Impact of sarcopenia on outcomes of percutaneous vertebroplasty and kyphoplasty: a comprehensive meta-analysis

Pablo Palacios; Isabel Palacios; Pablo Arauz de Robles; Alejandro Lorente; Gonzalo Mariscal; María Benlloch; Juan Carlos Gutiérrez; Ana Palacios

doi:10.31616/asj.2025.0265

Asian Spine J > Volume 20(3); 2026 > Article

Palacios, Palacios, de Robles, Lorente, Mariscal, Benlloch, Gutiérrez, and Palacios: Impact of sarcopenia on outcomes of percutaneous vertebroplasty and kyphoplasty: a comprehensive meta-analysis

Review Article

Asian Spine Journal 2026;20(3):572-584.

Online first: January 21, 2026

DOI: https://doi.org/10.31616/asj.2025.0265

Impact of sarcopenia on outcomes of percutaneous vertebroplasty and kyphoplasty: a comprehensive meta-analysis

Pablo Palacios¹

, Isabel Palacios²

, Pablo Arauz de Robles³

, Alejandro Lorente⁴

, Gonzalo Mariscal⁵

, María Benlloch⁶

, Juan Carlos Gutiérrez¹

, Ana Palacios⁴

¹Department of Traumatology and Orthopaedic Surgery, University Hospital Madrid Sanchinarro, Madrid, Spain

²Hospital Universitario del Henares, Coslada, Spain

³Hospital Universitario de Toledo, Toledo, Spain

⁴Ankle and Foot Surgery Unit, Department of Traumatology and Orthopaedic Surgery, University Hospital Ramón y Cajal, Madrid, Spain

⁵Institute for Research on Musculoskeletal Disorders, School of Medicine, Catholic University of Valencia, Valencia, Spain

⁶Department of Basic Medical Sciences, Catholic University of Valencia, Valencia, Spain

Corresponding author: María Benlloch García, Department of Basic Medical Sciences, Catholic University of Valencia, San Vicente Mártir, 46001 Valencia, Spain,
Tel: +34-963637412, E-mail: maria.benlloch@ucv.es

Received May 8, 2025 Revised September 10, 2025 Accepted September 29, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

This meta-analysis evaluated the impact of sarcopenia on the efficacy and safety of percutaneous vertebroplasty and kyphoplasty in patients with osteoporotic vertebral compression fractures.

Methods

Following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, a systematic literature search was conducted to identify studies comparing outcomes between patients with and without sarcopenia undergoing vertebroplasty or kyphoplasty. Twelve studies involving 1,786 patients were included. The primary outcomes were pain (measured using the Visual Analog Scale), refractures, disability (using the Oswestry Disability Index), length of hospital stay, and mortality rates. Heterogeneity was assessed using the I² statistic. Mean differences (MDs) and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, applying a random-effects model when heterogeneity was present.

Results

Patients with sarcopenia experienced significantly higher pain (MD, 0.82; 95% CI, 0.47–1.17; p<0.00001), greater disability (MD, 5.70; 95% CI, 4.54–6.87; p<0.00001), and increased refracture risk (OR, 2.58; 95% CI, 1.13–5.89; p=0.02) compared with those without sarcopenia. Length of hospital stay was also longer, and mortality rates were significantly higher in the sarcopenia group.

Conclusions

Sarcopenia is an important risk factor for adverse outcomes after vertebroplasty and kyphoplasty. A systematic assessment of sarcopenia and the development of tailored perioperative strategies may help mitigate these risks and improve patient outcomes (PROSPERO registration no., CRD42024628263).

Keywords: Sarcopenia; Vertebroplasty; Kyphoplasty; Outcomes; Meta-analysis

Key Points

Patients with sarcopenia experienced significantly higher pain levels post-intervention and at 1 year after the procedure.
The risk of refracture was significantly higher in patients with sarcopenia.
Sarcopenia was associated with higher disability scores and longer hospital stays following vertebroplasty or kyphoplasty.
Mortality risk was significantly elevated in sarcopenic patients undergoing these procedures.

