Risk Factors for Infection after Percutaneous Vertebroplasty Augmentation for Osteoporotic Vertebral Compression Fracture

Risk Factors for Infection after Percutaneous Vertebroplasty Augmentation for Osteoporotic Vertebral Compression Fracture | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk Factors for Infection after Percutaneous Vertebroplasty Augmentation for Osteoporotic Vertebral Compression Fracture Rongbin Chen, Jianquan Chen, Wenchuang Chen, Yizhi Pan, Shunpin Li, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3862789/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Percutaneous vertebral augmentation (PVA) is a widely implemented treatment of osteoporotic vertebral compression fracture (OVCF). Although rare, surgical site infection (SSI) is a serious complication of PVA. Even though it is of great medical significance to minimize SSIs after PVA, there have been few reports on systematic risk factor analysis and prevention strategies.The goal of this study was to analyze the incidence and risk factors of postoperative SSI in PVA at a single center and formulate prevention strategies. Methods: The study involved 2624 patients who underwent PVA for osteoporotic vertebral compression fracture (OVCF) at our hospital between 2015 and 2021. The case-control study method was utilized. The case group consisted of patients who developed postoperative infections, while the control group was composed of uninfected patients selected at a ratio of 1:3.We collected data on risk factors for SSIs from patients' electronic medical records, imaging findings, and laboratory test results. We then analyzed the independent risk factors for postoperative SSIs using Cox univariate and multivariate regression analyses. Results: In our study, 17/2624 patients (0.65%) developed postoperative vertebral infections.Use of steroid drugs, NEUT%, C-type bone cement leakage after the operation were identified as risk factors in univariate analysis but not in multivariate analysis. Finally, multivariate analysis revealed the following risk factors for infectious spondylitis: age ≥ 80 years, type 2 diabetes, pulmonary infection, Alb ≤ 35 g/L, preoperative MRI indicating signs of fluid accumulation in the fractured vertebral body, and D-type bone cement leakage after the operation. Conclusions: Multivariate analyses identified the abovementioned independent risk factors for postoperative SSIs after PVA. These data may help guide clinicians take preoperative preventive measures to reduce the incidence of postoperative SSIs after PVA. Trial registration: This study was approved by Guangdong Province Hospital of Traditional Chinese Medicine. This article is a retrospective study. Therefore, the institution waived the requirement to obtain distinct written informed consent from the patients (approval number: ZE2023-176-01). percutaneous vertebral augmentation risk factors osteoporotic vertebral compression fracture surgical site infection Figures Figure 1 Figure 2 Introduction With the increase in aging population globally, osteoporosis has become the most common bone disease [ 1 ]. Its global prevalence rate is estimated to be 18.3%, and it is more common in women [ 2 ]. Osteoporotic vertebral compression fracture (OVCF) is among the most common complications in patients with osteoporosis, and its incidence is progressively increasing [ 3 , 4 ]. It is well known that OVCF can cause constant pain and kyphotic deformity to patients and limit their activity, which can adversely affect their quality of life and even lead to death [ 5 ]. Percutaneous vertebral augmentation (PVA), including percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP), is a commonly used and effective minimally invasive surgical treatment for OVCF. It can restore the height of the injured vertebra to a certain degree, reconstruct the stability of the spine, quickly relieve pain, and improve the quality of life of the patient [ 6 , 7 ]. Although PVA is widely regarded as a safe surgical procedure, there are still many complications associated with it, which mainly include cement leakage, cement embolism, nerve injury, epidural hematoma, and infection [ 2 , 8 ]. Notably, although the incidence of postoperative surgical site infections (SSIs) after PVA is extremely low, in the event that this infection occurs, it will require long-term use of high-dose antibiotics for treatment or further surgical intervention, with a high disability and mortality rate [ 9 , 10 ]. However, current research on postoperative SSIs after PVA mainly comprises case reports, and there is no analysis of related risk factors. Therefore, to reduce the occurrence of postoperative SSIs after PVA, we will review relevant literature and clinical experience in this study. We will also collect possible risk factors for relevant cases, use a case-control study method to conduct Cox regression analyses, explore important independent risk factors closely related to postoperative SSIs after PVA, and establish an OVCF diagnosis and treatment process to guide clinical diagnosis and treatment. Methods and materials Patients We retrospectively collected case data of patients with OVCF who underwent PVA between January 2015 and December 2021 from the spinal surgery database of our hospital. We conducted this study in accordance with the World Medical Association's 2000 Declaration of Helsinki, and it was approved by our hospital’s ethics review committee (approval number: ZE2023-176-01). Given the retrospective design of this study, the institution waived the requirement to obtain written informed consent from the participants. The inclusion criteria for patients with postoperative SSIs were as follows [ 11 – 13 ]: Initial diagnosis was of OVCF; initial surgery was performed using PVA, and complete follow-up clinical data were available. Clinical manifestations were consistent with postoperative spinal infection, such as fever, night sweats, weight loss, local tenderness and percussion pain, or combined neurological dysfunction. Computed tomography (CT) revealed bone absorption and destruction around bone cement. Typical signs of infection like inflammation signal changes in bone cement-enhanced areas and abscess formation were visible on magnetic resonance imaging (MRI). Laboratory tests showed elevation of one or more inflammatory indicators, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and white blood cell (WBC) count. T-cell spot test for tuberculosis infection was positive. Blood culture and pathogen microbial examination or metagenomic next-generation sequencing confirmed pathogenic bacteria. If pathogenic microorganism examination or metagenomic next-generation sequencing results are negative, but patients exhibit clinical symptoms and imaging findings consistent with infection in the operation area, and respond effectively to antibiotic treatment, they still be diagnosed with a surgical site infection. The exclusion criteria for patients with postoperative SSIs were as follows: Patients with preoperative comorbidities like spinal metastases, multiple myeloma, or vascular tumors Patients with incomplete clinical and imaging data Patients who were followed up for less than one year According to the aforementioned inclusion and exclusion criteria, seventeen patients with surgical site infections were ultimately included in the infection group during the follow-up period.All patients in the infection group were readmitted to test for inflammatory indicators (WBC, ESR, and CRP) and underwent complete spinal X-ray, CT, and MRI scans as well as percutaneous puncture to obtain lesion tissue for microbial culture, histopathologic examination, and mNGS detection of tissue samples. Data collection We conducted a case-control study to analyze the risk factors for postoperative SSIs after PVA. Patients in the infection group were selected as the case group. For each patient in the case group, 3 patients who did not develop infections after the operation were selected from the non-infection group as the control group, with a total of 51 patients selected in the control group. The selection criteria for the control group were as follows: the same age and gender with the infection group, consistent preoperative diagnosis with the infection group, no infection or other serious complications after the operation, hospital admission and surgery performed within 3 months before or after the infection group, and same surgeon performing the surgery. The medical records and imaging data of patients in both groups were reviewed, and the follow-up period was at least 1 year. Imaging data were measured at and collected from the imaging department of our hospital. Demographic information was retrieved from our hospital’s database of follow-up findings. The visual analog scale (VAS) score was determined by questionnaires [ 14 ]. All data were anonymized and collected by two senior spine surgeons who assessed the data separately, and the inclusion of cases with controversial data was decided by discussion among authors. Risk factors For potential risk factors, we collected the following data from electronic medical records, based on our clinical experience and previous research describing possible risk factors [ 8 , 10 , 15 , 16 ]. Demographic information : We collected data on age and sex of patients. Clinical features : We collected data on the history of trauma, disease course, fractured segment, long-term use of steroid drugs before the operation, surgical segment, surgical method, and follow-up duration. Preoperative comorbidities : We collected information on pulmonary infection, urinary tract infection, other infections, hypertension, and type 2 diabetes. Preoperative laboratory tests We collected the findings for urine leukocyte levels, WBC counts, neutrophilic granulocyte ratio (NEUT%), ESR, CRP levels, and albumin levels (Alb, cases with Alb ≤ 35 g/L were distinguished to evaluate the severity of hypoalbuminemia) [ 17 ]. Imaging features : We collected information on the intravertebral vacuum cleft filling with liquid in the preoperative MRI of the fractured vertebral body and on whether there was bone cement leakage and the type of bone cement leakage after the operation. For the infection group, the following data were additionally collected from electronic medical records: preoperative VAS, time to infection, treatment plan, and microbiology results and treatment outcomes. Fluid sign in the fractured vertebral body is defined as the presence of an intravertebral vacuum cleft with fluid filling as the main feature. Based on preoperative MRI data, the typical manifestation is a low signal of the intravertebral cleft in T1-weighted sequences and a high signal in T2-weighted sequences [ 18 ]. The presence of bone cement leakage was determined on postoperatively acquired X-ray images in the anteroposterior and lateral views. The type of bone cement leakage was evaluated based on the method reported by Tomé-Bermejo et al. [ 19 ] and assessed by postoperative CT scans. There are four types of bone cement leakage, classified as BSCD (Fig. 1 ): through the basivertebral vein (Fig. 1 A, type B), through the segmental vein (Fig. 1 B, type S), through a cortical defect (Fig. 1 C, type C), and intradiscal leakage (Fig. 1 D, type D). Statistical analyses The statistical analysis of this study is based on R language (4.2.2). Normally distributed variables were represented as x̄ ± s; non-normally distributed variables were represented as M (P25, P75), and the classification variables were represented as n (%). The two-sample t test or nonparametric rank-sum test was used to compare continuous variables between the two groups, and χ² test and Fisher’s exact test were used to compare categorical variables between groups. The survival rate was described by the Kaplan–Meier method, and the difference in survival rate was evaluated using the stratified log-rank test. Univariate and multivariate analyses of the Cox proportional hazards model were used to estimate the simultaneous impact of prognostic factors on survival. When the P value was < 0.05, the difference was considered statistically significant, and all statistical tests were bilateral. Results Patient characteristics A total of 2,624 patients were included in this study. Among them, 17 patients (0.65%, mean age, 77.24 ± 9.48 years) were diagnosed as having SSIs after PVA, including 7 men and 10 women. All 17 patients underwent PVP, and their symptom of back pain was significantly alleviated after the operation.And no prophylactic antibiotics were used in all patients during