement leakage, uneven distribution of bone cement and intercostal nerve injury[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Some studies have shown that the risk of bone cement leakage in PVP surgery is as high as 39.3%[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIf there is severe leakage of bone cement, it will lead to serious complications such as pulmonary embolism and neurological dysfunction [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These difficulties make many doctors reluctant to perform percutaneous vertebroplasty on high thoracic vertebrae. Based on this, this article elaborates on a advanced technique for unilateral vertebroplasty of high thoracic vertebral compression fractures determined according to the rib alignment. This technique has the advantages of reducing bone cement leakage, enabling more uniform distribution of bone cement, and avoiding injury to the intercostal nerves.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Source\u003c/h2\u003e \u003cp\u003eRetrospectively, 28 patients with high thoracic vertebral (T8-T5) compression fractures, involving 29 high thoracic vertebrae, who were treated at Chinese Medicine Hospital of Shapingba District in Chong, China, from January 1, 2023, to November 20, 2024, were selected. All patients signed the informed consent forms, and the surgical treatments were initiated only after the approval from the hospital's ethics committee. All diagnoses were made in accordance with the \"Guidelines for the Diagnosis and Treatment of Osteoporotic Fractures\" released by China in 2017. At the same time, all PVP systems used during the surgery were provided by China Weigao Company, and the bone cement was provided by China Mingde Company\u003c/p\u003e \u003cp\u003e \u003cb\u003eSurgery Procedure and key technical points\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e1. Preparation before the surgery\u003c/h3\u003e\n\u003cp\u003eThe patient is placed in a prone position on the operating table. A soft pillow is placed under the chest and pelvis respectively to keep the thoracolumbar region in a hyperextended position, and both shoulders are fixed. The local area is disinfected with iodine. A 5-ml syringe needle is temporarily inserted between the spinous processes. The injured vertebra is identified under C-arm fluoroscopy, and the puncture height is determined on the lateral radiograph. Then, draw the posterior midline (the line connecting the spinous processes) on the body surface, and make a perpendicular line to the posterior midline to determine and mark the skin puncture point, which is about 3\u0026ndash;4 cm away from the posterior midline, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003e2. Preliminary positioning using a long needle of a syringe\u003c/h3\u003e\n\u003cp\u003eAfter routine disinfection with iodine and draping, a long syringe needle is used to perform local anesthesia on the skin, subcutaneous tissue, and zygapophyseal joints on the left or right side with 200 mg of 2% lidocaine injection. During this process, the long syringe needle can be re-examined under C-arm fluoroscopy to ensure it is near the pedicle of the vertebral arch, which appears near the \"cat's eye\" on the image.\u003c/p\u003e\n\u003ch3\u003e3. Determine the optimal anchor point according to the shape of the rib\u003c/h3\u003e\n\u003cp\u003eCut the skin about 1cm, use a puncture needle with a specification of 3.0mm or 3.5mm at the lateral edge of the facet joint on the left or right side of the injured vertebra. At this point, under C-arm fluoroscopy, the needle tip of the puncture needle should be about 0.5cm away from the lateral edge of the cat's eye (visualization of the pedicle of vertebral arch under X-ray fluoroscopy), aiming at the ipsilateral corner of the upper endplate of the vertebral body, the best anchoring point is not to break through the lower edge of the rib. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAt this moment, the puncture needle handle on the body surface is tilted outward from the posterior median line at an angle of about 30 to 40 degrees, but as the thoracic vertebral segment rises, the angle of inclination towards the head side becomes correspondingly larger. On the image, it is appropriate that the needle tip does not break through the lower edge of the rib, as long as the needle tip does not break through the lower edge of the rib, it is safe. If the needle tip breaks through the lower edge of the rib, there is a risk of damaging the intercostal nerves, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003e4. Use the puncture needle to perform the puncture gradually\u003c/h3\u003e\n\u003cp\u003eAfter determining the puncture angle, insert the needle slowly. When the needle tip of the puncture needle reaches the posterior edge of the vertebral body on the lateral view under C-arm fluoroscopy, the anteroposterior view should be fluoroscoped. At this point, on the anteroposterior view, the needle tip preferably should not break through the inner edge of the \"cat's eye\", otherwise there is a risk of entering the spinal canal.