Two different unilateral percutaneous vertebroplasty approaches for acute osteoporotic vertebral compression fractures: clinical and radiological outcomes

Two different unilateral percutaneous vertebroplasty approaches for acute osteoporotic vertebral compression fractures: clinical and radiological outcomes | 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 Two different unilateral percutaneous vertebroplasty approaches for acute osteoporotic vertebral compression fractures: clinical and radiological outcomes Anquan Huang, Haijun Liu, Yubo Liu, Jun Shen, Guoqing Zhu, Yefeng Wang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5663390/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Jul, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 6 You are reading this latest preprint version Abstract Objective To investigate whether the unilateral posterosuperior approach PVP is superior to the traditional unilateral transpedicular approach in the treatment of acute osteoporotic vertebral compression fractures (OVCFs). Methods A retrospective study was conducted on 167 patients with single-segment acute OVCFs admitted to our hospital from September 2019 to March 2022. Patients were divided into two groups according to the type of intraoperative approach used: the unipedicular posterosuperior approach vertebroplasty (UPV) group (n = 85) and the unilateral transpedicular approach vertebroplasty (UTV) group (n = 82). Surgical data, including operation time, blood loss, fluoroscopy frequency, puncture needle crossing the midline during surgery, and bone cement injection volume, were collected. Imaging data, such as vertebral height, distribution of bone cement, and cement leakage, were analyzed. Clinical efficacy indicators, including the Visual analogue scale (VAS) score and Oswestry Disability Index (ODI), were compared. Additionally, the occurrence of vertebral refracture, adjacent vertebral fracture, and postoperative complications was assessed. Results Both groups were followed up for an average of 13.6 months (range: 12–24 months). No statistically significant differences were detected between the UPV and UTV groups in terms of the VAS and ODI scores or the vertebral height. The two groups had similar blood loss rates, fluoroscopy frequencies, and operation times. However, the UPV group presented a greater volume of bone cement injected and a better dispersion pattern of bone cement (10.75 ± 0.48 vs 7.56 ± 1.86) (P < 0.05). The occurrence of vertebral collapse after surgery was positively correlated with the distribution of bone cement. Cement leakage was observed in 5 patients in the UPV group and 10 patients in the UTV group. The UPV group had 2 cases of adjacent vertebral refracture within six months, whereas the UTV group had 5 cases. One adverse event, pneumothorax, occurred in the UPV group. Conclusions PVP via the unilateral approach effectively relieves back pain in patients with OVCFs. The unilateral posterosuperior approach allows for the injection of a greater volume of bone cement, resulting in a more even distribution within the vertebral body. However, caution should be exercised to avoid excessive lateral puncture points. Percutaneous vertebroplasty Unilateral Osteoporotic vertebral compression fractures Distribution of bone cement Approach Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction OVCFs represent a significant pathological condition that profoundly impacts the well-being of elderly individuals. These fractures commonly arise from low-energy trauma and are accompanied by a constellation of symptoms, including back pain and spinal kyphosis. The incidence of OVCFs is alarmingly high, with a lifetime risk between 40% and 50% in women and between 13% and 22% in men with a history of osteoporosis[ 1 ]. Considering the remarkable progress in minimally invasive spinal surgery, PVP has been widely used to treat painful OVCFs[ 2 , 3 ]. This innovative technique effectively mitigates patient discomfort, expeditiously restores partial vertebral height and spinal functionality, and confers notable advantages, such as minimal invasiveness, reduced hospitalization duration, shorter operative procedures, and accelerated convalescence[ 4 ]. To minimize the risk of nerve root or dura mater damage, surgeons prefer the percutaneous approach through the pedicle for thoracolumbar vertebral body surgery. While cement injection via the bilateral transpedicular approach can achieve good cement filling, it has drawbacks such as a long operation time, patient discomfort during bilateral local anesthesia, and a high incidence of cement leakage[ 5 ]. Reports[ 6 , 7 ] indicate that both the unilateral and bilateral approaches can achieve satisfactory clinical and radiological outcomes. Although the unilateral approach is not the most frequently adopted approach currently, its merits like shorter operation time and reduced cement leakage still render it a favored alternative for some surgeons. However, the traditional unilateral transpedicular approach has limitations. It is constrained by the pedicle, making it difficult to adjust the puncture needle's direction and reach the center of the vertebral body. This results in uneven cement distribution within the affected vertebra, which can lead to long-term follow-up issues such as recurrent vertebral fractures[ 8 ], inadequate pain relief[ 9 ], and spinal side curvature. Therefore, the application of the unilateral transpedicular approach is somewhat limited[ 6 ]. Studies[ 8 , 10 ] have identified uneven cement distribution within the fractured vertebra as a key factor for residual back pain after PVP. Additionally, a lower amount of cement injection in unilateral vertebral augmentation is a risk factor for adjacent vertebral fractures[ 8 , 11 , 12 ]. Thus, further exploration is necessary to better apply the unilateral approach technique in clinical practice. To address these issues, our previous research[ 13 ] demonstrated that the unilateral posterosuperior approach through the vertebral body circumvents the limitations posed by the pedicle, thereby enabling enhanced mobility of the surrounding soft tissues. This precise adjustment can lead to more accurate placement within the central region of the vertebral body or the site of fracture, potentially resulting in better cement distribution. In contrast, the unilateral transpedicular approach is restricted by the pedicle, making it challenging to achieve such accurate needle placement and optimal cement distribution. Recently, we conducted a comparative analysis of the biomechanical properties associated with various approaches for vertebral augmentation, revealing that the unilateral posterosuperior approach is superior to the unilateral transpedicular approach and comparable to the bilateral transpedicular approach in terms of biomechanical stability[ 14 ]. Furthermore, the study also revealed that the distribution of bone cement in the unilateral posterosuperior approach was more uniform than that in the unilateral transpedicular approach. Nonetheless, the lack of adequate clinical data hinders the definitive confirmation of the superiority of the unilateral posterosuperior approach over the conventional unilateral transpedicular approach. In this study, we hypothesize that the UPV will offer superior outcomes in terms of clinical efficacy, including better pain relief, more stable vertebral structure, and fewer long-term complications, compared to the UTV. Our primary objective is to retrospectively evaluate the clinical efficacy of these two PVP surgical approaches for managing osteoporotic thoracolumbar compression fractures at our hospital, with a particular focus on further assessing their safety. This hypothesis will guide our research as we analyze the data and draw conclusions about the relative merits of the UPV and UTV approaches. Methods Patient characteristics We conducted a retrospective analysis of 167 patients with osteoporotic thoracolumbar compression fractures who underwent PVP via two different unilateral approach techniques at the Affiliated Suzhou Hospital of Nanjing Medical University between September 2019 and March 2022 (Fig. 1). This study protocol was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Suzhou Municipal Hospital (KL901131), and written informed consent was obtained from all patients. All patients had recently sustained single-segment thoracolumbar vertebral fractures, with intact bilateral pedicles, posterior walls, and columns. The inclusion criteria were as follows: age over 60 years, T score less than − 2.5 on a dual energy X-ray absorptiometry scan, and vertebral height loss less than 20% on lateral spine radiograph. Patients with multi-segmental spinal fractures, burst fractures, fractures with spinal cord injury, non-OVCFs, conservative treatment, or severe organ dysfunction were excluded from the study. The final cohort consisted of 85 patients in the UPV group, including 21 males and 64 females, with an age range of 60–91 years and an average age of 74.71 years. The injured vertebral levels were as follows: T5–10 (20 cases), T11–L2 (48 cases), and L3–5 (17 cases). The UTV group included 82 patients, with 18 males and 64 females, an age range of 60–95 years, and an average age of 76.89 years. The injured vertebral levels were as follows: T5–10 (18 cases), T11–L2 (45 cases), and L3–5 (19 cases). The two groups were comparable in terms of age, sex distribution, BMI, BMD, time of injury, and underlying conditions, with no statistically significant differences (P > 0.05) (Table 1 ). Surgical procedures and postoperative management A doctor in the inpatient department picked out one of two different pieces of paper indicating one of two different puncture protocols after the patient had granted consent. Each type of puncture was performed by one senior spine surgeon at Suzhou Municipal Hospital. All patients who underwent PVP were administered local anesthesia (with lidocaine) and closely monitored throughout the procedure. The patients were placed in the prone position. Dual C-arm fluoroscopy was employed to locate the injured vertebra accurately and mark the projection of the posterior surface of the pedicle. In the anteroposterior view, the bilateral pedicle shadows were aligned equidistantly with the spinous process shadow, whereas the endplate appeared as a linear shadow in the lateral view. A reduction technique was subsequently employed to restore the vertebral height as much as possible. Standard disinfection and draping procedures were performed. For the posterosuperior approach through the vertebral body, the puncture point was determined to be 5–7 cm above the outer surface projection of the pedicle, forming an angle of 20–30° with the sagittal plane and an angle of 40–45° with the horizontal plane. The introducer needle was then advanced to the posterosuperior aspect of the vertebral body, following the diagonal line observed on the lateral radiograph of the affected vertebra. The position of the needle tip was confirmed to have reached the anterior one-third of the vertebral body on the lateral radiograph, whereas anteroposterior fluoroscopy confirmed that the puncture needle exceeded the midline of the spinous process. The inner needle core was subsequently removed, and contrast agent was injected to detect any potential leakage. Bone cement was prepared, and the working channel was connected. Under fluoroscopic guidance, the bone cement was meticulously injected into the injured vertebra. The dispersion of the bone cement was carefully observed on both anteroposterior and lateral radiographs. The injection was ceased once the bone cement was adequately filled or reached proximity to the posterior wall of the vertebral body. Prior to the solidification of the bone cement, the cannula was rotated and removed. Throughout the procedure, the patient's sensory and motor function of the lower limbs was continuously monitored. The unilateral transpedicular approach involved inserting the needle at the outer upper edge of the pedicle, at 9–11:00 for the left side and at 1–3:00 for the right side, at an angle of 15–20° with respect to the sagittal plane. The puncture cannula was guided to the inner border of the pedicle from the anterior-posterior view and to the posterior wall of the vertebral body from the lateral view, ensuring safe passage of the needle through the pedicle and into the vertebral body. The cannula was then advanced to the anterior one-third of the vertebral body on the lateral radiograph, and the puncture needle