the first perioperative period. The average time to readmission was 4.06 ± 4.68 weeks. After readmission, all patients underwent puncture biopsy. The average follow-up time of patients in the infected group was 24.29 ( 7–84 ) months after the diagnosis of SSI. Notably, mNGS identified bacterial infection in 11 cases, with 3 cases of Staphylococcus epidermidis (17.65%), 2 cases of Propionibacterium humerusii (11.76%), 2 cases of Escherichia coli (11.76%), 1 case of Cutibacterium acnes (5.88%), 1 case of Roseomonas mucosa (5.88%), 1 case of Coagulase-negative Staphylococcus epidermidis (5.88%), and 1 case of Mycobacterium abscessus (5.88%). In 6 cases (35.29%) culture results of lesion tissues were negative for any mNGS-indicated strain; in these cases, the clinical diagnosis was made based on clinical features, laboratory tests, and empirical drug efficacy. In terms of the treatment, patients with identified pathogenic bacteria are prescribed sensitive antibiotics while patients with unclear pathogenic bacteria are given broad-spectrum antibiotics empirically. And all patients were treated with intravenous medication for a minimum of four weeks, followed by oral antibiotics for at least three months.Patients with clear pathogens were given specific antibiotics, and patients with unclear pathogens were given broad-spectrum antibiotics. Twelve patients underwent conservative treatment with antibiotic combination and brace fixation, whereas 5 patients underwent revision surgery(Posterior decompression and posterior pedicle screw fixation). In terms of treatment outcomes, 1 patient (5.88%) died during follow-up༈multiple systemic infections༉, 6 patients (35.29%) recovered to normal walking, 5 patients (29.41%) showed symptom resolution, and 5 patients (29.41%) needed to use a walker. The clinical characteristics of the 17 infected patients are shown in Table 1 , and the quantitative assignment of postoperative infection-related risk factors is shown in Table 2 . Table 1 Clinical characteristics of the infected group Variables Categories n (%) Age (years) Continuous 50 (77.24 ± 9.48) Sex Female 10 (58.82) Male 7 (41.18) Trauma Yes 7 (41.18) No 10 (58.82) Course of disease (days) Continuous 50 (13.65 ± 10.36) Location Thoracic 7 (41.18) Lumber 6 (35.29) Thoracic and Lumber 4 (23.53) Number of surgically treated segments ≤ 2 17 (100) > 2 0 (0) Type of intervention V 17 (100) K 0 (0) Hypertension Yes 10 (58.82) No 7 (41.18) Type 2 diabetes mellitus Yes 4 (23.53) No 13 (76.47) COPD Yes 2 (11.76) No 15 (88.24) Other complications Chronic renal insufficiency 1 (5.88) Cerebral infarction 1 (5.88) Optic neuritis 1 (5.88) Anemia 1 (5.88) Eczema 1 (5.88) Heart stent implantation status 1 (5.88) Interstitial pneumonia 1 (5.88) Use of hormone drugs Yes 1 (5.88) No 16 (94.12) Pulmonary infection Yes 5 (29.41) No 12 (70.59) Urinary tract infection Yes 1 (5.88) No 16 (94.12) Preoperative VAS Continuous 50 (7.00 ± 1.00) Urinary leukocyte Yes 8 (47.06) No 9 (52.94) Alb < 35 g/L 7 (41.18) ≥ 35 g/L 10 (58.82) WBC increase Yes 5 (29.41) No 12 (70.59) NEUT% increase Yes 7 (41.18) No 10 (58.82) CRP (mg/L) Continuous 50 (12.31 ± 9.84) ESR (mm/h) Continuous 50 (28.12 ± 18.43) Time interval to infection (weeks) Continuous 50 (4.06 ± 4.68) Pathogens Propionibacterium humerusii 2 (11.76) Cutibacterium acnes 1 (5.88) Staphylococcus epidermidis 3 (17.65) Escherichia coli 2 (11.76) Roseomonas mucosa 1 (5.88) Coagulase-negative Staphylococcus 1 (5.88) Mycobacterium abscessus 1 (5.88) Undefined 6 (35.29) Treatment Conservation 12 (70.59) Operation 5 (29.41) Outcome Normal walking 6 (35.29) Improved 5 (29.41) Uses a walker 5 (29.41) Died* 1 (5.88) COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; WBC, white blood cell count; VAS, visual analog scale; V, vertebroplasty; K, kyphoplasty; Alb, albumin; NEUT, neutrophilic granulocyte * Patient died early in follow-up. Table 2 Quantitative Assignment Table of Risk Factors Associated with Infection after PVA No. Variable Value X1 Age 0: <80; 1: ≥80 X2 Trauma 0: No; 1: Yes X3 Hypertension 0: No; 1: Yes X4 Type 2 diabetes mellitus 0: No; 1: Yes X5 Use of hormone drugs 0: No; 1: Yes X6 Urinary tract infection 0: No; 1: Yes X7 Pulmonary infection 0: No; 1: Yes X8 Number of surgically treated segments 0: ≤2; 1: >2 X9 Urinary leukocyte 0: No; 1: Yes X10 Alb 0: ≥35 g/L; 1: <35 g/L X11 WBC 0: No; 1: Yes X12 NEUT% 0: No; 1: Yes X13 CRP Real number (mg/L) X14 ESR Real number (mm/h) X15 MRI suggests fluid sign 0: No; 1: Yes X17 Type B of cement leakage 0: No; 1: Yes X18 Type S of cement leakage 0: No; 1: Yes X19 Type C of cement leakage 0: No; 1: Yes X20 Type D of cement leakage 0: No; 1: Yes CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; WBC, white blood cell count; Alb, albumin; NEUT, neutrophilic granulocyte; MRI, magnetic resonance imaging Single-factor analysis by Cox regression The results of univariate analysis showed that the following factors impacted the occurrence of postoperative SSIs after PVA: age ≥ 80 years (HR = 3.23, 95% CI 1.19 to 8.73; P = 0.021), preoperative type 2 diabetes (HR = 3.85, 95% CI 1.22 to 12.13; P = 0.021), pulmonary infection (HR = 14.75, 95% CI 4.11 to 52.98; P < 0.001), use of hormone drugs (HR = 10.07, 95% CI 1.23 to 82.45; P = 0.031), Alb ≤ 35 g/L (HR = 5.52, 95% CI 2.00 to 15.28; P = 0.001), NEUT% (HR = 2.85, 95% CI 1.05 to 7.68; P = 0.039), preoperative MRI indicating signs of fluid accumulation in the fractured vertebral body (HR = 5.91, 95% CI 2.05 to 17.04; P = 0.001), C-type bone cement leakage after the operation (HR = 6.75, 95% CI 2.04 to 22.31; P = 0.002), and D-type bone cement leakage after the operation (HR = 9.43, 95% CI 2.99 to 29.75; P < 0.001,Table 3 ). Table 3 Risk Factors and Parameter Estimates for Screening by Univariate Analysis of Cox Regression Models Variable Level HR 95% CI P Age < 80 Ref ≥ 80 3.23 1.19–8.73 0.021 * Traumatic history No Ref Yes 0.47 0.17–1.29 0.140 Hypertension No Ref Yes 1.85 0.68–5.01 0.226 Type 2 diabetes mellitus No Ref Yes 3.85 1.22–12.13 0.021 * Use of hormone drugs No Ref Yes 10.07 1.23–82.45 0.031 * Urinary tract infection No Ref Yes 0.60 0.08–4.59 0.622 Pulmonary infection No Ref Yes 14.75 4.11–52.98 2 No Ref Yes 2.64 0.83–8.46 0.102 Urinary leukocyte No Ref Yes 1.61 0.60–4.32 0.343 Alb > 35 Ref ≤ 35 5.52 2.00–15.28 0.001 ** WBC Normal Ref Ascension 2.00 0.69–5.82 0.204 NEUT% Normal Ref Ascension 2.85 1.05–7.68 0.039 * CRP_value 1 1.02 0.97–1.07 0.371 ESR_value 1 1.00 0.98–1.03 0.832 MRI suggests fluid sign No Ref Yes 5.91 2.05–17.04 0.001 ** Types of bone cement leakage Type B No Ref Yes 1.44 0.18–11.25 0.727 Type S No Ref Yes 2.07 0.27–16.15 0.487 Type C No Ref Yes 6.75 2.04–22.31 0.002 ** Type D No Ref Yes 9.43 2.99–29.75 < 0.001 *** CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; WBC, white blood cell count; Alb, albumin; NEUT, neutrophilic granulocyte; MRI, magnetic resonance imaging *: P < 0.05, **: P < 0.01, ***: P < 0.001. Ref: The reference level of the variable. 1: Variables are continuous variables Multiple-Factor Analysis by Cox Regressio n The results of multivariate analysis showed that the following were independent risk factors for postoperative SSIs after PVA: age ≥ 80 years (HR = 3.26, 95% CI 1.02 to 10.40; P = 0.046), preoperative type 2 diabetes (HR = 5.48, 95% CI 1.22 to 24.58; P = 0.026), pulmonary infection (HR = 23.63, 95% CI 4.26 to 131.22; P < 0.001), Alb ≤ 35 g/L (HR = 5.76, 95% CI 1.70 to 19.45; P = 0.005), preoperative MRI indicating signs of fluid accumulation in the fractured vertebral body (HR = 6.41, 95% CI 1.84 to 22.36; P = 0.004), and D-type bone cement leakage after the operation (HR = 3.93, 95% CI 1.02 to 15.15; P = 0.047, Table 4 ). Table 4 Risk Factors and Parameter Estimation for Screening by Multifactorial Analysis with Cox Regression Modeling Variable Level HR 95% CI P Age 35 Ref ≤ 35 5.76 1.70–19.45 0.005 ** Type 2 diabetes mellitus No Ref Yes 5.48 1.22–24.58 0.026 * MRI suggests fluid sign No Ref Yes 6.41 1.84–22.36 0.004 ** Pulmonary infection No Ref Yes 23.63 4.26–131.22 < 0.001 *** Type D of cement leakage No Ref Yes 3.93 1.02–15.15 0.047* Alb, albumin; MRI, magnetic resonance imaging. *: P < 0.05, **: P < 0.01, ***: P < 0.001. Ref: The reference level of the variable Discussion Postoperative SSI after PVA is rare. Abdelrahman et al. [ 10 ] reported that 6/1307 patients (0.46%) who underwent percutaneous vertebroplasty or kyphoplasty developed postoperative infection. Similarly, Park et al. [ 15 ] reported a postoperative infection rate of 0.36% (3/826 cases) after PVA. Liao et al. [ 9 ] reported that 18/5749 patients (0.32%) developed progressive infectious spondylitis after PVP. Shin et al. [ 20 ] reported that 2/104 patients (1.9%) developed various post-PVA infections. In our study, 17/2624 patients (0.65%) developed postoperative vertebral infections. In their prospective research and a review of 42 cases collected from 26 articles, Park et al. [ 15 ] reported a postoperative infection mortality rate of 15.1%. The mortality rate in the present study was 5.88% (1/17 cases). Due to the low incidence of the disease, the sample size at the single center is limited. To better investigate the risk factors of surgical site infection, a case-control study design was implemented. Patients in the control group were selected at a ratio of 1:3.The relevant case data underwent retrospective analysis, ultimately revealing a strong correlation between postoperative infections and advanced age (≥ 80 years), type 2 diabetes, hypoproteinemia (Alb ≤ 35 g/L), preoperative MRI indicating signs of fluid accumulation in the fractured vertebral body, and D-type bone cement leakage after the operation. Age and albumin Hypoalbuminemia and advanced age are reportedly risk factors for postoperative SSIs after PVA [ 10 , 15 ]. In this study, we identified hypoalbuminemia (Alb ≤ 35 g/L) and advanced age (age ≥ 80 years) as independent risk factors for postoperative SSIs after PVA. Older patients may have impaired immune function, reduced body function, malnutrition, or other underlying diseases, thus exacerbating the risk of postoperative SSIs [ 21 ]. Malnutrition is associated with compromised host resistance. Rhoads et al. [ 22 ] reported in as early as 1955 the association between hypoalbuminemia and increased postoperative infection risk. Andreas Eckart et al. [ 23 ] identified a relationship between hypoalbuminemia and inpatient mortality rate, which can serve as a predictor of the patient’s prognosis. Yamamoto et al. [ 24 ] identified hypoalbuminemia as an independent risk factor for prolonged hospitalization in predicting SSIs. Malnutrition can adversely affect the immune system; besides reducing bacterial clearance and impairing the chemotaxis of neutrophils, it also suppresses the antibacterial function of neutrophils, such as the transport of immune-related cells to the site of infection and effective components in the serum [ 25 ]. In addition, insufficient serum albumin can affect the colloid osmotic pressure of the blood. This results in tissue fluid leakage and swelling around the surgical site, which creates favorable conditions for bacterial growth and reproduction and consequently increases the risk of infection [ 26 ]. Notably, SSIs after PVA procedures are typically caused by low-virulence bacteria and are thus more likely to occur in older patients with poor nutrition and compromised immune function. Based on relevant literature reports [ 27 ], we believe that actively improving patients’ nutritional status during the perioperative period is essential to enhance their immune function and that their preoperative plasma albumin level should be stable at > 35 g/L. Doctors should inform older patients and patients with hypoalbuminemia (plasma albumin level ≤ 35 g/L) about the increased risk of postoperative infection before the operation itself. Diabetes mellitus The relationship between type 2 diabetes and increased risk of postoperative infections has been previously reported. Elevated HbA1c levels in patients with type 2 diabetes are reportedly associated with increased risk of early postoperative infections, and the risk of sternal infection is five-fold higher (OR = 5.3) when the HbA1c level is > 7.8% [ 28 ]. In terms of the effect on the immune system, poor long-term blood sugar control affects the function of monocytes and neutrophils, including adhesion, chemotaxis, phagocytosis, and other important processes; it also detrimentally affects β-cell reserves and insulin receptors, resulting in an infection-prone immunocompromised state [ 29 ]. Type 2 diabetes can cause microvascular