Continuity and Volume of Bone Cement and Anti Osteoporosis Treatment were Guarantee of Good Clinical Outcomes for Percutaneous Vertebroplasty: a Multicentre Study

Continuity and Volume of Bone Cement and Anti Osteoporosis Treatment were Guarantee of Good Clinical Outcomes for Percutaneous Vertebroplasty: a Multicentre 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 Continuity and Volume of Bone Cement and Anti Osteoporosis Treatment were Guarantee of Good Clinical Outcomes for Percutaneous Vertebroplasty: a Multicentre Study Zhen Cheng, Guangzong Ren, Ziyi Li, Xianda Gao, Di Zhang, Guiyue Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3993919/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Feb, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 10 You are reading this latest preprint version Abstract Background: As the most prevalent fragility fracture caused by osteoporosis, increasing attention was paid to vertebral compression fractures (VCF) day by day. Percutaneous vertebroplasty (PVP) had unique advantages in treatment of VCF and was used widely. Researching how to improving surgical efficacy and decreasing postoperative residual was able to benefit more patients. The purpose of our study was to seek for those associated factors with good clinical outcomes after PVP and provide evidence for improving surgical efficacy. Material and Methods: 186 patients who underwent PVP from January 2021 to January 2023 were reviewed retrospectively in the study. The patients were divided into two groups according to clinical outcomes. Preoperative general data and surgical data were collected for statistical analysis. Multivariate logistic regression analysis and the receiver operating characteristic curve were used to identify the associated factors with good clinical outcomes. Results: There were statistically significant differences between two groups in volume of bone cement (p=0.012), standardized treatment for osteoporosis (p=0.004)and bone cement continuity (p=0.006). The associated factors with good clinical outcomes after PVP were continuous bone cement (OR=2.237, 95% CI=1.191-4.201, p=0.012), standardized treatment for osteoporosis (OR=2.105, 95% CI=1.089-4.068, p=0.027) and volume of bone cement >5.5ml (OR=1.271, 95% CI=1.023-1.579, p=0.030). Conclusion: PVP effectively released the back pain of patients and was worthy of promotion. However, postoperative residual pain was an important factor that reduced the clinical outcomes. Continuous bone cement, Injected bone cement >5.5ml and tandardized treatment for osteoporosis were guarantee of good clinical outcomes for PVP Treatment Outcome Bone Cements Spinal Fractures Osteoporosis Multicenter Studies as Topic Figures Figure 1 Figure 2 Figure 3 Background As a public health problem, increasing attention was paid to osteoporosis with the arrival of an aging society. Vertebral compression fractures (VCF) was the most prevalent fragility fracture because of osteoporosis [ 1 , 2 ]. Conservative treatment consisted of prolonged bed rest, back brace immobilization and medication, which increased the risk of kyphosis, nonunion and death [ 3 ]. Percutaneous vertebroplasty (PVP) had unique advantages in treatment of VCF and greatly reduced the complications of conservative treatment especially for elderly patients [ 3 ]. During PVP, bone cement was injected into vertebral body through a small incision (approximately 1cm) and a special tubular channel. Injected bone cement stabled the fractured vertebral body and reduced the immediate pain [ 4 , 5 ]. PVP showed satisfactory clinical outcomes and was widely used, however, there were still part patients suffering from residual or unrelieved pain after the surgery [ 6 , 7 ]. Previous studies discussed the possible factors related to poor outcomes, however no consensus was gained. In our study, we divided patients in different groups according to the degree of pain relief and identified the risk factors of residual pain. The purpose of our study was to seek for those associated factors with good clinical outcomes after PVP and provide evidence for improving surgical efficacy. Material and methods Patients 186 patients who underwent PVP from January 2021 to January 2023 at The Third Hospital of Hebei Medical University and Changzhi People's Hospital in China were reviewed retrospectively in the study. The inclusion criteria included: 1) diagnosed as VCF before surgery according to imaging data; 2) bone mineral density (BMD) equal to or less than − 2.5; 3) without neurological symptoms; 4) single segment surgery with bilateral approach; 5) minimum 1-year follow-up visit. The exclusion criteria included: The exclusion criteria included: 1) spinal tumors, inflammation or other diseases; 2) combined with other fragility fractures; 3) new-onset VCF from postoperative to follow-up visit; 4) uncompleted data. Data analysis Visual Analogue Scale (VAS) score (range from 0 to 10) was used to assess preoperative and last follow-up pain. The recovery rate was calculated as: (Preoperative VAS - postoperative VAS)/ Preoperative VAS*100%. The patients with last follow-up recovery rate greater than the average were divided into Group Good Clinical Outcomes (Group GCO), while other patients with last follow-up recovery rate less than the average were divided into Group Poor Clinical Outcomes (Group PCO). Preoperative general data including age, gender, body mass index (BMI), bone mineral density (BMD), smoking, drinking, history of trauma or symptoms, followed up period, local kyphosis Cobb angle, lumbar lordosis (LL) and thoracic kyphosis (TK) was recorded for further statistical analysis. BMD was detected by using dual energy X-ray absorptiometry (DEXA). If there was an explicit history of trauma, the time of history was recorded from the onset of the trauma to the surgical day, and if not, the time of history was recorded from onset of the symptoms to the surgical day. local kyphosis Cobb angle was defined as the angle between the upper endplate of the upper vertebral body of the compressed vertebra and the lower endplate of the lower vertebral body of the compressed vertebra. LL was defined as the angle between the upper endplate of L1 vertebral body and the lower endplate of L5 vertebral body. TK was defined as angle between the upper endplate of T4 vertebral body and the lower endplate of T12 vertebral body. The measurement data including local kyphosis Cobb angle, LL and TK was measured three times and the average value was used for statistical testing. Surgical data including surgical segment, surgical time, volume of bone cement, fluoroscopy frequency, standardized treatment for osteoporosis and continuity of bone cement was recorded for further statistical analysis. All surgeries were performed with the assistance of a G-arm fluoroscopy instrument. During the surgery, each posterior-anterior or lateral X-ray was counted as one time of fluoroscopy frequency, in other words, simultaneous posterior-anterior and lateral X-ray was count as two times of fluoroscopy frequency. Continuous bone cement (Fig. 1 ) was defined as there was no gap between two pieces of bone cement