The application of different puncture approaches in percutaneous vertebroplasty/penetrating kyphoplasty

At present, the puncture approaches for percutaneous vertebroplasty (PVP)/penetrating keratoplasty (PKP) include unilateral pedicular approach, bilateral pedicular approach, and extrapedicular approach. This article summarizes 14 puncture approaches for PVP/PKP that are commonly used in clinical practice, including application conditions, optimalindications, and technical risks. In recent years, the extrapedicular approach has gained increasing popularity. Compared to traditional bilateral transpedicular techniques, the extrapedicular approach demonstrates advantages in reducing operative time, minimizing tissue trauma, lowering radiation exposure, and decreasing material costs. Importantly, it overcomes the anatomical limitation of the lateral pedicle wall on needle angulation in unilateral transpedicular puncture, allowing greater lateral inclination to position the needle tip near the vertebral midline, thereby facilitating symmetrical cement diffusion along the central axis. For thoracic and upper lumbar vertebrae, the extrapedicular approach is prioritized to mitigate the risk of spinal cord injury. Conversely, in the lower lumbar region, the unilateral transpedicular approach is recommended to avoid potential lumbar artery damage associated with extrapedicular puncture. The puncture path should be determined before surgery based on the technical advantages of the operator, and an appropriate surgical procedure should be selected based on the morphology of the fractured vertebra and related key parameters.