PATIENT FACTORS

It is suggested that decreased bone mineral density is associated with an increased risk of further fractures (new or recollapse) after vertebral augmentation of osteoporotic vertebral compression fractures. Grade of Recommendation: B

In a prospective comparative study, Liu et al1 investigated the risk factors of new vertebral compression fractured following a PVP in patients who had osteoporosis. The authors concluded that “The incidence of new VCFs after PV is relatively high and affected by several risk factors that are related to both the PV procedure and the natural course of osteoporosis.” This paper provides Level II evidence that the number of VCFs initially, CT value of nonfractured vertebrae, and activity level following discharge is strongly associated with the risk of new VCFs after PV.

In a prospective comparative study, Movrin et al2 assessed the adjacent level fracture risk after a BKP in comparison to a VP. Another aim of this study was to determine the possible dominant risk factor that is associated with new compression fractures. The authors concluded that “BK and VP are methods with a low risk of adjacent level fractures. The most important factors for new VCFs after a percutaneous augmentation procedure are the degree of osteoporosis and altered biomechanics in the treated area of the spine due to resistant kyphosis. These results suggest that the adjacent vertebrae would fracture eventually, even without the procedure. BK and VP offer a comparable rate of pain relief.” This paper provides Level II evidence that the degree of osteoporosis is a risk factor for new VCFs after percutaneous vertebral augmentation. In a prospective comparative study, Nieuwenhujse et al3 described the risk factors for new vertebral fractures, as well as estimate the fracture-free probabilities of multiple intact nontreated vertebrae given the patient- and vertebra-specific covariate status. The authors concluded that “New vertebral fractures after PVP were clustered within patients and depended heavily on the presence or absence of both patient- and vertebra-specific risk factors. Intradiskal cement leakage was a pronounced augmentation-related risk factor, for which a volumetric association was found.” This paper provides Level II evidence that patient level (low BMD, high spine deformity index, short-time since fracture onset) and vertebral-specific (thoracolumbar junction, close vicinity to the treated level) factors are associated with the development of new VCFs within 1-year after PVP. In a retrospective comparative study, Bae et al4 examined the risk factors for secondary new vertebral compression fractures (SNVCF) in patients with osteoporosis after they had undergone PVP. The authors concluded that “Poor bone mineral content can be a predictive factor of SNVCFs. To prevent SNVCFs, bone cement should be injected as evenly as possible into the vertebral body. Bone cement leakage into the disc space should be avoided.” This paper provides Level III evidence that patients developing SNVCF after PVP have lower bone mineral content (BMC) and cement leakage compared to those not developing SNVCF. In a retrospective comparative study, Chen et al5 investigated the risk factors that contributed to secondary vertebral compression fractures (SVCF) in patients who had undergone PVP or PKP due to an OVCF. The authors concluded that “older age and lower BMD were identified as risk factors of SVCF for OVCF patients following PVP/PKP surgery, whereas more ODA played a protective role in SVCF development.” This paper provides Level III evidence that increasing age is associated with higher likelihood of developing SVCF after PKP/PVP whereas higher BMD and higher outdoor activity is associated with decreased risk of developing fractures. In a retrospective comparative study, Gao et al6 studied the pre- and postoperative risk factors of the occurrence of short-term cement leakages, as well as long-term complications after PKP for OVCF. The authors concluded that “The presence of cortical disruption, large volume of cement, and low BMD of treated level are general but strong predictors for cement leakage. The presence of intravertebral cleft and Schmorl nodes are additional risk factors for cortical leakage. During follow-up, the occurrence of C-type leakage is a strong risk factor, for both new VCFs and recompression.” This paper provides Level III evidence that low BMD and cortical disruption are factors of cement leakage. Low BMD also associated with new VCF. IVC and Schmorl notes are respective risk factors for paravertebral type and c-type CL. In a retrospective comparative study, Hey et al7 assessed the relation between level-specific preoperative bone mineral density and subsequent vertebral fractures. Another aim of this study was to identify the factors that are associated with subsequent vertebral fractures. The authors concluded that “Level-specific T-scores are predictive of subsequent fractures and the odds ratio increases with lower T-scores from 2.2 or less to 2.6 or less. They have a low positive predictive value, but a high negative predictive value for subsequent fractures. Other significant associations with subsequent refractures include age and anterior vertebral height.” This paper provides Level III evidence that specific cutoffs of T-scores and age correlate with new fractures after vertebral augmentation procedures. In a prospective comparative study, Hiwatashi et al8 analyzed preoperative multidetector row CT (MDCT) in the prediction of subsequent fractures after PVP. The authors concluded that “The small size of the treated vertebrae may relate to subsequent fractures in adjacent vertebrae. Steroid use and low CT value of nonfractured vertebrae on preoperative MDCT can be associated with subsequent fractures in remote vertebrae.” The work group downgraded this potential Level II paper due to small sample size. This paper provides Level III Evidence that steroid use and low CT value are risk factors for new fractures in remote vertebrae while small vertebral size may be a risk for adjacent vertebral fractures. In a retrospective case-control study, Hu et al9 evaluated the factors that caused vertebral fractures after VP, as well as calculate the appropriate amount of bone cement to inject. The authors concluded that “Bone cement injection volume, BMD values, and sex were statistically significantly related to adjacent vertebral fractures after vertebroplasty, and cement injection volumes exceeding 40.5% caused adjacent vertebral fractures.” This paper provides Level III evidence that refractures after VP tend to occur more in females and those with lower BMD. In a retrospective comparative study, Huang et al10 examined the risk factors of vertebral new fractures after patients with primary osteoporotic thoracolumbar fractures had undergone PKP. The authors concluded that “Severe osteoporosis and bone cement leakage are risk factors of vertebral new fractures after PKP in patients with primary osteoporotic thoracolumbar fractures. Our findings suggest a requirement for anti-osteoporosis treatment after PKP operation for patients with primary osteoporotic thoracolumbar fractures.” This paper provides Level III evidence that osteoporosis and bone cement leakage are risk factors associated with new vertebra fractures post PKP. In a prospective comparative study, Komemushi et al11 assessed the relationship between biochemical marks of bone turnover, BMD, and new compression fractures following PVP. The authors concluded that “A combination of high levels of bone resorption markers and normal levels of bone formation markers may be associated with increased risk of new recurrent fractures after percutaneous vertebroplasty.” The work group downgraded this potential Level II paper due to no sample size, less than 80% follow-up, validated outcome measures not being used, and nonrandomization. This paper provides Level III evidence that high fracture risk patients (based on biochemical markers) have higher proportional of new fractures.