was positioned as close as possible to the midline of the spinous process on anteroposterior fluoroscopy. On the first postoperative day, all patients underwent X-ray and computed tomography (CT) examinations to assess the distribution of the bone cement and detect any potential cement leakage. Patients who did not experience discomfort were allowed to ambulate with waist protection. Additionally, all patients received systemic osteoporosis treatment, including zoledronic acid, calcium supplements, and vitamin D. Observation indicators and efficacy assessment (1) Surgical time, blood loss, number of fluoroscopy procedures, midline position of the puncture needle, and amount of bone cement injected were recorded in both groups. (2) Preoperative and postoperative VAS scores (1-day, 1-month, 3-month, 6-month, and 12-month) and ODI values were recorded in both groups to assess the clinical analgesic effect and functional recovery. (3) Postoperative X-rays and CT scans were used to evaluate the vertebral height, distribution of bone cement, cement leakage, and vertebral collapse in both groups. (4) The incidence of refracturing of the affected vertebra or adjacent vertebral fractures during the follow-up period was recorded. (5) Complications such as vascular, neural, and spinal cord injuries, as well as cement embolism, were documented. The distribution of bone cement was scored based on imaging data, with a total of 12 points. The vertebral body was divided into four quadrants on the anterior-posterior and lateral views. If the bone cement filled more than half of each quadrant, 1 point was assigned, resulting in a total of 8 points. Additionally, on the lateral radiograph, the contact between the bone cement and the upper and lower endplates of the vertebral body was observed, with 1 point assigned for each contact, totaling 2 points. Finally, the alignment of the bone cement with the midline of the vertebral body on the anterior-posterior and lateral views was assessed, with 1 point assigned for each alignment, totaling 2 points. All radiological parameters were measured individually and independently by radiologists and spinal surgeons to eliminate bias within and between observers. Statistical analysis The data was processed via SPSS 19.0 statistical software. Continuous variables were assessed for normality, and normally distributed data are presented as the means ± standard deviations (means ± SDss). Within-group comparisons were performed via t tests, whereas between-group comparisons were conducted via analysis of variance (ANOVA). Categorical variables are presented as frequencies and were analyzed via the chi-square test. Paired sample t tests and independent t tests were used to evaluate the differences between groups and between groups for preoperative and postoperative VAS and ODI data. A significance level of P < 0.05 was considered statistically significant. Results Baseline characteristics of the patients Surgeries were successful in both groups of patients. The two groups exhibited similar baseline characteristics, including age, sex ratio, BMI, BMD, time of injury, and underlying diseases, with no statistically significant differences (P > 0.05), indicating comparability (Table 1 ). Table 1 Baseline characteristics of the patients. Characteristic UPV Group (n = 85) UTV Group (n = 82) Statistics P value Age (years) 74.71 ± 8.47 76.89 ± 8.95 t = 1.62 0.107 Gender (male/female, number) 21/64 18/64 χ 2 = 0.177 0.674 BMI (kg/m 2 ) 23.05 ± 2.40 23.32 ± 2.83 t = 0.677 0.499 BMD (T score) -3.05 ± 0.45 -2.94 ± 0.31 t = 1.903 0.059 Course of disease (days) 5.56 ± 4.08 5.13 ± 3.52 t = 0.729 0.467 Underlying disease χ 2 = 0.395 0.821 Diabetes 31 (36.5%) 25 (30.5%) Hypertension 35 (41.2%) 32 (39%) Hyperlipidemia 15 (17.6%) 16(19.5%) Fracture segment χ 2 = 0.259 0.878 Thoracic (T5-T10) 20 (23.5%) 18(21.9%) Thoracolumbar (T11-L2) 48 (56.5%) 45(54.9%) Lumbar (L3-L5) 17 (20%) 19(23.2%) The data are presented as the means ± standard deviations. BMI, body mass index; BMD, bone mineral density. Surgical outcomes There were no statistically significant differences (P > 0.05) in terms of surgical duration, intraoperative blood loss, or X-ray exposure between the two cohorts (Table 2 ). The UPV group exhibited a 100% rate of midline puncture through the vertebral body, whereas the other group achieved only 26.8% midline puncture, with 73.2% failing to reach the midline, thus demonstrating a statistically significant difference (P < 0.05) (Table 2 ). In the UPV group, a greater volume of bone cement was injected into the thoracolumbar spine. Intraoperative fluoroscopy revealed satisfactory distribution of the cement in the UPV group, with no observed increase in cement leakage. Table 2 Comparison of the operation time, blood loss, X-ray perspective time, time of puncture to the center of the vertebra and bone cement dosage between the two groups Factors UPV Group (n = 85) UTV Group (n = 82) Statistics P value Operation time (min) 40.71 ± 5.12 42.13 ± 5.34 t = 1.754 0.081 Blood loss (mL) 6.86 ± 2.51 7.65 ± 3.21 t = 1.775 0.078 X-ray perspective times 16.58 ± 3.34 17.29 ± 3.94 t = 1.258 0.210 Puncture to the center of vertebra 85 (100%) 22 (26.8%) χ 2 = 97.071 0.000 Bone cement volume (mL) Thoracic (T5-T10) 4.42 ± 0.85 3.45 ± 0.73 t = 3.753 0.001 Thoracolumbar (T11-L2) 5.63 ± 1.06 4.54 ± 1.48 t = 4.103 0.000 Lumbar (L3-L5) 6.31 ± 1.25 4.70 ± 0.85 t = 4.561 0.000 Clinical indicators VAS scores were significantly lower than baseline scores in both cohorts, but no significant differences were detected between the groups at any of the measured time points (one day, three months, six months, or twelve months) (Fig. 2 A and Table 3 ). Similarly, both cohorts demonstrated comparable improvements in the ODI throughout the one-year follow-up period (Fig. 2 B and Table 3 ). There were no statistically significant differences (P > 0.05) in the preoperative VAS or ODI scores between the two cohorts. Table 3 Comparison of the VAS and ODI scores between the two groups at each time point Time VAS scores ODI scores UPV Group (n = 85) UTV Group (n = 82) T value P value UPV Group (n = 85) UTV Group (n = 82) T value P value preop 7.68 ± 0.74 7.56 ± 0.85 0.974 0.332 70.26 ± 10.57 68.16 ± 12.82 1.157 0.249 1 day 2.83 ± 0.57 3.06 ± 0.92 1.949 0.053 32.62 ± 8.35 34.68 ± 10.35 1.418 0.158 3 months 2.15 ± 0.72 2.54 ± 0.75 1.845 0.067 24.56 ± 5.23 25.73 ± 8.23 1.101 0.273 6 months 1.24 ± 0.52 1.38 ± 0.58 1.644 0.102 22.55 ± 5.64 23.51 ± 4.86 1.177 0.241 12 months 1.45 ± 0.59 1.62 ± 0.62 1.816 0.071 23.19 ± 4.32 24.65 ± 5.78 1.841 0.068 UPV, unipedicular posterosuperior approach vertebroplasty; UTV, unilateral transpedicular approach vertebroplasty; VAS, visual analog scale; ODI, Oswestry Disability Index. Radiological results There were no statistically significant differences (P > 0.05) in the anterior vertebral height between the two groups. The data indicated that the postoperative anterior vertebral height was slightly greater than the preoperative height in both groups, but the difference was not statistically significant (P < 0.05), and there was no significant difference between the groups. The incidence of vertebral collapse was 3.5% in the UPV group and 13.4% in the UTV group, indicating a significantly lower rate of vertebral collapse in the UPV group (P < 0.05). Among the 14 cases of recurrent collapse, the bone cement did not fully contact the upper and/or lower endplates. The analysis of the distribution of bone cement after surgery revealed that the UPV group presented a more favorable distribution than the UTV group did, with a statistically significant difference (P < 0.05), as presented in Table 4 (Figs. 3 and 4, representative cases). Intraoperative and postoperative X-rays revealed bone cement leakage in 5 patients (5.88%) in the UPV group, including 2 patients with disc leakage, 1 patient with vascular leakage, and 1 patient with lateral leakage. In the UTV group, there were 10 cases (12.2%) of bone cement leakage, including 4 cases of leakage into adjacent discs and lateral leakage and 2 cases of posterior leakage. Notably, no significant neurological compression symptoms were observed in either group, and there was no statistically significant difference in the incidence of bone cement leakage (P > 0.05). Table 4 Comparison of pain and functional efficacy between the two groups Factors UPV Group (n = 85) UTV group (n = 82) Statistics P value Preoperative vertebral height (mm) Thoracic (T5-T10) 21.23 ± 2.49 20.63 ± 3.45 t = 0.619 0.540 Thoracolumbar (T11-L2) 26.79 ± 3.15 26.15 ± 3.42 t = 1.069 0.288 Lumbar (L3-L5) 30.37 ± 2.25 30.68 ± 2.57 t = 0.383 0.704 Postoperative vertebral height (mm) Thoracic (T5-T10) 22.25 ± 2.85 22.68 ± 2.92 t = 0.427 0.672 Thoracolumbar (T11-L2) 28.34 ± 3.26 27.15 ± 3.25 t = 1.758 0.082 Lumbar (L3-L5) 30.92 ± 2.68 31.18 ± 2.72 t = 0.288 0.775 Bone cement distribution (the 12-score method) 10.75 ± 0.48 7.56 ± 1.86 t = 15.294 0.000 Vertebral body refracture (%) 0 2 (2.44%) χ 2 = 2.098 0.148 Adjacent vertebral fracture (%) 2 (2.35%) 5 (6.1%) χ 2 = 1.457 0.227 Bone cement leakage (%) 5 (5.88%) 10 (12.2%) χ 2 = 2.034 0.154 UPV, unipedicular posterosuperior approach vertebroplasty; UTV, unilateral transpedicular approach vertebroplasty. Complications During the one-year follow-up, no instances of pulmonary embolism or spinal cord injury were observed. In the UPV group, one patient experienced thoracic vertebral fracture, presenting with chest tightness on the first day postsurgery. Chest CT revealed pneumothorax, which resolved following treatment with closed thoracic drainage. The UPV group experienced two cases of adjacent vertebral fractures, whereas the UTV group experienced five cases of adjacent vertebral fractures and two cases of recurrent vertebral fractures, with no statistically significant disparities (P > 0.05). Discussion The optimal treatment for acute OVCFs should not only provide rapid and effective pain relief but also achieve vertebral body restoration, angle correction, and maintain vertebral height in the long term. In addition to alleviating patient pain, PVP can improve quality of life and prevent the vicious cycle of worsening osteoporosis due to prolonged bed rest. Previous studies[ 2 , 15 , 16 ] have shown that, compared with conservative treatment, vertebral augmentation significantly reduces patient pain and has a lower incidence of major complications. In this study, all patients were followed up for an average of 13.6 months, and PVP improved their quality of life, providing benefits from the surgery. Traditionally, the bilateral transpedicular approach has been the standard technique for PVP. The unilateral transpedicular approach is favored by many spine surgeons because of its shorter operation time, reduced trauma, decreased X-ray exposure, and better cost-effectiveness. Numerous studies[ 7 , 17 , 18 ] have reported that the unilateral approach for PVP can achieve results comparable to those of the bilateral approach. However, in clinical practice, the distribution of bone cement in the unilateral pedicle approach is not as good as that in the bilateral approach. The aim of this study was to determine whether UPV is superior to UTV in terms of clinical effectiveness. Our study revealed that both groups of patients had significant improvements in VAS and ODI scores compared with preoperative scores (P < 0.05), indicating that the use of the unilateral approach for PVP achieved similar immediate and relatively long-lasting improvements in pain and disability. However, no significant differences were observed between the two groups. The distribution of bone cement plays a crucial role in the success of PVP. Inadequate cement distribution can lead to poor pain relief, progressive vertebral collapse, and kyphotic deformity[ 9 , 19 ]. Previous studies[ 9 , 19 , 20 ] have shown that the position of the puncture needle during PVP can affect the cement distribution. For example, Schupfner et al[ 21 ] reported that the extrapedicular approach resulted in fewer cases of improper needle placement than did the transpedicular approach. To improve cement distribution during the unilateral transpedicular approach, Lv et al[ 9 ] developed a curved puncture device. In this study, we used a 12-point scoring system to evaluate the distribution of bone cement within the vertebral body[ 22 ]. The UPV group demonstrated a significantly improved 12-point cement distribution score compared to the UTV group (10.75 ± 0.48 vs. 7.56 ± 1.86, p < 0.05). This finding underscores the