Fracture Patterns and Efficacy of Prophylactic Vertebroplasty in Osteoporotic Vertebral Compression Fractures: A Retrospective Single-Center Study

Fracture Patterns and Efficacy of Prophylactic Vertebroplasty in Osteoporotic Vertebral Compression Fractures: A Retrospective Single-Center Study | 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 Fracture Patterns and Efficacy of Prophylactic Vertebroplasty in Osteoporotic Vertebral Compression Fractures: A Retrospective Single-Center Study Juo-Hau Su, Alvin Kai-Xing Lee, Yen-Jen Chen, Chien-Min Chen, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5327306/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: The concept of prophylactic vertebroplasty (PrVP) has been proposed to prevent recurrent fractures after vertebroplasty (VP); however, its efficacy remains controversial. The purpose of this study was to analyze fracture patterns and evaluate the effectiveness of PrVP in reducing refracture rates. Methods: A retrospective analysis was conducted from January 2015 to December 2023 involving consecutive patients who underwent VP for osteoporotic vertebral compression fractures (OVCFs). Fractures were classified according to the German Society for Orthopedics and Trauma (DGOU) Classification of Osteoporotic Fractures, and further divided into subgroups. Patients were categorized into PrVP or non-PrVP groups. The follow-up assessments included radiographic evaluations, pain scores, and disability indices between the two groups. Results: A total of 121 patients were included. PrVP was associated with reduced occurrence of subsequent vertebral compression fractures (VCFs) and adjacent vertebral fractures (AVFs) in the biendplate-involvement subgroup (7.7% versus 28.6%, P=0.031; 2.6% versus 23.8%, P=0.009). The postoperative disability scores at 3 months (12.1 ± 2.1 versus 12.9 ± 2.1, P=0.034) and at 6 months (11.7 ± 2.6 versus 12.8 ± 2.5, P=0.014) differed significantly between the groups. No significant differences were observed in AVF occurrence among the other fracture subgroups. Postoperative pain relief was significant in both groups, but the difference was not statistically significant. Conclusions: Our study highlights the potential benefits of PrVP in reducing AVF occurrence in patients with biendplate-involved. Postoperative disability scores improved significantly with PrVP, especially in patients receiving postoperative osteoporosis medication. Trial registration: This study was approved by the Research Ethics Committee of China Medical University Hospital (Approval number: CMUBH2019-001). Prophylactic vertebroplasty Osteoporotic vertebral compression fractures DGOU classification Endplate Subsequent vertebral compression fractures Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Globally, approximately 8.6 million patients suffer from OVCFs [1]. The estimated lifetime risk of developing an OVCF in white women is approximately 15%, and it increases to 27% in patients over 65 years of age [2, 3]. Overall, managing an acute OVCF includes pain control, activity modification, education, and treatment of the underlying osteoporosis. Patients can be treated conservatively with rest and/or medications or surgical management, such as vertebroplasty and kyphoplasty. However, conservative management often leads to increased incidences of new fractures at other vertebral levels [4]. Up to 17.5% of OVCF patients receiving conservative treatment were found to have subsequent new compression fractures, kyphosis progression, chronic pain and diminished functional conditions [5]. The impact of vertebral compression fractures (VCFs) on patients' physical function, quality of life (QoL), and societal burden is substantial. Vertebral augmentation (VA), comprising vertebroplasty and kyphoplasty, has become a widely accepted therapeutic option for osteoporosis-related VCFs resistant to conservative measures. While effectively relieving pain and enhancing functional recovery, concerns have arisen regarding the increased risk of new fractures, especially adjacent vertebral fractures (AVFs) and remote vertebral fractures (RVFs). The likelihood of subsequent vertebral fractures is influenced by factors such as the number of affected vertebrae and the shape of existing deformities. The risk of further vertebral fractures is 3-fold greater after the first fracture has occurred and increases to 23 times greater after the third fracture [6]. Ongoing studies on the efficacy of PrVP have produced inconclusive results. Given the current literature, it is crucial to provide recommendations for treatment decision-making. Additionally, the assessment and treatment of OVCFs require a multidisciplinary approach involving spine specialists and bone disease experts [7]. Two key aspects under investigation in VCF management are the correlation between fracture patterns and the occurrence of new adjacent fractures post- vertebroplasty and the potential of the PrVP in reducing refracture rates in patients with OVCFs. Consequently, we conducted a research study to analyze fracture patterns and PrVP in OVCFs. This study aimed to examine fracture patterns and evaluate the efficacy of PrVP in reducing the occurrence of recurrent fractures. Materials and Methods Study population From January 2015 to December 2023, we conducted a retrospective analysis involving consecutive patients who underwent VP for OVCFs at our department. Data concerning sex, age, hospital stay, fracture level, bone mass density (BMD), medications, and complications were extracted from medical records and operative protocols. The research was approved by the China Medical University Hospital Research Ethics Committee. (IRB: CMUBH2019-001) The inclusion criterion was patients admitted to the hospital for their first-ever acute or subacute VCF. Additionally, patients had to have undergone unsuccessful conservative treatment and/or had MRI with edema demonstrated in the fractured vertebra. The exclusion criteria included pathological fractures (caused by malignancy, infection, or other medical conditions), incomplete plain lateral radiographic follow-up (at least 6 months), burst fractures with retro-pulsed bony fragments into the spinal canal accompanied by neurological signs prior to surgery, refracture of a cemented vertebra, a history of previous spinal surgery, and multilevel osteoporotic vertebral body fractures. Commonly used trauma classification systems (AOSpine, Denis, TLICS, etc.) were not originally designed for osteoporotic fractures [8, 9]. Therefore, the fracture patterns in our study were categorized on the basis of the German Society for Orthopedics and Trauma (DGOU) Classification of Osteoporotic Fractures (Table 1) and further divided into three subgroups: (1) upper endplate involvement (OF2.1, OF3.1); (2) lower endplate involvement (OF2.3, OF3.3); and (3) biendplate involvement (OF4). A detailed explanation and representative images of each fracture type are presented (Figure 1). Preoperative fracture patterns and AVFs were studied on plain lateral radiographs preoperatively, postoperatively, at 3 months, and at the final follow-up. Consequently, all enrolled patients were assigned to either the PrVP group or the non-PrVP group. In the PrVP group, we omitted preventive cementing in the upper instrumented vertebra (UIV) if the fracture was near or at the superior endplate. Similarly, we omitted the preventive procedure in the lower instrumented vertebra (LIV) if the fracture was near or at the inferior endplate. The PrVP was used for both the UIV and LIV when both endplates were thin or fractured (Figure 2). Data collection Patients were regularly followed up for an average of 34 months. Radiographic assessments included standing plain lateral radiographs taken before surgery, immediately after surgery, at 3 months postsurgery, and at the final follow-up. The visual analog scale (VAS) score and Oswestry Disability Index (ODI) score were documented before the procedure, 3 months after the procedure, and at the 6-month mark. The incidence of new vertebral fractures and their patterns were systematically assessed for all patients. All measurements were conducted by the first and last authors, and any discrepancies were resolved through a consensus approach by measuring the endplates together to ensure accuracy. Statistical analysis Continuous data with a normal distribution are presented as the means and standard deviations. Student’s t test was used to compare continuous variables. A chi-square test or Fisher’s exact test was used to compare dichotomous values (gender, incidence of new VCFs and AVFs). A significance level of p < 0.05 was considered statistically significant. Results Initially, 121 patients met the inclusion criteria for the analysis, with a mean follow-up duration of 34 months (range 5–62 months). A total of 121 levels of VPs were used in our study. Follow-up at 6 months was completed for all 41 patients in the nonprophylactic group and 80 patients in the prophylactic group. The demographic characteristics of the three subgroups are presented in Table 2. There were no significant differences in patient age (P = 0.155), sex (P = 0.271), BMD (P = 0.159), or duration of follow-up (P=0.06) between the two groups. A total of 51 levels (42.1%) were classified into the upper endplate involvement group, 10 levels (8.3%) into the lower endplate involvement group, and 60 levels (49.6%) into the biendplate involvement group on the basis of preoperative anterior‒posterior (AP) and lateral spine plane films, dynamic views, and MR images. There were 13 AVFs, including 7 cases (13.7%) in the upper endplate involvement group and 6 cases (10%) in the biendplate involvement group (Table 3). In the upper endplate involvement group, 32 patients were treated with PrVP, and 19 patients were treated with index-level vertebroplasty only. AVFs were detected in 5 (15.6%) patients in the prophylactic group and in 2 (10.5%) patients in the nonprophylactic group. Six AVFs occurred over the superior caudal endplate, and one AVF occurred over the inferior cranial endplate. Additionally, a new RVF was found in 13 (40.6%) patients in the prophylactic group and in 5 (26.3%) patients in the nonprophylactic group. No significant differences were observed between the two groups regarding AVF (odds ratio [OR]=0.64, P=0.609) or new RVF (OR=0.52, P=0.301). In the lower endplate involvement group, 9 patients were treated with PrVP, and 1 patient was treated with index level vertebroplasty only. No AVFs occurred at all