In a retrospective comparative study, Lee et al12 evaluated the risk factors for a SNVCF after a PVP is done to treat an OVCF. The authors concluded that “Low BMD, high preoperative compression ratio, and high preoperative SI may be predictive factors for SNVCFs. In particular, to prevent AVCF, the injected bone cement should be distributed both evenly and symmetrically along the inferior-to-superior axis and the relative bone cement volume should not be excessive. Bone cement should be injected carefully to avoid upper adjacent intradiscal leakage. Prompt BMD correction is important to prevent SNVCF.” This paper provides Level III evidence that in patients with single-level OVCF, a low BMD and high preop SI are associated with the risk of developing secondary NVCFs following PVP. In a retrospective comparative study, Li et al13 examined the incidence and potential causative factors of refracture in patients with OVCF who had undergone PVP or PKP. The authors found that low BMD, treatment by PKP vs vertebroplasty, and low cement volume potentially risk a recollapse of the treated vertebra. This paper provides Level III evidence that low BMD is a risk factor of vertebral recollapse after PKP/PVP. In a retrospective comparative study, Lin et al14 evaluated the characteristics of a recurrent fracture of a new vertebral body in patients with osteoporosis after having undergone PVP. The authors concluded that “A substantial number of patients with osteoporosis develop new fractures after vertebroplasty; two-thirds of these new fractures occur in vertebrae adjacent to those previously treated. The following variables influence the outcome: BMI, history of fractures, history of metabolic diseases and medications, BMD of lumbar spine and hip, anti-osteoporosis therapy, and use of back brace.” The work group downgraded this potential Level III paper due to low sample size and nonconsecutive patients. This paper provides Level IV evidence that patients developing new fractures after PV for OVCF differ significantly from those not developing new fractures in terms of BMI (low BMI vs controls), lower BMD and lower serum PTH levels. In a retrospective comparative study, Lu et al15 assessed the risk factors for subsequent vertebral compression fractures after undergoing PVP. The authors concluded that “The only risk factor significantly associated with subsequent vertebral compression fractures following percutaneous vertebroplasty was a low bone mineral density T-score. Patients with lower bone mineral density have a higher incidence of vertebral compression fractures and thus need more intensive clinical and radiological follow-up.” This paper provides Level III evidence that low T-scores (low BMD) are associated with the development of new VCFs after PV in patients with OVCF. In a retrospective comparative study, Sun et al16 aimed to identify the risk factors that are related to the development of subsequent fractures following VP. The authors concluded that “The most important risk factors affecting subsequent fractures after vertebroplasty were osteoporosis and treated level at the thoracolumbar junction.” This paper provides Level III evidence that low BMD and thoracolumbar location is associated with the development of subsequent new fractures in OVCF patients after VP. In a retrospective comparative study, Takahara et al17 analyzed the risk factors among several possible predictors for de novo vertebral fractures following percutaneous vertebroplasty in patients who had osteoporosis. The authors concluded that “advanced age and decreased lumbar and hip BMD scores most strongly indicated a risk of adjacent VF following PVP.” This paper provides Level III evidence that lower BMD and advancing age are significant risk factors associated with vertebral collapse after PVP in postmenopausal women. In a retrospective comparative study, Tseng et al18 evaluated the characteristics and risk factors of new-onset VCF following PVP. The authors concluded that “older patient age, lower baseline BMD, and more pre-existing vertebral fractures were found to be risk factors for multiple vertebral compression fractures.” This paper provides Level III evidence that patients experiencing 2 or more VCFs after initial PVP for OVCF tend to be relatively older, with lower baseline BMD, and have more pre-existing VCFs. In a retrospective comparative study, Wang et al19 assessed the incidence, risk factors, and possible causative mechanism of symptomatic AVF. Another aim of the study was to assess the intrinsic relationship between cement leakage into the disc and AVF. The authors concluded that “Older age, lower BMD, and intravertebral clefts are the main risk factors for symptomatic AVF after vertebral augmentation, but intradiscal cement leakage does not increase the risk of AVF. AVF occurs because of the natural progression of osteoporosis. Even distribution of bone cement in the vertebral body is important in OVCF patients with intravertebral clefts.” This paper provides Level III evidence that advancing age, lower BMD, and the presence of IVC is associated with the risk of AVF after PV in patients with OVCF. In a retrospective comparative study, Wu et al20 investigated the possible risk factors of secondary adjacent vertebral fractures after PKP in the treatment of OVCF. The authors concluded that “Fissure fracture, absence of systemic anti-osteoporosis therapy, leakage of bone cement into intervertebral disc, topical anesthesia and loss in bone density are high-risk factors of secondary adjacent vertebral fracture after PKP.” This paper provides Level III evidence that fracture type, use of antiosteoporotic treatment, and bone density are factors associated with the development of secondary AVF after PKP in OVCF patients. In a retrospective comparative study, Yang et al21 evaluated the risk factors and correlation of secondary adjacent vertebral compression fractures in percutaneous kyphoplasty. The authors concluded that “Patients with a lower bone mineral density value preoperative, larger balloon volume, cement volume, recovery rate of vertebral height and bone cement leakage intraoperative have an increased risk of adjacent vertebral compression fracture after percutaneous kyphoplasty.” This paper provides Level III evidence that patients incurring ACVF after PKP for OVCF have lower BMD. In a retrospective comparative study, Lin et al22 aimed to quantify symptomatic new VCF, as well as identify the risk factors for NSVCF in patients who had gone through percutaneous vertebroplasty. The authors concluded that “The most important risk factor affecting new VCFs is osteoporosis. The incidence of new symptomatic VCFs after PVP is higher in osteoporotic patients with lower BMD.” The work group downgraded this potential Level III paper due to nonconsecutive patients, nonrandomization, validated outcome measures not being used, and the diagnostic method not being stated. This paper provides Level IV evidence that lower BMD scores to be associated with increased risk of new VCF after PVP. In a retrospective comparative study, Li et al23 studied the risk factors for adjacent vertebral compression fractures following percutaneous vertebroplasty in patients with OVCF after going through menopause. The authors concluded that “A long duration of menopause and preoperative multi-level vertebral fractures were the risk factors for AVCF in patients following PVP after menopause, while a high-level BMD acted in a protective role for AVCF development.” The work group downgraded this potential Level III paper due to information that was lacking on the experimental study. This paper provides Level IV evidence that the duration of menopause and number of preop vertebral fractures are associated with an increased risk of AVCF after PVP. On the contrary, BMD was associated with lower risk of AVCF after PVP. In a retrospective comparative study, Lee et al24 examined the risk factors for newly developed OVCFs after vertebroplasty, kyphoplasty, or conservative treatment. The authors concluded that “Osteoporotic vertebral compression fracture patients with low BMD T-score of the lumbar spine and those who have been treated by cement augmentation have an increased risk of new OVCFs after treatment and, therefore, require especially careful observation and attention.” The work group downgraded this potential Level II paper due to less than 80% follow-up, nonconsecutive patients, and nonrandomization. This paper provides Level III evidence due to low BMD and VK/KP (with reference to conservative treatment) is associated with increased odds of development of new fractures. In a retrospective comparative study, Rho et al25 aimed to quantify symptomatic new vertebral compression fractures in patients who had undergone percutaneous vertebroplasty or percutaneous kyphoplasty, as well as evaluate the factors that would cause de novo fractures. The authors concluded that “The most important risk factors affecting NVCFs were osteoporosis and intervertebral discal cement leakage.” The work group downgraded this Level III paper due to nonconsecutive patients and nonrandomization. This paper provides Level IV evidence that osteoporosis (low BMD T-scores) is associated with new VCFs after vertebral augmentation.

Work Group Narrative: A majority of the evidence supported this recommendation, however there was one outlier, as it did not find a statistically significant effect on the occurrence of new vertebral fractures.