advantages of the UPV technique in achieving optimal cement placement, potentially reducing postoperative complications and enhancing vertebral stability. This difference was attributed to the position of the puncture needle within the vertebral body, with the unipedicular posterosuperior approach allowing for more accurate placement in the center of the vertebral body in all patients, compared with only 26.8% in the other patients. The quantity of cement injected is a critical risk factor for adjacent vertebral fractures. Research has indicated that the unilateral approach can lead to lateral deviation in the distribution of cement within the vertebral body, resulting in an imbalance in stiffness between the two sides of the vertebra[ 9 ]. The stiffness on the nonenhanced side is notably lower than that on the enhanced side, hindering the effective restoration of the biomechanical properties of the injured vertebra. This can contribute to chronic postoperative pain and increase the likelihood of adjacent vertebral fractures or recurrent fractures in the treated vertebra. Insufficient cement injection fails to adequately stabilize the fractured trabeculae, whereas excessive injection increases the risk of cement leakage. Papanastassious et al[ 23 ] proposed an average appropriate cement injection volume of 5.5 mL for the thoracic vertebrae and 7.0 mL for the lumbar vertebrae. In our study, the UPV group exhibited cement injection volumes of 4.42 mL, 5.63 mL, and 6.31 mL for the thoracic, thoracolumbar, and lumbar vertebrae, respectively, whereas the other groups had volumes of 3.45 mL, 4.54 mL, and 4.70 mL, respectively. Our findings revealed a significantly greater volume of cement injected in the UPV group than in the UTV group, which can be attributed to the positioning of the puncture needle within the vertebral body. Thus, while ensuring surgical safety and efficacy, maintaining biomechanical stability and reducing the risk of leakage can be achieved by adjusting the injection volume of cement in the UPV group. Maintaining vertebral height is crucial for ensuring the long-term effectiveness of vertebral augmentation procedures. In this study, both groups showed a slight increase in anterior vertebral height on the first day after surgery, but the difference was not statistically significant. The improvement in radiographic indicators after surgery can be attributed to the preoperative and intraoperative reduction of the vertebral body, with the bone cement dispersing into small fracture fissures to maintain the reduction height. However, increasing the volume of bone cement alone did not significantly improve short-term radiographic indicators, as evidenced by the lack of significant improvement in the Cobb angle and anterior vertebral height during cement injection. During the final follow-up, the UTV group experienced partial loss of vertebral height, whereas the UPV group maintained greater vertebral height. Additionally, the VAS scores and ODI values indicating pain improvement in the UPV group were superior to those in the UTV group, despite the lack of a significant statistical difference between the two groups. The incidence of vertebral collapse was 3.5% in the UPV group and 13.4% in the UTV group. This large difference matters clinically. In the UTV group, more collapses can change spinal biomechanics, causing chronic pain and higher fracture risks. As Li et al[ 24 ] showed, a sponge-like distribution of bone cement helps maintain height, and reduces the risk of vertebral recompression, long-term pain, and functional impairment. Chen et al [ 25 ] reported a vertebral recompression rate of 9.7% in their cohort of 134 patients with OVCFs after percutaneous vertebroplasty, which was associated with persistent lower back pain and limited spinal mobility. Our study provides further evidence supporting the importance of maintaining vertebral height for the long-term effectiveness of vertebral augmentation procedures. Increasing the volume of bone cement is crucial for restoring mechanical balance in the spine, preventing further collapse of the vertebral body, and reducing the risk of refracture[ 26 ]. This can effectively improve patient outcomes in the middle to long term. Asymptomatic complications associated with vertebral augmentation procedures include bone cement leakage, pulmonary embolism, and intervertebral disc space leakage[ 27 ]. In our study, the UPV group presented 5 cases of bone cement leakage and 1 case of pneumothorax, whereas the other group presented 10 cases. For cement leakage, the UPV group had a 5.88% rate and the UTV group 12.2%. Despite no significant statistical difference, the UTV group's higher rate may pose risks like nerve irritation or adjacent fractures. Cement leakage may lead to serious sequelae[ 28 ]. For instance, when cement leaks into the adjacent spinal canal or intervertebral foramen, it can cause neurological dysfunction and paraplegia. Pulmonary embolism may be caused by free cement embolism, resulting in death. These potential complications play a crucial role in determining the surgical approach. Chang et al [ 29 ] reported a significant correlation between bone cement leakage in the PVP and the volume of injection. We hypothesize that the higher leakage rate in the UTV group may be attributed to the pursuit of better dispersion of bone cement during the procedure. In our study, the leakage rate did not significantly increase in the UPV group. This might be attributed to the favorable puncture position. Appropriate injection pressure not only does not increase the risk of leakage but also promotes a more uniform distribution of bone cement. Other symptomatic complications associated with bone cement, such as spinal infection, spinal cord injury, nerve root compression, and pneumothorax, necessitate targeted treatment. One case of pneumothorax was observed in the UPV group. The patient had a BMI of 18 and weak back muscles, which could have been caused by the puncture needle piercing the pleura owing to a slightly larger lateral opening distance during the puncture. Following its detection, the pneumothorax was successfully treated with closed thoracic drainage. Hence, it is important to ensure that the puncture point is not excessively lateral, particularly in thin patients, when performing a UPV puncture. Preoperative measurements of the lateral opening distance and the inward tilt angle of the puncture needle are necessary. Limitations There are multiple limitations to our study. The sample size was relatively small and the follow - up period short, restricting result generalizability. We didn't compare bone cement distribution strength, and factors like fracture morphology and vertebral kyphotic angle, which could have influenced outcomes, were not fully explored. Regarding long-term clinical outcomes, we failed to determine which approach (UPV or UTV) suits specific patient groups such as those with severe osteoporosis, complex vertebral anatomies, or multiple comorbidities due to lack of relevant data. Also, we didn't compare our findings with previous research on cement augmentation durability, missing potential insights on long-term UPV and UTV performance. Moreover, we didn't identify necessary follow-up studies; future research could have longer follow-up (e.g., 5–10 years) with patient-centered outcome measures to better understand long-term impacts and complications of each approach. Conclusions Our study demonstrated that the unilateral PVP approach is an effective treatment for painful OVCFs. The unipedicular posterosuperior approach allows easier access to the optimal injection point within the vertebral body and better distribution of bone cement, resulting in a greater volume of cement injection and better maintenance of the vertebral height. However, caution should be exercised in thin patients to avoid excessive lateral puncture points. Future long-term studies are needed to further evaluate the relative advantages and disadvantages of these approaches. Abbreviations PVP Percutaneous vertebroplasty OVCFs Osteoporotic vertebral compression fractures UPV Unipedicular posterosuperior approach vertebroplasty UTV Unilateral transpedicular approach vertebroplasty ODI Oswestry Disability Index VAS Visual analogue scale CT Computed tomography MRI Magnetic resonance imaging Declarations Acknowledgements Not applicable. Authors' contributions All the authors contributed to the study. TZ designed the research and revised the manuscript. AH and YL collected and analyzed the data and wrote the manuscript. HL carried out the data interpretations and assisted in the data discussion. JS, GZ, YW and BL revised the research with constructive discussions. All the authors read and approved the final manuscript. Funding This study was supported by the Key Disease Diagnosis and Treatment Technology Special Project of Suzhou, China (LCZX2019-10). The funders had no role in the study design, data collection, analysis, interpretation, or in the writing of this manuscript and the decision to submit it for publication. Data availability The datasets generated and/or analysed during the current study are not publicly available for data protection reasons. Data is available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate The portions of this study involving human participants, human materials, or human data were conducted in accordance with the Declaration of Helsinki and were approved by the Ethics Committee of Suzhou Municipal Hospital (KL901131). All patients provided written informed consent, explicitly informed of the study's aim to compare two surgical approaches (UPV and UTV), associated risks/benefits, and data usage for comparative analysis. Consent for publication Not applicable. Competing interests The authors declare no competing interests. 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Unilateral curved versus bipedicular vertebroplasty in the treatment of osteoporotic vertebral compre ssion fractures. BMC Surg. 2019;19(1):193. Cheng Y, Xie X. Therapeutic effects of single versus bilateral approaches for percutaneous kyphoplasty in osteoporotic compression fractures. Asian J Surg. 2024;47(5):2272–3. Dai C, Wang S, Zheng L, Wang K, Yu H, Chen Y. Unilateral and bilateral PVP for thoracolumbar OVCF with distant lumbosacral pain: a single-center retrospective analysis. World Neurosurg 2025:123687. Xiong YC, Guo W, Xu F, Zhang CC, Liang ZP, Wu L, Chen S, Zeng XW. Refracture of the cemented vertebrae after percutaneous vertebroplasty: risk factors and imaging findings. BMC Musculoskelet Disord. 2021;22(1):459. Lv Z, Chen Z, Chen H, Wang J, Han Y, Li X, Shen H, Zhang Y. Percutaneous Curved Vertebroplasty Versus Unipedicular Approach Vertebroplasty for Acute Osteoporotic Vertebral Compression Fractures: A Randomized Controlled Trial. Spine (Phila Pa 1976). 2023;48(8):552–8. Zhou C, Liao Y, Huang S, Li H, Zhu Z, Zheng L, Wang B, Wang Y. Effect of cement distribution type on clinical outcome after percutaneous vertebroplasty for osteoporotic vertebral compression fractures in the aging population. Front Surg. 2022;9:975832. Zhou C, Huang S, Liao Y, Chen H, Zhang Y, Li H, Zhu Z, Wang Y. Correlation analysis of larger side bone cement volume/vertebral body volume ratio with adjacent vertebral compression fractures during vertebroplasty. Front Endocrinol (Lausanne). 2023;14:1072087. Peng B, Zhang Z, Chen J, Zhang J, Wang Z. Correlation Study Between Bone Cement Distribution and Adjacent Vertebral Fractures After Percutaneous Vertebroplasty. World Neurosurg; 2023. Wang YF, Shen J, Li SY, Yu X, Zou TM. Kambin triangle approach in percutaneous vertebroplasty for the treatment of osteoporotic vertebral compression fractures. Med (Baltim). 2019;98(44):e17857. Gu C, Huang A, Wang Y, Liang D, Sun P, Zhang Z, Cai X, Shen J, Ou-Yang J, Zou T, et al. Biomechanics of the unilateral posterosuperior, unipedicular, and bipedicular approaches for treatment by percutaneous vertebroplasty: a comparative study. Am J translational Res. 2022;14(5):3448–55. Cazzato RL, Bellone T, Scardapane M, De Marini P, Autrusseau PA, Auloge P, Garnon J, Jennings JW, Gangi A. Vertebral augmentation reduces the 12-month mortality and morbidity in patients with osteoporotic vertebral compression fractures. Eur Radiol. 2021;31(11):8246–55. Pron G, Hwang M, Smith R, Cheung A, Murphy K. Cost-effectiveness studies of vertebral augmentation for osteoporotic vertebral fractures: a systematic review. Spine J 2022. Wu W, Zhang X, Li X, Yu S. Can the Unipedicular Approach Replace Bipedicular Percutaneous Balloon Kyphoplasty for the Management of Metastatic Vertebral Lesions? Acad Radiol. 