levels, but a new VCF was observed in 3 (33.3%) patients in the prophylactic group. In the biendplate-involvement group, 39 patients were treated with PrVP, and 21 patients were treated with index -level vertebroplasty only. AVFs were found in 1 (2.6%) patient in the prophylactic group and in 5 (23.8%) patients in the nonprophylactic group. Five AVFs were located over the superior caudal endplate, and one AVF was located over the inferior cranial endplate. In addition, a new RVF was found in 2 (2.5%) patients in the prophylactic group and in 1 (2.4%) patient in the nonprophylactic group. There were significant differences observed between the two groups regarding AVF (OR=11.88, P=0.009), but no significant differences were observed between the two groups regarding new RVF (OR=0.93, P=0.95; Table 4). Following the VP intervention, both cohorts experienced notable alleviation of pain and enhancement of daily functioning. The mean VAS score decreased dramatically from a baseline (preoperative) value of approximately 7 to 2 after three months for both groups. Similarly, the mean ODI score significantly decreased from approximately 38 before surgery to 12 after surgery in both groups. At the 6-month follow-up, there was a slight further decline in the VAS and ODI scores. Notably, the postoperative ODI scores at 3 and 6 months were significantly different between the two groups (at 3 months: 12.9 ± 2.1 vs. 12.1 ± 2.1, P=0.034; at 6 months: 12.8 ± 2.5 vs. 11.7 ± 2.6, P=0.014). However, no statistically significant differences were observed in the mean VAS score or preoperative ODI score between the two groups (Table 4, Figure 3). In terms of postoperative anti-osteoporotic medication (AOM), 71 patients were administered anti-osteoporotic medication, including the following: (1) Denosumab: 60 mg subcutaneously every 6 months. (2) Teriparatide: 20 mcg subcutaneously daily. (3) Alendronate: 70 mg orally once a week. (4) Raloxifene: 60 mg orally daily. (5) Zoledronic acid: 5 mg intravenously once a year. Dosages were standardized on the basis of current guidelines for managing osteoporosis in patients with vertebral fractures. The mean VAS score and ODI score were documented for both groups at various time points: preoperatively, at the 3-month mark, and at the 6-month mark (Table 5, Figure 3). Notably, there was a significant difference in the postoperative ODI score at 6 months between the two groups (11.1 ± 2.8 vs. 12.4 ± 2.5, P=0.014). However, no statistically significant differences were observed in the mean VAS score or ODI score among the other groups. Discussion The characteristics of OVCFs dictate whether conservative or surgical treatment is appropriate. Approximately one in five cases of conservatively managed OVCFs result in complications such as new fractures at other levels, chronic or persistent low back pain, progressive kyphotic deformity, and neurological compromise [5]. On the other hand, cement augmentation is a valuable treatment option for OVCFs and plays a crucial role in preventing further vertebral height loss and ongoing kyphotic deformity, thus preventing immobilization [4, 10-13]. Compared with balloon kyphoplasty and nonsurgical treatment, Zhu et al. identified it as the most effective method for improving pain, functional status, and quality of life [14]. Despite being less complex and more cost-effective than kyphoplasty, VP may entail a greater risk of complications. Subsequent fractures significantly impact the efficacy of VP, with new AVFs occurring in 20–25% of cases [15]. Additionally, a meta-analysis of more than 2 million patients revealed that those with OVCFs who underwent VA were 22% less likely to die within up to 10 years posttreatment than those who received non-surgical treatment [16]. Regarding the cause, no convincing conclusion has been obtained from current studies. Yen et al. reported a protective effect of VP within six months post surgery, reducing the incidence of any adjacent fracture by 21% [17]. In contrast, Buchbinder et al. reported no significant benefit of VP in terms of pain, disability, quality of life, or treatment success for acute or subacute osteoporotic vertebral fractures [18]. Consequently, there is a need to investigate the mechanism of refracture and explore alternative preventive strategies [19, 20]. This study represents the first attempt to scrutinize fracture patterns and evaluate the advantages of the PrVP for single-segment OVCFs. New VCFs after VP included those that affected the AVFs, recompression of cemented vertebral bodies, and RVFs. Hsieh et al demonstrated an unmet need to prevent symptomatic subsequent VCF in the first 6 months after primary VP (subacute phase), since the protective effects of AOMs are questionable during this period [21]. After VP, the redistribution of load-bearing kinetics shifts to other vertebrae, particularly those neighboring the original fracture site, thereby increasing the risk of AVFs. Clinical studies have demonstrated that most fractures occur at adjacent levels [22, 23]. On the basis of our published data, the incidence of AVFs was 17.1% (7/41) in the nonprophylactic group and 7.5% (6/80) in the prophylactic group, with no statistically significant difference between the groups (P = 0.107). While the incidence of new fractures in remote vertebrae is relatively lower than that in adjacent levels, preventing this complication is equally important. Previous studies have suggested that there is no statistically significant difference in the occurrence of remote fractures between the prophylactic and nonprophylactic groups [15, 19, 24]. These findings are consistent with our findings; the incidence of RVFs was 14.6% (6/41) in the nonprophylactic group and 22.5% (18/80) in the prophylactic group, with no statistically significant difference between the groups (P=0.304). This finding indicates that prophylactic augmentation does not influence the reduction of remote fractures. Previous studies have identified various factors associated with the recurrence of VCFs following augmentation procedures. Staples et al. reported no correlation between subsequent fractures and the injected cement volume, cement leakage, or VP level [25]. Yu et al. emphasized factors such as a preoperative intravertebral cleft, affected vertebrae in the thoracolumbar region, severe preoperative kyphotic deformity, a solid lump cement distribution pattern, and greater vertebral height restoration as primary risk factors [26]. Additionally, sarcopenia and advanced age are recognized as independent risk factors [27, 28]. Furthermore, Hsieh et al demonstrated that age, osteoporosis or osteopenia, and the Charlson comorbidity index (CCI) were identified as risk factors in the initial 6 months, but only osteoporosis or osteopenia and the CCI persisted as risk factors thereafter [21]. Biomechanically, the VP increases pressure in adjacent intervertebral discs by 19% and stresses in adjacent endplates and trabecular bone by 17% and 5%, respectively. Trabecular bone near endplates plays an important biomechanical role, distributing up to 85% of the applied load [29, 30]. Cement-induced stiffness modifies load transfer, potentially straining adjacent vertebrae. Nagaraja et al. reported that bone cement increases subsidence in the posterior regions of the treated endplates and the anterior region of the superior caudal endplate [31]. Consequently, increased subsidence may be the initial mechanism precipitating subsequent compression fractures after VP, particularly in vertebrae superior to the treated level. Clinical studies have shown variations in the predominant location (superior or inferior) of adjacent vertebral fractures after VP. Yen et al. reported a greater incidence of new fractures in upper adjacent vertebrae than in lower ones (36% versus 15%) [17]. Kobayashi et al. further performed PrVP in only the upper adjacent vertebrae because the incidence of new fractures was relatively low in the lower adjacent vertebrae [32]. Our findings align well with these studies, as 84.6% (11/13) of AVFs were located at the cranial endplate. Additionally, Han et al. demonstrated the beneficial effects of PrVP at the UIV and adjacent vertebra, indicating potential delays in the progression of proximal junctional kyphosis (PJK), proximal junctional failure (PJF), and proximal junctional fracture (PJFx), consequently reducing the reoperation rate following PJFX [22]. Similarly, Gassie et al. reported minimal occurrences of PJK and PJF following PrVP and UIV cement augmentation (11.1% and 4.2%, respectively) [33]. There is limited evidence regarding the treatment of biendplate-involved OVCFs classified as OF4 fractures. Most patients treated conservatively experienced minor symptoms and lower complication rates, but had a high incidence of neurological deficits at follow-up (14%). Conversely, surgical treatment resulted in lower rates of neurological deficits but higher rates of subsequent fractures (26% and 10%, respectively) [34]. Our published data indicate that the incidence of AVFs in the biendplate-involved subgroup was 23.8% (5/21) in the nonprophylactic group and 2.6% (1/39) in the prophylactic group, with a statistically significant difference (P = 0.009). Thus, PrVP appears to be a valid treatment strategy for biendplate OVCFs. Furthermore, several studies have indicated that the major cause of recurrent fracture is the progression of osteoporosis rather than therapeutic augmentation. Ebeling et al. reported that AOMs reduce the risk of subsequent vertebral fractures by 40–70% [35]. Therefore, patients diagnosed with OVCFs should receive appropriate anti-osteoporotic therapy promptly. Anabolic agents have greater anti-fracture efficacy and produce greater increases in bone density than antiresorptive drugs do. However, as the effects of anabolic agents are temporary, sequential treatment with antiresorptive drugs following anabolic therapy is necessary [7, 36]. In summary, PrVP in the biendplate-involved subgroup remains necessary for several reasons. First, the presence of OVCFs with biendplate-involved indicates poor bone quality, suggesting a likelihood of further fractures due to progressive deterioration. Second, the effectiveness of sequential osteoporosis medications takes several months to manifest, necessitating strict medication compliance to prevent new VCFs. Additionally, a significant proportion of AVFs occur shortly after VP, with 62% reported within 6 months in the non-preventive group [37]. Finally, the rapid relief of pain following