Risk factors for subsequent vertebral fractures after percutaneous vertebral augmentation in Asian populations: a systematic review and meta-analysis

Weijie Zheng; Jiexin Huang; Liang Jin; Qiaoli Zhang; TianFeng Li; WanChen Gong; Yuchen Xia; Zhengyi Lin; Fei Zhou; Chengwu Lu; Libao Zhang; Changhui Xue; Hong Ye; Linfeng Wang

doi:10.1186/s12891-025-08998-x

. 2025 Aug 16;26:791. doi: 10.1186/s12891-025-08998-x

Risk factors for subsequent vertebral fractures after percutaneous vertebral augmentation in Asian populations: a systematic review and meta-analysis

Weijie Zheng ^1,^2,^#, Jiexin Huang ^1,^#, Liang Jin ^1,^2,^#, Qiaoli Zhang ^1,^2,^#, TianFeng Li ^1,², WanChen Gong ^1,², Yuchen Xia ^1,², Zhengyi Lin ^1,², Fei Zhou ¹, Chengwu Lu ¹, Libao Zhang ¹, Changhui Xue ¹, Hong Ye ^1,^2,^✉, Linfeng Wang ^1,^2,^✉

PMCID: PMC12357439 PMID: 40819163

Abstract

Objective

To identify the risk factors for subsequent vertebral fractures after percutaneous vertebral augmentation through the meta-analysis.

Methods

Articles from 2019 to 2024 were retrieved from PubMed, Cochrane Library, Embase, and Web of Science. The quality of included studies was assessed using the Newcastle–Ottawa Scale (NOS), while data analysis was performed with R (The R Project for Statistical Computing).

Results

Fourteen articles comprising data from 5,673 patients were included in the analysis. Statistically significant differences were identified for age, gender, T-score (measured by dual-energy X-ray absorptiometry), body mass index (BMI), Computed tomography Hounsfield unit (CT HU) value, intravertebral cleft (IVC), multi-segment vertebral fractures, and bone cement leakage. In contrast, no statistically significant differences were observed for hypertension history, diabetes history, thoracolumbar vertebral fracture, postoperative Cobb angle, surgical method（percutaneous vertebroplasty/percutaneous kyphoplasty）, puncture method (unilateral/bilateral puncture), or bone cement volume.

Conclusion

In Asian populations, advanced age, female, low T-score, low BMI, low CT HU values, presence of IVC, multi-segment vertebral fractures, and bone cement leakage are identified as significant risk factors for subsequent vertebral fractures following PVA. Conversely, a history of anti-osteoporosis treatment is identified as a protective factor, whereas hypertension history, diabetes history, thoracolumbar vertebral fracture, postoperative Cobb angle, surgical method, puncture method, and bone cement volume demonstrate no significant correlation with subsequent vertebral fractures after PVA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-025-08998-x.

Keywords: Percutaneous vertebral augmentation, Subsequent vertebral fractures, Osteoporotic vertebral compression fracture, Meta-Analysis

Introduction

Osteoporosis, characterized by low bone mass and deterioration of bone microarchitecture, is a prevalent geriatric condition affecting more than 200 million women worldwide each year [1]. Osteoporosis causes more than 8.9 million fractures globally each year, and fragility fracture is one of the major causes of people becoming bedridden with serious complications [2]. Osteoporotic vertebral compression fracture (OVCF) represents one of the most prevalent fragility fractures, affecting 30–50% of individuals over 50, with incidence rising markedly with age [3]. In an aging society, improving the prognosis of OVCF has emerged as a critical area of research.

In contemporary medical practice, percutaneous vertebral augmentation (PVA) has emerged as a crucial therapeutic approach for OVCF. PVA includes a range of techniques, including percutaneous vertebroplasty, percutaneous kyphoplasty, and so on. Studies indicate that early PVA intervention after OVCF, compared to conservative treatment, significantly alleviates back pain and improves postoperative quality of life. However, some studies suggest there is no significant efficacy difference between PVA and placebo treatments, and even raise concerns that PVA may elevate the risk of compression fractures [4–7]. The underlying mechanisms driving subsequent vertebral fracture (SVF) after PVA remain unclear and warrant further investigation.

