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Vertebral metastases are frequently asymptomatic; however, the occurrence of a pathological (micro-)fracture may be associated with unremitting pain, instability, and even kyphoscoliotic deformity and require prompt and effective treatment. In symptomatic patients, the beneficial effect of conservative therapies requires too much time. Vertebroplasty (VP) may be an additional or even alternative local treatment modality for such patients. Currently, up to 80% of VP patients report important relief of metastasis-related pain. Ongoing deformity of the vertebral body is avoided. Morbidity rates are very low and the complication rates are markedly below 10%. Fatalities, if any, are almost always the result of cancer comorbidity rather than related to the VP procedure itself. The patient's mobility is often improved, thus avoiding much of the comorbidity of prolonged conservative treatment and bed rest. VP can successfully be combined with chemotherapy, radiotherapy, neurodecompression, and instrumentation. Even though VP is no panacea, it may be helpful to selected patients and instantly improve quality of life. Currently, VP has a solid basis for the palliative treatment of thoracic, lumbar, and sacral metastasis.

The authors report a series of 13 patients with osteoporotic vertebral fractures treated by transpedicular vertebroplasty. Because of a neurological complication due to posterior leakage of acrylic cement the classical percutaneous approach was converted to an open surgical procedure. The latter allows direct visual control of neural structures and immediate removal of spilled cement, thus eliminating the danger of compressive, chemical and thermal effects of methyl methacrylate on neural elements. By use of this elegant technique primary stability of fractured vertebras is obtained leading to prompt pain relief in all patients. Surgically controlled vertebroplasty can be used in conjunction with internal fixation. By having studied the different ways of cement escape in their patients, the authors are convinced that surgically controlled vertebroplasty is safer than percutaneous vertebroplasty.

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Williams' conservative approach with sequestrectomy alone is a safe operative modality. It should be used whenever possible. As demonstrated in our series with a long follow-up time, the results are as favorable as or better than results after standard microsurgical lumbar discectomy with curettement of the interspace. Whether the incidence of failed back surgery syndrome can be reduced by this approach remains to be proved.

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Soft system stabilization of lumbar motion segments in young patients with painful mechanical disease resistant to conservative treatment yields favourable long-term results only in a highly selected patient population.

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