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e5. Bone drill dilation\u003c/h2\u003e \u003cp\u003eContinue to insert the needle slowly. It can be screwed in by hand or gently tapped in with the help of a bone hammer. When the needle tip of the puncture needle passes through the posterior one-third of the vertebral body and enters the middle one-third, stop inserting the needle. Then, pull out the inner core of the puncture needle and replace it with an expanding bone drill. Rotate it clockwise to continue inserting the needle until the head of the expanding bone drill is located at the anterior one-fifth of the vertebral body on the lateral radiograph, and at this time, the head of the expanding bone drill on the anteroposterior radiograph should be close to the spinous process or just beyond it, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e6. Bone cement injection\u003c/h3\u003e\n\u003cp\u003eAt this time, inject the patient intravenously with 10 mg of dexamethasone sodium phosphate injection or betamethasone injection to suppress the immune function. Then, mix the bone cement and replace the expanding bone drill. Slowly inject the bone cement under the monitoring of the C-arm. At this point, when the angle at which the puncture needle handle tilts outward from the posterior midline is less than 30\u0026deg;-40\u0026deg;, the angle of the handle can be increased outward by hand while injecting the bone cement. When injecting the bone cement, it is necessary to inject while withdrawing under the monitoring of the lateral view of the C-arm.\u003c/p\u003e\n\u003ch3\u003e7. Bone cement injection Complete\u003c/h3\u003e\n\u003cp\u003eWhen the bone cement reaches approximately the anterior one-fourth of the vertebral body, the injection speed should be slow. When it reaches around the anterior two-fourths, the speed can be slightly increased. When it gets to about the anterior three-fourths, the speed should slow down again. Stop the injection until the bone cement is about to reach the posterior one-fourth. Then, take an anteroposterior view under C-arm fluoroscopy to confirm that the bone cement is well-distributed, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e5\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e8. Surgery Complete\u003c/h2\u003e \u003cp\u003eAfter the bone cement solidifies, withdraw the puncture needle. Apply pressure to dress the wound with sterile dressing, and then the surgery is completed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis article reported the treatment of 28 patients with high thoracic vertebral compression fractures, involving 29 high thoracic vertebrae (T8-T5). Among them, there were 8 cases of T8 vertebra, 12 cases of T7 vertebra, 7 cases of T6 vertebra, and 2 cases of T5 vertebra. All fractured vertebrae were augmented.\u003c/p\u003e \u003cp\u003ePost-operation, the distribution of bone cement was as follows: 16 cases of type I, 7 cases of type II, 0 cases of type III, 5 cases of type IV, and 1 case of type V. Twenty-four hours after the operation, the thoracolumbar pain of most patients was significantly alleviated, and the VAS score decreased significantly compared with that before the operation. Only 1 patient experienced minor right intercostal pain, which was significantly relieved after taking painkillers for 1 week. Only 2 patients had bone cement leakage, but no complications occurred, and there were no other serious complications, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTreatment Results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePatient Information\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMax Age\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMin Age\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvg Age\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75.61 ± 7.38\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFractured Vertebrae Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT5\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT7\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT8\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBone Cement Distribution Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType I\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (55.17%)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType II\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (24.14%)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType III\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType IV\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (17.24%)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType V\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.45%)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplications\u0026nbsp;Cases\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone Cement Leakage\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.90%)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight Intercostal Pain\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.45%)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e "},{"header":"Further Discussion","content":"\u003cp\u003ePercutaneous vertebroplasty is currently widely applied in the treatment of osteoporotic compression fractures. Both unilateral and bilateral punctures are very common in clinical practice, and their curative effects are similar[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn recent years, a method of single-curved approach vertebroplasty has been used, which can make the distribution of bone cement more uniform. However, it is more expensive, increasing the financial burden on patients[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The anatomical characteristics of the thoracic vertebrae are that the thoracic vertebral bodies gradually become smaller from bottom to top, the pedicles gradually become thinner, the medial inclination angle of the pedicles and the vertebral bodies gradually becomes smaller, and the inferior inclination angle of the pedicles gradually becomes larger, etc. These characteristics make unilateral vertebroplasty generally used for high-thoracic vertebral compression fractures[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e–\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, for high-thoracic vertebroplasty, the surgical difficulty gradually increases