SVF may be influenced by a multitude of factors, including but not limited to the patient’s age, nutritional status, IVC, vertebral height, surgical method, cement leakage, and operation time [8]. – [9] There remains considerable debate regarding the risk factors for SVF, with varying conclusions drawn by different scholars on the impact of factors [10–12]. The impact of surgical factors on SVF is a subject of intense scholarly interest. Some studies have indicated no significant difference in efficacy between PVP and PKP in the treatment of OVCF [13, 14], yet contrasting conclusions have also been presented [15, 16]. The debate over whether PVP or PKP raises the risk of SVF continues, with the potential influence of various factors that have yet to be precisely identified [17, 18].

Therefore, we conducted a meta-analysis examining 16 factors potentially associated with SVF, encompassing systemic factors involving the patient’s entire system, disease factors related to the fractured vertebrae, and surgical factors pertaining to the operation. The aim is to comprehensively assess the risk factors for SVF in patients with OVCF after PVA, providing a relatively thorough scientific basis for the clinical issue of preventing SVF.

Method

This systematic review and meta-analysis adhered to the preferred reporting items for systematic reviews and meta-analyses statements (PRISMA2020) [19]. The systematic review and meta-analysis was registered in the PROSPERO database. (PROSPERO ID: CRD42024620480)

Inclusion criteria

1. Original studies were published between 2019-2024; 2. Studies include patients with OVCF who have undergone PVA (including PVP or PKP); 3. Case-control studies, cohort studies, or randomized controlled trials.

Exclusion criteria

1. Reviews, letters, case reports, conference reports, and editorial comments; 2. Data presented in the literature cannot be used for conducting a meta-analysis, and the outcome indicators are incomplete; 3. Studies include patients with vertebral fractures caused by tumors; 4. Duplicate publications or studies using the same dataset; 5. Studies are not only published in English.

Information sources and literature search

Based on predefined search terms and strategies, the literature search was conducted independently by two researchers. In disputes over literature inclusion, two researchers consulted a third for a decision. Literature was retrieved from 4 databases: PubMed, Cochrane Library, Embase, and Web of Science. The PICO search strategy was used, with search terms including spinal fracture, compression fracture, subsequent fractures, refractures, secondary vertebral compression fractures, Vertebroplasty, Kyphoplasty, etc. (Supplement material).

Data extraction

Data was extracted independently by searchers, collecting the following information based on a pre-designed plan: (1) Research information: publication time, first author of the study, number of cases; (2) Systemic factors (factors affecting the patient’s entire body system): age, gender, BMI, T-score (measured by dual-energy X-ray absorptiometry), CT HU value, diabetes history, hypertension history, anti-osteoporosis treatment history; (3) Disease factors (factors related to fractured vertebrae): IVC, postoperative Cobb angle, thoracolumbar vertebral fracture, multi-segment fracture; (4) Surgical factors (factors related to PVA): surgical method (PVP/PKP), puncture method (unilateral/bilateral puncture), bone cement volume, bone cement leakage. Any disagreement was resolved through discussion with a third researcher.

Data analysis

Data was analyzed using the “meta” package in R language (Version 4.3.3). The odds ratio (OR) was used as the effect size for qualitative variables, and the weighted mean difference (WMD) was used for quantitative variables [20, 21]. The I² index was used to assess heterogeneity, with I² < 25% considered low heterogeneity, I² between 25% and 50% considered moderate heterogeneity, and I² > 50% considered high heterogeneity. If I² > 50%, a random-effects model was used to reduce the impact of high heterogeneity, otherwise, a fixed-effects model was used [22–24]. Sensitivity analysis was performed using the leave-one-out method to determine the robustness of the analysis results [25]. Funnel plots and Egger’s test were used to assess publication bias. P < 0.05 was considered statistically significant [26].

Assessment of the risk of bias

Risk assessment was conducted independently by two researchers, who used the Newcastle–Ottawa Scale (NOS) to assess the quality of the included studies. Any discrepancies in scoring between the two assessors were resolved through discussion with a third party. The NOS assigns a maximum of 9 points, where studies achieving a score of 7–9 are classified as high quality, those with a score of 4–6 are moderate quality, and those scoring below 4 are identified as low quality [27, 28].