Graphical Abstract

Introduction

Osteoporosis and sarcopenia are major public health concerns that markedly increase the risk of fragility fractures, particularly among older adults [1,2]. Sarcopenia, defined as an age-related decline in muscle mass and function [3,4], affects up to 44% of patients undergoing orthopedic surgery [5] and substantially compromises health and quality of life, especially when it coexists with osteoporosis [6]. Vertebral compression fractures, the most common complication of osteoporosis, cause severe pain, reduced mobility, and diminished quality of life [7] and are associated with increased morbidity and mortality [8].

Vertebroplasty and kyphoplasty are minimally invasive treatments for vertebral compression fractures, which are often associated with osteoporosis and malignancy [9]. Vertebroplasty involves the direct injection of bone cement into the fractured vertebra, whereas kyphoplasty entails the use of balloon inflation to create a cavity before cement insertion. Although kyphoplasty may reduce complications such as cement leakage and infection [10,11], both procedures yield similar outcomes in terms of pain relief, quality of life, vertebral height restoration, and kyphotic angle correction. However, kyphoplasty is substantially more expensive than vertebroplasty [12], despite producing comparable results in the management of osteoporotic fractures.

Although sarcopenia commonly coexists with osteoporosis, it is an independent condition that may further increase the risk of fragility fractures, largely due to its association with falls in the elderly population [5]. Sarcopenia may therefore be an important consideration when evaluating the outcomes of vertebral augmentation procedures, as the combination of skeletal fragility and muscular weakness could influence both efficacy and safety [13].

Previous meta-analyses have compared the efficacy and complications of vertebroplasty and kyphoplasty in patients with cancer [14,15] or in the general population [16,17]; however, the effects of sarcopenia have not been well characterized. Other limitations include variations in study methodologies and patient selection criteria. Further investigation into the impact of sarcopenia on vertebral augmentation outcomes can provide insights for optimizing patient selection and management strategies. Moreover, understanding how sarcopenia influences recovery and complication rates may facilitate the development of tailored therapeutic approaches for patients with sarcopenia.

Therefore, this meta-analysis aimed to evaluate the impact of sarcopenia on the efficacy and safety of percutaneous vertebroplasty and kyphoplasty in the treatment of vertebral compression fractures.

Methods

Ethical approval and informed consent were not required for this study as it did not involve human or animal subjects.

Eligibility criteria

This meta-analysis was prospectively registered (PROSPERO CRD42024628263) and conducted according to a predefined protocol. The study adhered to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines (Fig. 1) [18]. The research question was formulated using the PICOS strategy: Population (P): patients undergoing vertebroplasty or kyphoplasty; Intervention (I): the intervention group comprised patients diagnosed with sarcopenia; Comparator (C): the comparator group comprised patients without sarcopenia; Outcome (O): primary outcomes were the effects of sarcopenia on the efficacy and safety of vertebroplasty or kyphoplasty, including pain, refractures, disability, length of hospital stay, and mortality rates; and Study design (S): eligible studies included prospective and retrospective cohort studies as well as randomized controlled trials.

Exclusion criteria were applied to ensure study quality and comparability. Case reports, systematic reviews, and literature reviews were excluded. Studies with duplicate data, high risk of bias, non-shared variables, non-comparable data, or missing data were also excluded.

Data sources

A comprehensive literature search was conducted in PubMed, Embase, Scopus, and the Cochrane Collaboration Library. No time restrictions were applied. References of eligible studies were manually screened to identify additional relevant studies.

Literature search strategy

The following search terms were used across all databases and trial registries: “sarcopenia,” “kyphoplasty,” “vertebroplasty,” and “vertebral augmentation” (Supplement 1). Two independent reviewers screened the records for eligibility, and any disagreements were resolved by consensus.

Data extraction and data items

Data were independently extracted by two authors, with a third author consulted in cases of disagreement. Baseline characteristics were documented for each study. Outcome measures of interest included the Visual Analog Scale (VAS) scores for pain, residual back pain (RBP), refractures, Oswestry Disability Index (ODI) scores, length of stay (LOS), and mortality.