2023;30(10):2147–55. Qian Y, Li Y, Shen G, Zhong X, Tang C, He S. Comparison of unipedicular and bipedicular kyphoplasty for treating acute osteoporotic vertebral compression fractures in the lower lumbar spine: a retrospective study. BMC Musculoskelet Disord 2023, 24(1). Zhou Q, Wan Y, Ma L, Dong L, Yuan W. Percutaneous Curved Vertebroplasty Decrease the Risk of Cemented Vertebra Refracture Compared with Bilateral Percutaneous Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fractures. Clin Interv Aging. 2024;19:289–301. Hu X, Zhang Z, Yang Y, Zhang G, Cao S, Yu B, Zhang Y. Enhanced bone cement distribution in percutaneous vertebroplasty using a curved guide wire: a propensity score matching analysis. BMC Musculoskelet Disord. 2024;25(1):835. Schupfner R, Koniarikova K, Pfeifer C, Grechenig P, Bakota B, Staresinic M, Kerner MA, M¨¹ller M. An anatomical study of transpedicular vs. extrapedicular approach for kyphoplasty and vertebroplasty in the thoracic spine. Injury. 2021;52(Suppl 5):S63–9. Liu J, Tang J, Liu H, Gu Z, Zhang Y, Yu S. A novel and convenient method to evaluate bone cement distribution following percutaneous vertebral augmentation. Sci Rep. 2020;10(1):16320. Papanastassiou ID, Filis A, Gerochristou MA, Vrionis FD. Controversial issues in kyphoplasty and vertebroplasty in osteoporotic vertebral fractures. Biomed Res Int. 2014;2014:934206. Li Q, Long X, Wang Y, Guan T, Fang X, Guo D, Lv J, Hu X, Jiang X, Cai L. Clinical observation of two bone cement distribution modes after percutaneous vertebroplasty for oste oporotic vertebral compression fractures. BMC Musculoskelet Disord. 2021;22(1):577. Chen YJ, Chen WH, Chen HT, Hsu HC. Repeat needle insertion in vertebroplasty to prevent re-collapse of the treated vertebrae. Eur J Radiol. 2012;81(3):558–61. Tang B, Cui L, Chen X, Liu Y. Risk Factors for Cement Leakage in Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fractures: An Analysis of 1456 Vertebrae Augmented by Low-Viscosity Bone Cement. Spine (Phila Pa 1976). 2021;46(4):216–22. Kim HJ, Zuckerman SL, Cerpa M, Yeom JS, Lehman RA Jr., Lenke LG. Incidence and Risk Factors for Complications and Mortality After Vertebroplasty or Kyphoplasty in the Osteoporotic Vertebral Compression Fracture-Analysis of 1,932 Cases From the American College of Surgeons National Surgical Quality Improvement. Global Spine J 2020:2192568220976355. Hou JG, Zhang N, Chen GD. Factors affecting cement leakage in percutaneous vertebroplasty: a retrospective cohort study of 309 patients. Eur Rev Med Pharmacol Sci. 2023;27(9):3877–86. Chang X, Lv YF, Chen B, Li HY, Han XB, Yang K, Zhang W, Zhou Y, Li CQ. Vertebroplasty versus kyphoplasty in osteoporotic vertebral compression fracture: a meta-analysis of prospective comparative studies. Int orthop. 2015;39(3):491–500. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Jul, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 24 Apr, 2025 Reviews received at journal 23 Apr, 2025 Reviewers agreed at journal 15 Apr, 2025 Reviewers invited by journal 10 Apr, 2025 Submission checks completed at journal 27 Mar, 2025 First submitted to journal 25 Mar, 2025 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-5663390","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":441118233,"identity":"49fc57ee-c1bc-4e7d-a0c2-cc9ec2953d0e","order_by":0,"name":"Anquan Huang","email":"","orcid":"","institution":"Suzhou Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Anquan","middleName":"","lastName":"Huang","suffix":""},{"id":441118234,"identity":"ad5fe32d-5fde-4738-ab70-2242cb6f9291","order_by":1,"name":"Haijun Liu","email":"","orcid":"","institution":"Suzhou Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Haijun","middleName":"","lastName":"Liu","suffix":""},{"id":441118239,"identity":"f3501699-8bbd-45cb-a8d9-a9e3ddc56097","order_by":2,"name":"Yubo Liu","email":"","orcid":"","institution":"Suzhou Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yubo","middleName":"","lastName":"Liu","suffix":""},{"id":441118240,"identity":"6658e82d-298b-418c-b005-f7b515a242ea","order_by":3,"name":"Jun Shen","email":"","orcid":"","institution":"Suzhou Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Shen","suffix":""},{"id":441118242,"identity":"8e572cac-38cf-4bb8-a5c4-e81a885b8a8e","order_by":4,"name":"Guoqing Zhu","email":"","orcid":"","institution":"Suzhou Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Guoqing","middleName":"","lastName":"Zhu","suffix":""},{"id":441118243,"identity":"17e2ebb0-e0bf-40cf-84e0-433f45cabbb9","order_by":5,"name":"Yefeng Wang","email":"","orcid":"","institution":"Suzhou Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yefeng","middleName":"","lastName":"Wang","suffix":""},{"id":441118245,"identity":"2f372042-b869-4fc1-ab04-d96965d1fe27","order_by":6,"name":"Tianming Zou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYLCCBCBmA7MMGBj4mZkPPyCggbEBRYtkO1uaAUEtKFyD8zwKEvjUy7f3mD94UHMnmk+6/fLngoI7csaHeYCW1dhE47Si54xhQ8KxZ7ltMmfKpGcYPDM2O8x74AHDsbTcBhxamCVygFrYDue2SeSkMfMYHE7cdpgvwYCx4TBOLWxgLf/AWpI/A7XUb27mMZDAp4UHpCWxDaQl/YA0UEuCATMBLRI8xwpnJPaBbWED+uWw4YzDwEBOwOMX+fbmDR9/fDucO39G+uPPBX8Oy/P3Hz784EONDU4tyG40YIazEwgrBwH2B8wE1YyCUTAKRsGIBADIw1vIzP7AbQAAAABJRU5ErkJggg==","orcid":"","institution":"Suzhou Municipal Hospital","correspondingAuthor":true,"prefix":"","firstName":"Tianming","middleName":"","lastName":"Zou","suffix":""},{"id":441118246,"identity":"b9869e79-730f-47c4-8c35-ef4769fc6616","order_by":7,"name":"Chenxi Gu","email":"","orcid":"","institution":"Suzhou Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chenxi","middleName":"","lastName":"Gu","suffix":""},{"id":441118247,"identity":"7a730eee-dbf4-44e7-88da-e0d10c0b656b","order_by":8,"name":"Bin Lv","email":"","orcid":"","institution":"Zhejiang Provincial People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Lv","suffix":""}],"badges":[],"createdAt":"2024-12-17 16:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5663390/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5663390/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-025-08887-3","type":"published","date":"2025-07-04T15:57:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80577853,"identity":"938f75b0-32b4-45c2-8b55-5c33a3fdd193","added_by":"auto","created_at":"2025-04-14 22:59:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":76841,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the study\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5663390/v1/55b490bf7a11f373ea9f738d.png"},{"id":80579301,"identity":"a6e73ea5-5b58-4d50-8950-84c640922548","added_by":"auto","created_at":"2025-04-14 23:07:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":76646,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e Preoperative and postoperative mean VAS scores for the two groups during the 12-month follow-up. \u003cstrong\u003eB\u003c/strong\u003e Preoperative and postoperative mean ODI scores for the two groups during the 12-month follow-up.\u003c/p\u003e\n\u003cp\u003eUPV, unipedicular posterosuperior approach vertebroplasty; UTV, unilateral transpedicular approach vertebroplasty; VAS, visual analog scale; ODI, Oswestry Disability Index.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5663390/v1/80f55169899551c64b03db91.png"},{"id":80577862,"identity":"7d21ce8f-d3b3-44db-b173-a748bbaac937","added_by":"auto","created_at":"2025-04-14 22:59:51","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":313135,"visible":true,"origin":"","legend":"\u003cp\u003eA 73-year-old female patient with a thoracic 12 vertebral compression fracture who underwent UPV. \u003cstrong\u003eA \u003c/strong\u003ePreoperative magnetic resonance imaging suggested a vertebral compression fracture at T12. \u003cstrong\u003eB\u003c/strong\u003e The tip of the needle was in the midline of the vertebra. \u003cstrong\u003eC\u003c/strong\u003e Intraoperative lateral puncture via fluoroscopy. \u003cstrong\u003eD\u003c/strong\u003ePostoperative lateral fluoroscopy at 1 postoperative day. \u003cstrong\u003eE, F, G\u003c/strong\u003ePostoperative axial, coronal and sagittal CT images showing good distribution of bone cement.\u003c/p\u003e\n\u003cp\u003eUPV, unipedicular posterosuperior approach vertebroplasty.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5663390/v1/46b1d1efbfb5c68a6aef0a46.png"},{"id":80581884,"identity":"9f41278b-15f0-4e57-9eaf-5c097bb3364d","added_by":"auto","created_at":"2025-04-14 23:23:51","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":268146,"visible":true,"origin":"","legend":"\u003cp\u003eA 68-year-old female patient with a lumbar 3 vertebral compression fracture underwent UTV. \u003cstrong\u003eA \u003c/strong\u003ePreoperative lateral X-ray radiographs indicating a decrease in the height of the lumbar 3 vertebra. \u003cstrong\u003eB\u003c/strong\u003e Preoperative magnetic resonance imaging suggested a vertebral compression fracture of the lumbar 3 vertebra. \u003cstrong\u003eC, D \u003c/strong\u003ePostoperative anterolateral radiographs at 1-day postsurgery. \u003cstrong\u003eE, F, G \u003c/strong\u003ePostoperative coronal, sagittal and axial CT images showing a limited distribution of bone cement.\u003c/p\u003e\n\u003cp\u003eUTV, unilateral transpedicular approach vertebroplasty.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5663390/v1/21f9939166abaa24e2f90486.png"},{"id":86179912,"identity":"abcf1de2-5546-46c4-a6c2-4ee0bafdad5a","added_by":"auto","created_at":"2025-07-07 16:20:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1775423,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5663390/v1/cff40b26-ff9d-480e-a401-d7a31a628d3c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Two different unilateral percutaneous vertebroplasty approaches for acute osteoporotic vertebral compression fractures: clinical and radiological outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOVCFs represent a significant pathological condition that profoundly impacts the well-being of elderly individuals. These fractures commonly arise from low-energy trauma and are accompanied by a constellation of symptoms, including back pain and spinal kyphosis. The incidence of OVCFs is alarmingly high, with a lifetime risk between 40% and 50% in women and between 13% and 22% in men with a history of osteoporosis[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Considering the remarkable progress in minimally invasive spinal surgery, PVP has been widely used to treat painful OVCFs[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This innovative technique effectively mitigates patient discomfort, expeditiously restores partial vertebral height and spinal functionality, and confers notable advantages, such as minimal invasiveness, reduced hospitalization duration, shorter operative procedures, and accelerated convalescence[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo minimize the risk of nerve root or dura mater damage, surgeons prefer the percutaneous approach through the pedicle for thoracolumbar vertebral body surgery. While cement injection via the bilateral transpedicular approach can achieve good cement filling, it has drawbacks such as a long operation time, patient discomfort during bilateral local anesthesia, and a high incidence of cement leakage[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Reports[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] indicate that both the unilateral and bilateral approaches can achieve satisfactory clinical and radiological outcomes. Although the unilateral approach is not the most frequently adopted approach currently, its merits like shorter operation time and reduced cement leakage still render it a favored alternative for some surgeons. However, the traditional unilateral transpedicular approach has limitations. It is constrained by the pedicle, making it difficult to adjust the puncture needle's direction and reach the center of the vertebral body. This results in uneven cement distribution within the affected vertebra, which can lead to long-term follow-up issues such as recurrent vertebral fractures[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], inadequate pain relief[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], and spinal side curvature. Therefore, the application of the unilateral transpedicular approach is somewhat limited[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Studies[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] have identified uneven cement distribution within the fractured vertebra as a key factor for residual back pain after PVP. Additionally, a lower amount of cement injection in unilateral vertebral augmentation is a risk factor for adjacent vertebral fractures[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Thus, further exploration is necessary to better apply the unilateral approach technique in clinical practice.