Result

Literature search

From PubMed, Cochrane Library, Embase, and Web of Science, a total of 1,151 articles published between 2019 and 2024 were identified. After excluding 307 duplicates, 844 remaining articles’ abstracts were reviewed. Based on the inclusion and exclusion criteria, 81 articles on risk factors for SVF were selected. After reading the full text of these 81 articles, 18 articles were selected, and 63 articles were excluded because the data provided could not be used for this systematic review. 4 articles were excluded because they did not clearly group patients who chose conservative treatment and those who chose surgical treatment. A total of 14 articles were finally included for this analysis (Fig. 1). The 14 articles included 5,673 patients, all of which are retrospective cohort studies, with all articles having NOS ≥ 6 (Supplemental Table S1). All patients included in these 14 studies were from Asia. The basic information of the literatures is shown in Table 1.

Fig. 1 — Flow chart of the evidence search and selection process

Table 1.

Characteristics of the included studies

Author	Year	Country	Total patients	Refractures patients	Risk factors	NOS
Chen et al. [29]	2020	China	102	16	1,2,7,12,15	6
An et al. [30]	2021	China	257	82	1,2,3,4,9,13,14,15,16	8
Zhang et al. [31]	2021	China	2202	362	1,2,4,6,7,8,11,15,16	8
Li et al. [32]	2021	China	403	49	2,3,5,6,7,8,11,12,13,15,16	8
Chen et al. [33]	2021	China	109	13	1,2,9,10,15,16	7
Cheng et al. [34]	2022	China	247	23	1,2,3,5,6,7,8,11,13,15,16	7
Choi et al. [35]	2022	Korea	117	19	1,2,4,7,11,14,15,16	6
Zhang et al. [36]	2023	China	349	48	1,2,3,4,6,7,8,11,12,15,16	7
Qian et al. [37]	2023	China	332	43	2,6,7,10,11,13,16	6
Zhang et al. [38]	2023	China	279	47	1,2,3,5,6,7,11,13,15,16	6
Park et al. [39]	2023	Korea	128	28	1,2,4,7,11,14,15,16	6
Qi et al. [40]	2024	China	269	37	1,2,3,4,6,7,10,12,15	8
Nie et al. [41]	2024	China	611	165	1,2,3,4,7,8,9,10	7
Feng et al. [42]	2024	China	268	33	1,2,3,4,6,7,8,9,10,11,14,15,16	7

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Risk factors: 1. Age 2. Gender 3.BMI 4. T-score 5. CT HU value 6.Hypertension 7. Diabetes 8. Anti-osteoporosis treatment 9. Intravertebral cleft 10. Multi-segment fracture 11. Thoracolumbar vertebral fracture 12. Post-op Cobb angle 13 Surgical method 14. puncture method 15. Cement volume 16. Cement leakage

NOS the Newcastle–Ottawa Scale

Risk factors

Systemic factors

We included 8 systemic factors in our analysis: age, gender, BMI, T-score, CT HU value, hypertension history, diabetes history, and anti-osteoporosis treatment history (Table 2).

Table 2.

Overall analysis of all risk factors of secondary vertebral compression fractures after percutaneous vertebral augmentation

Risk factors	OR/WMD	95%CI	P	I²	Sensitivity analysis	Egger’s test
Age*	2.58^§	1.07—4.09	< 0.01	88%	Robust	0.1451
Gender*	1.35^†	1.41—1.60	< 0.01	33%	Robust	0.6931
BMI*	−1.08^§	−1.76— −0.39	< 0.01	71%	Robust	0.0940
T-score*	−0.56^§	−0.80— −0.33	< 0.01	95%	Robust	< 0.05
CT HU value*	−26.05^§	−44.37— −7.73	< 0.01	92%	Not Robust	0.9203
Hypertension	1.00^†	0,84—1.20	0.99	13%	Robust	0.078
Diabetes	1.15^†	0.96—1.38	0.13	39%	Robust	< 0.05
AOT*	0.33^†	0.22—0.49	< 0.01	62%	Robust	0.3866
IVC*	2.83^†	1.68—4.77	< 0.01	55%	Robust	0.4546
Multi-segment fracture*	2.40^†	1.63—3.78	< 0.01	26%	Robust	0.9414
TLVF	0.73^†	0.51—1.04	0.08	51%	Robust	0.5802
Post-op CA	1.42^§	−2.48—5.32	0.48	92%	Robust	0.4496
Surgical method	0.88^†	0.50—1.55	0.66	71%	Robust	0.6774
Method of puncture	1.14^†	0.61—2.11	0.68	59%	Not Robust	0.4373
Cement volume	−0.07^§	−0.35—0.22	0.64	95%	Robust	0.0506
Cement leakage*	2.29^†	1.41—3.73	< 0.01	81%	Robust	< 0.05