VP may lead patients to engage in early physical activity without adequate protective measures or short-term AOMs, thereby heightening the risk of subsequent VCFs. Our study has several limitations. First, it was a single-center retrospective, nonrandomized design with a limited number of patients in each subgroup. Second, we did not include data on newly occurring VCFs managed through conservative treatment. Additionally, some asymptomatic patients have declined imaging studies, impacting the assessment of new VCFs. Moreover, challenges in obtaining bone density measurements hinder preoperative and postoperative assessments. Finally, the strict selection criteria (single-segment fractures, no prior spinal surgery) resulted in a relatively small sample size. These limitations warrant the need for further research utilizing a randomized controlled trial approach to construct a predictive model for refracture risk after VP. This model (Figure 4) will assist clinicians in identifying high-risk patients for refracture, enabling the implementation of targeted intervention measures for the UIV and/or LIV. Conclusion We established a novel classification system and evaluated the correlation between fracture pattern and the occurrence of AVFs after VP. The PrVP in the biendplate involvement group demonstrated a decrease in the occurrence of subsequent VCFs and AVFs. In addition, there were significant differences observed in the PrVP group regarding postoperative ODI scores at the 3-month and 6-month follow-ups. Furthermore, statistically significant differences were observed in the postoperative ODI score at the 6-month follow-up among patients receiving postoperative osteoporosis medication. Abbreviations AOM: Anti-osteoporotic Medication AVF: Adjacent Vertebral Fracture BMD: Bone Mass Density DGOU: German Society for Orthopedics and Trauma LIV: Lower Instrumented Vertebra ODI: Oswestry Disability Index OVCF: Osteoporotic Vertebral Compression Fracture PJK: Proximal Junctional Kyphosis PJF: Proximal Junctional Failure PJFX: Proximal Junctional Fracture PrVP: Prophylactic Vertebroplasty QoL: Quality of Life RVF: Remote Vertebral Fracture UIV: Upper Instrumented Vertebra VA: Vertebral Augmentation VAS: Visual Analog Scale VCF: Vertebral Compression Fracture VP: Vertebroplasty Declarations Acknowledgements Not applicable Author contributions JH: data acquisition and analysis, drafting and revision of article KX: data analysis and interpretation, revision of article YJ: for independent resolution of conflicts during data extraction and interpretation CM: for independent resolution of conflicts during data extraction and interpretation PH: data extraction and interpretation CY: data extraction and interpretation HT: for independent resolution of conflicts during data screening and vetting of article CT: research design, data screening, drafting and revision of article, correspondence Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Data availability No datasets were generated or analysed during the current study. Ethical approval This study was approved by the Research Ethics Committee of China Medical University Hospital (Approval number: CMUBH2019-001), and all patients written informed consent. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Dong Y PR, Kang H, Song K, Guo Q, Zhao H, Zhu M, Zhang Y, Guan H, Li F. Global incidence, prevalence, and disability of vertebral fractures: a systematic analysis of the global burden of disease study 2019. Spine J. 2022:857-68. Dennison E, Cooper C. Epidemiology of osteoporotic fractures. Horm Res. 2000;54 Suppl 1:58-63. Melton LJ, 3rd, Kan SH, Frye MA, Wahner HW, O'Fallon WM, Riggs BL. Epidemiology of vertebral fractures in women. Am J Epidemiol. 1989;129(5):1000-11. Gonschorek O, Hauck S, Weiß T, Bühren V. Percutaneous vertebral augmentation in fragility fractures-indications and limitations. 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Percutaneous Vertebroplasty and Upper Instrumented Vertebra Cement Augmentation Reducing Early Proximal Junctional Kyphosis and Failure Rate in Adult Spinal Deformity: Case Series and Literature Review. Oper Neurosurg (Hagerstown). 2023;25(3):209-15. Spiegl UJA, Schenk P, Schnake KJ, Ullrich BW, Osterhoff G, Scheyerer MJ, et al. Treatment and Outcome of Osteoporotic Thoracolumbar Vertebral Body Fractures With Deformation of Both Endplates With or Without Posterior Wall Involvement (OF 4): Short-Term Results from the Prospective EOFTT Multicenter Study. Global Spine J. 2023;13(1_suppl):36S-43S. Ebeling PR, Akesson K, Bauer DC, Buchbinder R, Eastell R, Fink HA, et al. The Efficacy and Safety of Vertebral Augmentation: A Second ASBMR Task Force Report. J Bone Miner Res. 2019;34(1):3-21. Handel MN, Cardoso I, von Bulow C, Rohde JF, Ussing A, Nielsen SM, et al. Fracture risk reduction and safety by osteoporosis treatment compared with placebo or active comparator in postmenopausal women: systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials. BMJ. 2023;381:e068033. Voormolen MH, Lohle PN, Juttmann JR, van der Graaf Y, Fransen H, Lampmann LE. The risk of new osteoporotic vertebral compression fractures in the year after percutaneous vertebroplasty. J Vasc Interv Radiol. 2006;17(1):71-6. Tables Table 1. DGOU Osteoporotic Fracture (OF) Classification System OF1 OF2 OF3 OF4 OF5 No deformation Deformation of one endplate with posterior wall 1/5 involvement Deformation of Bi-endplate Anterior or posterior tension band failure OF2.1 Superior OF3.1 Superior OF4.1 Loss of vertebral frame structure OF2.2 Lateral OF3.2 Lateral OF4.2 Vertebral body collapse OF2.3 Inferior OF3.3 Inferior OF4.3 Pincer Table 2. The demographic and baseline characteristics of patients Total Nonprophylactic group Prophylactic group P value Number of patients 121 41 80 - Mean age in yrs 77.3 ± 8.4 76.2 ± 9.1 77.9 ± 8.0 0.155 Gender (M/F) 31/90 8/33 23/50 0.271 BMD (T-score) -2.93 ± 1.02 -2.77 ± 0.99 -3.02 ± 1.03 0.159 Mean follow-up in mos 33.9 ± 28.4 28.2 ± 14.7 36.8 ± 32.9 0.063 Fracture subgroup Upper endplate 51 19 32 - Lower endplate 10 1 9 - Bi-endplate 60 21 39 - — = not applicable. * Statistically significant. Table 3. Classification of adjacent vertebral fractures (AVFs) Total Upper endplate Lower endplate Bi-endplate 121 51 10 60 VCFs (%) 35 (28.9%) 23 (45.1%) 3 (30%) 9 (15%) RVFs (%) 24 (19.8%) 18 (35.3%) 3 (30%) 3 (5%) AVFs (%) 13 (10.7%) 7 (13.7%) 0 (0%) 6 (10%) At inferior cranial endplate 11 6 0 5 At superior caudal endplate 2 1 0 1 Table 4. Clinical status of patients Nonprophylactic group Prophylactic group P value VAS score Pre-OP 7.0 ± 1.0 6.8 ± 1.0 0.262 Post-OP at 3mo 1.8 ± 1.0 2.0 ± 0.9 0.094 Post-OP at 6mo 1.3 ± 0.6 1.3 ± 0.6 0.435 ODI score Pre-OP 37.0 ± 4.5 38.0 ± 4.4 0.122 Post-OP at 3mo 12.9 ± 2.1 12.1 ± 2.1 0.034* Post-OP at 6mo 12.8 ± 2.5 11.7 ± 2.6 0.014* VCFs (%) 12 (29.2%) 23 (28.8%) 0.953 Upper endplate 6 (31.6%) 17 (53.1%) 0.135 Lower endplate 0 (0%) 3 (33.3%) 1 Bi-endplate 6 (28.6%) 3 (7.7%) 0.031* AVFs (%) 7 (17.1%) 6 (7.5%) 0.107 Upper endplate 2 (10.5%) 5 (15.6%) 0.609 Lower endplate 0 (0%) 0 (0%) 1 Bi-endplate 5 (23.8%) 1 (2.6%) 0.009* RVFs(%) 6 (14.6%) 18 (22.5%) 0.304 Upper endplate 5 (26.3%) 13 (40.6%) 0.301 Lower endplate 0 (0%) 3 (33.3%) 1 Bi-endplate 1 (2.4%) 2 (2.5%) 0.95 Table 5. Osteoporosis medication after procedure for patients Non-medication group Medication group P value VAS score Pre-OP 6.8 ± 1.2 6.9 ± 1.0 0.323 Post-OP at 3mo 2.0 ± 0.7 2.0 ± 1.0 0.478 Post-OP at 6mo 1.2 ± 0.7 1.4 ± 0.6 0.084 ODI score Pre-OP 37.3 ± 4.2 37.8 ± 4.8 0.326 Post-OP at 3mo 11.9 ± 2.1 12.6 ± 2.2 0.093 Post-OP at 6mo 11.1 ± 2.8 12.4 ± 2.5 0.014* Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-5327306","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":370070368,"identity":"012ae64e-1324-4dfe-a0ca-fe5e52c52ffe","order_by":0,"name":"Juo-Hau Su","email":"","orcid":"","institution":"China Medical University Hospital, China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Juo-Hau","middleName":"","lastName":"Su","suffix":""},{"id":370070369,"identity":"6f5d2aaa-de17-4ab0-ba5c-2816b2e97805","order_by":1,"name":"Alvin Kai-Xing Lee","email":"","orcid":"","institution":"China Medical University Hospital, China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Alvin","middleName":"Kai-Xing","lastName":"Lee","suffix":""},{"id":370070370,"identity":"1406a3e0-87ee-4120-8f26-69080a6c58a8","order_by":2,"name":"Yen-Jen Chen","email":"","orcid":"","institution":"China Medical University Hospital, China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yen-Jen","middleName":"","lastName":"Chen","suffix":""},{"id":370070371,"identity":"9bf03a18-09fa-4fb1-bbad-e92d6f9e1687","order_by":3,"name":"Chien-Min Chen","email":"","orcid":"","institution":"Changhua Christian Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chien-Min","middleName":"","lastName":"Chen","suffix":""},{"id":370070372,"identity":"c88fbb55-1aa9-4dfd-a345-2a8f9d97d4b6","order_by":4,"name":"Pang-Hsuan Hsiao","email":"","orcid":"","institution":"China Medical University Hospital, China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Pang-Hsuan","middleName":"","lastName":"Hsiao","suffix":""},{"id":370070373,"identity":"164c1df3-999c-4c41-b131-81dc08e58fa1","order_by":5,"name":"Chia-Yu Lin","email":"","orcid":"","institution":"China Medical University Hospital, China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chia-Yu","middleName":"","lastName":"Lin","suffix":""},{"id":370070374,"identity":"aa6dc8ac-ae1c-47c6-931a-a38e9a37c1d1","order_by":6,"name":"Hsien-Te Chen","email":"","orcid":"","institution":"China Medical University Hospital, China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hsien-Te","middleName":"","lastName":"Chen","suffix":""},{"id":370070375,"identity":"c9beb66a-60b6-4a1b-b0c5-01438fbdd4ec","order_by":7,"name":"Chun Tseng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYHACNjACgw8gLjtBHcxgLRIgJuMMkBZmUrQw84BJAhr4pc8fe/Ch7F6dfHvv4dc2v7bJ8zEzMH74mINbi2RfMrvhjHPFEgZnzqVZ5/bdNmxjZmCWnLkNtxaDM8xs0rxtCRIGEjlmxrk9txmBWtiYeYnRIj//jZmxZc9te+K1MNzgMX7M8ON2IkEtkj3MZpIzziVIbjiTY8bY23A7uY2ZsRmvX/h5GJ9JfChL4JdvP2P84cef27bz25sPfviIRwsyYJNgbAPRjA3EqQcC5g8Mf4hWPApGwSgYBSMIAACuFkg+3TP+FAAAAABJRU5ErkJggg==","orcid":"","institution":"China Medical University Hospital, China Medical University","correspondingAuthor":true,"prefix":"","firstName":"Chun","middleName":"","lastName":"Tseng","suffix":""}],"badges":[],"createdAt":"2024-10-24 16:08:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5327306/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5327306/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67441536,"identity":"2405cdd1-ed41-4492-acf5-821f64a2aa50","added_by":"auto","created_at":"2024-10-25 06:07:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":592554,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic representation of three subcategories of osteoporotic vertebral fractures with (A) OVCF with upper endplate involvement; (B) OVCF with lower endplate involvement; and (C) OVCF with bi-endplate involvement.