\u003c/p\u003e \u003cp\u003eTo address these issues, our previous research[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] demonstrated that the unilateral posterosuperior approach through the vertebral body circumvents the limitations posed by the pedicle, thereby enabling enhanced mobility of the surrounding soft tissues. This precise adjustment can lead to more accurate placement within the central region of the vertebral body or the site of fracture, potentially resulting in better cement distribution. In contrast, the unilateral transpedicular approach is restricted by the pedicle, making it challenging to achieve such accurate needle placement and optimal cement distribution. Recently, we conducted a comparative analysis of the biomechanical properties associated with various approaches for vertebral augmentation, revealing that the unilateral posterosuperior approach is superior to the unilateral transpedicular approach and comparable to the bilateral transpedicular approach in terms of biomechanical stability[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Furthermore, the study also revealed that the distribution of bone cement in the unilateral posterosuperior approach was more uniform than that in the unilateral transpedicular approach. Nonetheless, the lack of adequate clinical data hinders the definitive confirmation of the superiority of the unilateral posterosuperior approach over the conventional unilateral transpedicular approach.\u003c/p\u003e \u003cp\u003eIn this study, we hypothesize that the UPV will offer superior outcomes in terms of clinical efficacy, including better pain relief, more stable vertebral structure, and fewer long-term complications, compared to the UTV. Our primary objective is to retrospectively evaluate the clinical efficacy of these two PVP surgical approaches for managing osteoporotic thoracolumbar compression fractures at our hospital, with a particular focus on further assessing their safety. This hypothesis will guide our research as we analyze the data and draw conclusions about the relative merits of the UPV and UTV approaches.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective analysis of 167 patients with osteoporotic thoracolumbar compression fractures who underwent PVP via two different unilateral approach techniques at the Affiliated Suzhou Hospital of Nanjing Medical University between September 2019 and March 2022 (Fig.\u0026nbsp;1). This study protocol was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Suzhou Municipal Hospital (KL901131), and written informed consent was obtained from all patients.\u003c/p\u003e \u003cp\u003eAll patients had recently sustained single-segment thoracolumbar vertebral fractures, with intact bilateral pedicles, posterior walls, and columns. The inclusion criteria were as follows: age over 60 years, T score less than \u0026minus;\u0026thinsp;2.5 on a dual energy X-ray absorptiometry scan, and vertebral height loss less than 20% on lateral spine radiograph. Patients with multi-segmental spinal fractures, burst fractures, fractures with spinal cord injury, non-OVCFs, conservative treatment, or severe organ dysfunction were excluded from the study. The final cohort consisted of 85 patients in the UPV group, including 21 males and 64 females, with an age range of 60\u0026ndash;91 years and an average age of 74.71 years. The injured vertebral levels were as follows: T5\u0026ndash;10 (20 cases), T11\u0026ndash;L2 (48 cases), and L3\u0026ndash;5 (17 cases). The UTV group included 82 patients, with 18 males and 64 females, an age range of 60\u0026ndash;95 years, and an average age of 76.89 years. The injured vertebral levels were as follows: T5\u0026ndash;10 (18 cases), T11\u0026ndash;L2 (45 cases), and L3\u0026ndash;5 (19 cases).\u003c/p\u003e \u003cp\u003e The two groups were comparable in terms of age, sex distribution, BMI, BMD, time of injury, and underlying conditions, with no statistically significant differences (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical procedures and postoperative management\u003c/h3\u003e\n\u003cp\u003eA doctor in the inpatient department picked out one of two different pieces of paper indicating one of two different puncture protocols after the patient had granted consent. Each type of puncture was performed by one senior spine surgeon at Suzhou Municipal Hospital. All patients who underwent PVP were administered local anesthesia (with lidocaine) and closely monitored throughout the procedure. The patients were placed in the prone position. Dual C-arm fluoroscopy was employed to locate the injured vertebra accurately and mark the projection of the posterior surface of the pedicle. In the anteroposterior view, the bilateral pedicle shadows were aligned equidistantly with the spinous process shadow, whereas the endplate appeared as a linear shadow in the lateral view. A reduction technique was subsequently employed to restore the vertebral height as much as possible. Standard disinfection and draping procedures were performed.\u003c/p\u003e \u003cp\u003eFor the posterosuperior approach through the vertebral body, the puncture point was determined to be 5\u0026ndash;7 cm above the outer surface projection of the pedicle, forming an angle of 20\u0026ndash;30\u0026deg; with the sagittal plane and an angle of 40\u0026ndash;45\u0026deg; with the horizontal plane. The introducer needle was then advanced to the posterosuperior aspect of the vertebral body, following the diagonal line observed on the lateral radiograph of the affected vertebra. The position of the needle tip was confirmed to have reached the anterior one-third of the vertebral body on the lateral radiograph, whereas anteroposterior fluoroscopy confirmed that the puncture needle exceeded the midline of the spinous process. The inner needle core was subsequently removed, and contrast agent was injected to detect any potential leakage. Bone cement was prepared, and the working channel was connected. Under fluoroscopic guidance, the bone cement was meticulously injected into the injured vertebra. The dispersion of the bone cement was carefully observed on both anteroposterior and lateral radiographs. The injection was ceased once the bone cement was adequately filled or reached proximity to the posterior wall of the vertebral body. Prior to the solidification of the bone cement, the cannula was rotated and removed. Throughout the procedure, the patient's sensory and motor function of the lower limbs was continuously monitored.\u003c/p\u003e \u003cp\u003eThe unilateral transpedicular approach involved inserting the needle at the outer upper edge of the pedicle, at 9\u0026ndash;11:00 for the left side and at 1\u0026ndash;3:00 for the right side, at an angle of 15\u0026ndash;20\u0026deg; with respect to the sagittal plane. The puncture cannula was guided to the inner border of the pedicle from the anterior-posterior view and to the posterior wall of the vertebral body from the lateral view, ensuring safe passage of the needle through the pedicle and into the vertebral body. The cannula was then advanced to the anterior one-third of the vertebral body on the lateral radiograph, and the puncture needle was positioned as close as possible to the midline of the spinous process on anteroposterior fluoroscopy.\u003c/p\u003e \u003cp\u003eOn the first postoperative day, all patients underwent X-ray and computed tomography (CT) examinations to assess the distribution of the bone cement and detect any potential cement leakage. Patients who did not experience discomfort were allowed to ambulate with waist protection. Additionally, all patients received systemic osteoporosis treatment, including zoledronic acid, calcium supplements, and vitamin D.\u003c/p\u003e\n\u003ch3\u003eObservation indicators and efficacy assessment\u003c/h3\u003e\n\u003cp\u003e(1) Surgical time, blood loss, number of fluoroscopy procedures, midline position of the puncture needle, and amount of bone cement injected were recorded in both groups. (2) Preoperative and postoperative VAS scores (1-day, 1-month, 3-month, 6-month, and 12-month) and ODI values were recorded in both groups to assess the clinical analgesic effect and functional recovery. (3) Postoperative X-rays and CT scans were used to evaluate the vertebral height, distribution of bone cement, cement leakage, and vertebral collapse in both groups. (4) The incidence of refracturing of the affected vertebra or adjacent vertebral fractures during the follow-up period was recorded. (5) Complications such as vascular, neural, and spinal cord injuries, as well as cement embolism, were documented.\u003c/p\u003e \u003cp\u003eThe distribution of bone cement was scored based on imaging data, with a total of 12 points. The vertebral body was divided into four quadrants on the anterior-posterior and lateral views. If the bone cement filled more than half of each quadrant, 1 point was assigned, resulting in a total of 8 points. Additionally, on the lateral radiograph, the contact between the bone cement and the upper and lower endplates of the vertebral body was observed, with 1 point assigned for each contact, totaling 2 points. Finally, the alignment of the bone cement with the midline of the vertebral body on the anterior-posterior and lateral views was assessed, with 1 point assigned for each alignment, totaling 2 points. All radiological parameters were measured individually and independently by radiologists and spinal surgeons to eliminate bias within and between observers.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data was processed via SPSS 19.0 statistical software. Continuous variables were assessed for normality, and normally distributed data are presented as the means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (means\u0026thinsp;\u0026plusmn;\u0026thinsp;SDss). Within-group comparisons were performed via t tests, whereas between-group comparisons were conducted via analysis of variance (ANOVA). Categorical variables are presented as frequencies and were analyzed via the chi-square test. Paired sample t tests and independent t tests were used to evaluate the differences between groups and between groups for preoperative and postoperative VAS and ODI data. A significance level of P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics of the patients\u003c/h2\u003e \u003cp\u003eSurgeries were successful in both groups of patients. The two groups exhibited similar baseline characteristics, including age, sex ratio, BMI, BMD, time of injury, and underlying diseases, with no statistically significant differences (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating comparability (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUPV Group (n\u0026thinsp;=\u0026thinsp;85)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUTV Group (n\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistics\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\u003e74.71\u0026thinsp;\u0026plusmn;\u0026thinsp;8.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.89\u0026thinsp;\u0026plusmn;\u0026thinsp;8.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.107\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (male/female, number)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21/64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18/64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.674\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.05\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.32\u0026thinsp;\u0026plusmn;\u0026thinsp;2.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;0.677\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.499\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMD (T score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-3.05\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-2.94\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;1.903\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCourse of disease (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.56\u0026thinsp;\u0026plusmn;\u0026thinsp;4.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.13\u0026thinsp;\u0026plusmn;\u0026thinsp;3.