Startseite Risk factors for progressive kyphosis after percutaneous kyphoplasty in osteoporotic vertebral compression fracture
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Risk factors for progressive kyphosis after percutaneous kyphoplasty in osteoporotic vertebral compression fracture

  • Cong Jin , Lei He , Xi Chen , Jiewen Zheng , Wei He und Weiqi Han EMAIL logo
Veröffentlicht/Copyright: 9. Dezember 2024
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Open Medicine
Aus der Zeitschrift Open Medicine Band 19 Heft 1

Abstract

Purpose

To investigate the risk factors associated with progressive kyphosis (PK) after percutaneous kyphoplasty (PKP) in osteoporotic vertebral compression fractures (OVCFs).

Methods

A single-center retrospective study (January 2020 to December 2022) analyzed 129 OVCF patients treated with PKP. Patients were divided into a PK group and a non-progressive kyphosis group. Clinical and radiological data were compared, and univariate and multivariate regression analyses identified independent risk factors for PK. A nomogram was then developed to predict the risk factors for PK after PKP.

Results

Of 129 patients, 47 (36.4%) experienced PK after PKP. Multivariate analysis identified independent risk factors for PK as preoperative kyphosis angle (OR = 1.26, P = 0.008), Type D magnetic resonance image (MRI) signal change on T2-weighted images (T2WI) (OR = 18.49, P = 0.003), black line signal (OR = 44.00, P < 0.001), intervertebral disc endplate complex (IDEC) injury (OR = 7.86, P = 0.021), and postoperative Oswestry Disability Index (ODI) score (OR = 1.18, P = 0.004). The nomogram, based on these factors, demonstrated strong discriminative performance (area under the curve = 0.953) and good calibration.

Conclusions

Preoperative kyphosis angle, Type D MRI signal change on T2WI, black line signal, IDEC injury, and higher postoperative ODI score are independent risk factors for PK after PKP. A nomogram based on these factors accurately predicts PK risk.

Keywords: risk factors; kyphosis; kyphoplasty; osteoporotic fractures; nomograms

1 Introduction

Osteoporotic vertebral compression fractures (OVCFs) are the most common fractures in patients with osteoporosis, capable of causing acute or chronic low back pain, kyphosis deformity, and cardiopulmonary dysfunction. These conditions can significantly impact patients’ quality of life, leading to high morbidity and mortality rates [1,2,3]. Percutaneous kyphoplasty (PKP) is considered an effective treatment for OVCFs, as it can restore the strength and stability of the vertebral body, providing significant pain relief [1,4]. Compared to conservative treatment, PKP significantly reduces the risk of complications such as pneumonia, deep vein thrombosis, and pressure sores caused by long-term bed rest, thereby lowering morbidity and mortality rates associated with OVCFs [3,5]. Papanastassiou et al. reported that compared to non-surgical treatment, PKP provided greater pain relief and fewer subsequent fractures in the treatment of OVCFs. PKP showed a slight advantage over percutaneous vertebroplasty (PVP) in terms of disability improvement and significantly outperformed PVP in enhancing quality of life [6]. Similarly, the study by Lange et al. demonstrated that patients with OVCFs who underwent surgical treatment had a higher overall survival rate compared to those receiving non-surgical treatment, with PKP patients potentially experiencing a survival advantage over those treated with PVP [7]. Svedbom et al. suggested that, in the United Kingdom, PKP may represent a cost-effective strategy for treating hospitalized patients with acute OVCFs compared to non-surgical treatment and PVP [8].

While PKP is associated with the risk of bone cement leakage and adjacent segment fractures, the literature reports incidences ranging from 5 to 40% for cement leakage and 5–15% for adjacent segment fractures within 1 year postoperatively [1–3,9]. Although previous literature has predominantly focused on the risk of bone cement leakage and adjacent segment fractures after PKP, few literature studies indicate a potential for further loss of vertebral height and recurrent kyphotic deformities after PKP. Additionally, it has been identified as a potential cause of postoperative residual pain [10,11]. Various factors may contribute to this, including the severity of OVCFs, residual postoperative kyphotic deformity, severity of osteoporosis, degeneration of adjacent intervertebral discs, and imbalance or weakness of paraspinal muscles [3,5,11–13].

To date, there have been no literature reports on the risk factors for progressive kyphosis (PK) after PKP for OVCFs. In the current study, clinical and radiological data from 129 OVCF patients who underwent PKP were retrospectively analyzed. The associations between various variables and PK were examined through univariate and multivariate regression analyses. Subsequently, a nomogram was developed to predict the risk factors for PK after PKP.