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CI confidence interval, TLVF thoracolumbar vertebral fracture, CT HU value Computed tomography Hounsfield unit value, AOT anti-osteoporosis treatment, IVC Intravertebral cleft, CA Cobb angle

^†OR Odds Ratio

^§WMD Weighted Mean Difference

*P < 0.05

All 14 studies reported the correlation between patient gender and SVF, and our analysis found that among Asian populations, female patients are more likely to occur SVF (OR = 1.35; 95%CI: 1.14—1.60; p < 0.01), with moderate heterogeneity (I²=33%) (Fig. 2).

Fig. 2 — Forest plots for outcomes on the risk of gender; CI, confidence interval; OR, odds ratio

Twelve studies investigated the correlation between age and SVF. The analysis results indicated that older patients in Asian populations are more susceptible to SVF (WMD = 2.58; 95%CI, 1.07—4.09; p < 0.01), (Fig. 3) with high heterogeneity (I² = 88%).

Fig. 3 — Forest plots for outcomes on the risk of age; CI, confidence interval; OR, odds ratio; RF, refracture; NRF, no-refracture

Eight studies reported the correlation between BMI and SVF (WMD=−1.08; 95%CI, −1.76— −0.39; p < 0.01), with high heterogeneity (I²=71%), indicating that lower BMI is associated with a higher risk of SVF in Asian populations (Fig. 4).

Fig. 4 — Forest plots for outcomes on the risk of BMI; CI, confidence interval; OR, odds ratio; BMI, body mass index; RF, refracture; NRF, no-refracture

Dual-energy X-ray absorptiometry (DXA), the most commonly used method for measuring BMD, often presents its results in terms of T-score [43]. The risk of T-score was reported by 8 studies (WMD=−0.56; 95%CI, −0.80—−0.33; p < 0.01) (Fig. 5) with high heterogeneity (I²=95%), which could not be effectively reduced by excluding any single study. The high heterogeneity may be related to different measurement instruments and different average bone density levels in different regions.

Fig. 5 — Forest plots for outcomes on the risk of T-score; CI, confidence interval; OR, odds ratio; RF, refracture; NRF, no-refracture

The analysis of CT HU values, another indicator for bone density assessment [44, 45], yielded similar results to T-score (WMD=−26.05; 95%CI, −44.37— −7.73; p < 0.01), with high heterogeneity (I²=92%) (Fig. 6).

Fig. 6 — Forest plots for outcomes on the risk of CT HU value; CI, confidence interval; OR, odds ratio; CT HU value, Computed tomography Hounsfield unit value; RF, refracture; NRF, no-refracture

The risk of SVF in diabetic patients was reported by 12 studies (OR = 1.15; 95%CI, 0.96—1.38; p = 0.13) with moderate heterogeneity (I²=39%). The risk of hypertension history was reported by 8 studies (OR = 1.00; 95%CI, 0.84—1.20; p = 0.99) with low heterogeneity (I²=13%) (Supplemental Figure S1-2).

Six studies reported on the relationship between anti-osteoporosis treatment and SVF (OR = 0.33; 95%CI, 0.22—0.49; p < 0.01) with high heterogeneity (I²=62%). After removing the study by Li et al. [32], the heterogeneity significantly decreased (I²=0%). The result indicates that antiosteoporosis treatment can effectively reduce the risk of SVF in Asian populations (Fig. 7).