according to postoperative posterior-anterior X-ray, while discontinuous bone cement (Fig. 2 ) was defined as there was a visible gap between two pieces of bone cement. Statistical Analysis SPSS program (version 27.0; SPSS Inc., Chicago, IL, USA) was used for statistical analysis. P-value < 0.05 was considered statistically significant. Quantitative data between Group GCO and Group PCO was tested by Student's t-test or Mann–Whitney U-test according to data distribution. Qualitative date was tested by Chi-square test. Associated factors of good clinical outcomes were identified by multivariate logistic regression analysis with adjusted odds ratios (ORs), 95% confidence intervals (CIs) and P-values. The potential factors were first screened by univariate analysis and the factor with p < 0.10 was selected into the multivariate logistic model. Youden index was calculated as sensitivity + specificity-1, and the maximum Youden index represented the cutoff value. Results 1) General data of total patients No serious complications were found in 186 patients after PVP. Total 186 patients included 24 males and 162 females and the average age was 70.74 ± 7.87. There were 40 patients underwent T7-10 PVP, 95 patients underwent T11-L2 PVP and 51 patients underwent L3-5 PVP with average follow-up visit 17.40 ± 7.62 months. BMD of all patients was equal or less than − 2.5 and the average value was − 3.17 ± 0.46. History of trauma was found in 139 patients (74.73%) and the average day of History of trauma or symptoms was 14.88 ± 13.84. The imaging measurement data, including local kyphosis Cobb angle, LL and TK, was 10.15 ± 6.80, 25.41 ± 10.16 and 41.58 ± 12.09, respectively. The average surgical time was 32.31 ± 11.53 min, and the average fluoroscopy frequency was 42.27 ± 13.50 times. The average volume of injected bone cement was 5.17 ± 1.46 ml. Continuous bone cement was found in 117 patients (62.90%). There were 126 patients received standardized anti-osteoporosis treatment (67.74%). 2) Comparison of patient characteristics between Group PCO and Group GCO The preoperative VAS score of total 186 patients was 7.69 ± 1.26 and the score decreased to last follow-up 2.17 ± 1.22 (p < 0.001). The average recovery rate was 71.92%±15.16%. There were 97 patients divided into Group GCO whose recovery rate greater than the average and other 89 patients was divided into Group PCO with recovery rate less than the average. There was no statistical difference in preoperative VAS score (p = 0.417) between Group PCO (7.64 ± 1.32) and Group GCO (7.74 ± 1.20). In both group, VAS score was significantly decreased after PVP (p < 0.001). However last follow-up VAS score (p < 0.001) and recovery rate (p < 0.001) in Group GCO (1.34 ± 0.68, 83.06%±7.69%) was significant greater than that in Group PCO (3.08 ± 1.02, 59.77%±11.52%) (Table 1 ). Comparison of other patient characteristics between two groups was showed in Table 1 and no statistical difference was found. Table 1 Comparison of patient characteristics between Group PCO and Group GCO Variable Group PCO (n = 89) Group GCO (n = 97) t/z/χ2 P-value Age (years) 71.09 ± 7.33 70.43 ± 7.26 0.519 0.603 Gender 1.241 0.271 male 14 10 female 75 87 Body Mass Index 23.60 ± 4.87 24.85 ± 5.09 1.549 0.121 Bone Mineral Density -3.22 ± 0.47 -3.13 ± 0.44 1.350 0.177 Smoking 0.819 0.365 Yes 12 9 No 77 88 Drinking 1.413 0.235 Yes 32 27 No 57 70 History of trauma or symptoms (days) 15.31 ± 14.34 14.48 ± 13.41 0.384 0.701 Followed up period (months) 17.87 ± 7.56 16.88 ± 7.41 0.788 0.431 Local kyphosis Cobb angle 10.51 ± 6.88 9.81 ± 6.74 0.751 0.452 Lumbar lordosis 24.81 ± 10.45 25.97 ± 9.91 1.089 0.276 Thoracic kyphosis 42.56 ± 12.12 40.68 ± 11.93 0.986 0.324 VAS score Preoperative 7.64 ± 1.32 7.74 ± 1.20 0.812 0.417 Last follow-up 3.08 ± 1.02 * 1.34 ± 0.68 * 10.400 < 0.001 Recovery rate (%) 59.77 ± 11.52 83.06 ± 7.69 11.807 < 0.001 * Significantly different from preoperative 3) Comparison of surgical data between Group PCO and Group GCO Comparison of surgical data between Group PCO and Group GCO was showed in Table 2 . No statistical difference was found in surgical segment (p = 0.118), surgical time (p = 0.246) and fluoroscopy frequency (p = 0.180) between two groups. The average volume of bone cement injected into the vertebral body in Group GCO was 5.43 ± 1.51, which was significantly higher (p = 0.012) than that in Group PCO (4.88 ± 1.34). There were 75 patients in Group GCO accepted standardized treatment for osteoporosis and the treatment ratio was 77.32%, while that ratio decreased to 57.30% in Group PCO (p = 0.004). According to the classification method above, bone cement of 70 patients in Group GCO was found continuous on postoperative posterior-anterior X-ray, and the ratio was 70.16%. In Group PCO, bone cement of 47 patients was found continuous and the ratio was only 52.81%. The Bone cement continuity rate was significantly higher in Group GCO than Group PCO (p = 0.006). Table 2 Comparison of surgical data between Group PCO and Group GCO Variable Group PCO (n = 89) Group GCO (n = 97) t/z/χ2 P-value Surgical segment 4.268 0.118 T7-10 15 25 T11-L2 44 51 L3-5 30 21 Surgical time (min) 31.40 ± 11.87 33.14 ± 11.21 1.159 0.246 Volume of bone cement (ml) 4.88 ± 1.34 5.43 ± 1.51 2.523 0.012 Fluoroscopy frequency (times) 40.80 ± 12.34 43.63 ± 14.42 1.341 0.180 Standardized treatment for osteoporosis 8.510 0.004 Yes 51 75 No 38 22 Continuity of bone cement 7.452 0.006 Yes 47 70 No 42 27 3) Logistic regression analysis and receiver operating characteristic (ROC) curve Logistic regression analysis was used to identify the associated factors of good clinical outcomes after PVP. First, potential factors were selected by univariate analysis and continuity of bone cement (p = 0.007), standardized treatment for osteoporosis (p = 0.004) and volume of bone cement (p = 0.010) were found statistically significant differences. Multivariate logistic regression showed three factors were closely associated with good clinical outcomes, which were continuity of bone cement (OR = 2.237, 95% CI = 1.191–4.201, p = 0.012), standardized treatment for osteoporosis (OR = 2.105, 95% CI = 1.089–4.068, p = 0.027) and volume of bone cement (OR = 1.271, 95% CI = 1.023–1.579, p = 0.030) (Table 3 ). The ROC curve analysis (Fig. 3 ) (Table 4 ) showed moderate accuracy for the association between volume of bone cement and good clinical outcomes (area under the curve: 0.603, P = 0.015). The cutoff value of volume of bone cement was 5.5ml. Table 3 Associated factors of Good clinical outcomes after PVP: multiple logistic regression analysis Variable Adjusted Odds Radio 95% Confidence Interval P-value Continuity of bone cement 2.237 1.191–4.201 0.012 Standardized treatment for osteoporosis 2.105 1.089–4.068 0.027 Volume of bone cement 1.271 1.023–1.579 0.030 Table 4 Sensitivity, specificity, AUC and cutoff of volume of bone cement Variable Sensitivity, Specificity AUC * Cutoff P-value Volume of bone cement 51.5% 70.8% 0.603 5.5 0.015 * Area under the curve Discussion Osteoporosis was a worldwide public health issue with around 200 million people suffering from the disease [ 1 , 8 ]. Approximately 9 million