In a prospective randomized control trial study, Alhashash et al26 assessed the effect of bone cement viscosity and bone porosity on cement leakage during VP. Another purpose of this study was to analyze the occurrence of new vertebral fractures after vertebroplasty. The authors concluded that “The clinical outcome of vertebroplasty was not influenced by cement viscosity. However, lower cement viscosity and higher degree of osteoporosis were found to be significant risk factors for cement leakage. Furthermore, the number of vertebral body fractures on presentation was a predictor for the occurrence of new fractures postoperatively.” The work group downgraded this potential Level I paper due to nonconsecutive patients and a lack of robust applications, including adjusted regression analysis. This paper provides Level II evidence that the proportion of patients incurring cement leakage post-VP is higher in those with lower T-score and those injected with low-viscous cement and patients with multiple fractures at presentation (preop) were noted to have higher rates of new fractures postoperatively.

References: 1. Liu WG, He SC, Deng G, et al. Risk factors for new vertebral fractures after percutaneous vertebroplasty in patients with osteoporosis: a prospective study. J Vasc Interv Radiol. 2012;23(9):1143-1149. doi:10.1016/j.jvir.2012.06.019 2. Movrin I, Vengust R, Komadina R. Adjacent vertebral fractures after percutaneous vertebral augmentation of osteoporotic vertebral compression fracture: a comparison of balloon kyphoplasty and vertebroplasty. Arch Orthop Trauma Surg. 2010;130(9):1157-1166. doi:10.1007/s00402-010-1106-3 3. Nieuwenhuijse MJ, Putter H, van Erkel AR, Dijkstra PD. New vertebral fractures after percutaneous vertebroplasty for painful osteoporotic vertebral compression fractures: a clustered analysis and the relevance of intradiskal cement leakage. Radiology. 2013;266(3):862-870. 4. Bae JS, Park JH, Kim KJ, Kim HS, Jang IT. Analysis of Risk Factors for Secondary New Vertebral Compression Fracture Following Percutaneous Vertebroplasty in Patients with Osteoporosis. World Neurosurg. 2017;99:387-394. 5. Chen Z, Chen Z, Wu Y, et al. Risk Factors of Secondary Vertebral Compression Fracture After Percutaneous Vertebroplasty or Kyphoplasty: A Retrospective Study of 650 Patients. Med Sci Monit. 2019;25:9255-9261. doi:10.12659/MSM.915312. 6. Gao C, Zong M, Wang WT, Xu L, Cao D, Zou YF. Analysis of risk factors causing short-term cement leakages and long-term complications after percutaneous kyphoplasty for osteoporotic vertebral compression fractures. Acta Radiol. 2018;59(5):577-585. doi:10.1177/0284185117725368 7. Hey HW, Tan JH, Tan CS, Tan HM, Lau PH, Hee HT. Subsequent Vertebral Fractures Post Cement Augmentation of the Thoracolumbar Spine: Does it Correlate With Level-specific Bone Mineral Density Scores? [published correction appears in Spine (Phila Pa 1976). 2016 Feb;41(4):368. Hwee Weng, Dennis Hey [corrected to Hey, Hwee Weng Dennis]; Jun, Hao Tan [corrected to Tan, Jun Hao]; Chuen, Seng Tan [corrected to Tan, Chuen Seng]; Ming, Bryan Tan Hsi [corrected to Tan, Hsi Ming Bryan]; Huh, Bernard Lau Puang [corrected to Lau, Puang Hu]. Spine (Phila Pa 1976). 2015;40(24):1903-1909. doi:10.1097/BRS.0000000000001066 8. Hiwatashi A, Yoshiura T, Yamashita K, Kamano H, Dashjamts T, Honda H. Subsequent fracture after percutaneous vertebroplasty can be predicted on preoperative multidetector row CT. AJNR Am J Neuroradiol. 2009;30(10):1830-1834. doi:10.3174/ajnr.A1722 9. Hu L, Sun H, Wang H, et al. Cement injection and postoperative vertebral fractures during vertebroplasty. J Orthop Surg Res. 2019;14(1):228. doi:10.1186/s13018-019-1273-z 10. Huang ZF, Xia P, Liu K, Xiong W. Analysis of risk factors of new fracture of vertebral body after percutaneous kyphoplasty in patients with primary osteoporotic fracture of thoracic and lumbar spine. J Biomater Tissue Eng. 2018;8(5):756-759. 11. Komemushi A, Tanigawa N, Kariya S, et al. Biochemical markers of bone turnover in percutaneous vertebroplasty for osteoporotic compression fracture. Cardiovasc Intervent Radiol. 2008;31(2):332-335. doi:10.1007/s00270-007-9246-8. 12. Lee HJ, Park J, Lee IW, Yi JS, Kim T. Clinical, Radiographic, and Morphometric Risk Factors for Adjacent and Remote Vertebral Compression Fractures Over a Minimum Follow-up of 4 Years After Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fractures: Novel Three-dimensional Voxel-Based Morphometric Analysis. World Neurosurg. 2019;125:e146-e157. doi:10.1016/j.wneu.2019.01.020 13. Li YX, Guo DQ, Zhang SC, et al. Risk factor analysis for re-collapse of cemented vertebrae after percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP). Int Orthop. 2018;42(9):2131-2139. doi:10.1007/s00264-018-3838-6 14. Lin H, Bao LH, Zhu XF, Qian C, Chen X, Han ZB. Analysis of recurrent fracture of a new vertebral body after percutaneous vertebroplasty in patients with osteoporosis. Orthop Surg. 2010;2(2):119-123. doi:10.1111/j.1757-7861.2010.00074.x 15. Lu K, Liang CL, Hsieh CH, Tsai YD, Chen HJ, Liliang PC. Risk factors of subsequent vertebral compression fractures after vertebroplasty. Pain Med. 2012;13(3):376-382. doi:10.1111/j.1526-4637.2011.01297.x 16. Sun G, Tang H, Li M, Liu X, Jin P, Li L. Analysis of risk factors of subsequent fractures after vertebroplasty. Eur Spine J. 2014;23(6):1339-1345. doi:10.1007/s00586-013-3110-0 17. Takahara K, Kamimura M, Moriya H, et al. Risk factors of adjacent vertebral collapse after percutaneous vertebroplasty for osteoporotic vertebral fracture in postmenopausal women. BMC Musculoskelet Disord. 2016;17:12. Published 2016 Jan 12. doi:10.1186/s12891-016-0887-0 18. Tseng YY, Yang TC, Tu PH, Lo YL, Yang ST. Repeated and multiple new vertebral compression fractures after percutaneous transpedicular vertebroplasty. Spine (Phila Pa 1976). 2009;34(18):1917-1922. doi:10.1097/BRS.0b013e3181ac8f07 19. Wang YT, Wu XT, Chen H, Wang C, Mao ZB. Adjacent-level symptomatic fracture after percutaneous vertebral augmentation of osteoporotic vertebral compression fracture: a retrospective analysis. J Orthop Sci. 2014;19(6):868-876. doi:10.1007/s00776-014-0610-7. 20. Wu J, Guan Y, Fan S. Analysis of risk factors of secondary adjacent vertebral fracture after percutaneous kyphoplasty. Biomedical Research (India). 2017;28(5):1956-1961. 21. Yang S, Liu Y, Yang H, Zou J. Risk factors and correlation of secondary adjacent vertebral compression fracture in percutaneous kyphoplasty. Int J Surg. 2016;36:138-142. 22. Lin Z, Du J, Lu C, Wang J. Risk factors of new symptomatic vertebral compression fractures after percutaneous vertebroplasty. Int J Clin Exp Med. 2019;12(1):949-954. 23. Li H, Yang DL, Ma L, Wang H, Ding WY, Yang SD. Risk Factors Associated with Adjacent Vertebral Compression Fracture Following Percutaneous Vertebroplasty After Menopause: A Retrospective Study. Med Sci Monit. 2017;23:5271-5276. Published 2017 Nov 5. doi:10.12659/msm.907364 24. Lee BG, Choi JH, Kim DY, Choi WR, Lee SG, Kang CN. Risk factors for newly developed osteoporotic vertebral compression fractures following treatment for osteoporotic vertebral compression fractures. Spine J. 2019;19(2):301-305. doi:10.1016/j.spinee.2018.06.347