Risk of bias assessment

The methodological quality of the observational studies was independently assessed by two reviewers using the Methodological Index for Non-Randomized Studies (MINORS) criteria (Table 1). This tool evaluates study design, patient selection, outcome measures, and follow-up. Scores range from 0 to 16 for non-comparative studies and 0 to 24 for comparative studies. For non-comparative studies, scores of 0–4 were considered very low quality, 5–7 low quality, 8–12 fair quality, and 13–16 high quality. For comparative studies, scores of 0–6 were deemed very low quality, 7–10 low quality, 11–15 fair quality, and 16–24 high quality. Any discrepancies in scoring between the two reviewers were resolved by discussion [19].

Statistical analysis

The meta-analysis was performed using the Review Manager (RevMan) ver. 5.4 (Cochrane Collaboration London, UK). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for dichotomous variables, and mean differences (MDs) with 95% CIs were calculated for continuous variables. Heterogeneity was assessed using the chi-square test and I² statistic. I² values of 25%, 50%, and 75% were interpreted as low, moderate, and high heterogeneity, respectively. A fixed-effects model was used if no significant heterogeneity was detected, and a random-effects model was applied in the case of significant heterogeneity. WebPlotDigitizer ver. 4.5 (https://automeris.io/) was used to extract data from figures when necessary. Missing data were handled in accordance with the Cochrane Handbook guidelines [20].

Publication bias assessment

Potential publication bias was evaluated using funnel plots in RevMan ver. 5.4. The vertical axis (y-axis) represented trial precision (standard error), and the horizontal axis (x-axis) represented effect size. Symmetry in the funnel plot suggested no significant publication bias, while asymmetry indicated possible non-publication of small trials with negative results or preferential publication of favorable results.

Additional analyses

Subgroup analyses were performed according to pain and disability assessment times (three groups: 1, 6, and 12 months post-intervention) and by intervention type (kyphoplasty or vertebroplasty) for refracture outcomes. Sensitivity analyses were performed to assess the robustness of findings by excluding the study with the highest weight for each outcome. All analyses were performed in RevMan ver. 5.4.

The quality of evidence and strength of recommendations were graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system implemented in GRADEpro (https://www.gradepro.org/). This approach considered study design, risk of bias, inconsistency, indirectness, imprecision, and the overall summary of findings [21].

Results

Study selection

Database searches (PubMed, EMBASE, Scopus, and the Cochrane Library) yielded 101 records. After title and abstract screening, 70 studies were excluded because they did not compare patients with and without sarcopenia, were unrelated to the study topic, explored other variables, were duplicates, or were case reports or reviews. The full texts of the remaining 31 studies were assessed, of which 19 were excluded for lacking shared variables, having a high risk of bias, being duplicate publications, or not being comparative studies. No additional studies were identified through reference screening. Ultimately, 12 studies were included in the meta-analysis (Fig. 1) [4,13,22–31].

Study characteristics

The 12 studies included 1,786 patients, 680 of whom had sarcopenia. Nine studies were conducted in China. The mean patient age ranged from 68 to 80 years. The inclusion criteria and baseline characteristics for the individual studies are summarized in Table 2, with additional details including mean T-scores and sarcopenia diagnostic criteria presented in Supplement 2.

Risk of bias

The methodological quality of the included studies, assessed using the MINORS tool, was considered high (Table 1).

Outcomes

Pain assessment (VAS and RBP)

Five studies evaluated pain using the VAS at 1, 6, and 12 months after kyphoplasty. Patients with sarcopenia had significantly higher VAS scores than those without sarcopenia at 1 month (MD, 1.30; 95% CI, 0.58–2.02; participants=447; studies=4; I²=93%; p=0.0004) and at 12 months (MD, 0.50; 95% CI, 0.31–0.70; participants=269; studies=2; I²=28%; p<0.00001). No significant differences were observed at 6 months (MD, 0.43; 95% CI, −0.07 to 0.94; participants=329; studies=3; I²=80%; p=0.09) (Fig. 2). When data from all time points were pooled (χ²=4.59, degree of freedom [df]=2; p=0.10), patients with sarcopenia had significantly greater pain than patients without sarcopenia (MD, 0.82; 95% CI, 0.47–1.17; participants=1,045; studies=5; I²=91%; p<0.00001).