lesions, leading to delayed wound healing, increased risk of postoperative site infection, insufficient nutrition, and inadequate local blood supply in the surgical area [ 30 ]. The Chinese Adult Perioperative Blood Glucose Monitoring Expert Consensus [ 31 ] recommends active blood glucose control for all surgeries, including percutaneous vertebral augmentation. For regular surgeries, the blood glucose control targets are as follows: HbA1c: < 8.5%; FPG or pre-meal blood sugar: 8–10 mmol/L, 2 hPG or any time point blood sugar 8–12 mmol/L when unable to eat, and short-term blood sugar < 15 mmol/L are also acceptable. In patients with poorly controlled diabetes, effective perioperative monitoring, supervision, and management of blood sugar levels should be ensured. The original hypoglycemic regimen before surgery can be transitioned to insulin, and based on fasting conditions, insulin doses for controlling postprandial blood sugar can be reduced. For patients with type 2 diabetes, oral hypoglycemic drugs and non-insulin injections should be discontinued on the day of surgery, and blood sugar should be monitored during the discontinuation period. Some experts recommend prophylactic use of antibiotics before PVA in high-risk patients to reduce the incidence of postoperative pyogenic spondylitis [ 9 , 32 ]. Pulmonary infection This study also identified pulmonary infection as an independent risk factor. Weir et al. [ 33 ] proposed in as early as 1983 the concept of “The term locus minoris resistentiae indicates a place of less resistance,” which means that the site of injury in the body is more susceptible to pathogen invasion. Therefore, pulmonary infection is easily spread to the surgical area via blood circulation. However, whether the infection spreads through arteries or veins remains unknown and needs further research. It is generally believed that primary pyogenic spondylitis occurs more commonly via the arterial than the venous route. However, the Batson vertebral venous system in the lumbar vertebrae may also be one of its transmission routes [ 34 ]. The artery supplies the middle intervertebral disc at the same segment, the upper half of the adjacent lower vertebral body, and the lower half of the upper vertebral body, and the arterial spread may involve two adjacent vertebrae and intervertebral discs [ 35 ]. The Batson vertebral venous system communicates with the body's veins, has slow blood flow, and lacks venous valves, and therefore, pathogens can spread through the venous system as well [ 36 ]. In this study, 1/17 and 5/17 patients who developed a postoperative infection had urinary tract infection and pulmonary infection before the operation, respectively. Unlike previous reports, we herein did not find a correlation between urinary tract infection and postoperative site infection [ 9 ]. This could be attributed to the small sample size. However, in patients who have other infections before the operation, we recommend actively controlling the primary lesion and performing surgical treatment after the infection is controlled. Intradiscal leakage Interestingly, to our knowledge, this is the first report identifying type D bone cement leakage (intradiscal leakage) as an independent risk factor for post-PVA SSIs. Polymethyl methacrylate (PMMA) bone cement is currently the first filling material for PVA surgery because of its cost-effectiveness, superior biomechanical properties, and stable chemical properties [ 37 ]. However, as PMMA bone cement is not degradable and lacks bioactivity, it does not bond with host bone tissue and can cause localized inflammation at the site in the long term [ 38 ]. Its leakage into the intervertebral disc can cause increased stress in the adjacent vertebrae, leading to changes in the mechanical load direction and biological metabolism of the intervertebral disc; these changes lead to imaging study findings of edema and increase the risk of fracture [ 39 ]. Inflammatory substances stimulate the intervertebral discs or elevate the pressure within the discs, thus producing discogenic low back pain [ 40 ]. It is easy to misdiagnose a spinal infection when a patient revisits the hospital with symptoms of low back pain after PVA and imaging shows periprosthetic inflammatory-like changes around the operated vertebrae and abnormal signals in the adjacent vertebrae and intervertebral discs. To our knowledge, two similar cases have been reported in the literature [ 41 ]. Both these patients had leakage of the intervertebral disc cement and needed to be readmitted for postoperative low back pain. Complete puncture biopsy did not reveal pathogenic bacteria; however, patient's symptoms alleviated with anti-osteoporosis treatment. Most spinal infections are transmitted through the bloodstream and first invade the vertebral body. However, intervertebral discs are avascular in adults. Bacteria invade the end artery arch near the intervertebral disc under the cartilage and then spread to the intervertebral disc via the endplate [ 42 ]. However, bone cement leakage into the intervertebral disc will lead to the formation of a bridge between the vertebral body and the intervertebral disc. This will cause the vertebral infection to spread to the disc; furthermore, it will increase the risk of infection, particularly in the neighboring vertebrae. In this study, one patient in the infection group who had pulmonary infection before the operation showed bone cement leakage into the intervertebral disc. Follow-up findings revealed that the infection spread to the intervertebral disc and the adjacent vertebrae, leading to kyphosis. Preoperative sputum culture and mNGS of the infected vertebrae both revealed the same pathogen, namely Mycobacterium abscessus . For preoperative co-infections occurring at other sites, disc cement leakage should be avoided to the extent possible when surgical treatment with PVA is performed after achieving good infection control. MRI suggests IVC filling with liquid Histologically, compression fracture with an intravertebral cleft sign appears quite similar to vertebral osteonecrosis, and the late gap can be replaced with being fluid. Therefore, the T2-weighted MRI sequences show high signal and 81% probability of intravertebral vacuum cleft filling with liquid in the thoracolumbar segment [ 43 ]. Although gas or fluid accumulation within the vertebral body seldom occurs in spinal infections, the possibility of an infection cannot be completely ruled out [ 44 , 45 ]. In the present study, 11/17 patients (64.7%) who developed infection showed signs of fluid accumulation before the operation. We identified nine bacterial pathogens using puncture biopsy or surgical pathological examination. In addition, although no bacteria were identified in 2 patients, their symptoms resolved with antibiotic treatment as confirmed by imaging examination. Therefore, we considered these as post-PVP infections. Notably, in these patients, MRI showed intravertebral fluid accumulation and CT showed intravertebral fissure and cavity formation. This may be attributed to intravertebral vascular injury and necrosis, which compromise local blood supply and make bacterial survival easier. In addition, incomplete filling of the cavity with the bone cement will cause mechanical instability within the vertebral body. Combined with stress concentration at the thoracolumbar junction, it will further damage spinal stability and exacerbate the infection. Treatment process The follow-up findings of patients with vertebral body infections after PVA are not optimistic. In our study, 12/17 patients (70.59%) received conservative treatment and 5/17 patients (29.41%) underwent surgical treatment. Among these patients, 6 patients (35.29%) recovered to normal walking, 5 patients (29.41%) showed symptom resolution, 5 patients (29.41%) needed to use a walker, and 1 patient (5.88%) died during follow-up. To minimize post-PVA infections, considering both previous literature reports[ 10 , 46 , 47 ]and our current findings, we summarized the following suggestions and developed a diagnosis and treatment flowchart, which is shown in Fig. 2 . Routine tests like WBC, ESR, CRP, chest X-ray (patients with advanced age, history of pulmonary tuberculosis, or lung tumors are recommended to undergo complete chest CT examination), thoracolumbar MRI, and CT examination should be mandatory before PVA surgery in patients with OVCF. PVA should be delayed in patients with atypical CT/MRI fracture signals or significantly elevated inflammatory parameters. Further notable improvements in enhanced MRI examinations and vertebral puncture biopsy are essential before PVA. Only after the inflammatory parameters have decreased and the possibility of an infection has been ruled out can the surgery be performed, and conservative treatment can be considered for cases not meeting these prerequisites. For patients with other infections, such as pulmonary infections or urinary tract infections, these infections should be actively treated first. Surgery can be performed at a later time when the inflammatory parameters have significantly decreased and the infection is under control. Among elderly patients, bone cement leakage should be minimized during surgery in elderly patients with severe immunodeficiency, poor blood glucose control ( HbA1c > 8.5% ; short-term blood glucose > 15 mmol / L), or suspected infection at other sites. Prophylactic antibiotics or antibiotic-loaded bone cement should be used perioperatively. In patients with a preoperative Alb level of ≤ 35 g/L, protein supplementation and nutritional support should be provided during and after surgery. Intraoperative biopsy should be routinely performed in patients with intravertebral fluid/fissure signs or suspected vertebral infections. Histopathology, general bacterial culture, and high-throughput gene sequencing examination should be performed in these patients. The use of antibiotic-loaded bone cement is recommended during the operation. It is recommended to ensure that the bone cement is fully filled in the cleft area in patients with intravertebral fluid signs. Limitations This was is a single-center retrospective study. Owing to the low incidence of SSIs after PVA, the sample size obtained from a single center is small, and because of the retrospective design, there may be information collection bias in the statistical data. There are limitations associated with the comprehensiveness of the collection of risk factors because there may be some risk factors that are yet unknown, thus necessitating further investigation. In the future, multicenter prospective studies with large sample sizes are needed to analyze the causes and prevention strategies. Conclusions Even though PVA is a minimally invasive intervention, postoperative SSI is a rare but significant complication. In this study, we retrospectively analyzed the possible risk factors for postoperative infection and found that age ≥ 80 years, type 2 diabetes, hypoproteinemia (Alb ≤ 35 g/L), pulmonary infection, intravertebral fluid signs, and bone cement leakage into the intervertebral disc were independent risk factors for post-PVA infections. These data may help guide clinicians take preoperative preventive measures to reduce the incidence of post-PVA infections. Abbreviations PVA: Percutaneous vertebral augmentation; OVCF: osteoporotic vertebral compression fracture, SSI: surgical site infection; PVP: percutaneous vertebroplasty; PKP: percutaneous kyphoplasty; SSIs: surgical site infections; CT: Computed tomography; MRI: magnetic resonance imaging; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; WBC: white blood cell; VAS: visual analog scale; NEUT%: neutrophilic granulocyte ratio; Alb: albumin; PMMA: Polymethyl methacrylate; COPD: chronic obstructive pulmonary disease; mNGS: metagenomic next-generation sequencing; IVC: intravertebral vacuum cleft Declarations Acknowledgements Not applicable. Authors' contributions RBC：Conception and design; Critical revision of the manuscript for important intellectual content; Analysis and interpretation of data；JQC：Acquisition and data ;Critical revision of the manuscript for important intellectual content；Drafting of the manuscript；WCC：Data curation；Analysis and interpretation of data;Drafting of the manuscript；YZP：Analysis and interpretation of data; Drafting of the manuscript；SPL： Drafting of the manuscript; Statistical analysis；MSC：Administrative,technical or material support; Supervision；YL：Administrative,technical or material support;Supervision. Funding This work was supported by grants from the Science and Technology Projects of Social Development in Zhuhai (2320004000271). Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate This work has been carried out in accordance with the Declaration of Helsinki (2000) of the World Medical Association. This study was approved by Guangdong Province Hospital of Traditional Chinese Medicine. This article is a retrospective study. Therefore, the institution waived the requirement to obtain distinct written informed consent from the patients (approval number: ZE2023-176-01). Consent for publication Not applicable. Competing interests All the authors declare that they have no confict of interest. Author details 1 The Second Clinical Medicine College, Guangzhou University of Chinese Medicine, Guangzhou, China；2 Guangdong Province Hospital of Chinese Medicine ZHUHAI, Zhuhai, China References Salari N, Darvishi N, Bartina Y, Larti M, Kiaei A, Hemmati M, et al. Global prevalence of osteoporosis among the world older adults: a comprehensive systematic review and meta-analysis. 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Liu JM, Deng HL, Chen XY, Zhou Y, Yang D, Duan MS, et al. Risk Factors for Surgical Site Infection After Posterior Lumbar Spinal Surgery. Spine (Phila Pa 1976) 2018;43:732–7. https://doi:10.1097/BRS.0000000000002419 Chen LM, Chen W, Chen YY, Deng W, Gao HK, Gao YH, et al. Expert consensus on preoperative glucose monitoring in adults. Chin J Diabetes 2021;29:81–5. (in Chinese) Syed MI, Avutu B, Shaikh A, Sparks H, Mohammed MI, Morar K. Vertebral osteomyelitis following vertebroplasty: is acne a potential contraindication and are prophylactic antibiotics mandatory prior to vertebroplasty? Pain Physician 2009;12:E285-90. Weir WR, Muraleedharan MV. Tuberculosis arising at the site of physical injury: eight case histories. J Infect 1983;7:63 – 6. https:// doi: 10.1016/s0163-4453(83)91049-6 Sato K, Yamada K, Yokosuka K, Yoshida T, Goto M, Matsubara T, et al. Pyogenic Spondylitis: Clinical Features, Diagnosis and Treatment. Kurume Med J 2019;65:83–9. https:// doi: 10.2739/kurumemedj.MS653001 Sapico FL, Montgomerie JZ. Vertebral osteomyelitis. Infect Dis Clin North Am 1990;4:539–50. Zheng YH, Cao P, Chen Z. Spinal infection. Int J Orthop 2014;35:24–6. https://doi:10.3969/j.issn.1673-7083.2014.01.009 (in Chinese) Zhu J, Yang S, Cai K, Wang S, Qiu Z, Huang J, et al. Bioactive poly (methyl methacrylate) bone cement for the treatment of osteoporotic vertebral compression fractures. Theranostics 2020;10:6544–60. https://doi:10.7150/thno.44428 Sugino A, Miyazaki T, Kawachi G, Kikuta K, Ohtsuki C. Relationship between apatite-forming ability and mechanical properties of bioactive PMMA-based bone cement modified with calcium salts and alkoxysilane. J Mater Sci Mater Med 2008;19:1399–405. https:// doi: 10.1007/s10856-007-3257-5 Lin EP, Ekholm S, Hiwatashi A, Westesson PL. Vertebroplasty: cement leakage into the disc increases the risk of new fracture of adjacent vertebral body. AJNR Am J Neuroradiol 2004;25:175–80. Qiao XW, Deng Q, Li ZF. Research Progress of Bone Cement Leakage after PKP for Osteoporotic Vertebral Compression Fractures. Medical Recapitulate 2021;27:3226–31. https://doi: 10.3969/j. issn.1006-2084.2021.16.020 (in Chinese) Wendling D, Runge M, Toussirot E, Bertolini E, Prati C. Vertebral osteitis adjacent to kyphoplasty. Joint Bone Spine 2010;77:67–9. https://doi:10.1016/j.jbspin.2009.11.004 Cheung WY, Luk KD. Pyogenic spondylitis. Int Orthop 2012;36:397–404. https://doi:10.1007/s00264-011-1384-6 Kim DY, Lee SH, Jang JS, Chung SK, Lee HY. Intravertebral vacuum phenomenon in osteoporotic compression fracture: report of 67 cases with quantitative evaluation of intravertebral instability. J Neurosurg 2004;100:24–31. https://doi:10.3171/spi.2004.100.1.0024 Resnick D, Niwayama G, Guerra J, Jr., Vint V, Usselman J. Spinal vacuum phenomena: anatomical study and review. Radiology 1981;139:341–8. https://doi:10.1148/radiology.139.2.7220878 Bielecki DK, Sartoris D, Resnick D, Van Lom K, Fierer J, Haghighi P. Intraosseous and intradiscal gas in association with spinal infection: report of three cases. AJR Am J Roentgenol 1986;147:83–6. https://doi:10.2214/ajr.147.1.83 Liu Z, Zhou Y, Lei F, Ye F, Zhou Q, Kang J, et al. Causes and preventive strategies of pyogenic spondylitis after percutaneous kyphoplasty. Chinese Journal of Spine and Spinal Cord 2020;30:880–7. https://doi:10.3969/j.issn.1004-406X.2020.10.03 (in Chinese) Pneumaticos SG, Chatziioannou SN, Savvidou C, Pilichou A, Rontogianni D, Korres DS. Routine needle biopsy during vertebral augmentation procedures. Is it necessary? Eur Spine J 2010;19:1894–8. https://doi:10.1007/s00586-010-1388-8 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3862789","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":267739943,"identity":"59b4ddef-ec72-4a06-92ba-2741cc2f0e26","order_by":0,"name":"Rongbin Chen","email":"","orcid":"","institution":"The Second Clinical Medicine College, Guangzhou University of Chinese Medicine, Guangzhou, China","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rongbin","middleName":"","lastName":"Chen","suffix":""},{"id":267739944,"identity":"a61852f7-3271-4602-97c9-2609f1612d9a","order_by":1,"name":"Jianquan Chen","email":"","orcid":"","institution":"The Second Clinical Medicine College, Guangzhou University of Chinese Medicine, Guangzhou, China","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jianquan","middleName":"","lastName":"Chen","suffix":""},{"id":267739945,"identity":"cf743a80-9af1-472d-b608-e309a5c5f687","order_by":2,"name":"Wenchuang Chen","email":"","orcid":"","institution":"The Second Clinical Medicine College, Guangzhou University of Chinese Medicine, Guangzhou, China","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wenchuang","middleName":"","lastName":"Chen","suffix":""},{"id":267739946,"identity":"46101f15-6f39-4d36-bb23-2a0b6e1d4b35","order_by":3,"name":"Yizhi Pan","email":"","orcid":"","institution":"The Second Clinical Medicine College, Guangzhou University of Chinese Medicine, Guangzhou, China","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yizhi","middleName":"","lastName":"Pan","suffix":""},{"id":267739947,"identity":"e1eddf73-657b-416b-b64c-c7090f376935","order_by":4,"name":"Shunpin Li","email":"","orcid":"","institution":"The Second Clinical Medicine College, Guangzhou University of Chinese Medicine, Guangzhou, China","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shunpin","middleName":"","lastName":"Li","suffix":""},{"id":267739948,"identity":"491d2996-145c-43de-8d57-cfaed6b1a2ab","order_by":5,"name":"Maoshui Chen","email":"","orcid":"","institution":"The Second Clinical Medicine College, Guangzhou University of Chinese Medicine, Guangzhou, China","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Maoshui","middleName":"","lastName":"Chen","suffix":""},{"id":267739949,"identity":"ef2f1aea-90dc-4ba5-8b29-0cc2a8aa37e7","order_by":6,"name":"Yong Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYBACPgYGNgbGBgYefvbmgw8SKmwIa2GDaZHsOZZs8OBMGvFaGAxm+KhJPmw7RIQWifRnj3l32MkYSPCwVSSwHWDgb+9OIKAlId2Y90wyj7l077EbCTx3GCTOnN1ASMsxad42Zh7LOefSbiRIPGMwkMglpCWxDailnsfgRo5ZQYLBYWK0JLMBtRwGa2FISCBGC88zNsm5bcfBgSyRcCCNh6Bf+NnTn0m8bau2B0Xlx5//bOT423vxa2EQSEDl8+BXDrbmAGE1o2AUjIJRMMIBAPaXRaGHcoH+AAAAAElFTkSuQmCC","orcid":"","institution":"The Second Clinical Medicine College, Guangzhou University of Chinese Medicine, Guangzhou, China","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-01-14 09:14:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3862789/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3862789/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49895429,"identity":"4439b9cb-865c-43df-9a6c-50cb2f10da84","added_by":"auto","created_at":"2024-01-19 21:42:30","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":160200,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMethod of assessing cement leakage type.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the postoperative review (CT) findings, four types were classified according to the classification proposed by Tomé-Bermejo et al.: (A) Through the basivertebral vein (type B); (B) Through the segmental vein (type S); (C) through a cortical defect (type C); and (D) intradiscal leakage (type D)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3862789/v1/47e7fc8869db9ee8c7261d56.jpeg"},{"id":49895430,"identity":"2d7420bb-7571-4c2c-b081-6c9b201dace8","added_by":"auto","created_at":"2024-01-19 21:42:30","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3185852,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDiagnosis and treatment flow chart\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOVCF, osteoporotic vertebral compression fracture; PVA, percutaneous vertebral augmentation; mNGS, metagenomic next-generation sequencing; Alb, albumin; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; WBC, white blood count; Alb, albumin; MRI, magnetic resonance imaging; CT, computed tomography; IVC, intravertebral vacuum cleft\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3862789/v1/669af9748f0be1b6e2ecaa4d.jpeg"},{"id":53438422,"identity":"0d4851e6-939d-49bf-aef2-5b0e93f0fd06","added_by":"auto","created_at":"2024-03-26 02:53:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":685975,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3862789/v1/246b8d4b-c352-4b08-aa57-80adca769a94.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk Factors for Infection after Percutaneous Vertebroplasty Augmentation for Osteoporotic Vertebral Compression Fracture","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith the increase in aging population globally, osteoporosis has become the most common bone disease [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Its global prevalence rate is estimated to be 18.3%, and it is more common in women [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Osteoporotic vertebral compression fracture (OVCF) is among the most common complications in patients with osteoporosis, and its incidence is progressively increasing [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It is well known that OVCF can cause constant pain and kyphotic deformity to patients and limit their activity, which can adversely affect their quality of life and even lead to death [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Percutaneous vertebral augmentation (PVA), including percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP), is a commonly used and effective minimally invasive surgical treatment for OVCF. It can restore the height of the injured vertebra to a certain degree, reconstruct the stability of the spine, quickly relieve pain, and improve the quality of life of the patient [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough PVA is widely regarded as a safe surgical procedure, there are still many complications associated with it, which mainly include cement leakage, cement embolism, nerve injury, epidural hematoma, and infection [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Notably, although the incidence of postoperative surgical site infections (SSIs) after PVA is extremely low, in the event that this infection occurs, it will require long-term use of high-dose antibiotics for treatment or further surgical intervention, with a high disability and mortality rate [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, current research on postoperative SSIs after PVA mainly comprises case reports, and there is no analysis of related risk factors.\u003c/p\u003e \u003cp\u003eTherefore, to reduce the occurrence of postoperative SSIs after PVA, we will review relevant literature and clinical experience in this study. We will also collect possible risk factors for relevant cases, use a case-control study method to conduct Cox regression analyses, explore important independent risk factors closely related to postoperative SSIs after PVA, and establish an OVCF diagnosis and treatment process to guide clinical diagnosis and treatment.\u003c/p\u003e"},{"header":"Methods and materials","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eWe retrospectively collected case data of patients with OVCF who underwent PVA between January 2015 and December 2021 from the spinal surgery database of our hospital. We conducted this study in accordance with the World Medical Association's 2000 Declaration of Helsinki, and it was approved by our hospital\u0026rsquo;s ethics review committee (approval number: ZE2023-176-01). Given the retrospective design of this study, the institution waived the requirement to obtain written informed consent from the participants.