fractures were closely associated with osteoporosis annually in the world and VCF was the most prevalent among these fractures [ 8 , 9 ]. VCF was the beginning of a series of fractures which not only reduced quality of life, but also affected the expected lifespan [ 8 , 9 ]. The prevalence of vertebral fracture increased with age and the incidence rate increased to 21.9% in women over 70 years old [ 10 ]. More and more attention was paid to the diagnosis and treatment VCF recent years around the world. Compared with conservative treatment, surgical intervention rapidly released the pain and thus led to more rapid mobilization and reduced the bedridden related complications [ 3 , 11 , 12 ]. The injected bone cement filled the fracture gap, enhanced the strength and stability of vertebral body, which achieved immediate analgesia. Advantages, including small incision, minimal bleeding, short surgical time, fewer surgical complications and satisfactory immediate surgical efficacy, made PVP widely used around the world [ 13 , 14 ]. However, residual pain in part patients became the main reason of poor clinical outcomes and previous studies had tried to seek for the related factors with no consensus [ 15 – 17 ]. Previous studies proposed various different types of bone cement distribution and concluded that the distribution was significantly associated with clinical outcomes [ 16 – 20 ]. The study of Yang et al. [ 16 ] showed patients with satisfactory bone cement distribution (bone cement spread from superior to the inferior end plate, from medial cortex of bilateral pedicles, from anterior cortex to posterior third of the vertebral body) complaint less back pain after PVP. Li et al. [ 17 ] found confluent cement masses was associated with better clinical outcomes than separated cement masses (isolated and rarely connected to each other), which was similar with the distribution in our study. Mo et al. [ 18 ] divide the bone cement distribution into two categories: sufficient group and insufficient group according to whether bone cement diffused in the fracture line and whether vacuum cleft existed. In their study, sufficient obtained better clinical outcomes. Tan et al. [ 19 ] found distribution that bone cement contacted both upper and lower endplates led to less postoperative back pain. Xu et al. [ 20 ] found if bone cement located on both sides (above and below) of the fracture on postoperative lateral X-ray, patients achieved better clinical outcomes. As a whole, uniformly distributed bone cement was the guarantee of good clinical outcomes after PVP. In our study, continuous bone cement provided uniform force to support fracture line, as a result, fractured vertebrae were more stable, which led to less postoperative back pain. The association between bone cement volume and clinical outcomes was still controversial [ 21 – 25 ]. Barriga-Martín et al. [ 21 ] found small amounts of injected cement obtained similar clinical results to higher amounts which instead, increased the possibility of cement leak and further complications. The study of Wang et al. [ 22 ] showed that injected bone cement volume > 4 ml provided good clinical outcomes compared with < 4 ml at both postoperative and last-follow visit. Martinčič et al. [ 23 ] suggested minimum volume of injected cement was 4–6 ml, due to stiffness of vertebral body increased as the volume of cement increased until 4–6 ml. Nieuwenhuijse et al. [ 24 ] found that the more residual pain patient complaint of, the less volume of bone cement on the CT scans and they proposed a individualized recommended dosage according to spinal segment, sex, fracture severity. Kim et al. [ 25 ] suggested injecting as much cement as possible if no leakage occurred. In our study, the correlation showed between volume of bone cement and clinical outcomes. More volume of bone cement provided more support and stability. For reducing bone cement leak, we suggested to increase the fluoroscopy frequency appropriately during injecting the bone cement, especially when obvious endplate cracks presented. Our study showed postoperative standardized anti osteoporosis treatment was beneficial for postoperative pain relief. Huang et al. [ 26 ] conducted a perspective cohort study that showed the similar results that patients who received postoperative zoledronic acid treatment complaint of less back pain at 12-month follow-up compared with control group. Kong et al. [ 27 ] observed that teriparatide treatment after PVP was also benefits to increase BMD and reduce pain. Hu et al. [ 28 ] injected Zoledronic Acid intravenously before PVP and found that patients with the combination method had advantages of long-term pain relief, increased bone density and lower risk of refracture. On the other hand, osteoporosis was associated with back pain independently, which significantly reduced the quality of life [ 29 , 30 ]. Pharmacological treatment for osteoporosis was effective to improve back pain and among drugs, teriparatide showed better effect and more patient satisfaction [ 30 , 31 ]. To sum up, anti osteoporosis treatment was an essential part for achieving long-term good clinical outcomes after PVP. In our study, there were still 33.26% patients not receiving standardized treatment for osteoporosis due to some reasons. So it is important to strengthen publicity and education on osteoporosis and make more patients benefiting from anti osteoporosis treatment. This study has several limitations. First this study was also limited by its retrospective nature. Second, the short follow-up time might lead to biased of results. Third, our study excluded patients with new-onset VCF from postoperative to follow-up visit for more accurate assessment of pain relief after surgery, which might ignore some evaluation data. Therefore, randomized controlled trial with long-term follow-up visit would be performed to verify the results. Conclusion PVP effectively released the back pain of patients and was worthy of promotion. However, postoperative residual pain was an important factor that reduced the clinical outcomes. Continuous bone cement, Injected bone cement > 5.5ml and tandardized treatment for osteoporosis were guarantee of good clinical outcomes for PVP Declarations Ethics approval and consent to participate The study was approved by the Institutional Ethics Board of The Third Hospital of Hebei Medical University and Changzhi People's Hospital. All participants approved the informed consent of the use of imaging and clinical data. The methods were carried out in accordance with the approved guidelines. Availability of Data and Materials The datasets generated or analyzed during this study are available from the corresponding author on reasonable request. Consent for Publication Not applicable. Competing Interests All authors have read and contributed to the submitted manuscript and have no conflict of interest to declare. Funding There is no funding source. References Kutsal FY, Ergin Ergani GO. 