Two studies assessed RBP after kyphoplasty, defined as postoperative moderate to severe pain (average VAS score ≥4) [32]. Patients with sarcopenia had a higher risk of RBP than those without sarcopenia (OR, 2.00; 95% CI, 1.11–3.59; participants=314; studies=2; I²=0%; p=0.02) (Fig. 3).

Disability assessment

All disability outcomes were reported in studies where kyphoplasty was the intervention. Four studies assessed the ODI at 1 month, and two at 6 and 12 months. Consequently, subgroups were created based on the timing of the ODI assessment. Significant differences were found at 1 month (MD, 5.27; 95% CI, 3.30–7.24; participants=447; studies=4; I2=86%; p<0.00001), at 6 months (MD, 5.12; 95% CI, 3.93–6.31; participants=269; studies=2; I²=0%; p<0.00001) and 12 months (MD, 6.96; 95% CI, 5.70–8.21; participants=269; studies=2; I²=56%; p<0.00001), showing higher disability in patients with sarcopenia. When data from all subgroups were pooled, these results remained significant (Fig. 4).

Refracture risk

Eight studies provided refracture data. Sarcopenia was associated with a higher risk of refracture after kyphoplasty (OR, 4.05; 95% CI, 1.55–10.63; studies=5; I²=87%; p=0.004) and after percutaneous vertebral augmentation without differentiation between vertebroplasty or kyphoplasty (OR, 2.79; 95% CI, 1.33–5.87; studies=1; p=0.007) (Fig. 5). One study comparing vertebroplasty in patients with sarcopenia only (without osteoporosis) to those with osteoporosis found no significant difference (OR, 0.38; 95% CI, 0.05–2.73; studies=1; p=0.33). Pooled analysis across all subgroups confirmed a higher risk of refracture in patients with sarcopenia (OR, 2.58; 95% CI, 1.13–5.89; studies=8; p=0.02) (Fig. 5).

LOS analysis

Two studies (Wang et al. [29] in 2021 and Yin et al. [31] in 2024) reported LOS after kyphoplasty, finding a significantly shorter stay in patients without sarcopenia (MD, 1.40; 95% CI, 1.06–1.73; studies=2; I²=0%; p<0.00001) (Supplement 3).

Mortality risk

Two studies (Bayram et al. [4] in 2020 and Yin et al. [31] in 2024) examined mortality after percutaneous vertebral augmentation and reported a significantly higher risk in patients with sarcopenia (OR, 19.74; 95% CI, 1.98–196.44; studies=2; I²=53%; p=0.01) (Supplement 4).

Additional analysis

Sensitivity analyses excluding the study with the highest weight for each outcome did not materially change the results (Supplement 5).

Publication bias

Visual inspection of funnel plots revealed no asymmetry for VAS score, refractures, disability, or mortality (Supplement 6). Funnel plots for RBP and LOS also appeared symmetrical (Supplement 6).

Quality of evidence (GRADE)

The GRADE summary of findings is shown in Table 3. The certainty of evidence was very low for VAS and refracture outcomes, low for LOS, and moderate for disability. Publication bias was detected primarily through funnel plots, and inconsistencies were assessed using forest plots.

Discussion

This meta-analysis evaluated the effects of sarcopenia on the efficacy and safety of percutaneous vertebroplasty and kyphoplasty in patients with vertebral compression fractures. Twelve studies, including 1,786 patients, were analyzed. Patients with sarcopenia had significantly higher post-intervention pain levels, particularly at 1 and 12 months, compared to those without sarcopenia. They also showed a markedly increased likelihood of refracture with both kyphoplasty and vertebroplasty, higher disability scores, longer hospital stays, and higher mortality rates. Although the included studies were generally of high quality, most were retrospective, and some lacked detailed reporting of patient losses during follow-up.