Fig. 7 — Forest plots for outcomes on the risk of anti-osteoporotic treatment; CI, confidence interval; OR, odds ratio; AOT, anti-osteoporotic treatment

Disease factors

Four factors were classified as disease factors: IVC, multi-segment vertebral fractures, thoracolumbar vertebral fracture, and postoperative Cobb angle (Table 2).

The risk of IVC was reported by 4 studies (OR = 2.83; 95%CI, 1.68—4.77; p < 0.01) with high heterogeneity (I²=55%), indicating that patients with IVC have a higher risk of SVF in Asian populations (Fig. 8). According to the analysis of 5 studies, patients with multi-segment vertebral fractures have an increased risk of SVF in Asian populations (OR = 2.40; 95%CI, 1.63—3.78; p < 0.01), with moderate heterogeneity (I²=26%) (Fig. 9).

Fig. 8 — Forest plots for outcomes on the risk of IVC; CI, confidence interval; OR, odds ratio; IVC, Intravertebral cleft

Fig. 9 — Forest plots for outcomes on the risk of multi-segment fractures; CI, confidence interval; OR, odds ratio

The factors of thoracolumbar vertebral fracture and postoperative Cobb angle showed no significant correlation with SVF in our analysis (Supplemental Figure S3-4).

Surgical factors

We included four surgical factors for analysis: surgical method (PVP/PKP), puncture method (unilateral/bilateral), bone cement volume, and bone cement leakage (Table 2).

Six studies reported the incidence of SVF in patients who underwent PVP or PKP. The analysis results indicated that there was no significant difference in the risk of SVF between patients who underwent these two surgical procedures in Asian populations (OR = 0.88; 95% CI, 0.50—1.55; p = 0.66), with high heterogeneity (I² = 71%) (Supplemental Figure S5).

Four studies reported on the correlation between puncture method and SVF. The analysis results indicated that there was no significant correlation between SVF and puncture method in Asian populations (OR = 1.14; 95% CI, 0.61—2.11; p = 0.68), with high heterogeneity (I² = 59%) (Supplemental Figure S6).

Eleven studies reported the correlation between bone cement volume and SVF (WMD=−0.07; 95%CI, −0.35—0.22; p = 0.64), indicating no statistical difference in bone cement volume between the no-fracture group and the subsequent fracture group in Asian populations (Supplemental Figure S7), with high heterogeneity (I²=95%). The high heterogeneity may be due to the need for varying volumes of bone cement injection for patients with different degrees of fracture compression or bone density.

The risk of bone cement leakage was reported by 11 articles (OR = 2.29; 95%CI, 1.41—3.73; p < 0.01), with high heterogeneity (I²=81%). The analysis result indicates that bone cement leakage may lead to a higher risk of SVF in Asian populations (Fig. 10).

Fig. 10 — Forest plots for outcomes on the risk of bone cement leakage; CI, confidence interval; OR, odds ratio; BCL, bone cement leakage

Sensitivity analyses and publication bias analyses

We performed sensitivity analysis on 16 factors using the leave-one-out method, and the results indicated that the analysis results were stable except for CT HU value and puncture method. The unstable results for CT HU value and puncture method may be due to the small number of studies included in the analysis (Supplemental Figure S8- 23).

We used funnel plots and Egger’s test to assess publication bias and found that the analysis results for T-score (p < 0.01), diabetes (p < 0.01), and bone cement volume (p < 0.01) were at risk of publication bias, and the analysis result for bone cement leakage (p = 0.0506) may be at risk of publication bias. The analysis results for other factors showed no risk of publication bias (Supplemental Figure S24- 39 & Table 2).

Discussion

Aging populations are increasing the prevalence of osteoporosis and its severe complication, OVCF, which cause back pain, bedridden states, and higher mortality [46]. PVA is a common treatment for OVCF, though it has its controversies and may lead to SVF [47]. As a postoperative complication of PVA, the influencing factors of SVF remain unclear. Therefore, we analyzed the relevant risk factors to assist clinicians in guiding OVCF patients to prevent SVF.