\u003c/p\u003e \u003cp\u003eThe inclusion criteria for patients with postoperative SSIs were as follows [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eInitial diagnosis was of OVCF; initial surgery was performed using PVA, and complete follow-up clinical data were available.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eClinical manifestations were consistent with postoperative spinal infection, such as fever, night sweats, weight loss, local tenderness and percussion pain, or combined neurological dysfunction.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eComputed tomography (CT) revealed bone absorption and destruction around bone cement. Typical signs of infection like inflammation signal changes in bone cement-enhanced areas and abscess formation were visible on magnetic resonance imaging (MRI).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLaboratory tests showed elevation of one or more inflammatory indicators, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and white blood cell (WBC) count. T-cell spot test for tuberculosis infection was positive. Blood culture and pathogen microbial examination or metagenomic next-generation sequencing confirmed pathogenic bacteria.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIf pathogenic microorganism examination or metagenomic next-generation sequencing results are negative, but patients exhibit clinical symptoms and imaging findings consistent with infection in the operation area, and respond effectively to antibiotic treatment, they still be diagnosed with a surgical site infection.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe exclusion criteria for patients with postoperative SSIs were as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePatients with preoperative comorbidities like spinal metastases, multiple myeloma, or vascular tumors\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatients with incomplete clinical and imaging data\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatients who were followed up for less than one year\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAccording to the aforementioned inclusion and exclusion criteria, seventeen patients with surgical site infections were ultimately included in the infection group during the follow-up period.All patients in the infection group were readmitted to test for inflammatory indicators (WBC, ESR, and CRP) and underwent complete spinal X-ray, CT, and MRI scans as well as percutaneous puncture to obtain lesion tissue for microbial culture, histopathologic examination, and mNGS detection of tissue samples.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eWe conducted a case-control study to analyze the risk factors for postoperative SSIs after PVA. Patients in the infection group were selected as the case group. For each patient in the case group, 3 patients who did not develop infections after the operation were selected from the non-infection group as the control group, with a total of 51 patients selected in the control group. The selection criteria for the control group were as follows: the same age and gender with the infection group, consistent preoperative diagnosis with the infection group, no infection or other serious complications after the operation, hospital admission and surgery performed within 3 months before or after the infection group, and same surgeon performing the surgery.\u003c/p\u003e \u003cp\u003e The medical records and imaging data of patients in both groups were reviewed, and the follow-up period was at least 1 year. Imaging data were measured at and collected from the imaging department of our hospital. Demographic information was retrieved from our hospital\u0026rsquo;s database of follow-up findings. The visual analog scale (VAS) score was determined by questionnaires [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. All data were anonymized and collected by two senior spine surgeons who assessed the data separately, and the inclusion of cases with controversial data was decided by discussion among authors.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eRisk factors\u003c/h2\u003e \u003cp\u003eFor potential risk factors, we collected the following data from electronic medical records, based on our clinical experience and previous research describing possible risk factors [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. \u003cem\u003eDemographic information\u003c/em\u003e: We collected data on age and sex of patients.\u003c/p\u003e \u003cp\u003e \u003cem\u003eClinical features\u003c/em\u003e: We collected data on the history of trauma, disease course, fractured segment, long-term use of steroid drugs before the operation, surgical segment, surgical method, and follow-up duration. \u003cem\u003ePreoperative comorbidities\u003c/em\u003e: We collected information on pulmonary infection, urinary tract infection, other infections, hypertension, and type 2 diabetes.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePreoperative laboratory tests\u003c/strong\u003e \u003cp\u003eWe collected the findings for urine leukocyte levels, WBC counts, neutrophilic granulocyte ratio (NEUT%), ESR, CRP levels, and albumin levels (Alb, cases with Alb\u0026thinsp;\u0026le;\u0026thinsp;35 g/L were distinguished to evaluate the severity of hypoalbuminemia) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eImaging features\u003c/em\u003e: We collected information on the intravertebral vacuum cleft filling with liquid in the preoperative MRI of the fractured vertebral body and on whether there was bone cement leakage and the type of bone cement leakage after the operation. For the infection group, the following data were additionally collected from electronic medical records: preoperative VAS, time to infection, treatment plan, and microbiology results and treatment outcomes.\u003c/p\u003e \u003cp\u003eFluid sign in the fractured vertebral body is defined as the presence of an intravertebral vacuum cleft with fluid filling as the main feature. Based on preoperative MRI data, the typical manifestation is a low signal of the intravertebral cleft in T1-weighted sequences and a high signal in T2-weighted sequences [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The presence of bone cement leakage was determined on postoperatively acquired X-ray images in the anteroposterior and lateral views. The type of bone cement leakage was evaluated based on the method reported by Tom\u0026eacute;-Bermejo et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and assessed by postoperative CT scans. There are four types of bone cement leakage, classified as BSCD (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e): through the basivertebral vein (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, type B), through the segmental vein (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB, type S), through a cortical defect (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC, type C), and intradiscal leakage (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD, type D).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eThe statistical analysis of this study is based on R language (4.2.2). Normally distributed variables were represented as \u003cem\u003ex̄\u003c/em\u003e \u0026plusmn; s; non-normally distributed variables were represented as M (P25, P75), and the classification variables were represented as n (%). The two-sample t test or nonparametric rank-sum test was used to compare continuous variables between the two groups, and χ\u0026sup2; test and Fisher\u0026rsquo;s exact test were used to compare categorical variables between groups. The survival rate was described by the Kaplan\u0026ndash;Meier method, and the difference in survival rate was evaluated using the stratified log-rank test. Univariate and multivariate analyses of the Cox proportional hazards model were used to estimate the simultaneous impact of prognostic factors on survival. When the \u003cem\u003eP\u003c/em\u003e value was \u0026lt;\u0026thinsp;0.05, the difference was considered statistically significant, and all statistical tests were bilateral.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eA total of 2,624 patients were included in this study. Among them, 17 patients (0.65%, mean age, 77.24\u0026thinsp;\u0026plusmn;\u0026thinsp;9.48 years) were diagnosed as having SSIs after PVA, including 7 men and 10 women. All 17 patients underwent PVP, and their symptom of back pain was significantly alleviated after the operation.And no prophylactic antibiotics were used in all patients during the first perioperative period. The average time to readmission was 4.06\u0026thinsp;\u0026plusmn;\u0026thinsp;4.68 weeks. After readmission, all patients underwent puncture biopsy. The average follow-up time of patients in the infected group was 24.29 ( 7\u0026ndash;84 ) months after the diagnosis of SSI.\u003c/p\u003e \u003cp\u003eNotably, mNGS identified bacterial infection in 11 cases, with 3 cases of \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e (17.65%), 2 cases of \u003cem\u003ePropionibacterium humerusii\u003c/em\u003e (11.76%), 2 cases of \u003cem\u003eEscherichia coli\u003c/em\u003e (11.76%), 1 case of \u003cem\u003eCutibacterium acnes\u003c/em\u003e (5.88%), 1 case of \u003cem\u003eRoseomonas mucosa\u003c/em\u003e (5.88%), 1 case of Coagulase-negative \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e (5.88%), and 1 case of \u003cem\u003eMycobacterium abscessus\u003c/em\u003e (5.88%). In 6 cases (35.29%) culture results of lesion tissues were negative for any mNGS-indicated strain; in these cases, the clinical diagnosis was made based on clinical features, laboratory tests, and empirical drug efficacy.\u003c/p\u003e \u003cp\u003eIn terms of the treatment, patients with identified pathogenic bacteria are prescribed sensitive antibiotics while patients with unclear pathogenic bacteria are given broad-spectrum antibiotics empirically. And all patients were treated with intravenous medication for a minimum of four weeks, followed by oral antibiotics for at least three months.Patients with clear pathogens were given specific antibiotics, and patients with unclear pathogens were given broad-spectrum antibiotics. Twelve patients underwent conservative treatment with antibiotic combination and brace fixation, whereas 5 patients underwent revision surgery(Posterior decompression and posterior pedicle screw fixation). In terms of treatment outcomes, 1 patient (5.88%) died during follow-up༈multiple systemic infections༉, 6 patients (35.29%) recovered to normal walking, 5 patients (29.41%) showed symptom resolution, and 5 patients (29.41%) needed to use a walker. The clinical characteristics of the 17 infected patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and the quantitative assignment of postoperative infection-related risk factors is shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical characteristics of the infected group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContinuous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e50 (77.24\u0026thinsp;\u0026plusmn;\u0026thinsp;9.48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e10 (58.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7 (41.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7 (41.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e10 (58.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCourse\u0026nbsp;of disease (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContinuous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e50 (13.65\u0026thinsp;\u0026plusmn;\u0026thinsp;10.36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThoracic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7 (41.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6 (35.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThoracic and Lumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e4 (23.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of surgically treated segments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e17 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e17 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e10 (58.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7 (41.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType 2 diabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e4 (23.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e13 (76.47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2 (11.