Osteoporosis and sarcopenia, characterized by loss of bone and muscle, respectively, are major contributors to fracture risk [6,33]. Osteoporotic vertebral fractures can lead to pain, reduced function, and reduced quality of life [34], effects that are amplified in patients with sarcopenia [35]. Although conservative care is standard, vertebroplasty and kyphoplasty provide effective pain relief and correction of deformity, with both improving pain and quality of life [12]. The choice of procedure depends on patient factors and fracture characteristics.

Sarcopenia has been shown to adversely affect outcomes after orthopedic procedures, including vertebral augmentation [36]. Patients with sarcopenia often present with lower bone mineral density, greater frailty, and reduced functional capacity [37,38], increasing their risk of complications and poor outcomes. Sarcopenia may also compromise spinal stability and predispose to refracture after surgery. Recognizing sarcopenia and its severity is therefore essential for planning vertebral augmentation and postoperative care. Notably, our findings indicate that patients with sarcopenia experience worse outcomes than those without sarcopenia, both in the short term (1 month) and long term (1 year), which can guide patient expectations and clinical management in this vulnerable group.

In this meta-analysis, patients with sarcopenia showed higher pain levels at 1 and 12 months post-intervention. This is consistent with studies suggesting that sarcopenia negatively influences pain outcomes after vertebral augmentation procedures [39,40]. However, some studies, such as that by Ohyama et al. [26], found no significant difference between patients with sarcopenia and those without sarcopenia, suggesting that sarcopenia may not be a key determinant of the outcomes of kyphoplasty for acute osteoporotic vertebral fractures.

The disability analysis showed higher ODI scores in patients with sarcopenia at all follow-up points (Fig. 4), which aligns with the broader understanding of the impact of sarcopenia on functional outcomes. Reduced muscle strength and impaired physical function likely contribute to greater disability following vertebral fractures and their treatment [4]. Comprehensive rehabilitation following intervention may therefore help optimize functional outcomes in these patients. Evidence suggests that patients with sarcopenia have poorer functional results in both the short and long term, emphasizing the importance of effective rehabilitation strategies to mitigate these adverse effects and improve recovery and overall quality of life [24].

The risk of refracture after vertebroplasty or kyphoplasty was also higher in patients with sarcopenia (Fig. 5). This contrasts with the findings of Kara and Ozturk [25], who reported no significant differences between patients with osteoporosis and those with sarcopenia alone. However, their study did not evaluate sarcopenia in patients with osteoporosis, potentially underestimating its impact on prognosis and quality of life. Given the higher refracture risk, early referral to rheumatology may be beneficial, especially since sarcopenia frequently coexists with osteoporosis [41]. Our findings are in line with most studies supporting the role of sarcopenia in spinal instability and increased fracture susceptibility [42]. Therefore, sarcopenia should be considered a key risk factor when assessing candidates for vertebral augmentation. However, some studies, such as the one by Gewiess et al. [43], have found no conclusive evidence of the link between sarcopenia, refractures, and falls.

Longer hospital stays in patients with sarcopenia are plausible given their greater frailty and the potential need for extended rehabilitation. This is corroborated by our results, showing that these patients experienced higher pain levels, which could complicate recovery. The included studies did not fully assess the range of postoperative complications, but it is reasonable to assume that individuals with sarcopenia are more prone to conditions such as pneumonia, postoperative bleeding, and septicemia [44], which could contribute to prolonged hospitalization and delayed recovery.

The observed higher mortality rates in patients with sarcopenia undergoing percutaneous vertebral augmentation (32/94 vs. 2/110 in non-sarcopenic patients) are clinically significant (Supplement 4). Sarcopenia is often associated with multiple comorbidities and increased frailty, which together drive postoperative mortality [45]. These findings underscore the importance of careful patient selection and comprehensive preoperative evaluation of sarcopenic individuals undergoing these interventions.