Our meta-analysis of 16 factors in patients after PVA identified advanced age, female gender, low BMI, low T-score, low CT HU value, IVC, multi-segment vertebral fractures, and bone cement leakage as risk factors for SVF. Anti-osteoporosis treatment was found to be protective. Hypertension, diabetes, thoracolumbar vertebral fracture, postoperative Cobb angle, surgical method, puncture method, and bone cement volume show no significant associations with SVF. As all included studies enrolled patients exclusively from Asian populations, these findings may be more applicable to Asian populations.

Systemic factors

Many studies have shown that postmenopausal women are particularly susceptible to osteoporosis due to estrogen level changes [48]. However, it is not clear whether female patients have a higher risk of SVF. Our analysis found that female patients are more likely to have SVF in Asian populations. We also found that among Asian populations, older age also correlates with a higher risk of SVF, likely due to BMD loss associated with age and menopause [49]. DXA T-score and CT HU value, as quantitative assessment indicators of BMD, were also analyzed in our study. The analysis results show that patients with lower DXA T-score or lower CT HU value are more likely to have SVF in Asian populations. The impact of age, gender, DXA T-score, or CT HU value on SVF still needs further clarification through multivariate analysis. Beyond DXA and CT HU value, several emerging techniques for osteoporosis assessment warrant attention. Cai et al. reported that MRI-based vertebral bone quality (VBQ) score may predict subsequent fractures following percutaneous vertebroplasty (PVA). The association between VBQ and refracture risk merits further investigation [50].

The analysis results of this article indicate that the lower the patient’s BMI, the higher the risk of SVF in Asian populations. Fang et al.‘s research [51] suggests that patients with poor nutritional status have a higher risk of SVF. Combined with our analysis result, we believe that compared with obesity causing increased stress on the vertebrae, malnutrition may have a greater impact on SVF. However, considering that the mean BMI of the patients included in the analyzed articles is within the normal range, further research is needed to confirm the impact of BMI on SVF in the obese population.

The analysis results of this article indicate that diabetes and hypertension may not be significantly related to SVF in Asian populations, which is similar to the research result of Ning et al. [52] However, SVF may be related to other diseases, such as sarcopenia and chronic gastritis [53–56]. The correlation between SVF and other chronic diseases is still worth further exploration.

The result indicates that patients who have undergone anti-osteoporosis treatment have a lower risk of SVF in Asian populations. The analysis of this article is consistent with current research results [57]. Therefore, we recommend that OVCF patients undergo systematic anti-osteoporosis treatment after PVA. The choice of anti-osteoporosis drugs and their effectiveness in preventing postoperative fractures is an area needing further research.

Disease factors

Among the 4 factors classified as disease factors, only IVC and multi-segment fractures showed statistical differences between the re-fracture group and the no-fracture group, while thoracolumbar vertebral fracture and postoperative Cobb angle showed no statistical differences in our analysis results. Our analysis results show that OVCF with IVC and multi-segment fractures are risk factors for SVF in Asian populations, which is consistent with some current research reports [58, 59]. There is still controversy over the surgical method for IVC and multi-segment fractures [60], and further research is needed to explore the treatment plan for these specific vertebral fractures.

Surgical factors

The study analyzed 4 surgical factors: surgical method (PVP/PKP), puncture method (unilateral/bilateral), bone cement volume, and bone cement leakage. The analysis results show that only bone cement leakage may be related to a higher risk of SVF, while other factors showed no significant difference in risk between the re-fracture and non-fracture groups.

Our findings align with Zhang et al. [61] in showing no significant difference between PVP and PKP in causing SVF. Gu et al. [62] also found no significant difference in pain relief between the two methods, while Wei et al. [60] reported a lower leakage rate with PKP. There is still controversy over the efficacy of PVP and PKP for OVCF patients, and the surgical method should be formulated based on the condition for different types of OVCF.

Our analysis results found that puncture method is not related to the risk of SVF, which is consistent with the research results of Zhang et al. [63] However, the evidence is not robust due to the limited number of studies, and further research is needed to clarify the puncture method’s impact on SVF. Current research suggests that puncture method can affect the distribution of bone cement and thus affect the risk of SVF. Consequently, many scholars believe that bone cement used in unilateral puncture should approach or extend beyond the vertebral body’s midline [64, 65]. Additionally, the decision for unilateral or bilateral puncture should be made by considering the extent of vertebral compression and the specific morphology of the compressed vertebrae.

