Letter to editor: Evaluating the effect of early balloon kyphoplasty on adjacent vertebral fracture risk in osteoporotic vertebral fracture management: a retrospective study
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Dear Editor,
I wish to extend my appreciation to Yamamoto et al. for their article, “Evaluating the effect of early balloon kyphoplasty on adjacent vertebral fracture risk in osteoporotic vertebral fracture management: a retrospective study. The authors focus on the relationship between the timing of balloon kyphoplasty (BKP) and the incidence of adjacent vertebral fractures (AVFs) offers valuable insight into a long-debated issue in spinal care. The study̓s strength is its clear clinical question and strong patient cohort. Analysing data from 189 patients across a wide timespan (2012–2023), the authors present an informative comparison between early (within 30 days) and delayed (>30 days) BKP. Prior assumptions that early BKP might prevent AVFs, their findings underscore vertebral instability as a stronger predictor of subsequent fracture risk than surgical timing [1]. This conclusion adds valuable information to previous literature .
I particularly commend the methodical identification of vertebral instability as the key variable, supported by detailed radiologic assessments and multivariate analysis (odds ratio, 2.73; p=0.01). This finding resembles earlier reports such as Kim et al. [2], who emphasised segmental instability and kyphotic deformity as major AVF risk factors post-vertebroplasty.
While the article contributes meaningfully to our understanding, there are some limitations to be considered. The study rightly shifts focus away from procedural timing to biomechanical considerations. However, it stops short of exploring how the degree of cement augmentation itself (i.e., volume, distribution, and cement-bone interface quality) might interact, with vertebral biomechanics and fracture propagation, an area identified as crucial by Iida et al. [3] Including such variables could have enriched the risk stratification model and provided actionable surgical guidance.
Moreover, while vertebral instability is framed as a radiographic factor, it would be interesting to consider it in the context of dynamic pain response and physical function. Integrating objective functional scores or patient-reported outcome measures (PROMs) might offer a more holistic interpretation of when surgical intervention is truly needed, as suggested in the study by Minamide et al. [4] comparing early and delayed kyphoplasty.
Another area for potential elaboration is the role of systemic bone health management. The findings highlight instability as a key risk, yet bone quality itself, measured by bone mineral density, was not significantly associated with AVF in this cohort. This seems ineffective and raises questions about the concurrent osteoporosis treatment these patients received. The integration of pharmacologic therapy in such protocols could influence not just fracture healing but also the mechanical integrity of adjacent vertebrae [5].
Nonetheless, this study effectively redirects clinical focus toward patient-specific risk factors rather than procedural timelines. It also encourages a more individualised approach to intervention, an idea that is gaining traction across spine and orthopaedic specialities.
In summary, Yamamoto et al. [1] provide an advanced and better understanding of AVFs post-BKP. Their emphasis on vertebral instability rather than intervention timing is well supported and clinically meaningful. I encourage further prospective research incorporating imaging biomarkers, cement augmentation parameters, and osteoporosis management strategies to refine patient selection and improve long-term outcomes.
Notes
Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Author Contributions
Both authors contributed equally to the conceptualization, original draft writing, and reviewing and editing.