Selective nerve block-guided bilateral T10 nerve root transection using unilateral biportal endoscopy for persistent severe intercostal neuralgia caused by cement leakage after percutaneous vertebroplasty: a case report and literature review

Abstract Background : Symptomatic cement leakage after percutaneous vertebroplasty (PVP) is uncommon but may cause severe radicular pain or neurological deficits when the leaked cement involves the spinal canal or neural foramen. Thoracic foraminal cement leakage presenting as refractory intercostal neuralgia is particularly rare, and identifying the responsible nerve root can be challenging when multiple adjacent foramina are involved. Case presentation: An 83-year-old woman underwent PVP for fresh osteoporotic compression fractures of T10 and L5. Her preoperative low back pain resolved completely after PVP; however, she immediately developed severe bilateral intercostal neuralgia radiating from the costal arches to the periumbilical region, with a visual analog scale score of 8. Computed tomography showed cement leakage into the bilateral T9/10 and T10/11 foraminal regions. Because imaging alone could not reliably determine the symptomatic level, staged bilateral selective nerve block was performed. Bilateral T9/10 foraminal block did not relieve the pain, whereas bilateral T10/11 foraminal block produced marked pain relief, indicating that the bilateral T10 nerve roots were responsible. After failed conservative treatment, unilateral biportal endoscopic bilateral T10 nerve root transection was performed. Intraoperatively, only a limited amount of cement that obstructed nerve root exposure was removed, followed by targeted transection of the bilateral T10 nerve roots under endoscopic visualization. The patient’s intercostal neuralgia resolved immediately after surgery, and no recurrence or major surgery-related complication was observed at the 3-month follow-up. Conclusion : In patients with symptomatic cement leakage after PVP, imaging findings may not always correspond to the responsible pain-generating level, especially when multiple adjacent foramina are involved. Selective nerve block may provide useful functional evidence for identifying the symptomatic nerve root. For carefully selected patients with refractory thoracic radicular pain, unilateral biportal endoscopic nerve root transection may represent an individualized salvage option when complete cement removal is unnecessary or associated with excessive surgical risk. However, because nerve root transection is irreversible, strict patient selection, reliable localization, adequate risk assessment, and informed consent are essential.