Lin et al. suggests that the volume of bone cement injection is not significantly related to SVF, but it can lead to a higher risk of adjacent vertebral fractures [66]. This is because too much bone cement can lead to bone cement leakage and increased stress on the intervertebral disc [67, 68]. Therefore, the impact of bone cement volume on adjacent vertebral fractures still needs further analysis.

Many current studies indicate that bone cement leakage is a risk factor for SVF [69, 70], which is consistent with our analysis results. This risk is likely due to leakage into the intervertebral disc, increasing stress on adjacent vertebrae [71]. Bone cement leakage is a common complication of PVA, not only leading to SVF but also causing serious consequences such as pulmonary embolism [72]. Therefore, cement leakage requires vigilant monitoring during clinical practice, with fluoroscopic observation of cement distribution during surgery. The impact of bone cement leakage on vertebral stress still requires further research.

Limitation and strength

This study has certain strengths. First, the patients included in the analysis have undergone PVA treatment, and we analyzed several surgery-related factors, which is relatively rare in current meta-analyses focusing on SVF. Second, we included up to 16 factors, and for each factor analyzed, we incorporated data from no fewer than three studies. Moreover, sensitivity analysis has proven that most of our analysis results are robust. Third, the included studies were published between 2020 and 2024, which are the latest research results in recent years. Fourth, after bias assessment, all included studies are of medium to high quality, meaning that the data used for analysis is relatively reliable.

This study has certain limitations. First, all included studies are cohort studies, and no randomized controlled trials are included. Second, our analysis of various factors is limited to single-factor analysis and does not consider the mutual influence of various factors. Third, as patients in all included studies were exclusively from Asia, extrapolation of these findings to other geographic regions should be interpreted with caution.

Conclusion

In summary, we identified 8 risk factors for subsequent OVCF in patients undergoing PVA in Asian populations: advanced age, female, low T-score, low BMI, low CT HU value, IVC, multi-segment vertebral fractures, and bone cement leakage, and 1 protective factor: history of anti-osteoporosis treatment. OVCF patients with risk factors should be more vigilant in preventing subsequent vertebral fractures after PVA, undergo systematic anti-osteoporosis treatment, and maintain good living habits

Supplementary Information

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Acknowledgements

The authors thank all patients and clinical researchers involved in the studies that included in this paper.

Clinical trial number

Not applicable.

Abbreviations

OVCF: Osteoporotic vertebral compression fracture
PVA: Percutaneous Vertebral Augmentation
PVP: Percutaneous vertebroplasty
PKP: Percutaneous kyphoplasty
SVF: subsequent vertebral fracture
NOS: the Newcastle–Ottawa Scale
DXA: dual-energy X-ray absorptiometry
CT HU: CT Hounsfield unit value
IVC: intravertebral cleft
CA: Cobb angle

Authors’ contributions

Weijie Zheng: Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing-original draft, Writing-review & editing.Jiexin Huang: Conceptualization, Data curation, Writing-original draft. Liang Jin: Data curation, Validation, Writing-original draft, Writing-review & editing.Qiaoli Zhang: Data curation, Formal analysis, Writing-review & editing.TianFeng Li; WangChen Gong; Yuchen Xia; Zhengyi Lin; Fei Zhou: Data curation, Formal analysis; Chengwu Lu; Libao Zhang; Changhui Xue: Data curation, Writing-review & editing.Hong Ye: Conceptualization, Formal analysis, Methodology, Writing-original draft, Writing-review & editing.Linfeng Wang: Conceptualization, Project administration, Formal analysis, Methodology, Writing-original draft, Supervision, Writing-review & editing.

Funding

N2024LH010/Nanping City Joint Fund Project for Scientific and Technological Innovation in the Medical and Health Field, China.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Institutional Review Board approval was not required because of the nature of this article.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Weijie Zheng, Jiexin Huang, Liang Jin and Qiaoli Zhang contributed equally to this work.

Contributor Information

Hong Ye, Email: 507647274@qq.com.

Linfeng Wang, Email: wanglf15@fjmu.edu.cn.

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