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;0.729\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.467\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderlying disease\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 \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.395\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.821\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (36.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (30.5%)\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\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (41.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (39%)\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\u003eHyperlipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (17.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(19.5%)\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\u003eFracture 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=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.259\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.878\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic (T5-T10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(21.9%)\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\u003eThoracolumbar (T11-L2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (56.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45(54.9%)\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\u003eLumbar (L3-L5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19(23.2%)\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 \u003cp\u003eThe data are presented as the means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations. BMI, body mass index; BMD, bone mineral density.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical outcomes\u003c/h3\u003e\n\u003cp\u003eThere were no statistically significant differences (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) in terms of surgical duration, intraoperative blood loss, or X-ray exposure between the two cohorts (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The UPV group exhibited a 100% rate of midline puncture through the vertebral body, whereas the other group achieved only 26.8% midline puncture, with 73.2% failing to reach the midline, thus demonstrating a statistically significant difference (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In the UPV group, a greater volume of bone cement was injected into the thoracolumbar spine. Intraoperative fluoroscopy revealed satisfactory distribution of the cement in the UPV group, with no observed increase in cement leakage.\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 the operation time, blood loss, X-ray perspective time, time of puncture to the center of the vertebra and bone cement dosage between the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUPV Group (n\u0026thinsp;=\u0026thinsp;85)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUTV Group (n\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistics\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\u003eOperation time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.71\u0026thinsp;\u0026plusmn;\u0026thinsp;5.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.13\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;1.754\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.86\u0026thinsp;\u0026plusmn;\u0026thinsp;2.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.65\u0026thinsp;\u0026plusmn;\u0026thinsp;3.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;1.775\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX-ray perspective times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.58\u0026thinsp;\u0026plusmn;\u0026thinsp;3.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.29\u0026thinsp;\u0026plusmn;\u0026thinsp;3.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;1.258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.210\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePuncture to the center of vertebra\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (26.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;97.071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone cement volume (mL)\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\u003eThoracic (T5-T10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;3.753\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracolumbar (T11-L2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.63\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.54\u0026thinsp;\u0026plusmn;\u0026thinsp;1.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;4.103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar (L3-L5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.31\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.70\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;4.561\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eClinical indicators\u003c/h3\u003e\n\u003cp\u003eVAS scores were significantly lower than baseline scores in both cohorts, but no significant differences were detected between the groups at any of the measured time points (one day, three months, six months, or twelve months) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003eA and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Similarly, both cohorts demonstrated comparable improvements in the ODI throughout the one-year follow-up period (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003eB and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). There were no statistically significant differences (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) in the preoperative VAS or ODI scores between the two cohorts.\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\u003eComparison of the VAS and ODI scores between the two groups at each time point\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" 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 \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eVAS scores\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003eODI scores\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUPV Group (n\u0026thinsp;=\u0026thinsp;85)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUTV Group (n\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT\u003c/p\u003e \u003cp\u003evalue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003cp\u003evalue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUPV Group (n\u0026thinsp;=\u0026thinsp;85)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUTV Group (n\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eT\u003c/p\u003e \u003cp\u003evalue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eP\u003c/p\u003e \u003cp\u003evalue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epreop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e7.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.974\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.332\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e70.26\u0026thinsp;\u0026plusmn;\u0026thinsp;10.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e68.16\u0026thinsp;\u0026plusmn;\u0026thinsp;12.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.249\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.949\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e32.62\u0026thinsp;\u0026plusmn;\u0026thinsp;8.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e34.68\u0026thinsp;\u0026plusmn;\u0026thinsp;10.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.418\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.158\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.845\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e24.56\u0026thinsp;\u0026plusmn;\u0026thinsp;5.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e25.73\u0026thinsp;\u0026plusmn;\u0026thinsp;8.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.273\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.644\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e22.55\u0026thinsp;\u0026plusmn;\u0026thinsp;5.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e23.51\u0026thinsp;\u0026plusmn;\u0026thinsp;4.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.241\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.816\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e23.19\u0026thinsp;\u0026plusmn;\u0026thinsp;4.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e \u003cp\u003e24.65\u0026thinsp;\u0026plusmn;\u0026thinsp;5.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.841\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.068\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\u003eUPV, unipedicular posterosuperior approach vertebroplasty; UTV, unilateral transpedicular approach vertebroplasty; VAS, visual analog scale; ODI, Oswestry Disability Index.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRadiological results\u003c/h2\u003e \u003cp\u003e There were no statistically significant differences (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) in the anterior vertebral height between the two groups. The data indicated that the postoperative anterior vertebral height was slightly greater than the preoperative height in both groups, but the difference was not statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and there was no significant difference between the groups. The incidence of vertebral collapse was 3.5% in the UPV group and 13.4% in the UTV group, indicating a significantly lower rate of vertebral collapse in the UPV group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Among the 14 cases of recurrent collapse, the bone cement did not fully contact the upper and/or lower endplates. The analysis of the distribution of bone cement after surgery revealed that the UPV group presented a more favorable distribution than the UTV group did, with a statistically significant difference (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), as presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e (Figs.\u0026nbsp;3 and 4, representative cases).\u003c/p\u003e \u003cp\u003eIntraoperative and postoperative X-rays revealed bone cement leakage in 5 patients (5.88%) in the UPV group, including 2 patients with disc leakage, 1 patient with vascular leakage, and 1 patient with lateral leakage. In the UTV group, there were 10 cases (12.2%) of bone cement leakage, including 4 cases of leakage into adjacent discs and lateral leakage and 2 cases of posterior leakage. Notably, no significant neurological compression symptoms were observed in either group, and there was no statistically significant difference in the incidence of bone cement leakage (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\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\u003eComparison of pain and functional efficacy between the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUPV Group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;85)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUTV group (n\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistics\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\u003ePreoperative vertebral height (mm)\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\u003eThoracic (T5-T10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.23\u0026thinsp;\u0026plusmn;\u0026thinsp;2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.63\u0026thinsp;\u0026plusmn;\u0026thinsp;3.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;0.619\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.540\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracolumbar (T11-L2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.79\u0026thinsp;\u0026plusmn;\u0026thinsp;3.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.15\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;1.069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.288\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar (L3-L5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.37\u0026thinsp;\u0026plusmn;\u0026thinsp;2.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;0.383\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative vertebral height (mm)\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\u003eThoracic (T5-T10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.25\u0026thinsp;\u0026plusmn;\u0026thinsp;2.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;0.427\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.672\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracolumbar (T11-L2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.34\u0026thinsp;\u0026plusmn;\u0026thinsp;3.