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5327306/v1/9471636095a1a84c7387d851.png"},{"id":67440908,"identity":"8a790bb7-80a7-4009-921e-fda68875aaf7","added_by":"auto","created_at":"2024-10-25 05:59:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":392330,"visible":true,"origin":"","legend":"\u003cp\u003eThe diagram distinguishes between endplate involvement (orange) and preventive cementing (blue) in OVCFs. (A,B) Preventive cementing was omitted in UIV and LIV if the fracture was near or at the respective endplates. (C) PrVP was performed for both UIV and LIV when thinning or fractures were present in both endplates.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5327306/v1/2dd5ceb8621b067afe62ea5e.png"},{"id":67441537,"identity":"a6d96004-d519-4efd-8907-42ddc3b35166","added_by":"auto","created_at":"2024-10-25 06:07:22","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":50786,"visible":true,"origin":"","legend":"\u003cp\u003eThe mean VAS and ODI scores at preoperatively, 3 months after surgery, and 6 months after surgery between (A,B) non-prophylactic group and prophylactic group. (C,D) non-AOM group and AOM group.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5327306/v1/154d07b9533b1b953d25c5a1.png"},{"id":67440911,"identity":"51a3c909-c581-4728-ab7f-84020e2c9e7f","added_by":"auto","created_at":"2024-10-25 05:59:22","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":114613,"visible":true,"origin":"","legend":"\u003cp\u003eThe Osteoporotic Vertebral Compression Fracture management algorithm\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5327306/v1/f46b355faedcd16711a8f5f2.png"},{"id":70533918,"identity":"ed67f25d-b531-4fa2-91bb-6c5b55f97e79","added_by":"auto","created_at":"2024-12-04 06:24:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1666114,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5327306/v1/faeab309-b362-464a-bf9e-eaf3ff4b40e9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Fracture Patterns and Efficacy of Prophylactic Vertebroplasty in Osteoporotic Vertebral Compression Fractures: A Retrospective Single-Center Study","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, approximately 8.6 million patients suffer from OVCFs [1]. The estimated lifetime risk of developing an OVCF in white women is approximately 15%, and it increases to 27% in patients over 65 years of age [2, 3]. Overall, managing an acute OVCF includes pain control, activity modification, education, and treatment of the underlying osteoporosis. Patients can be treated conservatively with rest and/or medications or surgical management, such as vertebroplasty and kyphoplasty. However, conservative management often leads to increased incidences of new fractures at other vertebral levels [4]. Up to 17.5% of OVCF patients receiving conservative treatment were found to have subsequent new compression fractures, kyphosis progression, chronic pain and diminished functional conditions [5]. The impact of vertebral compression fractures (VCFs) on patients\u0026apos; physical function, quality of life (QoL), and societal burden is substantial.\u003c/p\u003e\n\u003cp\u003eVertebral augmentation (VA), comprising vertebroplasty and kyphoplasty, has become a widely accepted therapeutic option for osteoporosis-related VCFs resistant to conservative measures. While effectively relieving pain and enhancing functional recovery, concerns have arisen regarding the increased risk of new fractures, especially adjacent vertebral fractures (AVFs) and remote vertebral fractures (RVFs). The likelihood of subsequent vertebral fractures is influenced by factors such as the number of affected vertebrae and the shape of existing deformities. The risk of further vertebral fractures is 3-fold greater after the first fracture has occurred and increases to 23 times greater after the third fracture [6].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; Ongoing studies on the efficacy of PrVP have produced inconclusive results. Given the current literature, it is crucial to provide recommendations for treatment decision-making. Additionally, the assessment and treatment of OVCFs require a multidisciplinary approach involving spine specialists and bone disease experts [7]. Two key aspects under investigation in VCF management are the correlation between fracture patterns and the occurrence of new adjacent fractures post- vertebroplasty and the potential of the PrVP in reducing refracture rates in patients with OVCFs. Consequently, we conducted a research study to analyze fracture patterns and PrVP in OVCFs. This study aimed to examine fracture patterns and evaluate the efficacy of PrVP in reducing the occurrence of recurrent fractures.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom January 2015 to December 2023, we conducted a retrospective analysis involving consecutive patients who underwent VP for OVCFs at our department. Data concerning sex, age, hospital stay, fracture level, bone mass density (BMD), medications, and complications were extracted from medical records and operative protocols. The research was approved by the China Medical University Hospital Research Ethics Committee. (IRB: CMUBH2019-001)\u003c/p\u003e\n\u003cp\u003eThe inclusion criterion was patients admitted to the hospital for their first-ever acute or subacute VCF. Additionally, patients had to have undergone unsuccessful conservative treatment and/or had MRI with edema demonstrated in the fractured vertebra. The exclusion criteria included pathological fractures (caused by malignancy, infection, or other medical conditions), incomplete plain lateral radiographic follow-up (at least 6 months), burst fractures with retro-pulsed bony fragments into the spinal canal accompanied by neurological signs prior to surgery, refracture of a cemented vertebra, a history of previous spinal surgery, and multilevel osteoporotic vertebral body fractures.\u003c/p\u003e\n\u003cp\u003eCommonly used trauma classification systems (AOSpine, Denis, TLICS, etc.) were not originally designed for osteoporotic fractures [8, 9]. Therefore, the fracture patterns in our study were categorized on the basis of the German Society for Orthopedics and Trauma (DGOU) Classification of Osteoporotic Fractures (Table 1) and further divided into three subgroups: (1) upper endplate involvement (OF2.1, OF3.1); (2) lower endplate involvement (OF2.3, OF3.3); and (3) biendplate involvement (OF4). A detailed explanation and representative images of each fracture type are presented (Figure 1). Preoperative fracture patterns and AVFs were studied on plain lateral radiographs preoperatively, postoperatively, at 3 months, and at the final follow-up.\u003c/p\u003e\n\u003cp\u003eConsequently, all enrolled patients were assigned to either the PrVP group or the non-PrVP group. In the PrVP group, we omitted preventive cementing in the upper instrumented vertebra (UIV) if the fracture was near or at the superior endplate. Similarly, we omitted the preventive procedure in the lower instrumented vertebra \u0026nbsp; (LIV) if the fracture was near or at the inferior endplate. The PrVP was used for both the UIV and LIV when both endplates were thin or fractured (Figure 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were regularly followed up for an average of 34 months. Radiographic assessments included standing plain lateral radiographs taken before surgery, immediately after surgery, at 3 months postsurgery, and at the final follow-up. The visual analog scale (VAS) score and Oswestry Disability Index (ODI) score were documented before the procedure, 3 months after the procedure, and at the 6-month mark. The incidence of new vertebral fractures and their patterns were systematically assessed for all patients. All measurements were conducted by the first and last authors, and any discrepancies were resolved through a consensus approach by measuring the endplates together to ensure accuracy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; Continuous data with a normal distribution are presented as the means and standard deviations. Student\u0026rsquo;s t test was used to compare continuous variables. A chi-square test or Fisher\u0026rsquo;s exact test was used to compare dichotomous values (gender, incidence of new VCFs and AVFs). A significance level of p \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eInitially, 121 patients met the inclusion criteria for the analysis, with a mean follow-up duration of 34 months (range 5\u0026ndash;62 months). A total of 121 levels of VPs were used in our study. Follow-up at 6 months was completed for all 41 patients in the nonprophylactic group and 80 patients in the prophylactic group. The demographic characteristics of the three subgroups are presented in Table 2. There were no significant differences in patient age (P = 0.155), sex (P = 0.271), BMD (P = 0.159), or duration of follow-up (P=0.06) between the two groups.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; A total of 51 levels (42.1%) were classified into the upper endplate involvement group, 10 levels (8.3%) into the lower endplate involvement group, and 60 levels (49.6%) into the biendplate involvement group on the basis of preoperative anterior‒posterior (AP) and lateral spine plane films, dynamic views, and MR images. There were 13 AVFs, including 7 cases (13.7%) in the upper endplate involvement group and 6 cases (10%) in the biendplate involvement group (Table 3).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; In the upper endplate involvement group, 32 patients were treated with PrVP, and 19 patients were treated with index-level vertebroplasty only. AVFs were detected in 5 (15.6%) patients in the prophylactic group and in 2 (10.5%) patients in the nonprophylactic group. Six AVFs occurred over the superior caudal endplate, and one AVF occurred over the inferior cranial endplate. Additionally, a new RVF was found in 13 (40.6%) patients in the prophylactic group and in 5 (26.3%) patients in the nonprophylactic group. No significant differences were observed between the two groups regarding AVF (odds ratio [OR]=0.64, P=0.609) or new RVF (OR=0.52, P=0.301).