This study has several limitations. First, because the objective was to examine whether patients diagnosed with sarcopenia after vertebroplasty or kyphoplasty interventions experienced more complications than those without sarcopenia, the included studies were not randomized clinical trials, which would have been ideal for a meta-analysis. Eleven of the 12 studies had a retrospective design. Retrospective studies are inherently susceptible to selection and information bias due to their reliance on existing data that may not be uniformly collected or comprehensively documented. This limitation restricts our ability to draw causal inferences between sarcopenia and outcomes of percutaneous vertebral augmentation. Future prospective studies are needed to address these issues. Second, some studies had limited follow-up periods (1, 3, or 6 months), potentially underestimating the long-term effects of sarcopenia on outcomes such as refractures, disabilities, and mortality. A longer follow-up is necessary to capture the full spectrum of complications and to evaluate the durability of treatment effects. Third, data on vertebral fracture severity in relation to sarcopenia status were scarce. Only two studies (Lidar et al. [13] in 2022; Wu et al. [30] in 2024) addressed fracture classification or timing, and neither provided sufficient detail or stratification by sarcopenia status. Consequently, we could not assess whether sarcopenia was associated with more severe vertebral fractures. Fourth, there was notable heterogeneity among the included studies in terms of patient demographics, sarcopenia assessment methods, and surgical techniques. This variability may complicate direct comparisons of results. Although subgroup and sensitivity analyses were performed to minimize heterogeneity, residual variability may persist. Different methods for assessing sarcopenia (e.g., various computed tomography-based approaches or dual-energy X-ray absorptiometry) may also have contributed to inconsistent findings. Standardized diagnostic and classification criteria for sarcopenia are therefore essential to ensure consistency and comparability in future research. Fifth, funnel plot analysis revealed significant asymmetry for most outcomes, suggesting that publication bias cannot be entirely ruled out. Finally, the findings of this meta-analysis are specific to percutaneous vertebroplasty and kyphoplasty and may not be generalizable to other treatments for osteoporotic vertebral compression fractures. Comparative studies evaluating different treatment modalities are needed to determine the optimal approach for managing fractures in patients with sarcopenia.

Conclusions

This meta-analysis found a significant association between sarcopenia and adverse outcomes after percutaneous vertebroplasty and kyphoplasty for osteoporotic vertebral compression fractures. Compared with patients without sarcopenia, those with sarcopenia had higher pain levels, greater disability, increased refracture risk, longer hospital stays, and higher mortality rates. These findings establish sarcopenia as an important risk factor that should be systematically evaluated when selecting candidates for vertebral augmentation procedures and highlight the need for tailored perioperative management strategies in this vulnerable population.

Notes

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Acknowledgments

Primary data availability for the systematic literature review are in the referenced publications.

Author Contributions

Conceptualization: PP, IP, PAdR, AL, GM, MB, JCG, AP. Data curation: PP, IP, GM, MB, JPG, AP. Formal analysis: PP, IP, PAdR, AL, GM, MB. Funding acquisition: NA. Methodology: PP, IP, PAdR, AL, GM, MB, JCG, AP. Project administration: NA. Visualization: PP, IP, PAdR, AL, GM, MB. Writing–original draft: PP, IP, PAdR, AL, GM, MB, JCG, AP. Writing–review & editing: PP, GM, MB, JCP, AP. Final approval of the manuscript: all authors.

Supplementary Materials

Supplementary materials can be available from https://doi.org/10.31616/2025.0265.

Supplement 1. Research in PUBMED database.

asj-2025-0265-Supplement-1.pdf

Supplement 2. Comparative table of T-scores by study.

asj-2025-0265-Supplement-2.pdf

Supplement 3. Length of stay after kyphoplasty analysis.

asj-2025-0265-Supplement-3,4,5.pdf

Supplement 4. Forest plot of mortality in both types of patients.

asj-2025-0265-Supplement-3,4,5.pdf

Supplement Forest plot of mortality in both types of patients.

asj-2025-0265-Supplement-3,4,5.pdf

Supplement 6. Forest plot of mortality in both types of patients.

asj-2025-0265-Supplement-6.pdf

Fig. 1

Study selection flow diagram (Preferred Reporting Items for Systematic Reviews and Meta-analyses).