2 Materials and methods

2.1 Study design

From January 2020 to December 2022, a single-center retrospective study was conducted at Shaoxing People’s Hospital, retrospectively analyzing 129 patients with OVCFs treated with PKP. Based on whether PK occurred at the last follow-up, patients were divided into a PK group and a non-progressive kyphosis (NPK) group. Referring to previous literature, if the final follow-up kyphosis angle (KA) difference is greater than 10°, we define it as PK [14]. Clinical and radiological data of the two groups were compared, and a nomogram was developed to predict the risk factors for PK after PKP for OVCFs.

2.2 Participants

The inclusion criteria for this study consisted of patients aged over 60 years with single-segment OVCF caused by low-energy trauma, treated with PKP, preoperative bone mineral density (BMD) examination results of ≤−1.0 standard deviations (SD), and a minimum follow-up duration of 1 year. Exclusion criteria included secondary osteoporosis resulting from prolonged glucocorticoid use, endocrine disorders, and spinal infections; pathological fractures induced by primary or metastatic spinal tumors; and patients with severe cardiopulmonary insufficiency and coagulation disorders who were intolerant of surgery.

2.3 PKP

The same two surgeons performed all operations with the aid of C-arm fluoroscopy. The patient was in a prone position, with the chest and iliac crest elevated, and the abdomen suspended. Thereafter, the OVCF was reduced in the hyperextension position, and the needle entry point was marked under C-arm fluoroscopy guidance. Unilateral or bilateral transpedicular puncture was performed until the tip of the puncture cannula reached the anterior and middle thirds of the vertebral body in the lateral view. Subsequently, a working channel was created. After balloon expansion through the working channel implantation, bone cement (Heraeus, Germany) was gradually injected into the vertebral bodies. The patients could move freely with a soft brace 24 h postoperatively and received anti-osteoporosis treatment for 12 months. All PKP surgical instruments used during the procedure were manufactured by Canwell Company (Jinhua, China). Anti-osteoporotic management included daily oral administration of calcitriol at a dosage of 0.25 µg (Catalent Germany Eberbach GmbH, Eberbach, Germany) and calcium carbonate at 600 mg (Haleon, Suzhou, China). Zoledronic acid infusions (5 mg, Novartis, Basel, Switzerland) were initiated intravenously on the first postoperative day, with subsequent infusions administered annually for a 3-year course.

2.4 Baseline data outcomes

The baseline data for all patients were directly obtained from the hospital’s medical record information system, including gender, age, fracture location, height, weight, BMD, history of hypertension and diabetes, smoking status, alcohol consumption, and fracture type. BMD was measured using dual-energy X-ray absorptiometry, with the measured BMD being the average value from L1 to L4, excluding the fractured vertebra.

2.5 Radiographic outcomes

Radiological evaluation parameters, encompassing vertebral height loss (VHL) and KA, were assessed using electronic measurement tools integrated into the Picture Archiving and Communication System (PACS V3.0, Zhejiang Rad Information Technology Company, Hangzhou, China). These measurements were conducted by two radiologists, and the results were subsequently averaged. To minimize evaluation bias, all assessments were conducted in a blinded manner. The radiologists performing the evaluations were unaware of the clinical details and treatment assignments of the patients, ensuring objectivity in the assessments.

The VHL was measured on lateral X-rays preoperatively, postoperatively, and at the last follow-up. The methodology for VHL measurement is elucidated in Figure 1. The postoperative VHL difference denotes the subtraction of preoperative VHL from postoperative VHL. The VHL improvement rate is calculated as the postoperative VHL difference divided by preoperative VHL, multiplied by 100%. Furthermore, the VHL difference at the last follow-up is defined as the subtraction of VHL at the last follow-up from postoperative VHL.

Figure 1 Measurement method for VHL and KA. (1) The KA (β) was measured as the angle between the superior endplate of the vertebra above and the inferior endplate of the vertebra below on lateral radiography. (2) (a) Anterior height of the cranial vertebrae, (b) posterior height of the cranial vertebrae, (c) anterior height of the caudal vertebrae, (d) posterior height of the caudal vertebrae, (e) anterior height of the fractured vertebrae, (f) posterior height of the fractured vertebrae. VHL = ( a + b + c + d ) 4 − ( e + f ) 2 ( a + b + c + d ) 4 × 100 % \left[\frac{\frac{(a+b+c+d)}{4}-\frac{(e+f)}{2}}{\frac{(a+b+c+d)}{4}}\right]\times 100 \% .
Figure 1

Measurement method for VHL and KA. (1) The KA (β) was measured as the angle between the superior endplate of the vertebra above and the inferior endplate of the vertebra below on lateral radiography. (2) (a) Anterior height of the cranial vertebrae, (b) posterior height of the cranial vertebrae, (c) anterior height of the caudal vertebrae, (d) posterior height of the caudal vertebrae, (e) anterior height of the fractured vertebrae, (f) posterior height of the fractured vertebrae. VHL = ( a + b + c + d ) 4 − ( e + f ) 2 ( a + b + c + d ) 4 × 100 % .