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.15\u0026thinsp;\u0026plusmn;\u0026thinsp;3.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;1.758\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar (L3-L5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.18\u0026thinsp;\u0026plusmn;\u0026thinsp;2.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;0.288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.775\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone cement distribution (the 12-score method)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;15.294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertebral body refracture (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;2.098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjacent vertebral fracture (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;1.457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.227\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone cement leakage (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5.88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (12.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;2.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.154\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\u003eUPV, unipedicular posterosuperior approach vertebroplasty; UTV, unilateral transpedicular approach vertebroplasty.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eComplications\u003c/h2\u003e \u003cp\u003eDuring the one-year follow-up, no instances of pulmonary embolism or spinal cord injury were observed. In the UPV group, one patient experienced thoracic vertebral fracture, presenting with chest tightness on the first day postsurgery. Chest CT revealed pneumothorax, which resolved following treatment with closed thoracic drainage. The UPV group experienced two cases of adjacent vertebral fractures, whereas the UTV group experienced five cases of adjacent vertebral fractures and two cases of recurrent vertebral fractures, with no statistically significant disparities (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe optimal treatment for acute OVCFs should not only provide rapid and effective pain relief but also achieve vertebral body restoration, angle correction, and maintain vertebral height in the long term. In addition to alleviating patient pain, PVP can improve quality of life and prevent the vicious cycle of worsening osteoporosis due to prolonged bed rest. Previous studies[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] have shown that, compared with conservative treatment, vertebral augmentation significantly reduces patient pain and has a lower incidence of major complications. In this study, all patients were followed up for an average of 13.6 months, and PVP improved their quality of life, providing benefits from the surgery.\u003c/p\u003e \u003cp\u003eTraditionally, the bilateral transpedicular approach has been the standard technique for PVP. The unilateral transpedicular approach is favored by many spine surgeons because of its shorter operation time, reduced trauma, decreased X-ray exposure, and better cost-effectiveness. Numerous studies[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] have reported that the unilateral approach for PVP can achieve results comparable to those of the bilateral approach. However, in clinical practice, the distribution of bone cement in the unilateral pedicle approach is not as good as that in the bilateral approach.\u003c/p\u003e \u003cp\u003eThe aim of this study was to determine whether UPV is superior to UTV in terms of clinical effectiveness. Our study revealed that both groups of patients had significant improvements in VAS and ODI scores compared with preoperative scores (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), indicating that the use of the unilateral approach for PVP achieved similar immediate and relatively long-lasting improvements in pain and disability. However, no significant differences were observed between the two groups.\u003c/p\u003e \u003cp\u003eThe distribution of bone cement plays a crucial role in the success of PVP. Inadequate cement distribution can lead to poor pain relief, progressive vertebral collapse, and kyphotic deformity[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Previous studies[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] have shown that the position of the puncture needle during PVP can affect the cement distribution. For example, Schupfner et al[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] reported that the extrapedicular approach resulted in fewer cases of improper needle placement than did the transpedicular approach. To improve cement distribution during the unilateral transpedicular approach, Lv et al[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] developed a curved puncture device. In this study, we used a 12-point scoring system to evaluate the distribution of bone cement within the vertebral body[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The UPV group demonstrated a significantly improved 12-point cement distribution score compared to the UTV group (10.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48 vs. 7.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.86, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This finding underscores the advantages of the UPV technique in achieving optimal cement placement, potentially reducing postoperative complications and enhancing vertebral stability. This difference was attributed to the position of the puncture needle within the vertebral body, with the unipedicular posterosuperior approach allowing for more accurate placement in the center of the vertebral body in all patients, compared with only 26.8% in the other patients.\u003c/p\u003e \u003cp\u003eThe quantity of cement injected is a critical risk factor for adjacent vertebral fractures. Research has indicated that the unilateral approach can lead to lateral deviation in the distribution of cement within the vertebral body, resulting in an imbalance in stiffness between the two sides of the vertebra[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The stiffness on the nonenhanced side is notably lower than that on the enhanced side, hindering the effective restoration of the biomechanical properties of the injured vertebra. This can contribute to chronic postoperative pain and increase the likelihood of adjacent vertebral fractures or recurrent fractures in the treated vertebra. Insufficient cement injection fails to adequately stabilize the fractured trabeculae, whereas excessive injection increases the risk of cement leakage. Papanastassious et al[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] proposed an average appropriate cement injection volume of 5.5 mL for the thoracic vertebrae and 7.0 mL for the lumbar vertebrae. In our study, the UPV group exhibited cement injection volumes of 4.42 mL, 5.63 mL, and 6.31 mL for the thoracic, thoracolumbar, and lumbar vertebrae, respectively, whereas the other groups had volumes of 3.45 mL, 4.54 mL, and 4.70 mL, respectively. Our findings revealed a significantly greater volume of cement injected in the UPV group than in the UTV group, which can be attributed to the positioning of the puncture needle within the vertebral body. Thus, while ensuring surgical safety and efficacy, maintaining biomechanical stability and reducing the risk of leakage can be achieved by adjusting the injection volume of cement in the UPV group.\u003c/p\u003e \u003cp\u003eMaintaining vertebral height is crucial for ensuring the long-term effectiveness of vertebral augmentation procedures. In this study, both groups showed a slight increase in anterior vertebral height on the first day after surgery, but the difference was not statistically significant. The improvement in radiographic indicators after surgery can be attributed to the preoperative and intraoperative reduction of the vertebral body, with the bone cement dispersing into small fracture fissures to maintain the reduction height. However, increasing the volume of bone cement alone did not significantly improve short-term radiographic indicators, as evidenced by the lack of significant improvement in the Cobb angle and anterior vertebral height during cement injection.\u003c/p\u003e \u003cp\u003eDuring the final follow-up, the UTV group experienced partial loss of vertebral height, whereas the UPV group maintained greater vertebral height. Additionally, the VAS scores and ODI values indicating pain improvement in the UPV group were superior to those in the UTV group, despite the lack of a significant statistical difference between the two groups. The incidence of vertebral collapse was 3.5% in the UPV group and 13.4% in the UTV group. This large difference matters clinically. In the UTV group, more collapses can change spinal biomechanics, causing chronic pain and higher fracture risks. As Li et al[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] showed, a sponge-like distribution of bone cement helps maintain height, and reduces the risk of vertebral recompression, long-term pain, and functional impairment. Chen et al [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] reported a vertebral recompression rate of 9.7% in their cohort of 134 patients with OVCFs after percutaneous vertebroplasty, which was associated with persistent lower back pain and limited spinal mobility. Our study provides further evidence supporting the importance of maintaining vertebral height for the long-term effectiveness of vertebral augmentation procedures. Increasing the volume of bone cement is crucial for restoring mechanical balance in the spine, preventing further collapse of the vertebral body, and reducing the risk of refracture[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This can effectively improve patient outcomes in the middle to long term.\u003c/p\u003e \u003cp\u003eAsymptomatic complications associated with vertebral augmentation procedures include bone cement leakage, pulmonary embolism, and intervertebral disc space leakage[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In our study, the UPV group presented 5 cases of bone cement leakage and 1 case of pneumothorax, whereas the other group presented 10 cases. For cement leakage, the UPV group had a 5.88% rate and the UTV group 12.2%. Despite no significant statistical difference, the UTV group's higher rate may pose risks like nerve irritation or adjacent fractures. Cement leakage may lead to serious sequelae[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. For instance, when cement leaks into the adjacent spinal canal or intervertebral foramen, it can cause neurological dysfunction and paraplegia. Pulmonary embolism may be caused by free cement embolism, resulting in death. These potential complications play a crucial role in determining the surgical approach. Chang et al [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] reported a significant correlation between bone cement leakage in the PVP and the volume of injection. We hypothesize that the higher leakage rate in the UTV group may be attributed to the pursuit of better dispersion of bone cement during the procedure. In our study, the leakage rate did not significantly increase in the UPV group. This might be attributed to the favorable puncture position. Appropriate injection pressure not only does not increase the risk of leakage but also promotes a more uniform distribution of bone cement.\u003c/p\u003e \u003cp\u003eOther symptomatic complications associated with bone cement, such as spinal infection, spinal cord injury, nerve root compression, and pneumothorax, necessitate targeted treatment. One case of pneumothorax was observed in the UPV group. The patient had a BMI of 18 and weak back muscles, which could have been caused by the puncture needle piercing the pleura owing to a slightly larger lateral opening distance during the puncture. Following its detection, the pneumothorax was successfully treated with closed thoracic drainage. Hence, it is important to ensure that the puncture point is not excessively lateral, particularly in thin patients, when performing a UPV puncture. Preoperative measurements of the lateral opening distance and the inward tilt angle of the puncture needle are necessary.