A lateral decubitus percutaneous vertebroplasty using a facet-joint-transgressing unipedicular trajectory in a hemiplegic patient: a case report with a position-trajectory-gravity coupling strategy.

BACKGROUND: Percutaneous vertebroplasty (PVP) is typically performed in the prone position using a standard transpedicular approach. However, patients with hemiplegia often cannot tolerate prone positioning due to spasticity and postural instability. Moreover, achieving symmetrical cement distribution through a unilateral approach remains technically challenging. This study introduces a modified technique incorporating a facet-joint-transgressing trajectory combined with a lateral decubitus position to optimize cement dispersion. CASE PRESENTATION: We report a 70-year-old woman with right-sided hemiplegia following cerebral hemorrhage who presented with an acute L3 osteoporotic vertebral compression fracture. Because of intolerance to prone positioning, PVP was performed in the lateral decubitus position. A novel unilateral puncture strategy via a facet-joint-transgressing trajectory was adopted to achieve a more medialized and anterior needle placement. Cement was injected during the doughy phase, using gravitational forces to facilitate cross-midline diffusion. Postoperative imaging confirmed satisfactory bilateral cement distribution without leakage. The patient experienced immediate pain relief and significant functional improvement. CONCLUSION: This case demonstrates a novel position-trajectory-gravity coupling strategy, integrating lateral decubitus positioning with a facet-joint-transgressing unilateral approach. This technique enables effective bilateral cement distribution under constrained positioning conditions and expands the technical feasibility of PVP in patients unable to tolerate standard prone positioning.