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Cite Share Download PDF Status: Published Journal Publication published 07 Feb, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 25 Oct, 2024 Reviews received at journal 14 Jul, 2024 Reviews received at journal 05 Jul, 2024 Reviewers agreed at journal 04 Jul, 2024 Reviewers agreed at journal 04 Jul, 2024 Reviewers invited by journal 20 Jun, 2024 Editor assigned by journal 18 Jun, 2024 Editor invited by journal 06 Mar, 2024 Submission checks completed at journal 06 Mar, 2024 First submitted to journal 27 Feb, 2024 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. 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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-3993919","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":276756110,"identity":"95bd6821-9096-4236-817f-3ce5feddb453","order_by":0,"name":"Zhen Cheng","email":"","orcid":"","institution":"Changzhi People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhen","middleName":"","lastName":"Cheng","suffix":""},{"id":276756111,"identity":"4b25d462-5db4-45d3-b09d-a0f96c9a59ce","order_by":1,"name":"Guangzong Ren","email":"","orcid":"","institution":"Changzhi People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Guangzong","middleName":"","lastName":"Ren","suffix":""},{"id":276756112,"identity":"452759bd-7ecc-4c2b-bbed-b76029c5cf59","order_by":2,"name":"Ziyi Li","email":"","orcid":"","institution":"Changzhi People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ziyi","middleName":"","lastName":"Li","suffix":""},{"id":276756113,"identity":"eaa47ef0-505f-411d-8781-59ef9dfa2d5b","order_by":3,"name":"Xianda Gao","email":"","orcid":"","institution":"The Third Hospital of Hebei Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xianda","middleName":"","lastName":"Gao","suffix":""},{"id":276756114,"identity":"87eb323e-7b4f-4872-87a3-25937c68217d","order_by":4,"name":"Di Zhang","email":"","orcid":"","institution":"The Third Hospital of Hebei Medical University","correspondingAuthor":false,"prefix":"","firstName":"Di","middleName":"","lastName":"Zhang","suffix":""},{"id":276756115,"identity":"eddc51d5-033c-4505-ab9f-787753bf5116","order_by":5,"name":"Guiyue Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYDACCSjNz9588MEHAxs74rVI9hxLNpxRkJZMvBaDGT5qwjwfDjE2ENLBP7v52MOvbXb2BhI8bMw2BgeYGdgPH92A15I7x9KNZduSmc2le489zjG4w8fAk5Z2A58WA4kcM2nJtgNslnPOpRvnGDxjZpDgMSOgJf8bSAuPwQ2gXguDw4wNhLXksEl+bDsgAdbCQIwWiRtpQJXnkg3AgdxjkJbMRsgv/DOSn0n+KLOzB0fljz82dvzsh4/h1QICzLxsSDw2nOqQAOOPP8QoGwWjYBSMghELAGMhSVIXHklRAAAAAElFTkSuQmCC","orcid":"","institution":"Changzhi People’s Hospital","correspondingAuthor":true,"prefix":"","firstName":"Guiyue","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-02-27 12:47:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3993919/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3993919/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-024-08153-y","type":"published","date":"2025-02-07T15:57:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":52298832,"identity":"ec2c2a48-1bbb-4842-930e-b683a0689aa1","added_by":"auto","created_at":"2024-03-08 18:21:48","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":502535,"visible":true,"origin":"","legend":"\u003cp\u003eDiscontinuous bone cement: there was a visible gap between two pieces of bone cement\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3993919/v1/c0af57862371d2f1f7115934.jpeg"},{"id":52298231,"identity":"497ca882-54a8-448a-a49b-ed1125be6e22","added_by":"auto","created_at":"2024-03-08 18:13:48","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":609542,"visible":true,"origin":"","legend":"\u003cp\u003eContinuous bone cement: there was no gap between two pieces of bone cement.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3993919/v1/ba6f12bcc1352a2ea9b0a329.jpeg"},{"id":52298233,"identity":"a3daa69a-df5b-4f74-947f-e386c962b681","added_by":"auto","created_at":"2024-03-08 18:13:48","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":150710,"visible":true,"origin":"","legend":"\u003cp\u003eThe receiver operating characteristic curve of volume of bone cement\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3993919/v1/cafdf53d94ca5474a68b3518.jpeg"},{"id":75930461,"identity":"04a8a4bf-1fb8-418f-af12-ad79ceabd1ab","added_by":"auto","created_at":"2025-02-10 16:12:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2067347,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3993919/v1/3ebe46fb-4164-4027-b921-ad337f33a13f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Continuity and Volume of Bone Cement and Anti Osteoporosis Treatment were Guarantee of Good Clinical Outcomes for Percutaneous Vertebroplasty: a Multicentre Study","fulltext":[{"header":"Background","content":"\u003cp\u003eAs a public health problem, increasing attention was paid to osteoporosis with the arrival of an aging society. Vertebral compression fractures (VCF) was the most prevalent fragility fracture because of osteoporosis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Conservative treatment consisted of prolonged bed rest, back brace immobilization and medication, which increased the risk of kyphosis, nonunion and death [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Percutaneous vertebroplasty (PVP) had unique advantages in treatment of VCF and greatly reduced the complications of conservative treatment especially for elderly patients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDuring PVP, bone cement was injected into vertebral body through a small incision (approximately 1cm) and a special tubular channel. Injected bone cement stabled the fractured vertebral body and reduced the immediate pain [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. PVP showed satisfactory clinical outcomes and was widely used, however, there were still part patients suffering from residual or unrelieved pain after the surgery [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Previous studies discussed the possible factors related to poor outcomes, however no consensus was gained. In our study, we divided patients in different groups according to the degree of pain relief and identified the risk factors of residual pain. The purpose of our study was to seek for those associated factors with good clinical outcomes after PVP and provide evidence for improving surgical efficacy.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e186 patients who underwent PVP from January 2021 to January 2023 at The Third Hospital of Hebei Medical University and Changzhi People's Hospital in China were reviewed retrospectively in the study. The inclusion criteria included: 1) diagnosed as VCF before surgery according to imaging data; 2) bone mineral density (BMD) equal to or less than \u0026minus;\u0026thinsp;2.5; 3) without neurological symptoms; 4) single segment surgery with bilateral approach; 5) minimum 1-year follow-up visit. The exclusion criteria included: The exclusion criteria included: 1) spinal tumors, inflammation or other diseases; 2) combined with other fragility fractures; 3) new-onset VCF from postoperative to follow-up visit; 4) uncompleted data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eVisual Analogue Scale (VAS) score (range from 0 to 10) was used to assess preoperative and last follow-up pain. The recovery rate was calculated as: (Preoperative VAS - postoperative VAS)/ Preoperative VAS*100%. The patients with last follow-up recovery rate greater than the average were divided into Group Good Clinical Outcomes (Group GCO), while other patients with last follow-up recovery rate less than the average were divided into Group Poor Clinical Outcomes (Group PCO).