25. Rho YJ, Choe WJ, Chun YI. Risk factors predicting the new symptomatic vertebral compression fractures after percutaneous vertebroplasty or kyphoplasty. Eur Spine J. 2012;21(5):905-911. doi:10.1007/s00586-011-2099-5 26. Alhashash M, Shousha M, Barakat AS, Boehm H. Effects of Polymethylmethacrylate Cement Viscosity and Bone Porosity on Cement Leakage and New Vertebral Fractures After Percutaneous Vertebroplasty: A Prospective Study. Global Spine J. 2019;9(7):754-760.

It is suggested that increasing age and female sex are associated with increased risk of further fractures (new or recollapse) after vertebral augmentation of osteoporotic vertebral compression fractures.

Grade of Recommendation: B

AGE:

In a prospective comparative study, Zhang et al1 investigated the relationship between handgrip strength (HGS) and the risk of a subsequent vertebral fracture (SVF) after percutaneous vertebral augmentation (PVA). The authors concluded that “Low HGS was significantly associated with lower SVF-free survival among elderly patients who underwent single-level PVA for osteoporotic vertebral fracture.” This paper provides Level II evidence that in both men and women, hand grip strength, older age, and lower BMI associated with higher risk of subsequent VF. In a retrospective comparative study, Bayram et al2 assessed whether central sarcopenia is associated with outcomes in patients with VCF, who were managed with PVA treatment. The authors concluded that “There is a significant correlation between sarcopenia and postoperative mortality after vertebral augmentation procedure in patients with VCFs.” This paper provides Level III evidence that increasing age, ASA score and sarcopenia (PLVI value) are associated with increased risk of mortality in patients with OVCF undergoing vertebral augmentation. In a retrospective comparative study, Chen et al3 evaluated the risk factors that contributed to secondary vertebral compression fractures (SVCF) in patients who had undergone PVP or PKP due to an OVCF. The authors concluded that “older age and lower BMD were identified as risk factors of SVCF for OVCF patients following PVP/PKP surgery, whereas more ODA played a protective role in SVCF development.” This paper provides Level III evidence that increasing age is associated with higher likelihood of developing SVCF after PKP/PVP whereas higher BMD and higher outdoor activity is associated with decreased risk of developing fractures. In a retrospective comparative study, Hey et al4 aimed to determine the relationship between level-specific preoperative BMD and subsequent vertebral fractures. Another aim of this study was to identify the factors that are associated with subsequent vertebral fractures. The authors concluded that “Level-specific T-scores are predictive of subsequent fractures and the odds ratio increases with lower T-scores from 2.2 or less to 2.6 or less. They have a low positive predictive value, but a high negative predictive value for subsequent fractures. Other significant associations with subsequent refractures include age and anterior vertebral height.” This paper provides Level III evidence that specific cutoffs of T-scores and age correlate with new fractures after vertebral augmentation procedures. In a retrospective comparative study, Takahara et al5 studied the risk factors among several possible predictors for de novo vertebral fractures following PVP in patients who had osteoporosis. The authors concluded that “advanced age and decreased lumbar and hip BMD scores most strongly indicated a risk of adjacent VF following PVP.” This paper provides Level III evidence that lower BMD and advancing age are significant risk factors associated with vertebral collapse after PVP in postmenopausal women. In a retrospective comparative study, Tseng et al6 evaluated the characteristics and risk factors of new-onset VCF following VP. The authors concluded that “older patient age, lower baseline BMD, and more pre-existing vertebral fractures were found to be risk factors for multiple vertebral compression fractures.” This paper provides Level III evidence that patients experiencing 2 or more VCFs after initial PVP for OVCF tend to be relatively older, with lower baseline BMD, and have more preexisting VCFs. In a retrospective comparative study, Wang et al7 examined the incidence, risk factors, and possible causative mechanism of symptomatic AVF. Another aim of the study was to assess the intrinsic relationship between cement leakage into the disc and AVF. The authors concluded that “Older age, lower BMD, and intravertebral clefts are the main risk factors for symptomatic AVF after vertebral augmentation, but intradiscal cement leakage does not increase the risk of AVF. AVF occurs because of the natural progression of osteoporosis. Even distribution of bone cement in the vertebral body is important in OVCF patients with intravertebral clefts.” This paper provides Level III evidence that advancing age, lower BMD, and the presence of IVC is associated with the risk of AVF after PV in patients with OVCF. In a retrospective comparative study, Lee et al8 analyzed the factors that affected new compression fractures in vertebral bodies that were adjacent to or remote from those who were previously treated with PVP. The authors concluded that “PVP done on multiple levels and older age patients increases the risk of developing new symptomatic vertebral compression fracture after PVP.” The work group downgraded this potential Level III paper due to nonrandomization, and less than 80% follow-up. This paper provides Level IV paper that when PVP is done on multiple levels on older patients, the risk of new symptomatic VCF is increased. FEMALE:

