Commentary on “Risk factors for cement leakage after percutaneous vertebral augmentation for osteoporotic vertebral compression fractures: a meta-analysis”

Dear Editor, We read with great interest the meta-analysis by Wu et al, titled “Risk factors for cement leakage after percutaneous vertebral augmentation for osteoporotic vertebral compression fractures: a meta-analysis”[1]. This study provides a comprehensive and timely synthesis of anatomical and surgical factors contributing to cement leakage (CL), a common and potentially serious complication of percutaneous vertebral augmentation. Our commentary was prepared in accordance with the TITAN 2025 guidelines for transparency in artificial intelligence reporting[2]. We commend the authors for their rigorous methodology and clinically relevant findings, which offer valuable guidance for spine surgeons in risk stratification and procedural planning. Two aspects of the proposed risk model may benefit from further contextualization to enhance its clinical applicability. First, while cortical bone integrity, intravertebral vacuum cleft (IVC), and basivertebral foramen sign are convincingly identified as significant anatomical predictors, their integration into preoperative decision-making could be strengthened through standardized imaging criteria. For instance, the degree of cortical disruption (e.g., focal vs. circumferential) and the dimensions of the basivertebral foramen on CT sagittal reconstructions may influence not only the risk of leakage but also the choice of surgical approach and cement viscosity. Establishing quantitative thresholds – possibly through CT-based morphometric analysis – could help standardize risk assessment across institutions and reduce interpretive variability[3]. Second, the meta-analysis highlights cement volume as a modifiable risk factor, yet the discussion on optimal volume thresholds remains generalized. In clinical practice, the balance between achieving adequate vertebral height restoration and minimizing leakage risk is nuanced. A more explicit discussion on volume titration strategies – guided by fracture morphology, vertebral body volume, and intraoperative fluoroscopic feedback – would assist surgeons in individualizing cement injection. Additionally, while surgical method (percutaneous vertebroplasty [PVP] vs. percutaneous kyphoplasty [PKP]) was not found to be an independent risk factor in the pooled analysis, the reported incidence difference (PVP 36% vs. PKP 18%) warrants careful interpretation. Clarifying the role of surgical technique in specific fracture subtypes (e.g., those with IVC or severe cortical disruption) could further refine procedural selection[4]. We also note the emphasis on preoperative imaging evaluation to identify high-risk anatomical features. While the meta-analysis provides strong evidence for cortical integrity and IVC, practical intraoperative strategies to mitigate leakage – such as staged cement injection, use of high-viscosity cement, or real-time fluoroscopic monitoring – could be further elaborated to enhance procedural safety. In summary, we congratulate the authors on a methodologically sound and clinically informative meta-analysis. Refining imaging-based risk criteria with quantitative metrics, elaborating cement volume guidance, and clarifying technique-specific considerations may further optimize the prevention of CL and support the development of individualized treatment protocols for osteoporotic vertebral compression fractures. Sincerely,