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThere are multiple limitations to our study. The sample size was relatively small and the follow - up period short, restricting result generalizability. We didn't compare bone cement distribution strength, and factors like fracture morphology and vertebral kyphotic angle, which could have influenced outcomes, were not fully explored. Regarding long-term clinical outcomes, we failed to determine which approach (UPV or UTV) suits specific patient groups such as those with severe osteoporosis, complex vertebral anatomies, or multiple comorbidities due to lack of relevant data. Also, we didn't compare our findings with previous research on cement augmentation durability, missing potential insights on long-term UPV and UTV performance. Moreover, we didn't identify necessary follow-up studies; future research could have longer follow-up (e.g., 5\u0026ndash;10 years) with patient-centered outcome measures to better understand long-term impacts and complications of each approach.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur study demonstrated that the unilateral PVP approach is an effective treatment for painful OVCFs. The unipedicular posterosuperior approach allows easier access to the optimal injection point within the vertebral body and better distribution of bone cement, resulting in a greater volume of cement injection and better maintenance of the vertebral height. However, caution should be exercised in thin patients to avoid excessive lateral puncture points. Future long-term studies are needed to further evaluate the relative advantages and disadvantages of these approaches.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePVP Percutaneous vertebroplasty\u003c/p\u003e \u003cp\u003eOVCFs Osteoporotic vertebral compression fractures\u003c/p\u003e \u003cp\u003eUPV Unipedicular posterosuperior approach vertebroplasty\u003c/p\u003e \u003cp\u003eUTV Unilateral transpedicular approach vertebroplasty\u003c/p\u003e \u003cp\u003eODI Oswestry Disability Index\u003c/p\u003e \u003cp\u003eVAS Visual analogue scale\u003c/p\u003e \u003cp\u003eCT Computed tomography\u003c/p\u003e \u003cp\u003eMRI Magnetic resonance imaging\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors contributed to the study. TZ designed the research and revised the manuscript. AH and YL collected and analyzed the data and wrote the manuscript. HL carried out the data interpretations and assisted in the data discussion. JS, GZ, YW and BL revised the research with constructive discussions. All the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Key Disease Diagnosis and Treatment Technology Special Project of Suzhou, China (LCZX2019-10).\u0026nbsp;The funders had no role in the study design, data collection, analysis, interpretation, or in the writing of this manuscript and the decision to submit it for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available for data protection reasons. Data is available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe portions of this study involving human participants, human materials, or human data were conducted in accordance with the Declaration of Helsinki and were approved by the Ethics Committee of Suzhou Municipal Hospital (KL901131). All patients provided written informed consent, explicitly informed of the study's aim to compare two surgical approaches (UPV and UTV), associated risks/benefits, and data usage for comparative analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlsoof D, Anderson G, McDonald CL, Basques B, Kuris E, Daniels AH. Diagnosis and Management of Vertebral Compression Fracture. Am J Med. 2022;135(7):815\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLainez Ramos-Bossini AJ, Lopez Zuniga D, Ruiz Santiago F. 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BMC Musculoskelet Disord. 2021;22(1):459.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLv Z, Chen Z, Chen H, Wang J, Han Y, Li X, Shen H, Zhang Y. Percutaneous Curved Vertebroplasty Versus Unipedicular Approach Vertebroplasty for Acute Osteoporotic Vertebral Compression Fractures: A Randomized Controlled Trial. Spine (Phila Pa 1976). 2023;48(8):552\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou C, Liao Y, Huang S, Li H, Zhu Z, Zheng L, Wang B, Wang Y. Effect of cement distribution type on clinical outcome after percutaneous vertebroplasty for osteoporotic vertebral compression fractures in the aging population. Front Surg. 2022;9:975832.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou C, Huang S, Liao Y, Chen H, Zhang Y, Li H, Zhu Z, Wang Y. Correlation analysis of larger side bone cement volume/vertebral body volume ratio with adjacent vertebral compression fractures during vertebroplasty. 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Acad Radiol. 2023;30(10):2147\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQian Y, Li Y, Shen G, Zhong X, Tang C, He S. Comparison of unipedicular and bipedicular kyphoplasty for treating acute osteoporotic vertebral compression fractures in the lower lumbar spine: a retrospective study. BMC Musculoskelet Disord 2023, 24(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou Q, Wan Y, Ma L, Dong L, Yuan W. Percutaneous Curved Vertebroplasty Decrease the Risk of Cemented Vertebra Refracture Compared with Bilateral Percutaneous Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fractures. Clin Interv Aging. 2024;19:289\u0026ndash;301.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu X, Zhang Z, Yang Y, Zhang G, Cao S, Yu B, Zhang Y. Enhanced bone cement distribution in percutaneous vertebroplasty using a curved guide wire: a propensity score matching analysis. BMC Musculoskelet Disord. 2024;25(1):835.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchupfner R, Koniarikova K, Pfeifer C, Grechenig P, Bakota B, Staresinic M, Kerner MA, M\u0026uml;\u0026sup1;ller M. An anatomical study of transpedicular vs. extrapedicular approach for kyphoplasty and vertebroplasty in the thoracic spine. Injury. 2021;52(Suppl 5):S63\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu J, Tang J, Liu H, Gu Z, Zhang Y, Yu S. A novel and convenient method to evaluate bone cement distribution following percutaneous vertebral augmentation. Sci Rep. 2020;10(1):16320.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePapanastassiou ID, Filis A, Gerochristou MA, Vrionis FD. Controversial issues in kyphoplasty and vertebroplasty in osteoporotic vertebral fractures. Biomed Res Int. 2014;2014:934206.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Q, Long X, Wang Y, Guan T, Fang X, Guo D, Lv J, Hu X, Jiang X, Cai L. Clinical observation of two bone cement distribution modes after percutaneous vertebroplasty for oste oporotic vertebral compression fractures. BMC Musculoskelet Disord. 2021;22(1):577.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen YJ, Chen WH, Chen HT, Hsu HC. Repeat needle insertion in vertebroplasty to prevent re-collapse of the treated vertebrae. Eur J Radiol. 2012;81(3):558\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang B, Cui L, Chen X, Liu Y. Risk Factors for Cement Leakage in Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fractures: An Analysis of 1456 Vertebrae Augmented by Low-Viscosity Bone Cement. Spine (Phila Pa 1976). 2021;46(4):216\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim HJ, Zuckerman SL, Cerpa M, Yeom JS, Lehman RA Jr., Lenke LG. Incidence and Risk Factors for Complications and Mortality After Vertebroplasty or Kyphoplasty in the Osteoporotic Vertebral Compression Fracture-Analysis of 1,932 Cases From the American College of Surgeons National Surgical Quality Improvement. Global Spine J 2020:2192568220976355.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHou JG, Zhang N, Chen GD. Factors affecting cement leakage in percutaneous vertebroplasty: a retrospective cohort study of 309 patients. Eur Rev Med Pharmacol Sci. 2023;27(9):3877\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang X, Lv YF, Chen B, Li HY, Han XB, Yang K, Zhang W, Zhou Y, Li CQ. Vertebroplasty versus kyphoplasty in osteoporotic vertebral compression fracture: a meta-analysis of prospective comparative studies. Int orthop. 2015;39(3):491\u0026ndash;500.\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":"Percutaneous vertebroplasty, Unilateral, Osteoporotic vertebral compression fractures, Distribution of bone cement, Approach","lastPublishedDoi":"10.21203/rs.3.rs-5663390/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5663390/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo investigate whether the unilateral posterosuperior approach PVP is superior to the traditional unilateral transpedicular approach in the treatment of acute osteoporotic vertebral compression fractures (OVCFs).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective study was conducted on 167 patients with single-segment acute OVCFs admitted to our hospital from September 2019 to March 2022. Patients were divided into two groups according to the type of intraoperative approach used: the unipedicular posterosuperior approach vertebroplasty (UPV) group (n\u0026thinsp;=\u0026thinsp;85) and the unilateral transpedicular approach vertebroplasty (UTV) group (n\u0026thinsp;=\u0026thinsp;82). Surgical data, including operation time, blood loss, fluoroscopy frequency, puncture needle crossing the midline during surgery, and bone cement injection volume, were collected. Imaging data, such as vertebral height, distribution of bone cement, and cement leakage, were analyzed. Clinical efficacy indicators, including the Visual analogue scale (VAS) score and Oswestry Disability Index (ODI), were compared. Additionally, the occurrence of vertebral refracture, adjacent vertebral fracture, and postoperative complications was assessed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBoth groups were followed up for an average of 13.6 months (range: 12\u0026ndash;24 months). No statistically significant differences were detected between the UPV and UTV groups in terms of the VAS and ODI scores or the vertebral height. The two groups had similar blood loss rates, fluoroscopy frequencies, and operation times. However, the UPV group presented a greater volume of bone cement injected and a better dispersion pattern of bone cement (10.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48 vs 7.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.86) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The occurrence of vertebral collapse after surgery was positively correlated with the distribution of bone cement. Cement leakage was observed in 5 patients in the UPV group and 10 patients in the UTV group. The UPV group had 2 cases of adjacent vertebral refracture within six months, whereas the UTV group had 5 cases. One adverse event, pneumothorax, occurred in the UPV group.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePVP via the unilateral approach effectively relieves back pain in patients with OVCFs. The unilateral posterosuperior approach allows for the injection of a greater volume of bone cement, resulting in a more even distribution within the vertebral body. However, caution should be exercised to avoid excessive lateral puncture points.\u003c/p\u003e","manuscriptTitle":"Two different unilateral percutaneous vertebroplasty approaches for acute osteoporotic vertebral compression fractures: clinical and radiological outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-14 22:59:46","doi":"10.21203/rs.3.rs-5663390/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-24T09:31:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-23T23:28:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123996751972838261395654054213276952123","date":"2025-04-15T13:30:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-10T10:48:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-27T11:21:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-03-25T17:55:18+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":"4b080b87-0dc2-4a28-b50b-1b07f625753f","owner":[],"postedDate":"April 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:12:48+00:00","versionOfRecord":{"articleIdentity":"rs-5663390","link":"https://doi.org/10.1186/s12891-025-08887-3","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2025-07-04 15:57:20","publishedOnDateReadable":"July 4th, 2025"},"versionCreatedAt":"2025-04-14 22:59:46","video":"","vorDoi":"10.1186/s12891-025-08887-3","vorDoiUrl":"https://doi.org/10.1186/s12891-025-08887-3","workflowStages":[]},"version":"v1","identity":"rs-5663390","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5663390","identity":"rs-5663390","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}