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; In the lower endplate involvement group, 9 patients were treated with PrVP, and 1 patient was treated with index level vertebroplasty only. No AVFs occurred at all levels, but a new VCF was observed in 3 (33.3%) patients in the prophylactic group.\u003c/p\u003e\n\u003cp\u003eIn the biendplate-involvement group, 39 patients were treated with PrVP, and 21 patients were treated with index -level vertebroplasty only. AVFs were found in 1 (2.6%) patient in the prophylactic group and in 5 (23.8%) patients in the nonprophylactic group. Five AVFs were located over the superior caudal endplate, and one AVF was located over the inferior cranial endplate. In addition, a new RVF was found in 2 (2.5%) patients in the prophylactic group and in 1 (2.4%) patient in the nonprophylactic group. There were significant differences observed between the two groups regarding AVF (OR=11.88, P=0.009), but no significant differences were observed between the two groups regarding new RVF (OR=0.93, P=0.95; Table 4).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; Following the VP intervention, both cohorts experienced notable alleviation of pain and enhancement of daily functioning. The mean VAS score decreased dramatically from a baseline (preoperative) value of approximately 7 to 2 after three months for both groups. Similarly, the mean ODI score significantly decreased from approximately 38 before surgery to 12 after surgery in both groups. At the 6-month follow-up, there was a slight further decline in the VAS and ODI scores. Notably, the postoperative ODI scores at 3 and 6 months were significantly different between the two groups (at 3 months: 12.9 \u0026plusmn; 2.1 vs. 12.1 \u0026plusmn; 2.1, P=0.034; at 6 months: 12.8 \u0026plusmn; 2.5 vs. 11.7 \u0026plusmn; 2.6, P=0.014). However, no statistically significant differences were observed in the mean VAS score or preoperative ODI score between the two groups (Table 4, Figure 3).\u003c/p\u003e\n\u003cp\u003eIn terms of postoperative anti-osteoporotic medication (AOM), 71 patients were administered anti-osteoporotic medication, including the following: (1) Denosumab: 60 mg subcutaneously every 6 months. (2) Teriparatide: 20 mcg subcutaneously daily. (3) Alendronate: 70 mg orally once a week. (4) Raloxifene: 60 mg orally daily. (5) Zoledronic acid: 5 mg intravenously once a year. Dosages were standardized on the basis of current guidelines for managing osteoporosis in patients with vertebral fractures. The mean VAS score and ODI score were documented for both groups at various time points: preoperatively, at the 3-month mark, and at the 6-month mark (Table 5, Figure 3). Notably, there was a significant difference in the postoperative ODI score at 6 months between the two groups (11.1 \u0026plusmn; 2.8 vs. 12.4 \u0026plusmn; 2.5, P=0.014). However, no statistically significant differences were observed in the mean VAS score or ODI score among the other groups.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe characteristics of OVCFs dictate whether conservative or surgical treatment is appropriate. Approximately one in five cases of conservatively managed OVCFs result in complications such as new fractures at other levels, chronic or persistent low back pain, progressive kyphotic deformity, and neurological compromise [5]. On the other hand, cement augmentation is a valuable treatment option for OVCFs and plays a crucial role in preventing further vertebral height loss and ongoing kyphotic deformity, thus preventing immobilization [4, 10-13]. Compared with balloon kyphoplasty and nonsurgical treatment, Zhu et al. identified it as the most effective method for improving pain, functional status, and quality of life [14]. Despite being less complex and more cost-effective than kyphoplasty, VP may entail a greater risk of complications. Subsequent fractures significantly impact the efficacy of VP, with new AVFs occurring in 20\u0026ndash;25% of cases [15]. Additionally, a meta-analysis of more than 2 million patients revealed that those with OVCFs who underwent VA were 22% less likely to die within up to 10 years posttreatment than those who received non-surgical treatment [16]. Regarding the cause, no convincing conclusion has been obtained from current studies. Yen et al. reported a protective effect of VP within six months post surgery, reducing the incidence of any adjacent fracture by 21% [17]. In contrast, Buchbinder et al. reported no significant benefit of VP in terms of pain, disability, quality of life, or treatment success for acute or subacute osteoporotic vertebral fractures [18]. Consequently, there is a need to investigate the mechanism of refracture and explore alternative preventive strategies [19, 20]. This study represents the first attempt to scrutinize fracture patterns and evaluate the advantages of the PrVP for single-segment OVCFs.\u003c/p\u003e\n\u003cp\u003eNew VCFs after VP included those that affected the AVFs, recompression of cemented vertebral bodies, and RVFs. Hsieh et al demonstrated an unmet need to prevent symptomatic subsequent VCF in the first 6 months after primary VP (subacute phase), since the protective effects of AOMs are questionable during this period [21]. After VP, the redistribution of load-bearing kinetics shifts to other vertebrae, particularly those neighboring the original fracture site, thereby increasing the risk of AVFs. Clinical studies have demonstrated that most fractures occur at adjacent levels [22, 23]. On the basis of our published data, the incidence of AVFs was 17.1% (7/41) in the nonprophylactic group and 7.5% (6/80) in the prophylactic group, with no statistically significant difference between the groups (P = 0.107). While the incidence of new fractures in remote vertebrae is relatively lower than that in adjacent levels, preventing this complication is equally important. Previous studies have suggested that there is no statistically significant difference in the occurrence of remote fractures between the prophylactic and nonprophylactic groups [15, 19, 24]. These findings are consistent with our findings; the incidence of RVFs was 14.6% (6/41) in the nonprophylactic group and 22.5% (18/80) in the prophylactic group, with no statistically significant difference between the groups (P=0.304). This finding indicates that prophylactic augmentation does not influence the reduction of remote fractures.\u003c/p\u003e\n\u003cp\u003ePrevious studies have identified various factors associated with the recurrence of VCFs following augmentation procedures. Staples et al. reported no correlation between subsequent fractures and the injected cement volume, cement leakage, or VP level [25]. Yu et al. emphasized factors such as a preoperative intravertebral cleft, affected vertebrae in the thoracolumbar region, severe preoperative kyphotic deformity, a solid lump cement distribution pattern, and greater vertebral height restoration as primary risk factors [26]. Additionally, sarcopenia and advanced age are recognized as independent risk factors [27, 28]. Furthermore, Hsieh et al demonstrated that age, osteoporosis or osteopenia, and the Charlson comorbidity index (CCI) were identified as risk factors in the initial 6 months, but only osteoporosis or osteopenia and the CCI persisted as risk factors thereafter [21]. Biomechanically, the VP increases pressure in adjacent intervertebral discs by 19% and stresses in adjacent endplates and trabecular bone by 17% and 5%, respectively. Trabecular bone near endplates plays an important biomechanical role, distributing up to 85% of the applied load [29, 30]. Cement-induced stiffness modifies load transfer, potentially straining adjacent vertebrae. Nagaraja et al. reported that bone cement increases subsidence in the posterior regions of the treated endplates and the anterior region of the superior caudal endplate [31]. Consequently, increased subsidence may be the initial mechanism precipitating subsequent compression fractures after VP, particularly in vertebrae superior to the treated level.\u003c/p\u003e\n\u003cp\u003eClinical studies have shown variations in the predominant location (superior or inferior) of adjacent vertebral fractures after VP. Yen et al. reported a greater incidence of new fractures in upper adjacent vertebrae than in lower ones (36% versus 15%) [17]. Kobayashi et al. further performed PrVP in only the upper adjacent vertebrae because the incidence of new fractures was relatively low in the lower adjacent vertebrae [32]. Our findings align well with these studies, as 84.6% (11/13) of AVFs were located at the cranial endplate. Additionally, Han et al. demonstrated the beneficial effects of PrVP at the UIV and adjacent vertebra, indicating potential delays in the progression of proximal junctional kyphosis (PJK), proximal junctional failure (PJF), and proximal junctional fracture (PJFx), consequently reducing the reoperation rate following PJFX [22]. Similarly, Gassie et al. reported minimal occurrences of PJK and PJF following PrVP and UIV cement augmentation (11.1% and 4.2%, respectively) [33].\u003c/p\u003e\n\u003cp\u003eThere is limited evidence regarding the treatment of biendplate-involved OVCFs classified as OF4 fractures. Most patients treated conservatively experienced minor symptoms and lower complication rates, but had a high incidence of neurological deficits at follow-up (14%). Conversely, surgical treatment resulted in lower rates of neurological deficits but higher rates of subsequent fractures (26% and 10%, respectively) [34]. Our published data indicate that the incidence of AVFs in the biendplate-involved subgroup was 23.8% (5/21) in the nonprophylactic group and 2.6% (1/39) in the prophylactic group, with a statistically significant difference (P = 0.009). Thus, PrVP appears to be a valid treatment strategy for biendplate OVCFs.\u003c/p\u003e\n\u003cp\u003eFurthermore, several studies have indicated that the major cause of recurrent fracture is the progression of osteoporosis rather than therapeutic augmentation. Ebeling et al. reported that AOMs reduce the risk of subsequent vertebral fractures by 40\u0026ndash;70% [35]. Therefore, patients diagnosed with OVCFs should receive appropriate anti-osteoporotic therapy promptly. Anabolic agents have greater anti-fracture efficacy and produce greater increases in bone density than antiresorptive drugs do. However, as the effects of anabolic agents are temporary, sequential treatment with antiresorptive drugs following anabolic therapy is necessary [7, 36].