In a retrospective comparative study, Civelek et al9 evaluated the risk factors for new symptomatic VCF after having undergone BKP. The authors concluded that “If the patients experience severe or mild back pain with higher preoperative KA, especially in the first 2 months, then they deserve detailed radiologic examination. To avoid subsequent fracture in the same or adjacent level, vertebral body should be filled adequately and sagittal balance should be obtained with KA correction. BK alone did not influence the incidence of subsequent VCF.” This paper provides Level III evidence that female sex and higher preop KA have higher new symptomatic VCF after BK. In a retrospective case-control study, Hu et al10 assessed the factors that caused vertebral fractures after VP, as well as calculate the appropriate amount of bone cement to inject. The authors concluded that “Bone cement injection volume, BMD values, and sex were statistically significantly related to adjacent vertebral fractures after vertebroplasty, and cement injection volumes exceeding 40.5% caused adjacent vertebral fractures.” This paper provides Level III evidence that refractures after VP tend to occur more in females and those with lower BMD. In a retrospective comparative study, Moon et al11 investigated the incidence and influential factors of new VCF in women after having undergone kyphoplasty. The authors concluded that “When kyphoplasty is planned for the management of patients with osteoporotic VCFs, the application of a small amount of PMMA can be considered in order to lower the risk of new fractures in adjacent vertebrae. The post-operative use of anti-osteoporotic medication is recommended for the prevention of new VCFs.” This paper provides Level III evidence that female patients incurring new VCF after index kyphoplasty for OVCF have lower BMI and longer duration of symptoms compared to those not incurring new VCFs. References: 1. Zhang SB, Chen H, Xu HW, Yi YY, Wang SJ, Wu DS. Association between handgrip strength and subsequent vertebral-fracture risk following percutaneous vertebral augmentation. J Bone Miner Metab. 2021;39(2):186-192. doi:10.1007/s00774-020-01131-z 2. Bayram S, Akgul T, Adiyaman AE, Karalar S, Dolen D, Aydoseli A. Effect of Sarcopenia on Mortality after Percutaneous Vertebral Augmentation Treatment for Osteoporotic Vertebral Compression Fractures in Elderly Patients: A Retrospective Cohort Study. World Neurosurgery.138:e354-e360. 3. Chen Z, Chen Z, Wu Y, et al. Risk Factors of Secondary Vertebral Compression Fracture After Percutaneous Vertebroplasty or Kyphoplasty: A Retrospective Study of 650 Patients. Med Sci Monit. 2019;25:9255-9261. doi:10.12659/MSM.915312 4. Hey HW, Tan JH, Tan CS, Tan HM, Lau PH, Hee HT. Subsequent Vertebral Fractures Post Cement Augmentation of the Thoracolumbar Spine: Does it Correlate With Level-specific Bone Mineral Density Scores? [published correction appears in Spine (Phila Pa 1976). 2016 Feb;41(4):368. Hwee Weng, Dennis Hey [corrected to Hey, Hwee Weng Dennis]; Jun, Hao Tan [corrected to Tan, Jun Hao]; Chuen, Seng Tan [corrected to Tan, Chuen Seng]; Ming, Bryan Tan Hsi [corrected to Tan, Hsi Ming Bryan]; Huh, Bernard Lau Puang [corrected to Lau, Puang Hu]. Spine (Phila Pa 1976). 2015;40(24):1903-1909. doi:10.1097/BRS.0000000000001066 5. Takahara K, Kamimura M, Moriya H, et al. Risk factors of adjacent vertebral collapse after percutaneous vertebroplasty for osteoporotic vertebral fracture in postmenopausal women. BMC Musculoskelet Disord. 2016;17:12. doi:10.1186/s12891-016-0887-0 6. Tseng YY, Yang TC, Tu PH, Lo YL, Yang ST. Repeated and multiple new vertebral compression fractures after percutaneous transpedicular vertebroplasty. Spine (Phila Pa 1976). 2009;34(18):1917-1922. doi:10.1097/BRS.0b013e3181ac8f07 7. Wang YT, Wu XT, Chen H, Wang C, Mao ZB. Adjacent-level symptomatic fracture after percutaneous vertebral augmentation of osteoporotic vertebral compression fracture: a retrospective analysis. J Orthop Sci. 2014;19(6):868-876. doi:10.1007/s00776-014-0610-7. 8. Lee WS, Sung KH, Jeong HT, et al. Risk factors of developing new symptomatic vertebral compression fractures after percutaneous vertebroplasty in osteoporotic patients. Eur Spine J. 2006;15(12):1777-1783. doi:10.1007/s00586-006-0151-7 9. Civelek E, Cansever T, Yilmaz C, et al. The retrospective analysis of the effect of balloon kyphoplasty to the adjacent-segment fracture in 171 patients. J Spinal Disord Tech. 2014;27(2):98-104. doi:10.1097/bsd.0b013e31824e9b98 10. Hu L, Sun H, Wang H, et al. Cement injection and postoperative vertebral fractures during vertebroplasty. J Orthop Surg Res. 2019;14(1):228. doi:10.1186/s13018-019-1273-z 11. Moon ES, Kim HS, Park JO, et al. The incidence of new vertebral compression fractures in women after kyphoplasty and factors involved. Yonsei Med J. 2007;48(4):645-652. doi:10.3349/ymj.2007.48.4.645

It is suggested that multiple preexisting vertebral fractures are associated with increased risk of further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.