The KA was measured preoperatively, postoperatively, and at the last follow-up as the angle between the superior endplate of the vertebra above and the inferior endplate of the vertebra below on lateral radiography (Figure 1). Postoperative KA difference is determined by subtracting preoperative KA from postoperative KA. The KA improvement rate is computed as the postoperative KA difference divided by preoperative KA, multiplied by 100%. Similarly, the KA difference at the last follow-up is defined as the subtraction of KA at the last follow-up from postoperative KA. If the KA difference at the last follow-up exceeded 10°, it was classified as PK.

2.6 Magnetic resonance image (MRI) evaluation

Thoracolumbar MRI examinations were undertaken for all patients preoperatively using a 1.5 T MRI device (Siemens, Germany) equipped with a spine coil. The examination protocol comprised T1-weighted spin echo (SE) sagittal, T2-weighted SE axial, T2-weighted SE sagittal, and short tau inversion recovery (STIR) sagittal sections. Diagnosis of recent OVCF was established based on the presence of a hypointense signal on T1-weighted images. Furthermore, classifications of MRI signal changes on T2-weighted images (T2WI) [15] were obtained (Figure 2a–d). Data pertaining to black line signal (Figure 2e and f) and homogeneous high signal (Figure 2g and h) were derived from STIR images [16], while evaluation of the integrity of the intervertebral disc endplate complex (IDEC) was conducted on T2WI [17,18] (Figure 2i and j).

Figure 2 Fracture assessment on magnetic resonance imaging. (a)–(d) Subtyping based on MRI signal changes on T2WI. (a) Type A – confined high signal change (yellow arrow), (b) Type B – diffuse high signal change (yellow arrow), (c) Type C – confined low signal change (yellow arrow), and (d) Type D – diffuse low signal change (yellow arrow). (e) and (f) Typical black line signal change on STIR images. Black line signal is defined as a black line exceeding half of the anteroposterior diameter of the vertebral body on STIR images. (e) Typical black line signal (yellow arrow) and (f) non-black line signal. (g) and (h) Typical homogeneous high signal change on STIR images. Homogeneous high signal is defined as an area of homogeneous high signal exceeding half of the vertebral body area on STIR images. (g) Typical homogeneous high signal (yellow arrow) and (h) non-homogeneous high signal. (i) and (j) Assessment of IDEC integrity on T2WI. (i) Injury to the IDEC above the fractured vertebra (yellow arrow). (j) Intact IDEC both above and below the injured vertebra. T2WI: T2-weighted images; STIR: short tau inversion recovery; IDEC: intervertebral disc endplate complex.
Figure 2

Fracture assessment on magnetic resonance imaging. (a)–(d) Subtyping based on MRI signal changes on T2WI. (a) Type A – confined high signal change (yellow arrow), (b) Type B – diffuse high signal change (yellow arrow), (c) Type C – confined low signal change (yellow arrow), and (d) Type D – diffuse low signal change (yellow arrow). (e) and (f) Typical black line signal change on STIR images. Black line signal is defined as a black line exceeding half of the anteroposterior diameter of the vertebral body on STIR images. (e) Typical black line signal (yellow arrow) and (f) non-black line signal. (g) and (h) Typical homogeneous high signal change on STIR images. Homogeneous high signal is defined as an area of homogeneous high signal exceeding half of the vertebral body area on STIR images. (g) Typical homogeneous high signal (yellow arrow) and (h) non-homogeneous high signal. (i) and (j) Assessment of IDEC integrity on T2WI. (i) Injury to the IDEC above the fractured vertebra (yellow arrow). (j) Intact IDEC both above and below the injured vertebra. T2WI: T2-weighted images; STIR: short tau inversion recovery; IDEC: intervertebral disc endplate complex.