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e15 (88.24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChronic renal insufficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCerebral infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOptic neuritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEczema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeart stent implantation status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterstitial pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of hormone drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e16 (94.12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5 (29.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e12 (70.59)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e16 (94.12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative VAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContinuous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e50 (7.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary leukocyte\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e8 (47.06)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e9 (52.94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;35 g/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7 (41.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;35 g/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e10 (58.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC increase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5 (29.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e12 (70.59)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNEUT% increase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7 (41.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e10 (58.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP (mg/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContinuous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e50 (12.31\u0026thinsp;\u0026plusmn;\u0026thinsp;9.84)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESR (mm/h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContinuous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e50 (28.12\u0026thinsp;\u0026plusmn;\u0026thinsp;18.43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime interval to infection (weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContinuous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e50 (4.06\u0026thinsp;\u0026plusmn;\u0026thinsp;4.68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathogens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePropionibacterium humerusii\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2 (11.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eCutibacterium acnes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e3 (17.65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eEscherichia coli\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2 (11.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eRoseomonas mucosa\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eCoagulase-negative Staphylococcus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMycobacterium abscessus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUndefined\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6 (35.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e12 (70.59)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5 (29.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal walking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6 (35.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5 (29.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUses a walker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5 (29.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDied*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1 (5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCOPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; WBC, white blood cell count; VAS, visual analog scale; V, vertebroplasty; K, kyphoplasty; Alb, albumin; NEUT, neutrophilic granulocyte\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* Patient died early in follow-up.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuantitative Assignment Table of Risk Factors Associated with Infection after PVA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: \u0026lt;80; 1: \u0026ge;80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType 2 diabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUse of hormone drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrinary tract infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePulmonary infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of surgically treated segments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: \u0026le;2; 1: \u0026gt;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrinary leukocyte\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: \u0026ge;35 g/L; 1: \u0026lt;35 g/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNEUT%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReal number (mg/L)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eESR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReal number (mm/h)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRI suggests fluid sign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType B of cement leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType S of cement leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType C of cement leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType D of cement leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: No; 1: Yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eCRP, C-reactive protein; ESR, erythrocyte sedimentation rate; WBC, white blood cell count; Alb, albumin; NEUT, neutrophilic granulocyte; MRI, magnetic resonance imaging\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSingle-factor analysis by Cox regression\u003c/h2\u003e \u003cp\u003eThe results of univariate analysis showed that the following factors impacted the occurrence of postoperative SSIs after PVA: age\u0026thinsp;\u0026ge;\u0026thinsp;80 years (HR\u0026thinsp;=\u0026thinsp;3.23, 95% CI 1.19 to 8.73; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021), preoperative type 2 diabetes (HR\u0026thinsp;=\u0026thinsp;3.85, 95% CI 1.22 to 12.13; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021), pulmonary infection (HR\u0026thinsp;=\u0026thinsp;14.75, 95% CI 4.11 to 52.98; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), use of hormone drugs (HR\u0026thinsp;=\u0026thinsp;10.07, 95% CI 1.23 to 82.45; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031), Alb\u0026thinsp;\u0026le;\u0026thinsp;35 g/L (HR\u0026thinsp;=\u0026thinsp;5.52, 95% CI 2.00 to 15.28; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), NEUT% (HR\u0026thinsp;=\u0026thinsp;2.85, 95% CI 1.05 to 7.68; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.039), preoperative MRI indicating signs of fluid accumulation in the fractured vertebral body (HR\u0026thinsp;=\u0026thinsp;5.91, 95% CI 2.05 to 17.04; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), C-type bone cement leakage after the operation (HR\u0026thinsp;=\u0026thinsp;6.75, 95% CI 2.04 to 22.31; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), and D-type bone cement leakage after the operation (HR\u0026thinsp;=\u0026thinsp;9.43, 95% CI 2.99 to 29.75; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001,Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk Factors and Parameter Estimates for Screening by Univariate Analysis of Cox Regression Models\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.19\u0026ndash;8.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.021\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraumatic history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.17\u0026ndash;1.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.68\u0026ndash;5.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.226\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType 2 diabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.22\u0026ndash;12.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.021\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of hormone drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.23\u0026ndash;82.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.031\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.08\u0026ndash;4.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.622\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.11\u0026ndash;52.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of surgical segments\u0026thinsp;\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.83\u0026ndash;8.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary leukocyte\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.60\u0026ndash;4.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.343\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.00\u0026ndash;15.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAscension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69\u0026ndash;5.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.204\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNEUT%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAscension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.05\u0026ndash;7.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.039\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP_value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.97\u0026ndash;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.371\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESR_value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.98\u0026ndash;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.832\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRI suggests fluid sign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.05\u0026ndash;17.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypes of bone cement leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.18\u0026ndash;11.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.727\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.27\u0026ndash;16.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.487\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.04\u0026ndash;22.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.99\u0026ndash;29.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eCRP, C-reactive protein; ESR, erythrocyte sedimentation rate; WBC, white blood cell count; Alb, albumin; NEUT, neutrophilic granulocyte; MRI, magnetic resonance imaging\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*: \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **: \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***: \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Ref: The reference level of the variable. 1: Variables are continuous variables\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eMultiple-Factor Analysis by Cox Regressio\u003c/b\u003en\u003c/p\u003e \u003cp\u003eThe results of multivariate analysis showed that the following were independent risk factors for postoperative SSIs after PVA: age\u0026thinsp;\u0026ge;\u0026thinsp;80 years (HR\u0026thinsp;=\u0026thinsp;3.26, 95% CI 1.02 to 10.40; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.046), preoperative type 2 diabetes (HR\u0026thinsp;=\u0026thinsp;5.48, 95% CI 1.22 to 24.58; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026), pulmonary infection (HR\u0026thinsp;=\u0026thinsp;23.63, 95% CI 4.26 to 131.22; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Alb\u0026thinsp;\u0026le;\u0026thinsp;35 g/L (HR\u0026thinsp;=\u0026thinsp;5.76, 95% CI 1.70 to 19.45; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005), preoperative MRI indicating signs of fluid accumulation in the fractured vertebral body (HR\u0026thinsp;=\u0026thinsp;6.41, 95% CI 1.84 to 22.36; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004), and D-type bone cement leakage after the operation (HR\u0026thinsp;=\u0026thinsp;3.93, 95% CI 1.02 to 15.15; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.047, Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk Factors and Parameter Estimation for Screening by Multifactorial Analysis with Cox Regression Modeling\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.02\u0026ndash;10.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.046\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.70\u0026ndash;19.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType 2 diabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.22\u0026ndash;24.