as the vertebral body level rises. There are often defects such as bone cement leakage and uneven distribution of bone cement. Moreover, complications are likely to occur, such as nerve injury caused by mis-puncture, paravertebral vein injury, pedicle fracture, rib fracture, pneumothorax, and spinal nerve compression caused by bone cement leakage into the spinal canal[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs early as 2014, some researchers suggested that performing thoracic vertebroplasty via the rib approach. However, current literature has not presented the specific operation method and details steps. This article specifically demonstrates the puncture technique of unilateral high-thoracic vertebroplasty, which is designed based on the anatomical structures of the ribs thoracic vertebrae. The intercostal nerve emerges from the lower edge of the rib. In this technique, the initial anchor point does not break through the lower edge of the rib. By using the rib's shape to restrict the position of the initial puncture point, injury to the intercostal nerve is naturally avoided. Different from the conventional initial anchor point which is located at the lateral edge of the pedicle projection, the initial anchor point of this technique is approximately 0.5 cm away from the lateral edge of the pedicle projection, and aims at the ipsilateral angle of the upper endplate of the vertebral body, while not breaking through the lower edge of the rib. This restricts the inclination angle of the puncture needle. After determining the initial anchor point, insert the needle and set the abduction angle at approximately 30°-40°. This can maximize the needle's reach to the middle part of the vertebral body, avoid the puncture needle from breaking through the spinal canal, make the distribution of bone cement more uniform, and prevent serious complications caused by bone cement leakage.\u003c/p\u003e\u003cp\u003eThree marker lines, namely the central vertical line and the vertical lines at the inner edges of the bilateral pedicles, are set on the postoperative anteroposterior X-ray film, and the vertebral body is divided into zones 1–4 from left to right. According to the postoperative bone cement distribution, it is classified into five types. If all four zones are filled with bone cement, it is considered the best distribution, and if only one zone is filled, it is regarded as poor distribution. Type I means that all zones 1–4 are filled with bone cement, Type II means that zones 2 and 3 are filled, Type III means that zones 1 and 4 are filled, Type IV means that either zones 1 and 2 or zones 3 and 4 are filled, and Type V means that either zone 1 or zone 4 is filled. The results of this study show that there are 23 vertebral bodies with Type I and Type II distributions in total, accounting for 79.31%, indicating that the bone cement distribution is good with this method.\u003c/p\u003e\u003cp\u003eThe results of this study show that the thoracolumbar pain of most patients was significantly alleviated 24 hours after the operation, indicating that this method has a good therapeutic effect. Meanwhile, bone cement leakage occurred in only 2 vertebral bodies (6.90%), which is much lower than the conventional rate of 39.3%, and no complications caused by bone cement leakage were observed. This indicates that this method can significantly reduce the incidence of bone cement leakage. In addition, with this method, only 1 patient experienced right intercostal pain after the operation, suggesting a possible intercostal nerve injury. However, the symptoms of this patient were significantly relieved after taking painkillers for 1 week, and no complications such as spinal nerve compression or pneumothorax occurred, indicating that this method is relatively safe.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe high-thoracic vertebroplasty designed based on the rib shape has a favorable treatment effect, with positive bone cement distribution and relatively high safety, making it worthy of reference and application. However, due to the small sample size, further clinical verification is still required.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclosures of Conflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no conflicts of interest in this article\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the concept and design of this study. Material preparation, data collection, and analysis will be carried out by authors 2 to 5. The initial draft of the manuscript was written by the authors, and all authors provided comments on previous versions of the manuscript. All authors have read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe sincerely thank every patient for their participation and contribution, as well as every author for their hard work. We also appreciate the editors and experts who took the time to review our article despite their busy schedules, and thank everyone who has been helpful to us!\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eALSOOF, D. et al. Diagnosis and management of vertebral compression fracture [J]. \u003cem\u003eAm. J. Med.\u003c/em\u003e \u003cb\u003e135\u003c/b\u003e (7), 815\u0026ndash;821 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBUCHBINDER, R. et al. Percutaneous vertebroplasty for osteoporotic vertebral compression fracture [J]. Cochrane Database of Systematic Reviews, (11). (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLIU, J. et al. Percutaneous Vertebral Augmentation for Osteoporotic Vertebral Compression Fracture in the Midthoracic Vertebrae (T5-8): A Retrospective Study of 101 Patients with 111 Fractured Segments [J]. \u003cem\u003eWorld Neurosurg.