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

Article information

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

Publication date (electronic) : 2026 January 21

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

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 2025 May 8; Revised 2025 September 10; Accepted 2025 September 29.

Abstract

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.

Fig. 1

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

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.

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].

Table 1

Assessment of the quality of studies through MINORS

Results

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.

Table 2

Baseline characteristics of the 12 included studies

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).

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.

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).

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.

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).

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.

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).

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.

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.

Table 3

Grade assessment of included outcomes

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.

Supplementary Materials

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