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.026\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRI suggests fluid sign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.84\u0026ndash;22.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.26\u0026ndash;131.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType D of cement leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.02\u0026ndash;15.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.047*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAlb, albumin; MRI, magnetic resonance imaging.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*: \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **: \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***: \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Ref: The reference level of the variable\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePostoperative SSI after PVA is rare. Abdelrahman et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] reported that 6/1307 patients (0.46%) who underwent percutaneous vertebroplasty or kyphoplasty developed postoperative infection. Similarly, Park et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] reported a postoperative infection rate of 0.36% (3/826 cases) after PVA. Liao et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] reported that 18/5749 patients (0.32%) developed progressive infectious spondylitis after PVP. Shin et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] reported that 2/104 patients (1.9%) developed various post-PVA infections. In our study, 17/2624 patients (0.65%) developed postoperative vertebral infections. In their prospective research and a review of 42 cases collected from 26 articles, Park et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] reported a postoperative infection mortality rate of 15.1%. The mortality rate in the present study was 5.88% (1/17 cases). Due to the low incidence of the disease, the sample size at the single center is limited. To better investigate the risk factors of surgical site infection, a case-control study design was implemented. Patients in the control group were selected at a ratio of 1:3.The relevant case data underwent retrospective analysis, ultimately revealing a strong correlation between postoperative infections and advanced age (\u0026ge;\u0026thinsp;80 years), type 2 diabetes, hypoproteinemia (Alb\u0026thinsp;\u0026le;\u0026thinsp;35 g/L), preoperative MRI indicating signs of fluid accumulation in the fractured vertebral body, and D-type bone cement leakage after the operation.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAge and albumin\u003c/h2\u003e \u003cp\u003eHypoalbuminemia and advanced age are reportedly risk factors for postoperative SSIs after PVA [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In this study, we identified hypoalbuminemia (Alb\u0026thinsp;\u0026le;\u0026thinsp;35 g/L) and advanced age (age\u0026thinsp;\u0026ge;\u0026thinsp;80 years) as independent risk factors for postoperative SSIs after PVA. Older patients may have impaired immune function, reduced body function, malnutrition, or other underlying diseases, thus exacerbating the risk of postoperative SSIs [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Malnutrition is associated with compromised host resistance. Rhoads et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] reported in as early as 1955 the association between hypoalbuminemia and increased postoperative infection risk. Andreas Eckart et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] identified a relationship between hypoalbuminemia and inpatient mortality rate, which can serve as a predictor of the patient\u0026rsquo;s prognosis. Yamamoto et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] identified hypoalbuminemia as an independent risk factor for prolonged hospitalization in predicting SSIs. Malnutrition can adversely affect the immune system; besides reducing bacterial clearance and impairing the chemotaxis of neutrophils, it also suppresses the antibacterial function of neutrophils, such as the transport of immune-related cells to the site of infection and effective components in the serum [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In addition, insufficient serum albumin can affect the colloid osmotic pressure of the blood. This results in tissue fluid leakage and swelling around the surgical site, which creates favorable conditions for bacterial growth and reproduction and consequently increases the risk of infection [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Notably, SSIs after PVA procedures are typically caused by low-virulence bacteria and are thus more likely to occur in older patients with poor nutrition and compromised immune function. Based on relevant literature reports [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], we believe that actively improving patients\u0026rsquo; nutritional status during the perioperative period is essential to enhance their immune function and that their preoperative plasma albumin level should be stable at \u0026gt;\u0026thinsp;35 g/L. Doctors should inform older patients and patients with hypoalbuminemia (plasma albumin level\u0026thinsp;\u0026le;\u0026thinsp;35 g/L) about the increased risk of postoperative infection before the operation itself.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDiabetes mellitus\u003c/h2\u003e \u003cp\u003eThe relationship between type 2 diabetes and increased risk of postoperative infections has been previously reported. Elevated HbA1c levels in patients with type 2 diabetes are reportedly associated with increased risk of early postoperative infections, and the risk of sternal infection is five-fold higher (OR\u0026thinsp;=\u0026thinsp;5.3) when the HbA1c level is \u0026gt;\u0026thinsp;7.8% [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In terms of the effect on the immune system, poor long-term blood sugar control affects the function of monocytes and neutrophils, including adhesion, chemotaxis, phagocytosis, and other important processes; it also detrimentally affects β-cell reserves and insulin receptors, resulting in an infection-prone immunocompromised state [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Type 2 diabetes can cause microvascular lesions, leading to delayed wound healing, increased risk of postoperative site infection, insufficient nutrition, and inadequate local blood supply in the surgical area [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The Chinese Adult Perioperative Blood Glucose Monitoring Expert Consensus [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] recommends active blood glucose control for all surgeries, including percutaneous vertebral augmentation. For regular surgeries, the blood glucose control targets are as follows: HbA1c: \u0026lt; 8.5%; FPG or pre-meal blood sugar: 8\u0026ndash;10 mmol/L, 2 hPG or any time point blood sugar 8\u0026ndash;12 mmol/L when unable to eat, and short-term blood sugar\u0026thinsp;\u0026lt;\u0026thinsp;15 mmol/L are also acceptable. In patients with poorly controlled diabetes, effective perioperative monitoring, supervision, and management of blood sugar levels should be ensured. The original hypoglycemic regimen before surgery can be transitioned to insulin, and based on fasting conditions, insulin doses for controlling postprandial blood sugar can be reduced. For patients with type 2 diabetes, oral hypoglycemic drugs and non-insulin injections should be discontinued on the day of surgery, and blood sugar should be monitored during the discontinuation period. Some experts recommend prophylactic use of antibiotics before PVA in high-risk patients to reduce the incidence of postoperative pyogenic spondylitis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePulmonary infection\u003c/h2\u003e \u003cp\u003eThis study also identified pulmonary infection as an independent risk factor. Weir et al. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] proposed in as early as 1983 the concept of \u0026ldquo;The term locus minoris resistentiae indicates a place of less resistance,\u0026rdquo; which means that the site of injury in the body is more susceptible to pathogen invasion. Therefore, pulmonary infection is easily spread to the surgical area via blood circulation. However, whether the infection spreads through arteries or veins remains unknown and needs further research. It is generally believed that primary pyogenic spondylitis occurs more commonly via the arterial than the venous route. However, the Batson vertebral venous system in the lumbar vertebrae may also be one of its transmission routes [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The artery supplies the middle intervertebral disc at the same segment, the upper half of the adjacent lower vertebral body, and the lower half of the upper vertebral body, and the arterial spread may involve two adjacent vertebrae and intervertebral discs [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The Batson vertebral venous system communicates with the body's veins, has slow blood flow, and lacks venous valves, and therefore, pathogens can spread through the venous system as well [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In this study, 1/17 and 5/17 patients who developed a postoperative infection had urinary tract infection and pulmonary infection before the operation, respectively. Unlike previous reports, we herein did not find a correlation between urinary tract infection and postoperative site infection [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This could be attributed to the small sample size. However, in patients who have other infections before the operation, we recommend actively controlling the primary lesion and performing surgical treatment after the infection is controlled.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eIntradiscal leakage\u003c/h2\u003e \u003cp\u003eInterestingly, to our knowledge, this is the first report identifying type D bone cement leakage (intradiscal leakage) as an independent risk factor for post-PVA SSIs. Polymethyl methacrylate (PMMA) bone cement is currently the first filling material for PVA surgery because of its cost-effectiveness, superior biomechanical properties, and stable chemical properties [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. However, as PMMA bone cement is not degradable and lacks bioactivity, it does not bond with host bone tissue and can cause localized inflammation at the site in the long term [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Its leakage into the intervertebral disc can cause increased stress in the adjacent vertebrae, leading to changes in the mechanical load direction and biological metabolism of the intervertebral disc; these changes lead to imaging study findings of edema and increase the risk of fracture [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Inflammatory substances stimulate the intervertebral discs or elevate the pressure within the discs, thus producing discogenic low back pain [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. It is easy to misdiagnose a spinal infection when a patient revisits the hospital with symptoms of low back pain after PVA and imaging shows periprosthetic inflammatory-like changes around the operated vertebrae and abnormal signals in the adjacent vertebrae and intervertebral discs. To our knowledge, two similar cases have been reported in the literature [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Both these patients had leakage of the intervertebral disc cement and needed to be readmitted for postoperative low back pain. Complete puncture biopsy did not reveal pathogenic bacteria; however, patient's symptoms alleviated with anti-osteoporosis treatment. Most spinal infections are transmitted through the bloodstream and first invade the vertebral body. However, intervertebral discs are avascular in adults. Bacteria invade the end artery arch near the intervertebral disc under the cartilage and then spread to the intervertebral disc via the endplate [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. However, bone cement leakage into the intervertebral disc will lead to the formation of a bridge between the vertebral body and the intervertebral disc. This will cause the vertebral infection to spread to the disc; furthermore, it will increase the risk of infection, particularly in the neighboring vertebrae. In this study, one patient in the infection group who had pulmonary infection before the operation showed bone cement leakage into the intervertebral disc. Follow-up findings revealed that the infection spread to the intervertebral disc and the adjacent vertebrae, leading to kyphosis. Preoperative sputum culture and mNGS of the infected vertebrae both revealed the same pathogen, namely \u003cem\u003eMycobacterium abscessus\u003c/em\u003e. For preoperative co-infections occurring at other sites, disc cement leakage should be avoided to the extent possible when surgical treatment with PVA is performed after achieving good infection control.