\u003c/p\u003e\n\u003cp\u003eIn summary, PrVP in the biendplate-involved subgroup remains necessary for several reasons. First, the presence of OVCFs with biendplate-involved indicates poor bone quality, suggesting a likelihood of further fractures due to progressive deterioration. Second, the effectiveness of sequential osteoporosis medications takes several months to manifest, necessitating strict medication compliance to prevent new VCFs. Additionally, a significant proportion of AVFs occur shortly after VP, with 62% reported within 6 months in the non-preventive group [37]. Finally, the rapid relief of pain following VP may lead patients to engage in early physical activity without adequate protective measures or short-term AOMs, thereby heightening the risk of subsequent VCFs.\u003c/p\u003e\n\u003cp\u003eOur study has several limitations. First, it was a single-center retrospective, nonrandomized design with a limited number of patients in each subgroup. Second, we did not include data on newly occurring VCFs managed through conservative treatment. Additionally, some asymptomatic patients have declined imaging studies, impacting the assessment of new VCFs. Moreover, challenges in obtaining bone density measurements hinder preoperative and postoperative assessments. Finally, the strict selection criteria (single-segment fractures, no prior spinal surgery) resulted in a relatively small sample size. These limitations warrant the need for further research utilizing a randomized controlled trial approach to construct a predictive model for refracture risk after VP. This model (Figure 4) will assist clinicians in identifying high-risk patients for refracture, enabling the implementation of targeted intervention measures for the UIV and/or LIV.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe established a novel classification system and evaluated the correlation between fracture pattern and the occurrence of AVFs after VP. The PrVP in the biendplate involvement group demonstrated a decrease in the occurrence of subsequent VCFs and AVFs. In addition, there were significant differences observed in the PrVP group regarding postoperative ODI scores at the 3-month and 6-month follow-ups. Furthermore, statistically significant differences were observed in the postoperative ODI score at the 6-month follow-up among patients receiving postoperative osteoporosis medication.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAOM: Anti-osteoporotic Medication\u003c/p\u003e\n\u003cp\u003eAVF: Adjacent Vertebral Fracture\u003c/p\u003e\n\u003cp\u003eBMD: Bone Mass Density\u003c/p\u003e\n\u003cp\u003eDGOU: German Society for Orthopedics and Trauma\u003c/p\u003e\n\u003cp\u003eLIV: Lower Instrumented Vertebra\u003c/p\u003e\n\u003cp\u003eODI: Oswestry Disability Index\u003c/p\u003e\n\u003cp\u003eOVCF: Osteoporotic Vertebral Compression Fracture\u003c/p\u003e\n\u003cp\u003ePJK: Proximal Junctional Kyphosis\u003c/p\u003e\n\u003cp\u003ePJF: Proximal Junctional Failure\u003c/p\u003e\n\u003cp\u003ePJFX: Proximal Junctional Fracture\u003c/p\u003e\n\u003cp\u003ePrVP: Prophylactic Vertebroplasty\u003c/p\u003e\n\u003cp\u003eQoL: Quality of Life\u003c/p\u003e\n\u003cp\u003eRVF: Remote Vertebral Fracture\u003c/p\u003e\n\u003cp\u003eUIV: Upper Instrumented Vertebra\u003c/p\u003e\n\u003cp\u003eVA: Vertebral Augmentation\u003c/p\u003e\n\u003cp\u003eVAS: Visual Analog Scale\u003c/p\u003e\n\u003cp\u003eVCF: Vertebral Compression Fracture\u003c/p\u003e\n\u003cp\u003eVP: Vertebroplasty\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\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJH: data acquisition and analysis, drafting and revision of article\u003c/p\u003e\n\u003cp\u003eKX: data analysis and interpretation, revision of article\u003c/p\u003e\n\u003cp\u003eYJ: for independent resolution of conflicts during data extraction and interpretation\u003c/p\u003e\n\u003cp\u003eCM: for independent resolution of conflicts during data extraction and interpretation\u003c/p\u003e\n\u003cp\u003ePH: data extraction and interpretation\u003c/p\u003e\n\u003cp\u003eCY: data extraction and interpretation\u003c/p\u003e\n\u003cp\u003eHT: for independent resolution of conflicts during data screening and vetting of article\u003c/p\u003e\n\u003cp\u003eCT: research design, data screening, drafting and revision of article, correspondence\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Research Ethics Committee of China Medical University Hospital (Approval number: CMUBH2019-001), and all patients written informed consent.\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\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDong Y PR, Kang H, Song K, Guo Q, Zhao H, Zhu M, Zhang Y, Guan H, Li F. Global incidence, prevalence, and disability of vertebral fractures: a systematic analysis of the global burden of disease study 2019. Spine J. 2022:857-68.\u003c/li\u003e\n\u003cli\u003eDennison E, Cooper C. Epidemiology of osteoporotic fractures. Horm Res. 2000;54 Suppl 1:58-63.\u003c/li\u003e\n\u003cli\u003eMelton LJ, 3rd, Kan SH, Frye MA, Wahner HW, O'Fallon WM, Riggs BL. Epidemiology of vertebral fractures in women. Am J Epidemiol. 1989;129(5):1000-11.\u003c/li\u003e\n\u003cli\u003eGonschorek O, Hauck S, Wei\u0026szlig; T, B\u0026uuml;hren V. Percutaneous vertebral augmentation in fragility fractures-indications and limitations. Eur J Trauma Emerg Surg. 2017;43(1):9-17.\u003c/li\u003e\n\u003cli\u003ePetitt JC, Desai A, Kashkoush A, Ahorukomeye P, Potter TO, Stout A, et al. Failure of Conservatively Managed Traumatic Vertebral Compression Fractures: A Systematic Review. World Neurosurg. 2022;165:81-8.\u003c/li\u003e\n\u003cli\u003eLunt M, O'Neill TW, Felsenberg D, Reeve J, Kanis JA, Cooper C, et al. Characteristics of a prevalent vertebral deformity predict subsequent vertebral fracture: results from the European Prospective Osteoporosis Study (EPOS). Bone. 2003;33(4):505-13.\u003c/li\u003e\n\u003cli\u003eAl Taha K, Lauper N, Bauer DE, Tsoupras A, Tessitore E, Biver E, et al. Multidisciplinary and Coordinated Management of Osteoporotic Vertebral Compression Fractures: Current State of the Art. J Clin Med. 2024;13(4).\u003c/li\u003e\n\u003cli\u003eBlattert TR, Schnake KJ, Gonschorek O, Gercek E, Hartmann F, Katscher S, et al. Nonsurgical and Surgical Management of Osteoporotic Vertebral Body Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J. 2018;8(2 Suppl):50S-5S.\u003c/li\u003e\n\u003cli\u003eSchnake KJ, Blattert TR, Hahn P, Franck A, Hartmann F, Ullrich B, et al. Classification of Osteoporotic Thoracolumbar Spine Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J. 2018;8(2 Suppl):46S-9S.\u003c/li\u003e\n\u003cli\u003e Acaroğlu E, Nordin M, Randhawa K, Chou R, C\u0026ocirc;t\u0026eacute; P, Mmopelwa T, et al. The Global Spine Care Initiative: a summary of guidelines on invasive interventions for the management of persistent and disabling spinal pain in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):870-8.\u003c/li\u003e\n\u003cli\u003e Comstock BA, Sitlani CM, Jarvik JG, Heagerty PJ, Turner JA, Kallmes DF. Investigational vertebroplasty safety and efficacy trial (INVEST): patient-reported outcomes through 1 year. Radiology. 2013;269(1):224-31.\u003c/li\u003e\n\u003cli\u003e Firanescu CE, de Vries J, Lodder P, Schoemaker MC, Smeets AJ, Donga E, et al. Percutaneous Vertebroplasty is no Risk Factor for New Vertebral Fractures and Protects Against Further Height Loss (VERTOS IV). Cardiovasc Intervent Radiol. 2019;42(7):991-1000.\u003c/li\u003e\n\u003cli\u003e Patel D, Liu J, Ebraheim NA. Managements of osteoporotic vertebral compression fractures: A narrative review. World J Orthop. 2022;13(6):564-73.\u003c/li\u003e\n\u003cli\u003e Zhu RS, Kan SL, Ning GZ, Chen LX, Cao ZG, Jiang ZH, et al. Which is the best treatment of osteoporotic vertebral compression fractures: balloon kyphoplasty, percutaneous vertebroplasty, or non-surgical treatment? A Bayesian network meta-analysis. Osteoporos Int. 2019;30(2):287-98.\u003c/li\u003e\n\u003cli\u003e Lei F, He W, Tian X, Li Z, Zheng L, Kang J, et al. Prophylactic Percutaneous Kyphoplasty Treatment for Nonfractured Vertebral Bodies in Thoracolumbar for Osteoporotic Patients. Biomed Res Int. 2020;2020:8593516.\u003c/li\u003e\n\u003cli\u003e Hinde K, Maingard J, Hirsch JA, Phan K, Asadi H, Chandra RV. Mortality Outcomes of Vertebral Augmentation (Vertebroplasty and/or Balloon Kyphoplasty) for Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta-Analysis. Radiology. 2020;295(1):96-103.\u003c/li\u003e\n\u003cli\u003e Yen CH, Teng MM, Yuan WH, Sun YC, Chang CY. Preventive vertebroplasty for adjacent vertebral bodies: a good solution to reduce adjacent vertebral fracture after percutaneous vertebroplasty. AJNR Am J Neuroradiol. 2012;33(5):826-32.\u003c/li\u003e\n\u003cli\u003e Buchbinder R, Johnston RV, Rischin KJ, Homik J, Jones CA, Golmohammadi K, et al. Percutaneous vertebroplasty for osteoporotic vertebral compression fracture. Cochrane Database Syst Rev. 2018;4(4):Cd006349.\u003c/li\u003e\n\u003cli\u003e Chen Z, Song C, Lin H, Sun J, Liu W. Does prophylactic vertebral augmentation reduce the refracture rate in osteoporotic vertebral fracture patients: a meta-analysis. Eur Spine J. 2021;30(9):2691-7.\u003c/li\u003e\n\u003cli\u003e Parreira PCS, Maher CG, Megale RZ, March L, Ferreira ML. An overview of clinical guidelines for the management of vertebral compression fracture: a systematic review. Spine J. 2017;17(12):1932-8.\u003c/li\u003e\n\u003cli\u003e Hsieh YC, Yang YS, Chien LN, Chiang YH, Lin JH. Timing of symptomatic subsequent vertebral compression fracture associated with different demographic factors. Eur Spine J. 2022;31(9):2439-47.\u003c/li\u003e\n\u003cli\u003e Han S, Hyun SJ, Kim KJ, Jahng TA, Jeon SI, Wui SH, et al. Effect of Vertebroplasty at the Upper Instrumented Vertebra and Upper Instrumented Vertebra +1 for Prevention of Proximal Junctional Failure in Adult Spinal Deformity Surgery: A Comparative Matched-Cohort Study. World Neurosurg. 2019;124:e436-e44.\u003c/li\u003e\n\u003cli\u003e Sun HB, Shan JL, Tang H. Percutaneous vertebral augmentation for osteoporotic vertebral compression fractures will increase the number of subsequent fractures at adjacent vertebral levels: a systematic review and meta-analysis. Eur Rev Med Pharmacol Sci. 2021;25(16):5176-88.