\u003c/p\u003e \u003cp\u003ePreoperative general data including age, gender, body mass index (BMI), bone mineral density (BMD), smoking, drinking, history of trauma or symptoms, followed up period, local kyphosis Cobb angle, lumbar lordosis (LL) and thoracic kyphosis (TK) was recorded for further statistical analysis. BMD was detected by using dual energy X-ray absorptiometry (DEXA). If there was an explicit history of trauma, the time of history was recorded from the onset of the trauma to the surgical day, and if not, the time of history was recorded from onset of the symptoms to the surgical day. local kyphosis Cobb angle was defined as the angle between the upper endplate of the upper vertebral body of the compressed vertebra and the lower endplate of the lower vertebral body of the compressed vertebra. LL was defined as the angle between the upper endplate of L1 vertebral body and the lower endplate of L5 vertebral body. TK was defined as angle between the upper endplate of T4 vertebral body and the lower endplate of T12 vertebral body. The measurement data including local kyphosis Cobb angle, LL and TK was measured three times and the average value was used for statistical testing.\u003c/p\u003e \u003cp\u003eSurgical data including surgical segment, surgical time, volume of bone cement, fluoroscopy frequency, standardized treatment for osteoporosis and continuity of bone cement was recorded for further statistical analysis. All surgeries were performed with the assistance of a G-arm fluoroscopy instrument. During the surgery, each posterior-anterior or lateral X-ray was counted as one time of fluoroscopy frequency, in other words, simultaneous posterior-anterior and lateral X-ray was count as two times of fluoroscopy frequency. Continuous bone cement (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) was defined as there was no gap between two pieces of bone cement according to postoperative posterior-anterior X-ray, while discontinuous bone cement (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) was defined as there was a visible gap between two pieces of bone cement.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eSPSS program (version 27.0; SPSS Inc., Chicago, IL, USA) was used for statistical analysis. P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Quantitative data between Group GCO and Group PCO was tested by Student's t-test or Mann\u0026ndash;Whitney U-test according to data distribution. Qualitative date was tested by Chi-square test. Associated factors of good clinical outcomes were identified by multivariate logistic regression analysis with adjusted odds ratios (ORs), 95% confidence intervals (CIs) and P-values. The potential factors were first screened by univariate analysis and the factor with p\u0026thinsp;\u0026lt;\u0026thinsp;0.10 was selected into the multivariate logistic model. Youden index was calculated as sensitivity\u0026thinsp;+\u0026thinsp;specificity-1, and the maximum Youden index represented the cutoff value.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e1) General data of total patients\u003c/h2\u003e \u003cp\u003eNo serious complications were found in 186 patients after PVP. Total 186 patients included 24 males and 162 females and the average age was 70.74\u0026thinsp;\u0026plusmn;\u0026thinsp;7.87. There were 40 patients underwent T7-10 PVP, 95 patients underwent T11-L2 PVP and 51 patients underwent L3-5 PVP with average follow-up visit 17.40\u0026thinsp;\u0026plusmn;\u0026thinsp;7.62 months. BMD of all patients was equal or less than \u0026minus;\u0026thinsp;2.5 and the average value was \u0026minus;\u0026thinsp;3.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46. History of trauma was found in 139 patients (74.73%) and the average day of History of trauma or symptoms was 14.88\u0026thinsp;\u0026plusmn;\u0026thinsp;13.84. The imaging measurement data, including local kyphosis Cobb angle, LL and TK, was 10.15\u0026thinsp;\u0026plusmn;\u0026thinsp;6.80, 25.41\u0026thinsp;\u0026plusmn;\u0026thinsp;10.16 and 41.58\u0026thinsp;\u0026plusmn;\u0026thinsp;12.09, respectively. The average surgical time was 32.31\u0026thinsp;\u0026plusmn;\u0026thinsp;11.53 min, and the average fluoroscopy frequency was 42.27\u0026thinsp;\u0026plusmn;\u0026thinsp;13.50 times. The average volume of injected bone cement was 5.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.46 ml. Continuous bone cement was found in 117 patients (62.90%). There were 126 patients received standardized anti-osteoporosis treatment (67.74%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2) Comparison of patient characteristics between Group PCO and Group GCO\u003c/h2\u003e \u003cp\u003eThe preoperative VAS score of total 186 patients was 7.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26 and the score decreased to last follow-up 2.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.22 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The average recovery rate was 71.92%\u0026plusmn;15.16%. There were 97 patients divided into Group GCO whose recovery rate greater than the average and other 89 patients was divided into Group PCO with recovery rate less than the average. There was no statistical difference in preoperative VAS score (p\u0026thinsp;=\u0026thinsp;0.417) between Group PCO (7.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32) and Group GCO (7.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20). In both group, VAS score was significantly decreased after PVP (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However last follow-up VAS score (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and recovery rate (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in Group GCO (1.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68, 83.06%\u0026plusmn;7.69%) was significant greater than that in Group PCO (3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02, 59.77%\u0026plusmn;11.52%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Comparison of other patient characteristics between two groups was showed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and no statistical difference was found.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of patient characteristics between Group PCO and Group GCO\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup PCO (n\u0026thinsp;=\u0026thinsp;89)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup GCO (n\u0026thinsp;=\u0026thinsp;97)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et/z/χ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.09\u0026thinsp;\u0026plusmn;\u0026thinsp;7.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.43\u0026thinsp;\u0026plusmn;\u0026thinsp;7.