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eMRI suggests IVC filling with liquid\u003c/h2\u003e \u003cp\u003eHistologically, compression fracture with an intravertebral cleft sign appears quite similar to vertebral osteonecrosis, and the late gap can be replaced with being fluid. Therefore, the T2-weighted MRI sequences show high signal and 81% probability of intravertebral vacuum cleft filling with liquid in the thoracolumbar segment [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Although gas or fluid accumulation within the vertebral body seldom occurs in spinal infections, the possibility of an infection cannot be completely ruled out [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. In the present study, 11/17 patients (64.7%) who developed infection showed signs of fluid accumulation before the operation. We identified nine bacterial pathogens using puncture biopsy or surgical pathological examination. In addition, although no bacteria were identified in 2 patients, their symptoms resolved with antibiotic treatment as confirmed by imaging examination. Therefore, we considered these as post-PVP infections. Notably, in these patients, MRI showed intravertebral fluid accumulation and CT showed intravertebral fissure and cavity formation. This may be attributed to intravertebral vascular injury and necrosis, which compromise local blood supply and make bacterial survival easier. In addition, incomplete filling of the cavity with the bone cement will cause mechanical instability within the vertebral body. Combined with stress concentration at the thoracolumbar junction, it will further damage spinal stability and exacerbate the infection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTreatment process\u003c/h2\u003e \u003cp\u003eThe follow-up findings of patients with vertebral body infections after PVA are not optimistic. In our study, 12/17 patients (70.59%) received conservative treatment and 5/17 patients (29.41%) underwent surgical treatment. Among these patients, 6 patients (35.29%) recovered to normal walking, 5 patients (29.41%) showed symptom resolution, 5 patients (29.41%) needed to use a walker, and 1 patient (5.88%) died during follow-up. To minimize post-PVA infections, considering both previous literature reports[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]and our current findings, we summarized the following suggestions and developed a diagnosis and treatment flowchart, which is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eRoutine tests like WBC, ESR, CRP, chest X-ray (patients with advanced age, history of pulmonary tuberculosis, or lung tumors are recommended to undergo complete chest CT examination), thoracolumbar MRI, and CT examination should be mandatory before PVA surgery in patients with OVCF. PVA should be delayed in patients with atypical CT/MRI fracture signals or significantly elevated inflammatory parameters. Further notable improvements in enhanced MRI examinations and vertebral puncture biopsy are essential before PVA. Only after the inflammatory parameters have decreased and the possibility of an infection has been ruled out can the surgery be performed, and conservative treatment can be considered for cases not meeting these prerequisites.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFor patients with other infections, such as pulmonary infections or urinary tract infections, these infections should be actively treated first. Surgery can be performed at a later time when the inflammatory parameters have significantly decreased and the infection is under control.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e Among elderly patients, bone cement leakage should be minimized during surgery in elderly patients with severe immunodeficiency, poor blood glucose control ( HbA1c\u0026thinsp;\u0026gt;\u0026thinsp;8.5% ; short-term blood glucose\u0026thinsp;\u0026gt;\u0026thinsp;15 mmol / L), or suspected infection at other sites. Prophylactic antibiotics or antibiotic-loaded bone cement should be used perioperatively.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIn patients with a preoperative Alb level of \u0026le;\u0026thinsp;35 g/L, protein supplementation and nutritional support should be provided during and after surgery.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIntraoperative biopsy should be routinely performed in patients with intravertebral fluid/fissure signs or suspected vertebral infections. Histopathology, general bacterial culture, and high-throughput gene sequencing examination should be performed in these patients. The use of antibiotic-loaded bone cement is recommended during the operation. It is recommended to ensure that the bone cement is fully filled in the cleft area in patients with intravertebral fluid signs.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis was is a single-center retrospective study. Owing to the low incidence of SSIs after PVA, the sample size obtained from a single center is small, and because of the retrospective design, there may be information collection bias in the statistical data. There are limitations associated with the comprehensiveness of the collection of risk factors because there may be some risk factors that are yet unknown, thus necessitating further investigation. In the future, multicenter prospective studies with large sample sizes are needed to analyze the causes and prevention strategies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eEven though PVA is a minimally invasive intervention, postoperative SSI is a rare but significant complication. In this study, we retrospectively analyzed the possible risk factors for postoperative infection and found that age\u0026thinsp;\u0026ge;\u0026thinsp;80 years, type 2 diabetes, hypoproteinemia (Alb\u0026thinsp;\u0026le;\u0026thinsp;35 g/L), pulmonary infection, intravertebral fluid signs, and bone cement leakage into the intervertebral disc were independent risk factors for post-PVA infections. These data may help guide clinicians take preoperative preventive measures to reduce the incidence of post-PVA infections.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePVA: Percutaneous vertebral augmentation; OVCF: osteoporotic vertebral compression fracture, SSI: surgical site infection; PVP: percutaneous vertebroplasty; PKP: percutaneous kyphoplasty; SSIs: surgical site infections; CT: Computed tomography; MRI: magnetic resonance imaging; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; WBC: white blood cell; VAS: visual analog scale; NEUT%: neutrophilic granulocyte ratio; Alb: albumin; PMMA: Polymethyl methacrylate; COPD: chronic obstructive pulmonary disease; mNGS: metagenomic next-generation sequencing; IVC: intravertebral vacuum cleft\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRBC：Conception and design; Critical revision of the manuscript for important intellectual content; Analysis and interpretation of data；JQC：Acquisition and data ;Critical revision of the manuscript for important intellectual content；Drafting of the manuscript；WCC：Data curation；Analysis and interpretation of data;Drafting of the manuscript；YZP：Analysis and interpretation of data; Drafting of the manuscript；SPL： Drafting of the manuscript; Statistical analysis；MSC：Administrative,technical or material support; Supervision；YL：Administrative,technical or material support;Supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from the Science and Technology Projects of Social Development in Zhuhai (2320004000271).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work has been carried out in accordance with the Declaration of Helsinki (2000) of the World Medical Association. This study was approved by Guangdong Province Hospital of Traditional Chinese Medicine. This article is a retrospective study. Therefore, the institution waived the requirement to obtain distinct written informed consent from the patients (approval number: ZE2023-176-01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors declare that they have no confict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1 The Second Clinical Medicine College, Guangzhou University of Chinese Medicine, Guangzhou, China；2 Guangdong Province Hospital of Chinese Medicine ZHUHAI, Zhuhai, China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSalari N, Darvishi N, Bartina Y, Larti M, Kiaei A, Hemmati M, et al. 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Eur Spine J 2010;19:1894\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1007/s00586-010-1388-8\u003c/span\u003e\u003cspan address=\"https://doi:10.1007/s00586-010-1388-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"percutaneous vertebral augmentation, risk factors, osteoporotic vertebral compression fracture, surgical site infection","lastPublishedDoi":"10.21203/rs.3.rs-3862789/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3862789/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ePercutaneous vertebral augmentation (PVA) is a widely implemented treatment of osteoporotic vertebral compression fracture (OVCF). Although rare, surgical site infection (SSI) is a serious complication of PVA. Even though it is of great medical significance to minimize SSIs after PVA, there have been few reports on systematic risk factor analysis and prevention strategies.The goal of this study was to analyze the incidence and risk factors of postoperative SSI in PVA at a single center and formulate prevention strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe study involved 2624 patients who underwent PVA for osteoporotic vertebral compression fracture (OVCF) at our hospital between 2015 and 2021. The case-control study method was utilized. The case group consisted of patients who developed postoperative infections, while the control group was composed of uninfected patients selected at a ratio of 1:3.We collected data on risk factors for SSIs from patients' electronic medical records, imaging findings, and laboratory test results. We then analyzed the independent risk factors for postoperative SSIs using Cox univariate and multivariate regression analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eIn our study, 17/2624 patients (0.65%) developed postoperative vertebral infections.Use of steroid drugs, NEUT%, C-type bone cement leakage after the operation were identified as risk factors in univariate analysis but not in multivariate analysis. Finally, multivariate analysis revealed the following risk factors for infectious spondylitis: age ≥ 80 years, type 2 diabetes, pulmonary infection, Alb ≤ 35 g/L, preoperative MRI indicating signs of fluid accumulation in the fractured vertebral body, and D-type bone cement leakage after the operation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eMultivariate analyses identified the abovementioned independent risk factors for postoperative SSIs after PVA. These data may help guide clinicians take preoperative preventive measures to reduce the incidence of postoperative SSIs after PVA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eThis study was approved by Guangdong Province Hospital of Traditional Chinese Medicine. This article is a retrospective study. Therefore, the institution waived the requirement to obtain distinct written informed consent from the patients (approval number: ZE2023-176-01).\u003c/p\u003e","manuscriptTitle":"Risk Factors for Infection after Percutaneous Vertebroplasty Augmentation for Osteoporotic Vertebral Compression Fracture","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-19 21:42:25","doi":"10.21203/rs.3.rs-3862789/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7864b8ce-e421-4d32-93ab-222c7ec924c8","owner":[],"postedDate":"January 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-26T02:45:21+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-19 21:42:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3862789","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3862789","identity":"rs-3862789","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}