\u003c/li\u003e\n\u003cli\u003e Eichler MC, Spross C, Ewers A, Mayer R, Kulling FA. Prophylactic adjacent-segment vertebroplasty following kyphoplasty for a single osteoporotic vertebral fracture and the risk of adjacent fractures: a retrospective study and clinical experience. J Neurosurg Spine. 2016;25(4):528-34.\u003c/li\u003e\n\u003cli\u003e Staples MP, Howe BM, Ringler MD, Mitchell P, Wriedt CH, Wark JD, et al. New vertebral fractures after vertebroplasty: 2-year results from a randomised controlled trial. Arch Osteoporos. 2015;10:229.\u003c/li\u003e\n\u003cli\u003e Yu W, Xu W, Jiang X, Liang D, Jian W. Risk Factors for Recollapse of the Augmented Vertebrae After Percutaneous Vertebral Augmentation: A Systematic Review and Meta-Analysis. World Neurosurg. 2018;111:119-29.\u003c/li\u003e\n\u003cli\u003e Jing C, Wang H, Liu P, Yang S, Zhang L, Yang P, et al. Effect of sarcopenia on refractures of adjacent vertebra after percutaneous kyphoplasty. BMC Musculoskelet Disord. 2024;25(1):210.\u003c/li\u003e\n\u003cli\u003e Wang WF, Lin CW, Xie CN, Liu HT, Zhu MY, Huang KL, et al. The association between sarcopenia and osteoporotic vertebral compression refractures. Osteoporos Int. 2019;30(12):2459-67.\u003c/li\u003e\n\u003cli\u003e Eswaran SK, Gupta A, Adams MF, Keaveny TM. Cortical and trabecular load sharing in the human vertebral body. J Bone Miner Res. 2006;21(2):307-14.\u003c/li\u003e\n\u003cli\u003e Polikeit A, Nolte LP, Ferguson SJ. The effect of cement augmentation on the load transfer in an osteoporotic functional spinal unit: finite-element analysis. Spine (Phila Pa 1976). 2003;28(10):991-6.\u003c/li\u003e\n\u003cli\u003e Nagaraja S, Awada HK, Dreher ML, Bouck JT, Gupta S. Effects of vertebroplasty on endplate subsidence in elderly female spines. J Neurosurg Spine. 2015;22(3):273-82.\u003c/li\u003e\n\u003cli\u003e Kobayashi N, Numaguchi Y, Fuwa S, Uemura A, Matsusako M, Okajima Y, et al. Prophylactic vertebroplasty: cement injection into non-fractured vertebral bodies during percutaneous vertebroplasty. Acad Radiol. 2009;16(2):136-43.\u003c/li\u003e\n\u003cli\u003e Gassie K, Pressman E, Vicente AC, Flores-Milan G, Gordon J, Alayli A, et al. Percutaneous Vertebroplasty and Upper Instrumented Vertebra Cement Augmentation Reducing Early Proximal Junctional Kyphosis and Failure Rate in Adult Spinal Deformity: Case Series and Literature Review. Oper Neurosurg (Hagerstown). 2023;25(3):209-15.\u003c/li\u003e\n\u003cli\u003e Spiegl UJA, Schenk P, Schnake KJ, Ullrich BW, Osterhoff G, Scheyerer MJ, et al. Treatment and Outcome of Osteoporotic Thoracolumbar Vertebral Body Fractures With Deformation of Both Endplates With or Without Posterior Wall Involvement (OF 4): Short-Term Results from the Prospective EOFTT Multicenter Study. Global Spine J. 2023;13(1_suppl):36S-43S.\u003c/li\u003e\n\u003cli\u003e Ebeling PR, Akesson K, Bauer DC, Buchbinder R, Eastell R, Fink HA, et al. The Efficacy and Safety of Vertebral Augmentation: A Second ASBMR Task Force Report. J Bone Miner Res. 2019;34(1):3-21.\u003c/li\u003e\n\u003cli\u003e Handel MN, Cardoso I, von Bulow C, Rohde JF, Ussing A, Nielsen SM, et al. Fracture risk reduction and safety by osteoporosis treatment compared with placebo or active comparator in postmenopausal women: systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials. BMJ. 2023;381:e068033.\u003c/li\u003e\n\u003cli\u003e Voormolen MH, Lohle PN, Juttmann JR, van der Graaf Y, Fransen H, Lampmann LE. The risk of new osteoporotic vertebral compression fractures in the year after percutaneous vertebroplasty. J Vasc Interv Radiol. 2006;17(1):71-6.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. DGOU Osteoporotic Fracture (OF) Classification System\u003c/p\u003e\n\u003ctable width=\"1124\"\u003e\n \u003ctbody\u003e\n \u003ctr style=\"height: 35px;\"\u003e\n \u003ctd style=\"height: 35px; width: 134px;\"\u003e\n \u003cp\u003eOF1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 274px;\"\u003e\n \u003cp\u003eOF2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 265px;\"\u003e\n \u003cp\u003eOF3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 291px;\"\u003e\n \u003cp\u003eOF4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 160px;\"\u003e\n \u003cp\u003eOF5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 48px;\"\u003e\n \u003ctd style=\"height: 48px; width: 134px;\"\u003e\n \u003cp\u003eNo deformation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 48px; width: 274px;\"\u003e\n \u003cp\u003eDeformation of one endplate with posterior wall \u0026lt; 1/5 involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 48px; width: 265px;\"\u003e\n \u003cp\u003eDeformation of one endplate with posterior wall \u0026gt; 1/5 involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 48px; width: 291px;\"\u003e\n \u003cp\u003eDeformation of Bi-endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 48px; width: 160px;\"\u003e\n \u003cp\u003eAnterior or posterior tension band failure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 35px;\"\u003e\n \u003ctd style=\"height: 35px; width: 134px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 274px;\"\u003e\n \u003cp\u003e\u0026nbsp; OF2.1 Superior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; OF3.1 Superior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 291px;\"\u003e\n \u003cp\u003e\u0026nbsp;OF4.1 Loss of vertebral frame structure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 160px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 35px;\"\u003e\n \u003ctd style=\"height: 35px; width: 134px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 274px;\"\u003e\n \u003cp\u003e\u0026nbsp; OF2.2 Lateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; OF3.2 Lateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 291px;\"\u003e\n \u003cp\u003e\u0026nbsp;OF4.2 Vertebral body collapse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 160px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 35px;\"\u003e\n \u003ctd style=\"height: 35px; width: 134px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 274px;\"\u003e\n \u003cp\u003e\u0026nbsp; OF2.3 Inferior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; OF3.3 Inferior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 291px;\"\u003e\n \u003cp\u003e\u0026nbsp;OF4.3 Pincer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 35px; width: 160px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. The demographic and baseline characteristics of patients\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable width=\"1118\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 241px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eNonprophylactic group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eProphylactic group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 197px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 241px;\"\u003e\n \u003cp\u003eNumber of patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 197px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 241px;\"\u003e\n \u003cp\u003eMean age in yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e77.3 \u0026plusmn; 8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e76.2 \u0026plusmn; 9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e77.9 \u0026plusmn; 8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 197px;\"\u003e\n \u003cp\u003e0.155\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 241px;\"\u003e\n \u003cp\u003eGender (M/F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e31/90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e8/33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e23/50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 197px;\"\u003e\n \u003cp\u003e0.271\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 241px;\"\u003e\n \u003cp\u003eBMD (T-score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e-2.93 \u0026plusmn; 1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e-2.77 \u0026plusmn; 0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e-3.02 \u0026plusmn; 1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 197px;\"\u003e\n \u003cp\u003e0.159\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 241px;\"\u003e\n \u003cp\u003eMean follow-up in mos\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e33.9 \u0026plusmn; 28.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e28.2 \u0026plusmn; 14.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e36.8 \u0026plusmn; 32.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 197px;\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 241px;\"\u003e\n \u003cp\u003eFracture subgroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 280px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 238px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 197px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 241px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Upper endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 197px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 241px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Lower endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 197px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 241px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Bi-endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 197px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026mdash; = not applicable.\u003c/p\u003e\n\u003cp\u003e* Statistically significant.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3. Classification of\u0026nbsp;adjacent vertebral fractures (AVFs)\u0026nbsp;\u003c/p\u003e\n\u003ctable width=\"1121\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 279px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 258px;\"\u003e\n \u003cp\u003eUpper endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 222px;\"\u003e\n \u003cp\u003eLower endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eBi-endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 258px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 222px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003eVCFs (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e35 (28.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 258px;\"\u003e\n \u003cp\u003e23 (45.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 222px;\"\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e9 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026nbsp; RVFs (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e24 (19.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 258px;\"\u003e\n \u003cp\u003e18 (35.