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.519\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.241\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.271\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody Mass Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.60\u0026thinsp;\u0026plusmn;\u0026thinsp;4.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.85\u0026thinsp;\u0026plusmn;\u0026thinsp;5.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.549\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.121\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone Mineral Density\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-3.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-3.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.177\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.819\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.365\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrinking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.413\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of trauma or symptoms (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.31\u0026thinsp;\u0026plusmn;\u0026thinsp;14.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.48\u0026thinsp;\u0026plusmn;\u0026thinsp;13.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.701\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollowed up period (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.87\u0026thinsp;\u0026plusmn;\u0026thinsp;7.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.88\u0026thinsp;\u0026plusmn;\u0026thinsp;7.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.788\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.431\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal kyphosis Cobb angle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.51\u0026thinsp;\u0026plusmn;\u0026thinsp;6.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.81\u0026thinsp;\u0026plusmn;\u0026thinsp;6.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.751\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar lordosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.81\u0026thinsp;\u0026plusmn;\u0026thinsp;10.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.97\u0026thinsp;\u0026plusmn;\u0026thinsp;9.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.276\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic kyphosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.56\u0026thinsp;\u0026plusmn;\u0026thinsp;12.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.68\u0026thinsp;\u0026plusmn;\u0026thinsp;11.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.986\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.324\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.812\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.417\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecovery rate (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.77\u0026thinsp;\u0026plusmn;\u0026thinsp;11.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.06\u0026thinsp;\u0026plusmn;\u0026thinsp;7.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.807\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e*\u003c/sup\u003eSignificantly different from preoperative\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3) Comparison of surgical data between Group PCO and Group GCO\u003c/h2\u003e \u003cp\u003eComparison of surgical data between Group PCO and Group GCO was showed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. No statistical difference was found in surgical segment (p\u0026thinsp;=\u0026thinsp;0.118), surgical time (p\u0026thinsp;=\u0026thinsp;0.246) and fluoroscopy frequency (p\u0026thinsp;=\u0026thinsp;0.180) between two groups. The average volume of bone cement injected into the vertebral body in Group GCO was 5.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.51, which was significantly higher (p\u0026thinsp;=\u0026thinsp;0.012) than that in Group PCO (4.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.34). There were 75 patients in Group GCO accepted standardized treatment for osteoporosis and the treatment ratio was 77.32%, while that ratio decreased to 57.30% in Group PCO (p\u0026thinsp;=\u0026thinsp;0.004). According to the classification method above, bone cement of 70 patients in Group GCO was found continuous on postoperative posterior-anterior X-ray, and the ratio was 70.16%. In Group PCO, bone cement of 47 patients was found continuous and the ratio was only 52.81%. The Bone cement continuity rate was significantly higher in Group GCO than Group PCO (p\u0026thinsp;=\u0026thinsp;0.006).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of surgical data between Group PCO and Group GCO\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup PCO (n\u0026thinsp;=\u0026thinsp;89)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup GCO (n\u0026thinsp;=\u0026thinsp;97)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et/z/χ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical segment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.118\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT7-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT11-L2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL3-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.40\u0026thinsp;\u0026plusmn;\u0026thinsp;11.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.14\u0026thinsp;\u0026plusmn;\u0026thinsp;11.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.246\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVolume of bone cement (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.523\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFluoroscopy frequency (times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.80\u0026thinsp;\u0026plusmn;\u0026thinsp;12.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.63\u0026thinsp;\u0026plusmn;\u0026thinsp;14.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.180\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStandardized treatment for osteoporosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.510\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContinuity of bone cement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.452\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3) Logistic regression analysis and receiver operating characteristic (ROC) curve\u003c/h2\u003e \u003cp\u003eLogistic regression analysis was used to identify the associated factors of good clinical outcomes after PVP. First, potential factors were selected by univariate analysis and continuity of bone cement (p\u0026thinsp;=\u0026thinsp;0.007), standardized treatment for osteoporosis (p\u0026thinsp;=\u0026thinsp;0.004) and volume of bone cement (p\u0026thinsp;=\u0026thinsp;0.010) were found statistically significant differences. Multivariate logistic regression showed three factors were closely associated with good clinical outcomes, which were continuity of bone cement (OR\u0026thinsp;=\u0026thinsp;2.237, 95% CI\u0026thinsp;=\u0026thinsp;1.191\u0026ndash;4.201, p\u0026thinsp;=\u0026thinsp;0.012), standardized treatment for osteoporosis (OR\u0026thinsp;=\u0026thinsp;2.105, 95% CI\u0026thinsp;=\u0026thinsp;1.089\u0026ndash;4.068, p\u0026thinsp;=\u0026thinsp;0.027) and volume of bone cement (OR\u0026thinsp;=\u0026thinsp;1.271, 95% CI\u0026thinsp;=\u0026thinsp;1.023\u0026ndash;1.579, p\u0026thinsp;=\u0026thinsp;0.030) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The ROC curve analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) showed moderate accuracy for the association between volume of bone cement and good clinical outcomes (area under the curve: 0.603, P\u0026thinsp;=\u0026thinsp;0.015). The cutoff value of volume of bone cement was 5.5ml.