Grade of Recommendation: B

In a prospective randomized control trial study, Alhashash et al1 studied the effect of bone cement viscosity and bone porosity on cement leakage during VP. Another purpose of this study was to analyze the occurrence of new vertebral fractures after VP. The authors concluded that “The clinical outcome of vertebroplasty was not influenced by cement viscosity. However, lower cement viscosity and higher degree of osteoporosis were found to be significant risk factors for cement leakage. Furthermore, the number of vertebral body fractures on presentation was a predictor for the occurrence of new fractures postoperatively.” The work group downgraded this potential Level I paper due to nonconsecutive patients and a lack of robust applications, including adjusted regression analysis. This paper provides Level II evidence that the proportion of patients incurring cement leakage post-VP is higher in those with lower T-score and those injected with low-viscous cement and patients with multiple fractures at presentation (preop) were noted to have higher rates of new fractures postoperatively. In a prospective comparative study, Liu et al2 evaluated the risk factors of new VCF following a PVP in patients who had osteoporosis. The authors concluded that “The incidence of new VCFs after PV is relatively high and affected by several risk factors that are related to both the PV procedure and the natural course of osteoporosis.” This paper provides Level II evidence that the number of VCFs initially, CT value of nonfractured vertebrae, and activity level following discharge is strongly associated with the risk of new VCFs after PV. In a prospective comparative study, Voormolen et al3 investigated the incidence, location, and potential causative mechanisms of new VCF in patients with OVCF treated with PVP. The authors concluded that “New VCFs occurred after PV in 24% of patients. Half of new VCFs occurred in levels adjacent to treated levels and half were symptomatic. The presence of more than two preexisting VCFs was the only independent risk factor for the development of a new VCF.” The work group downgraded this potential Level I paper due to less than 80% follow-up. This paper provides Level II evidence that the presence of multiple preexisting VCFs (3 or more) is a risk-factor for new VCF after PV. In a retrospective comparative study, Lee et al4 assessed the risk factors, prevention, and incidence of new vertebral compression fractures having undergoing percutaneous vertebroplasty. The authors concluded that “The most important elements related to reducing NVCF were treating osteoporosis and improving BMD and BMI. More aggressive BMD and BMI correction is more important than the vertebroplasty technique.” This paper provides Level III evidence that lower BMI and higher number of compression fractures are associated with a high risk of new VCF after vertebroplasty. In a retrospective comparative study, Ren et al5 aimed to determine the risk factors of new VCF in osteoporotic patients after undergoing PVP. The authors concluded that “The incidence of new symptomatic VCFs after PVP was higher in osteoporotic patients with initial multiple-level fractures.” This paper provides Level III evidence that a higher BMI and increase in number of initial VCFs are associated with increased risk of new VCFs after PVP. In a retrospective comparative study, Tseng et al6 examined the characteristics and risk factors of new-onset VCF following VP. The authors concluded that “older patient age, lower baseline BMD, and more pre-existing vertebral fractures were found to be risk factors for multiple vertebral compression fractures.” This paper provides Level III evidence that patients experiencing 2 or more VCFs after initial PVP for OVCF tend to be relatively older, with lower baseline BMD, and have more preexisting VCFs. In a retrospective comparative study, Li et al7 analyzed the risk factors for adjacent VCF following PVP in patients with OVCF after going through menopause. The authors concluded that “A long duration of menopause and preoperative multi-level vertebral fractures were the risk factors for AVCF in patients following PVP after menopause, while a high-level BMD acted in a protective role for AVCF development.” The work group downgraded this potential Level III paper due to information that was lacking on the experimental study. This paper provides Level IV evidence that the duration of menopause and number of preop vertebral fractures are associated with an increased risk of AVCF after PVP. On the contrary, BMD was associated with lower risk of AVCF after PVP. References: 1. Alhashash M, Shousha M, Barakat AS, Boehm H. Effects of Polymethylmethacrylate Cement Viscosity and Bone Porosity on Cement Leakage and New Vertebral Fractures After Percutaneous Vertebroplasty: A Prospective Study. Global Spine J. 2019;9(7):754-760. 2. Liu WG, He SC, Deng G, et al. Risk factors for new vertebral fractures after percutaneous vertebroplasty in patients with osteoporosis: a prospective study. J Vasc Interv Radiol. 2012;23(9):1143-1149. doi:10.1016/j.jvir.2012.06.019 3. Voormolen MH, Lohle PN, Juttmann JR, van der Graaf Y, Fransen H, Lampmann LE. The risk of new osteoporotic vertebral compression fractures in the year after percutaneous vertebroplasty. J Vasc Interv Radiol. 2006;17(1):71-76. 4. Lee DG, Park CK, Park CJ, Lee DC, Hwang JH. Analysis of Risk Factors Causing New Symptomatic Vertebral Compression Fractures After Percutaneous Vertebroplasty for Painful Osteoporotic Vertebral Compression Fractures: A 4-year Follow-up. J Spinal Disord Tech. 2015;28(10):E578-583. 5. Ren HL, Jiang JM, Chen JT, Wang JX. Risk factors of new symptomatic vertebral compression fractures in osteoporotic patients undergone percutaneous vertebroplasty. Eur Spine J. 2015;24(4):750-758. 6. Tseng YY, Yang TC, Tu PH, Lo YL, Yang ST. Repeated and multiple new vertebral compression fractures after percutaneous transpedicular vertebroplasty. Spine (Phila Pa 1976). 2009;34(18):1917-1922. doi:10.1097/BRS.0b013e3181ac8f07 7. Li H, Yang DL, Ma L, Wang H, Ding WY, Yang SD. Risk Factors Associated with Adjacent Vertebral Compression Fracture Following Percutaneous Vertebroplasty After Menopause: A Retrospective Study. Med Sci Monit. 2017; 23:5271-5276.

It is suggested that lower serum 25(OH)D levels are associated with increased risk of further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.

Grade of Recommendation: B In a prospective randomized control trial study, Martinez-Ferrer et al1 aimed to describe the risk factors (clinical and radiological factors/densitometric and biochemical parameters) that were related to the development of vertebral fractures after undergoing percutaneous vertebroplasty. The authors concluded that “nearly 30% of patients with osteoporotic VF treated with VP presented a new VF after the procedure. Age, especially >80 years, and low vitamin D serum levels were related to the development of new VF in these patients, as were the number of vertebrae treated per patient and the presence of inferior disk cement leakage after the procedure.” The work group downgraded this potential Level I paper due to nonconsecutive patients and less than 80% follow-up. This paper provides Level II evidence that lower (deficient) 25 (OH)D levels is associated with increased risk of VCF after VP. In a prospective comparative study, Zafeiris et al2 evaluated the incidence of recurrent fractures after undergoing kyphoplasty, and determine whether the status of bone metabolism and 25-hydroxybitamin D (25(OH)D) levels would affect the occurrence of these fractures. The authors concluded that “Bone metabolism and 25(OH)D levels seem to play a role in the occurrence of postkyphoplasty recurrent vertebral compression fractures.” The work group downgraded this potential Level II paper due to nonconsecutive patients, nonmasked reviewers, nonmasked patients, nonrandomization, and small sample size. This paper provides Level III evidence that patients incurring new VCFs after maiden KP tend to have a lower vit D level compared to those not incurring fractures. References: 1. Martinez-Ferrer A, Blasco J, Carrasco JL, et al. Risk factors for the development of vertebral fractures after percutaneous vertebroplasty. J Bone Miner Res. 2013;28(8):1821-1829. doi:10.1002/jbmr.1899 2. Zafeiris CP, Lyritis GP, Papaioannou NA, et al. Hypovitaminosis D as a risk factor of subsequent vertebral fractures after kyphoplasty. Spine J. 2012;12(4):304-312. doi:10.1016/j.spinee.2012.02.016

It is suggested that lower BMI is associated with increased risk of further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.

Grade of Recommendation: B In a prospective comparative study, Zhang et al1 aimed to find the relationship between handgrip strength (HGS) and the risk of a subsequent vertebral fracture (SVF) after percutaneous vertebral augmentation (PVA). The authors concluded that “Low HGS was significantly associated with lower SVF-free survival among elderly patients who underwent single-level PVA for osteoporotic vertebral fracture.” This paper provides Level II evidence that in both men and women, hand grip strength, older age, and lower BMI associated with higher risk of subsequent VF. In a retrospective comparative study, Lee et al2 assessed the risk factors, prevention, and incidence of new VCF undergoing PVP. The authors concluded that “The most important elements related to reducing NVCF were treating osteoporosis and improving BMD and BMI. More aggressive BMD and BMI correction is more important than the vertebroplasty technique.” This paper provides Level III evidence that lower BMI and higher number of compression fractures are associated with a high risk of new VCF after vertebroplasty. In a retrospective comparative study, Lin et al3 investigated the risk factors for new VCF following VP. The authors concluded that “New VCFs are common in patients with a low BMI, which suggests osteoporosis as a mechanism of fracture.” This paper provides Level III evidence that lower BMI (less than 22kg/m2) and greater kyphosis correction are associated with increased hazards of developing a new VCF in patients undergoing PV for single-level OVCF. In a retrospective comparative study, Moon et al4 evaluated the incidence and influential factors of new VCF in women after having undergone kyphoplasty. The authors concluded that “When kyphoplasty is planned for the management of patients with osteoporotic VCFs, the application of a small amount of PMMA can be considered in order to lower the risk of new fractures in adjacent vertebrae. The post-operative use of anti-osteoporotic medication is recommended for the prevention of new VCFs.” This paper provides Level III evidence that female patients incurring new VCF after index kyphoplasty for OVCF have lower BMI and longer duration of symptoms compared to those not incurring new VCFs. In a retrospective comparative study, Lin et al5 examined the characteristics of a recurrent fracture of a new vertebral body in patients with osteoporosis after having undergone PVP. The authors concluded that “A substantial number of patients with osteoporosis develop new fractures after vertebroplasty; two-thirds of these new fractures occur in vertebrae adjacent to those previously treated. The following variables influence the outcome: BMI, history of fractures, history of metabolic diseases and medications, BMD of lumbar spine and hip, anti-osteoporosis therapy, and use of back brace.” The work group downgraded this potential Level III paper due to low sample size and nonconsecutive patients. This paper provides Level IV evidence that patients developing new fractures after PV for OVCF differ significantly from those not developing new fractures in terms of BMI (low BMI vs controls), lower BMD and lower serum PTH levels. A retrospective comparative study, Ren et al6 analyzed the risk factors of new VCF in osteoporotic patients after undergoing percutaneous vertebroplasty. The authors concluded that “The incidence of new symptomatic VCFs after PVP was higher in osteoporotic patients with initial multiple-level fractures.” This paper provides Level III evidence that a higher BMI and increase in number of initial VCFs are associated with increased risk of new VCFs after PVP. Work Group Narrative: The majority of the evidence supports this recommendation, but considering that one article6 showed the opposite (higher BMI with increased initial OCVFs), more research is needed.

