Intraoperative three-dimensional imaging-guided vertebral body stenting for cleft-associated very severe osteoporotic vertebral compression fractures: a surgical technique case series

Very severe osteoporotic vertebral compression fractures (vsOVCF) associated with intravertebral clefts represent a technically challenging subgroup of vertebral augmentation because of severe vertebral collapse, distorted intravertebral anatomy, and increased risk of cement leakage. Conventional fluoroscopy alone may be insufficient for accurate device positioning in these cases. We describe the surgical technique and technical utility of intraoperative three-dimensional (3D) imaging during vertebral body stenting (VBS) in three consecutive patients with cleft-associated vsOVCF without neurological deficits. All patients demonstrated intravertebral clefts on preoperative imaging. The procedure was performed using a bilateral transpedicular approach under biplanar fluoroscopy with adjunctive intraoperative 3D rotational imaging. Intraoperative 3D imaging enabled confirmation of balloon and stent positioning within residual cancellous bone rather than within the cleft cavity. Vertebral height restoration ranged from 9% to 18%, and all patients experienced marked pain relief, with mean Numerical Rating Scale scores improving from 8.0 preoperatively to 1.0 postoperatively. Cement leakage into the adjacent disc occurred in two cases, although no spinal canal leakage or symptomatic complications were observed. Postoperative computed tomography at 3 and 6 months demonstrated maintained vertebral height without recollapse, osteonecrosis, or implant-related complications. Intraoperative 3D imaging may serve as a useful technical adjunct for safer and more controlled VBS in anatomically complex fractures.