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociated factors of Good clinical outcomes after PVP: multiple logistic regression analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted Odds Radio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% Confidence Interval\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContinuity of bone cement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.191\u0026ndash;4.201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStandardized treatment for osteoporosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.089\u0026ndash;4.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVolume of bone cement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.023\u0026ndash;1.579\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSensitivity, specificity, AUC and cutoff of volume of bone cement\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSensitivity,\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAUC\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCutoff\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVolume of bone cement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e*\u003c/sup\u003e Area under the curve\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOsteoporosis was a worldwide public health issue with around 200\u0026nbsp;million people suffering from the disease [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Approximately 9\u0026nbsp;million fractures were closely associated with osteoporosis annually in the world and VCF was the most prevalent among these fractures [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. VCF was the beginning of a series of fractures which not only reduced quality of life, but also affected the expected lifespan [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The prevalence of vertebral fracture increased with age and the incidence rate increased to 21.9% in women over 70 years old [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. More and more attention was paid to the diagnosis and treatment VCF recent years around the world. Compared with conservative treatment, surgical intervention rapidly released the pain and thus led to more rapid mobilization and reduced the bedridden related complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The injected bone cement filled the fracture gap, enhanced the strength and stability of vertebral body, which achieved immediate analgesia. Advantages, including small incision, minimal bleeding, short surgical time, fewer surgical complications and satisfactory immediate surgical efficacy, made PVP widely used around the world [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, residual pain in part patients became the main reason of poor clinical outcomes and previous studies had tried to seek for the related factors with no consensus [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious studies proposed various different types of bone cement distribution and concluded that the distribution was significantly associated with clinical outcomes [\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The study of Yang et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] showed patients with satisfactory bone cement distribution (bone cement spread from superior to the inferior end plate, from medial cortex of bilateral pedicles, from anterior cortex to posterior third of the vertebral body) complaint less back pain after PVP. Li et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] found confluent cement masses was associated with better clinical outcomes than separated cement masses (isolated and rarely connected to each other), which was similar with the distribution in our study. Mo et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] divide the bone cement distribution into two categories: sufficient group and insufficient group according to whether bone cement diffused in the fracture line and whether vacuum cleft existed. In their study, sufficient obtained better clinical outcomes. Tan et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] found distribution that bone cement contacted both upper and lower endplates led to less postoperative back pain. Xu et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] found if bone cement located on both sides (above and below) of the fracture on postoperative lateral X-ray, patients achieved better clinical outcomes. As a whole, uniformly distributed bone cement was the guarantee of good clinical outcomes after PVP. In our study, continuous bone cement provided uniform force to support fracture line, as a result, fractured vertebrae were more stable, which led to less postoperative back pain.\u003c/p\u003e \u003cp\u003eThe association between bone cement volume and clinical outcomes was still controversial [\u003cspan additionalcitationids=\"CR22 CR23 CR24\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Barriga-Mart\u0026iacute;n et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] found small amounts of injected cement obtained similar clinical results to higher amounts which instead, increased the possibility of cement leak and further complications. The study of Wang et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] showed that injected bone cement volume\u0026thinsp;\u0026gt;\u0026thinsp;4 ml provided good clinical outcomes compared with \u0026lt;\u0026thinsp;4 ml at both postoperative and last-follow visit. Martinčič et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] suggested minimum volume of injected cement was 4\u0026ndash;6 ml, due to stiffness of vertebral body increased as the volume of cement increased until 4\u0026ndash;6 ml. Nieuwenhuijse et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] found that the more residual pain patient complaint of, the less volume of bone cement on the CT scans and they proposed a individualized recommended dosage according to spinal segment, sex, fracture severity. Kim et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] suggested injecting as much cement as possible if no leakage occurred. In our study, the correlation showed between volume of bone cement and clinical outcomes. More volume of bone cement provided more support and stability. For reducing bone cement leak, we suggested to increase the fluoroscopy frequency appropriately during injecting the bone cement, especially when obvious endplate cracks presented.