References: 1. Zhang SB, Chen H, Xu HW, Yi YY, Wang SJ, Wu DS. Association between handgrip strength and subsequent vertebral-fracture risk following percutaneous vertebral augmentation. J Bone Miner Metab. 2021;39(2):186-192. doi:10.1007/s00774-020-01131-z 2. Lee DG, Park CK, Park CJ, Lee DC, Hwang JH. Analysis of Risk Factors Causing New Symptomatic Vertebral Compression Fractures After Percutaneous Vertebroplasty for Painful Osteoporotic Vertebral Compression Fractures: A 4-year Follow-up. J Spinal Disord Tech. 2015;28(10):E578-583. 3. Lin WC, Cheng TT, Lee YC, et al. New vertebral osteoporotic compression fractures after percutaneous vertebroplasty: retrospective analysis of risk factors. J Vasc Interv Radiol. 2008;19(2 Pt 1):225-231. doi:10.1016/j.jvir.2007.09.008 4. Moon ES, Kim HS, Park JO, et al. The incidence of new vertebral compression fractures in women after kyphoplasty and factors involved. Yonsei Med J. 2007;48(4):645-652. doi:10.3349/ymj.2007.48.4.645 5. Lin H, Bao LH, Zhu XF, Qian C, Chen X, Han ZB. Analysis of recurrent fracture of a new vertebral body after percutaneous vertebroplasty in patients with osteoporosis. Orthop Surg. 2010;2(2):119-123. doi:10.1111/j.1757-7861.2010.00074.x 6. Ren HL, Jiang JM, Chen JT, Wang JX. Risk factors of new symptomatic vertebral compression fractures in osteoporotic patients undergone percutaneous vertebroplasty. Eur Spine J. 24(4):750-758.

Comorbidities may be considered as a factor in increased risk of further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.

Grade of Recommendation: C Work Group Narrative: This is a grade C recommendation because there are not enough specific comorbidities identified in the papers available.

In a prospective comparative study, Deen et al1 analyzed the results of BKP in a group of organ transplant recipients, while also comparing VCF in transplant patients and patients with primary osteoporosis. The authors concluded that “balloon kyphoplasty can be performed safely in organ transplant recipients with VCFs. The degree of pain relief is equivalent to that seen in patients with primary osteoporosis. Results are durable at 12-month follow-up. Transplant patients developed earlier and more severe bony disease, with more severe baseline pain, a higher incidence of multiple fractures at the time of diagnosis, and a greater risk of new fracture development posttreatment, as compared with the primary osteoporosis group.” This paper provides Level II evidence that transplant patients have more severe bony disease, more severe baseline pain with higher incidence of multiple fractures at diagnosis. Although postop VAS, sagittal alignment improvement and narcotic analgesic usage may not differ across transplant and nontransplant patients, the former has higher risk of new fracture development post BKP. In a retrospective comparative study, Chen et al2 assessed the risk factors for cement leak and adjacent vertebral fracture in and after kyphoplasty for osteoporotic vertebral fractures. The authors concluded that “Diabetes and the alteration of the Cobb angle following PKP are factors positively related to the occurrence of postoperative adjacent vertebral fractures. It is also demonstrated that the integrity of vertebral walls and average volumes of injected cement are the possible risk factors of cement leakage while performing the PKP.” This paper provides Level III evidence that the incidence of postoperative adjacent vertebral fractures is higher in diabetics and altered Cobb angle (postsurgery). In a retrospective comparative study, Spross et al3 examined the incidence and possible risk factors of adjacent vertebral fractures with the SWISSpine (SSR) registry dataset. The authors concluded that “patients with a preoperative segmental kyphosis >30 degrees or patients with comorbidities like rheumatoid arthritis and a cardiovascular disease are at high risk of ASF within 6 months after the index surgery. In case of an ASF event, back pain levels are significantly increased.” This paper provides Level III evidence that a preop kyphotic angle of over 30°, and patient-specific comorbidities (such as RA, cardiovascular disease) are significantly associated with the risk of new adjacent segment fracture (ASF) after BKP. References: 1. Deen HG, Aranda-Michel J, Reimer R, Miller DA, Putzke JD. Balloon kyphoplasty for vertebral compression fractures in solid organ transplant recipients: results of treatment and comparison with primary osteoporotic vertebral compression fractures. Spine J. 2006;6(5):494-499. doi:10.1016/j.spinee.2006.01.011 2. Chen C, Fan P, Xie X, Wang Y. Risk Factors for Cement Leakage and Adjacent Vertebral Fractures in Kyphoplasty for Osteoporotic Vertebral Fractures. Clin Spine Surg. 2020;33(6):E251-E255. doi:10.1097/BSD.0000000000000928 3. Spross C, Aghayev E, Kocher R, Röder C, Forster T, Kuelling FA. Incidence and risk factors for early adjacent vertebral fractures after balloon kyphoplasty for osteoporotic fractures: analysis of the SWISSspine registry. Eur Spine J. 2014;23(6):1332-1338. doi:10.1007/s00586-013-3052-6.

There is insufficient evidence to make a recommendation for or against the use of various biomedical markers as risk factors for further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.

Grade of Recommendation: I

In a prospective comparative study, Komemushi et al1 assessed the relationship between biochemical marks of bone turnover, BMD, and new compression fractures following PVP. The authors concluded that “A combination of high levels of bone resorption markers and normal levels of bone formation markers may be associated with increased risk of new recurrent fractures after percutaneous vertebroplasty.” The work group downgraded this potential Level II paper due to small sample size, less than 80% follow-up, validated outcome measures not being used, and nonrandomization. This paper provides Level III evidence that high fracture risk patients (based on biochemical markers) have higher proportional of new fractures. References: 1. Komemushi A, Tanigawa N, Kariya S, et al. Biochemical markers of bone turnover in percutaneous vertebroplasty for osteoporotic compression fracture. Cardiovasc Intervent Radiol. 2008;31(2):332-335. doi:10.1007/s00270-007-9246-8.

There is insufficient evidence to make a recommendation for or against the effect of long-term steroid use on the outcome of vertebral augmentation for osteoporotic vertebral compression fractures.