Fig. 2

Forest plot showing Visual Analog Scale (VAS) pain outcomes at different follow-up times. VAS pain showing higher level of pain in patients with sarcopenia at 1 and 12 months. No significant differences were observed at 6 months. SD, standard deviation; IV, inverse variance; CI, confidence interval; df, degree of freedom. ^a)CI calculated by Wald-type method. ^b)Tau² calculated by DerSimonian and Laird method.

Fig. 3

Forest plot of residual back pain analysis showing significant differences in favor of patients without sarcopenia (odds ratio, 2.00; 95% confidence interval [CI], 1.11 to 3.59). M–H, Mantel-Haenszel; df, degree of freedom.

Fig. 4

Forest plot of disability assessment. The analysis showed significantly worse Oswestry Disability Index (ODI) scores in patients with sarcopenia at different follow-up times. SD, standard deviation; IV, inverse variance; CI, confidence interval; df, degree of freedom. ^a)CI calculated by Wald-type method. ^b)Tau² calculated by DerSimonian and Laird method.

Fig. 5

Forest plot measuring risk of refractures. Results showed a significantly higher risk of refractures in patients with sarcopenia. OR, odds ratio; SE, standard error; IV, inverse variance; CI, confidence interval; df, degree of freedom. ^a)CI calculated by Wald-type method. ^b)Tau² calculated by DerSimonian and Laird method.

Table 1

Assessment of the quality of studies through MINORS

Study	Clearly stated aim	Consecutive patients	Prospective collection data	Endpoints	Assessment endpoint	Follow-up period	Loss less than 5%	Study size	Adequate control group	Contemporary group	Baseline control	Statistical analyses	MINORS
Bayram et al. [4] (2020)	2	2	0	0	2	2	0	2	2	2	2	2	18
Bo et al. [22] (2022)	2	2	0	0	2	2	0	2	2	2	2	1	17
Chen et al [23] (2022)	2	2	0	2	2	1	0	2	2	2	2	2	19
Jing et al. [24] (2023)	2	2	0	2	1	0	0	0	2	2	2	2	16
Kara and Ozturk [25] (2023)	2	2	0	2	2	2	0	2	2	2	2	2	20
Lidar et al. [13] (2022)	2	1	0	1	2	2	0	2	2	2	2	2	18
Ohyama et al. [26] (2021)	2	2	2	2	2	2	2	1	2	2	2	2	23
Peng et al. [27] (2023)	2	2	0	2	2	2	0	2	2	2	2	2	20
Wang et al. [28] (2019)	2	2	0	2	2	2	0	2	2	1	2	2	19
Wang et al. [29] (2021)	2	2	0	2	2	2	0	1	2	1	2	2	18
Wu et al. [30] (2024)	2	2	0	2	2	2	0	2	2	2	2	2	20
Yin et al. [31] (2024)	2	2	0	2	2	2	0	1	2	2	2	2	19

MINORS, Methodological Index for Non-Randomized Studies.