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 222px;\"\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e3 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026nbsp; AVFs (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e13 (10.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 258px;\"\u003e\n \u003cp\u003e7 (13.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 222px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e6 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026nbsp; At inferior cranial endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 258px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 222px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026nbsp; At superior caudal endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 258px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 222px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Table 4. Clinical status of patients\u003c/p\u003e\n\u003ctable width=\"933\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003eNonprophylactic group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003eProphylactic group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eVAS score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Pre-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e7.0 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e6.8 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.262\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Post-OP at 3mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e1.8 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e2.0 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.094\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Post-OP at 6mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e1.3 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e1.3 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.435\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eODI score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Pre-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e37.0 \u0026plusmn; 4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e38.0 \u0026plusmn; 4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.122\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Post-OP at 3mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e12.9 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e12.1 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.034*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Post-OP at 6mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e12.8 \u0026plusmn; 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e11.7 \u0026plusmn; 2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.014*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eVCFs (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e12 (29.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e23 (28.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.953\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Upper endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e6 (31.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e17 (53.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.135\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Lower endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e3 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Bi-endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e6 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e3 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.031*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eAVFs (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e7 (17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e6 (7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Upper endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e2 (10.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e5 (15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.609\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Lower endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Bi-endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e5 (23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e1 (2.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.009*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eRVFs(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e6 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e18 (22.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.304\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Upper endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e5 (26.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e13 (40.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.301\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Lower endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e3 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Bi-endplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e2 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Table 5. Osteoporosis medication after procedure for patients\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable width=\"993\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 243px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\n \u003cp\u003eNon-medication group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003eMedication group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 243px;\"\u003e\n \u003cp\u003eVAS score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 243px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Pre-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\n \u003cp\u003e6.8 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003e6.9 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e0.323\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 243px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Post-OP at 3mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\n \u003cp\u003e2.0 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003e2.0 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e0.478\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 243px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Post-OP at 6mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\n \u003cp\u003e1.2 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003e1.4 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 243px;\"\u003e\n \u003cp\u003eODI score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 243px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Pre-OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\n \u003cp\u003e37.3 \u0026plusmn; 4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003e37.8 \u0026plusmn; 4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e0.326\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 243px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Post-OP at 3mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\n \u003cp\u003e11.9 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003e12.6 \u0026plusmn; 2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e0.093\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 243px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Post-OP at 6mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\n \u003cp\u003e11.1 \u0026plusmn; 2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 247px;\"\u003e\n \u003cp\u003e12.4 \u0026plusmn; 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e0.014*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"Prophylactic vertebroplasty, Osteoporotic vertebral compression fractures, DGOU classification, Endplate, Subsequent vertebral compression fractures","lastPublishedDoi":"10.21203/rs.3.rs-5327306/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5327306/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe concept of prophylactic vertebroplasty (PrVP) has been proposed to prevent recurrent fractures after vertebroplasty (VP); however, its efficacy remains controversial. The purpose of this study was to analyze fracture patterns and evaluate the effectiveness of PrVP in reducing refracture rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective analysis was conducted from January 2015 to December 2023 involving consecutive patients who underwent VP for osteoporotic vertebral compression fractures (OVCFs). Fractures were classified according to the German Society for Orthopedics and Trauma (DGOU) Classification of Osteoporotic Fractures, and further divided into subgroups. Patients were categorized into PrVP or non-PrVP groups. The follow-up assessments included radiographic evaluations, pain scores, and disability indices between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 121 patients were included. PrVP was associated with reduced occurrence of subsequent vertebral compression fractures (VCFs) and adjacent vertebral fractures (AVFs) in the biendplate-involvement subgroup (7.7% versus 28.6%, P=0.031; 2.6% versus 23.8%, P=0.009). The postoperative disability scores at 3 months (12.1 ± 2.1 versus 12.9 ± 2.1, P=0.034) and at 6 months (11.7 ± 2.6 versus 12.8 ± 2.5, P=0.014) differed significantly between the groups. No significant differences were observed in AVF occurrence among the other fracture subgroups. Postoperative pain relief was significant in both groups, but the difference was not statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Our study highlights the potential benefits of PrVP in reducing AVF occurrence in patients with biendplate-involved. Postoperative disability scores improved significantly with PrVP, especially in patients receiving postoperative osteoporosis medication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eThis study was approved by the Research Ethics Committee of China Medical University Hospital (Approval number: CMUBH2019-001).\u003c/p\u003e","manuscriptTitle":"Fracture Patterns and Efficacy of Prophylactic Vertebroplasty in Osteoporotic Vertebral Compression Fractures: A Retrospective Single-Center Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-25 05:59:18","doi":"10.21203/rs.3.rs-5327306/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":"53e3d3dc-8f75-4c71-bd93-6f8a1a4529c4","owner":[],"postedDate":"October 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-04T06:23:56+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-25 05:59:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5327306","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5327306","identity":"rs-5327306","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}