Grade of Recommendation: I

In a retrospective comparative study, Hiwatashi et al1 aimed to determine the characteristics of patients with new fractures following VP. The authors concluded that “Patients who are on long-term steroid medication have an elevated risk of developing new fractures after vertebroplasty.” This paper provides Level III evidence that in patients with osteoporotic compression fractures, a higher proportion of patients developing new fractures after PVP are those on long-term steroid medications. In a prospective comparative study, Hiwatashi et al2 evaluated preoperative multidetector row CT (MDCT) in the prediction of subsequent fractures after PVP. The authors concluded that “The small size of the treated vertebrae may relate to subsequent fractures in adjacent vertebrae. Steroid use and low CT value of nonfractured vertebrae on preoperative MDCT can be associated with subsequent fractures in remote vertebrae.” The work group downgraded this potential Level II paper due to small sample size. This paper provides Level III evidence that steroid use and low CT value are risk factors for new fractures in remote vertebrae while small vertebral size may be a risk for adjacent vertebral fractures. In a retrospective case control study, Koch et al3 compared the effectiveness and complication rate in patients undergoing PVP to treat VCF as a result of secondary osteoporosis, in relation to patients with primary osteoporosis who were treated with PVP. The authors concluded that “Percutaneous vertebroplasty performed for vertebral compression fractures as a result of long-term corticosteroid therapy is as safe and effective in relieving pain as PVP performed in patients with vertebral compression fractures as a result of primary osteoporosis.” This paper provides Level III evidence that steroid use is not a significant predictor of poor outcomes, specific to complication rates and development of new fractures. References: 1. Hiwatashi A, Westesson PL. Patients with osteoporosis on steroid medication tend to sustain subsequent fractures. Am J Neuroradiol. 2007;28:1055–1057 2. Hiwatashi A, Yoshiura T, Yamashita K, Kamano H, Dashjamts T, Honda H. Subsequent fracture after percutaneous vertebroplasty can be predicted on preoperative multidetector row CT. AJNR Am J Neuroradiol. 2009;30(10):1830-1834. doi:10.3174/ajnr.A1722 3. Koch CA, Layton KF, Kallmes DF. Outcomes of patients receiving long-term corticosteroid therapy who undergo percutaneous vertebroplasty. AJNR Am J Neuroradiol. 2007;28(3):563-566.

There is insufficient evidence to make a recommendation for or against the impact of high preop sacral inclination and high spinal deformity Index in evaluating risk of further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.

Grade of Recommendation: I

In a prospective comparative study, Nieuwenhujse et al1 investigated the risk factors for new vertebral fractures, as well as estimate the fracture-free probabilities of multiple intact nontreated vertebrae given the patient- and vertebra-specific covariate status. The authors concluded that “New vertebral fractures after PVP were clustered within patients and depended heavily on the presence or absence of both patient- and vertebra-specific risk factors. Intradiskal cement leakage was a pronounced augmentation-related risk factor, for which a volumetric association was found.” This paper provides Level II evidence that patient level (low BMD, high spine deformity index, short-time since fracture onset) and vertebral-specific (thoracolumbar junction, close vicinity to the treated level) factors are associated with the development of new VCFs within one-year after PVP. In a retrospective comparative study, Lee et al2 studied the risk factors for a SNVCF after a PVP is done to treat an OVCF. The authors concluded that “Low BMD, high preoperative compression ratio, and high preoperative SI may be predictive factors for SNVCFs. In particular, to prevent AVCF, the injected bone cement should be distributed both evenly and symmetrically along the inferior-to-superior axis and the relative bone cement volume should not be excessive. Bone cement should be injected carefully to avoid upper adjacent intradiscal leakage. Prompt BMD correction is important to prevent SNVCF.” This paper provides Level III evidence that in patients with single-level OVCF, a low BMD and high preop SI are associated with the risk of developing secondary NVCFs following PVP. References: 1. Nieuwenhuijse MJ, Putter H, van Erkel AR, Dijkstra PD. New vertebral fractures after percutaneous vertebroplasty for painful osteoporotic vertebral compression fractures: a clustered analysis and the relevance of intradiskal cement leakage. Radiology. 2013;266(3):862-870. 2. Lee HJ, Park J, Lee IW, Yi JS, Kim T. Clinical, Radiographic, and Morphometric Risk Factors for Adjacent and Remote Vertebral Compression Fractures Over a Minimum Follow-up of 4 Years After Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fractures: Novel Three-dimensional Voxel-Based Morphometric Analysis. World Neurosurg. 2019;125:e146-e157. doi:10.1016/j.wneu.2019.01.020

There is insufficient evidence to make a recommendation for or against the impact of activity level in evaluating risk of further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.

Grade of Recommendation: I

n a prospective comparative study, Liu et al1 examined the risk factors of new VCF following a PVP in patients who had osteoporosis. The authors concluded that “The incidence of new VCFs after PV is relatively high and affected by several risk factors that are related to both the PV procedure and the natural course of osteoporosis.” This paper provides Level II evidence that the number of VCFs initially, CT value of nonfractured vertebrae, and activity level following discharge is strongly associated with the risk of new VCFs after PV. In a retrospective comparative study, Chen et al2 analyzed the risk factors that contributed to SVCF in patients who had undergone PVP or PKP due to an OVCF. The authors concluded that “older age and lower BMD were identified as risk factors of SVCF for OVCF patients following PVP/PKP surgery, whereas more ODA played a protective role in SVCF development.” This paper provides Level III evidence that increasing age is associated with higher likelihood of developing SVCF after PKP/PVP whereas higher BMD and higher outdoor activity is associated with decreased risk of developing fractures. References: 1. Liu WG, He SC, Deng G, et al. Risk factors for new vertebral fractures after percutaneous vertebroplasty in patients with osteoporosis: a prospective study. J Vasc Interv Radiol. 2012;23(9):1143-1149. doi:10.1016/j.jvir.2012.06.019 2. Chen Z, Chen Z, Wu Y, et al. Risk Factors of Secondary Vertebral Compression Fracture After Percutaneous Vertebroplasty or Kyphoplasty: A Retrospective Study of 650 Patients. Med Sci Monit. 2019;25:9255-9261. doi:10.12659/MSM.915312

There is insufficient evidence to make a recommendation for or against the impact of ASA score in predicting VAS scores after vertebral augmentation of osteoporotic vertebral compression fractures.

Grade of Recommendation: I

In a retrospective comparative study, Bayram et al1 assessed whether central sarcopenia is associated with outcomes in patients with VCF, who were managed with percutaneous vertebral augmentation treatment. The authors concluded that “There is a significant correlation between sarcopenia and postoperative mortality after vertebral augmentation procedure in patients with VCFs.” This paper provides Level III evidence that increasing age, ASA score and sarcopenia (PLVI value) are associated with increased risk of mortality in patients with OVCF undergoing vertebral augmentation. References: 1. Bayram S, Akgul T, Adiyaman AE, Karalar S, Dolen D, Aydoseli A. Effect of Sarcopenia on Mortality after Percutaneous Vertebral Augmentation Treatment for Osteoporotic Vertebral Compression Fractures in Elderly Patients: A Retrospective Cohort Study. World Neurosurgery. 2020;138:e354-e360.