\u003c/em\u003e \u003cb\u003e122\u003c/b\u003e, e1381\u0026ndash;e7 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eROSE, L. \u0026amp; BATEMAN, G. Clinical significance of cement leakage in kyphoplasty and vertebroplasty: a systematic review [J]. \u003cem\u003eEur. Spine J.\u003c/em\u003e \u003cb\u003e33\u003c/b\u003e (4), 1484\u0026ndash;1489 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHSIEH M-K et al. Risk factors of neurological deficit and pulmonary cement embolism after percutaneous vertebroplasty [J]. \u003cem\u003eJ. Orthop. Surg, Res.\u003c/em\u003e \u003cb\u003e14\u003c/b\u003e, 1\u0026ndash;8 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYAN, L. et al. A comparison between unilateral transverse process-pedicle and bilateral puncture techniques in percutaneous kyphoplasty [J]. \u003cem\u003eSpine\u003c/em\u003e \u003cb\u003e39\u003c/b\u003e (26B), B19\u0026ndash;B26 (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHU, B. \u0026amp; ZHANG, X. Comparison of the efficacy and safety of vertebroplasty with different pedicle approaches for osteoporotic vertebral [J]. \u003cem\u003eEur. Spine J.\u003c/em\u003e \u003cb\u003e33\u003c/b\u003e (8), 3191\u0026ndash;3212 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBOGDUK N. Functional anatomy of the spine [J]. \u003cem\u003eHandb. Clin. Neurol.\u003c/em\u003e \u003cb\u003e136\u003c/b\u003e, 675\u0026ndash;688 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSCHUPFNER, R. et al. An anatomical study of transpedicular vs. extrapedicular approach for kyphoplasty and vertebroplasty in the thoracic spine [J]. \u003cem\u003eInjury\u003c/em\u003e \u003cb\u003e52\u003c/b\u003e, S63\u0026ndash;S9 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDING, Y. et al. Vertebral augmentation via the rib approach: Surgical essentials and therapeutic effects [J]. \u003cem\u003eNeurochirurgie\u003c/em\u003e \u003cb\u003e68\u003c/b\u003e (4), 386\u0026ndash;392 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZHONG, R. et al. Unilateral curved versus bipedicular vertebroplasty in the treatment of osteoporotic vertebral compression fractures [J]. \u003cem\u003eBMC Surg.\u003c/em\u003e \u003cb\u003e19\u003c/b\u003e, 1\u0026ndash;9 (2019).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6843510/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6843510/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e:\u003c/em\u003e Percutaneous vertebroplasty is a very common method for the treatment of thoracolumbar osteoporotic vertebral compression fractures. However, when it comes to cases of high thoracic vertebrae, there exist challenging difficulties such as the risk of high puncture ,a steep learning curve of the procedure and multiple complications.As a result, Many doctors are not confident or reluctant to perform percutaneous vertebroplasty on high thoracic vertebrae\u003c/p\u003e\n\u003cp\u003eIn order to solve the aforementioned challenges, this article elaborates on the surgical techniques for unilateral vertebroplasty for high thoracic vertebral compression fractures determined by the course of the ribs under X-ray fluoroscopy\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eExplore a safe and effective method of percutaneous vertebroplasty for high thoracic vertebrae, which can\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ereduce bone cement leakage\u003c/li\u003e\n \u003cli\u003emake the distribution of bone cement more uniform\u003c/li\u003e\n \u003cli\u003eavoid complications such as intercostal nerve injury\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMaterials and Methods\u003c/strong\u003e\u003c/em\u003e: Retrospectively selected 28 patients (including 29 high thoracic vertebrae) , and all of them were treated with unilateral percutaneous vertebroplasty for high thoracic vertebrae determined by the course of the ribs under X-ray fluoroscopy\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe hardness of all 29 fractured vertebrae was enhanced after the procedure.\u003c/li\u003e\n \u003cli\u003eThe pain of all patients was significantly relieved 24 hours after the procedure.\u003c/li\u003e\n \u003cli\u003e23 cases (79.31%) with type I and type II distribution of bone cement after the procedure.\u003c/li\u003e\n \u003cli\u003eOnly 1 patient (3.45%) had right intercostal pain, and 2 patients (6.90%) had bone cement leakage\u003c/li\u003e\n \u003cli\u003eThe complication incidence rate of the new procedure was much lower than traditional percutaneous vertebroplasty, and there were no occurrences of other serious complications.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/em\u003e: The high thoracic vertebroplasty designed according to the shape of the ribs under X-ray fluoroscopyhas a good therapeutic effect, with better distribution of bone cement, a lower incidence of postoperative complications and higher safety. It is worthy of clinical reference and application.\u003c/p\u003e","manuscriptTitle":"Surgical techniques for unilateral percutaneous vertebroplasty of high thoracic vertebrae determined by the shape of the ribs under X-ray fluoroscopyunder X-Ray Fluoroscopy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 08:06:40","doi":"10.21203/rs.3.rs-6843510/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"63fc66d7-9f0a-45b6-8481-8086d7cbb70e","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":50565278,"name":"Health sciences/Diseases"},{"id":50565279,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-07-31T03:23:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-01 08:06:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6843510","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6843510","identity":"rs-6843510","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}