BACKGROUND CONTEXT: Denosumab (XGeva) is a receptor activator of nuclear 
factor-κB ligand (RANKL)-antibody that was approved by the Food and Drug 
Administration (FDA) in 2010 for the prevention of skeletal fractures in 
patients with bone metastases from solid tumors. Although there is a widespread 
use of such drug in patients under risk of pathological fractures, the 
compatibility of denosumab therapy with percutaneous vertebroplasty (an 
interventional procedure commonly used for pain control in such population) has 
not yet been established.
PURPOSE: To present the serial imaging findings and technical report of an 
attempted percutaneous vertebroplasty in a patient with refractory pain and a 
lytic pathological vertebral fracture related to small cell lung cancer spinal 
metastasis and who was actively under medical treatment with denosumab.
STUDY DESIGN: Retrospective review and case report.
METHODS: The authors present the imaging findings and technical report of an 
attempted percutaneous vertebroplasty in the only patient found to be actively 
under treatment with denosumab after a retrospective review of the databank of 
patients with pathological fractures referred to the Department of Radiology of 
the Ohio State University for percutaneous vertebroplasty (a total sample of 20 
patients) since the FDA approval of denosumab (November 2010) until June 2013 (a 
30-month period).
RESULTS: Although the computed tomography scan of the thoracic spine, performed 
6 weeks after the initiation of the treatment with denosumab, presented a 
remarkable remodeling of the previously lytic vertebral lesion (which became 
markedly sclerotic in appearance), the clinical response in terms of pain 
improvement was not satisfactory. At the time of the percutaneous vertebroplasty 
(which was indicated for pain control), after advancing the 11-gauge needle 
through the pedicle with extreme difficulty, the needle repeatedly deviated 
laterally and, despite several attempts, it was not possible to penetrate the 
vertebral body and perform the cement injection.
CONCLUSIONS: This is the first report of the technical peculiarities of 
percutaneous vertebroplasty in patients under medical treatment with denosumab. 
According to our experience, because of its RANKL-mediated effects on 
osteoclasts activity, denosumab has been shown to induce a fast and marked 
sclerotic response on vertebral bodies that may not be accompanied by a 
satisfactory improvement in pain control (especially in patients with mechanical 
type of pain) and which may actually prevent the successful performance of 
percutaneous vertebroplasty. Therefore, it is of paramount importance that 
future studies evaluating patients with vertebral fractures under treatment with 
denosumab include long-term pain outcome measures. Additionally, further 
investigation is warranted to determine the optimal order of treatment and the 
best timeframe for combining percutaneous vertebroplasty and denosumab therapy 
in patients presenting with acute vertebral compression fractures and refractory 
axial pain.