\u003c/p\u003e \u003cp\u003eOur study showed postoperative standardized anti osteoporosis treatment was beneficial for postoperative pain relief. Huang et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] conducted a perspective cohort study that showed the similar results that patients who received postoperative zoledronic acid treatment complaint of less back pain at 12-month follow-up compared with control group. Kong et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] observed that teriparatide treatment after PVP was also benefits to increase BMD and reduce pain. Hu et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] injected Zoledronic Acid intravenously before PVP and found that patients with the combination method had advantages of long-term pain relief, increased bone density and lower risk of refracture. On the other hand, osteoporosis was associated with back pain independently, which significantly reduced the quality of life [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Pharmacological treatment for osteoporosis was effective to improve back pain and among drugs, teriparatide showed better effect and more patient satisfaction [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. To sum up, anti osteoporosis treatment was an essential part for achieving long-term good clinical outcomes after PVP. In our study, there were still 33.26% patients not receiving standardized treatment for osteoporosis due to some reasons. So it is important to strengthen publicity and education on osteoporosis and make more patients benefiting from anti osteoporosis treatment.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First this study was also limited by its retrospective nature. Second, the short follow-up time might lead to biased of results. Third, our study excluded patients with new-onset VCF from postoperative to follow-up visit for more accurate assessment of pain relief after surgery, which might ignore some evaluation data. Therefore, randomized controlled trial with long-term follow-up visit would be performed to verify the results.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePVP effectively released the back pain of patients and was worthy of promotion. However, postoperative residual pain was an important factor that reduced the clinical outcomes. Continuous bone cement, Injected bone cement\u0026thinsp;\u0026gt;\u0026thinsp;5.5ml and tandardized treatment for osteoporosis were guarantee of good clinical outcomes for PVP\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Ethics Board of The Third Hospital of Hebei Medical University and Changzhi People\u0026apos;s Hospital. All participants approved the informed consent of the use of imaging and clinical data. The methods were carried out in accordance with the approved guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated or analyzed during this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have read and contributed to the submitted manuscript and have no conflict of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no funding source.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKutsal FY, Ergin Ergani GO. 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PMID: 25273935; PMCID: PMC4293947.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Treatment Outcome, Bone Cements, Spinal Fractures, Osteoporosis, Multicenter Studies as Topic","lastPublishedDoi":"10.21203/rs.3.rs-3993919/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3993919/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs the most prevalent fragility fracture caused by osteoporosis, increasing attention was paid to vertebral compression fractures (VCF) day by day. Percutaneous vertebroplasty (PVP) had unique advantages in treatment of VCF and was used widely. Researching how to improving surgical efficacy and decreasing postoperative residual was able to benefit more patients. The purpose of our study was to seek for those associated factors with good clinical outcomes after PVP and provide evidence for improving surgical efficacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterial and Methods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e186 patients who underwent PVP from January 2021 to January 2023 were reviewed retrospectively in the study. The patients were divided into two groups according to clinical outcomes. Preoperative general data and surgical data were collected for statistical analysis. Multivariate logistic regression analysis and the receiver operating characteristic curve were used to identify the associated factors with good clinical outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were statistically significant differences between two groups in volume of bone cement (p=0.012), standardized treatment for osteoporosis (p=0.004)and bone cement continuity (p=0.006). The associated factors with good clinical outcomes after PVP were continuous bone cement (OR=2.237, 95% CI=1.191-4.201, p=0.012), standardized treatment for osteoporosis (OR=2.105, 95% CI=1.089-4.068, p=0.027) and volume of bone cement \u0026gt;5.5ml (OR=1.271, 95% CI=1.023-1.579, p=0.030).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePVP effectively released the back pain of patients and was worthy of promotion. However, postoperative residual pain was an important factor that reduced the clinical outcomes. Continuous bone cement, Injected bone cement \u0026gt;5.5ml and tandardized treatment for osteoporosis were guarantee of good clinical outcomes for PVP\u003c/p\u003e","manuscriptTitle":"Continuity and Volume of Bone Cement and Anti Osteoporosis Treatment were Guarantee of Good Clinical Outcomes for Percutaneous Vertebroplasty: a Multicentre Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-08 18:13:43","doi":"10.21203/rs.3.rs-3993919/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-25T05:57:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-14T15:20:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-05T06:07:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330372951927017349603875187465250691646","date":"2024-07-04T14:09:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"182783050253927879101520115474601809479","date":"2024-07-04T10:49:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-20T09:18:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-18T06:21:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-03-06T10:37:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-06T10:29:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-02-27T12:42:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fb2eaa8a-ead5-4f91-b072-e6c3965d7871","owner":[],"postedDate":"March 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-10T16:03:24+00:00","versionOfRecord":{"articleIdentity":"rs-3993919","link":"https://doi.org/10.1186/s12891-024-08153-y","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2025-02-07 15:57:52","publishedOnDateReadable":"February 7th, 2025"},"versionCreatedAt":"2024-03-08 18:13:43","video":"","vorDoi":"10.1186/s12891-024-08153-y","vorDoiUrl":"https://doi.org/10.1186/s12891-024-08153-y","workflowStages":[]},"version":"v1","identity":"rs-3993919","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3993919","identity":"rs-3993919","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}