Table 2

Baseline characteristics of the 12 included studies

Study	Region	Period	Type of study	Follow-up (mo)	Total Group 1/Group 2	Age (yr) Group 1/Group 2	Female Group 1/Group 2	Study		Inclusion criteria
Study	Region	Period	Type of study	Follow-up (mo)	Total Group 1/Group 2	Age (yr) Group 1/Group 2	Female Group 1/Group 2	Group 1	Group 2	Inclusion criteria
Bayram et al. [4] (2020)	Turkey	2009–2018	Retrospective study	48.27±38.67	51/52	75/69.33	31/33	Low PVLI (sarcopenic)	High PVLI (non-sarcopenic)	Vertebroplasty or kyphoplasty
Bo et al. [22] (2022)	China	2015–2020	Retrospective study	>12	56/100a)	70.2/69.5	35/67	Residual back pain	Non-residual back pain	Percutaneous vertebroplasty
Chen et al. [23] (2022)	China	2017–2019	Retrospective study	3	69/145	80.76/76.64	55/99	Sarcopenia	Non-sarcopenia	Percutaneous kyphoplasty
Jing et al. [24] (2023)	China	2020–2021	Retrospective study	1	38/338a)	76.21/69.71	305 total	Refracture group	Non-refracture group	Percutaneous kyphoplasty
Kara and Ozturk [25] (2023)	Turkey	2016–2021	Retrospective study	30.57±19.84	10OS/40OSP/54OO	74.79±8.68	74	OS/OSP	OO	Vertebroplasty because of a thoracic or lumbar vertebral fracture
Lidar et al. [13] (2022)	China	2007–2017	Retrospective case–control study	24	26/63a)	80.1/80.2	21/37	Refracture group	Non-refracture group	Percutaneous vertebral augmentation
Ohyama et al. [26] (2021)	Japan	2016–2017	Prospective study	6	39/21	78.4/76.9	31/16	Sarcopenia	Non-sarcopenia	kyphoplasty
Peng et al. [27] (2023)	China	2021–2022	Retrospective study	6	45/56	69.4/68.7	24/31	Sarcopenia	Non-sarcopenia	Percutaneous kyphoplasty
Wang et al. [28] (2019)	China	2016–2017	Retrospective study	12	48/189	75.15/69.46	38/163	Sarcopenia	Non-sarcopenia	Percutaneous kyphoplasty
Wang et al. [29] (2021)	China	2017–2018	Retrospective study	12	34/43	80,24/75.12	14/27	Sarcopenia	Non-sarcopenia	Percutaneous kyphoplasty
Wu et al. [30] (2024)	China	2021–2022	Retrospective study	12	43/125	74.0/74.0	28/97	Sarcopenia	Non-sarcopenia	Percutaneous kyphoplasty
Yin et al. [31] (2024)	China	2016–2019	Retrospective study	36	43/58	79.16/74.05	25/26	Sarcopenia	Non-sarcopenia	Percutaneous kyphoplasty

Values are presented as mean±standard deviation or number.

PLVI, psoas lumbar vertebral index; OS group, only sarcopenia; OO group, only osteoporosis; OSP group, osteosarcopenia.

^a) Number of patients with sarcopenia: 40 patients in Bo et al. [22] (2022), 177 in Jing et al. [24] (2023), and 41 in Lidar et al. [13] (2022).

Table 3

Grade assessment of included outcomes

Variable	No. of studies	Certainty assessment						No. of patients		Effect		Certainty	Importance

		Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Sarcopenia	Non-sarcopenia	Relative (95% CI)	Absolute (95% CI)
VAS	5	Non-randomised studies	Not serious	Not serious	Not serious	Not serious	Publication bias strongly suspecteda)	204	303	-	MD 0.82 higher (0.47 higher to 1.17 higher)	Very lowa)	Critical

Refractures	8	Non-randomised studies	Not serious	Seriousb)	Not serious	Not serious	Publication bias strongly suspected; strong associationa)			OR 2.58 (1.13 to 5.89)	3 fewer per 1,000 (from 6 fewer to 1 fewer)	Very lowa),b)	Critical

Disability	4	Non-randomised studies	Not serious	Not serious	Not serious	Not serious	Publication bias strongly suspected; very strong associationa)	165	282	-	MD 5.7 higher (4.54 higher to 6.87 higher)	Moderatea)	Critical

LOS	2	Non-randomised studies	Not serious	Not serious	Not serious	Not serious	None	77	101	-	MD 1.4 higher (1.06 higher to 1.73 higher)	Low	Critical

CI, confidence interval; VAS, Visual Analog Scale; MD, mean difference; OR, odds ratio; LOS, length of stay.

^a) Publication bias detected through the funnel plots.

^b) Inconsistency assessed by forest plots.

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