2.7 Clinical outcomes

Clinical outcomes were evaluated through the utilization of a visual analog scale (VAS) [19] and the Oswestry Disability Index (ODI) [20]. Measurement of pain on the VAS was performed, with zero representing the absence of pain and ten signifying intolerable pain. Assessment of pain levels occurred at preoperative, postoperative, and last follow-up time points. Self-assessment of disability using the ODI was conducted concurrently at the preoperative, postoperative, and last follow-up stages.

2.8 Operative outcomes

Operative data, encompassing operative time, unilateral or bilateral puncture, and volume of injected bone cement, were directly extracted from the surgical records in the hospital’s electronic medical record system. In alignment with previous literature [21], the assessment of bone cement form classifications was conducted based on postoperative lateral X-rays (Figure 3). Furthermore, postoperative X-rays in both anteroposterior and lateral views were employed to ascertain the presence of bone cement leakage and determine its location.

Figure 3 Classification of bone cement form on lateral radiography. (a) Type A – bone cement contacts only the superior endplate of the vertebral body. (b) Type B – bone cement extends only to the inferior endplate of the vertebral body. (c) Type C – bone cement contacts both the superior and inferior endplates of the vertebral body simultaneously. (d) Type D – bone cement does not contact either the superior or the inferior endplate of the vertebral body simultaneously.
Figure 3

Classification of bone cement form on lateral radiography. (a) Type A – bone cement contacts only the superior endplate of the vertebral body. (b) Type B – bone cement extends only to the inferior endplate of the vertebral body. (c) Type C – bone cement contacts both the superior and inferior endplates of the vertebral body simultaneously. (d) Type D – bone cement does not contact either the superior or the inferior endplate of the vertebral body simultaneously.

2.9 Statistical analysis

Statistical analysis was conducted using SPSS (version 19.0; SPSS Inc., Chicago, IL, USA) on the Windows platform. The comparison of gender, history of hypertension, fracture type, black line signal, homogeneous high signal, IDEC injury, and cement leakage between the two groups was executed through the utilization of the Chi-squared test. Yates’ correction was implemented to assess fracture location, history of diabetes, smoking status, alcohol consumption, MRI signal change on T2WI, unilateral or bilateral puncture, bone cement form, and leakage site between the groups.

Evaluation of age, height, weight, postoperative VHL, and postoperative KA difference was carried out through independent samples t-tests, with the confirmation of normal distribution by the Shapiro–Wilk normality test and assessment of variance homogeneity by Levene’s test. Welch t-tests were applied to compare VHL at the last follow-up, VHL difference at the last follow-up, preoperative KA, postoperative KA, and KA at the last follow-up between the groups.

Body mass index (BMI), BMD, postoperative VHL difference, VHL improvement rate, KA improvement rate, KA difference at the last follow-up, operative time, and bone cement volume between the groups were assessed using Wilcoxon tests. Two-way mixed ANOVA tests were employed to analyze the VAS and ODI scores. Furthermore, the relationship between PK and independent variables was modeled using logistic regression. The significance level was set at 0.05.

  1. Informed consent: Informed consent was obtained from all patients.

  2. Ethical approval: The authors confirm that the study was performed in accordance with the Declaration of Helsinki. The study was approved by the Ethics Committee of the Shaoxing People’s Hospital, reference number NO202404101.

3 Results

3.1 Baseline data

A total of 129 patients were enrolled in this study, with 47 cases (36.4%) assigned to the PK group and 82 cases (63.6%) to the NPK group. In terms of gender, age, height, weight, BMI, BMD, history of hypertension, history of diabetes, smoking, and alcohol consumption, no significant statistical differences were observed between the two groups. However, there were notable statistical differences in fracture location and fracture type (P < 0.001) (Table 1).

Table 1

Comparison of baseline data between the two groups

Characteristics NPK group PK group P value
n 82 47
Gender, n (%) 0.204
 Male 22 (17.1%) 8 (6.2%)
 Female 60 (46.5%) 39 (30.2%)
Age, mean ± SD 69.67 ± 8.42 71.57 ± 7.50 0.201
Fracture location, n (%) <0.001
 TL 52 (40.3%) 47 (36.4%)
 L 22 (17.1%) 0 (0%)
 T 8 (6.2%) 0 (0%)
Height (m), mean ± SD 1.60 ± 0.07 1.58 ± 0.08 0.136
Weight (kg), mean ± SD 59.32 ± 9.03 56.71 ± 10.27 0.136
BMI (kg/m2), median (IQR) 22.77 (20.85, 24.12) 22.22 (20.01, 24.19) 0.411
BMD, median (IQR) −2.95 (−3.78, −2.03) −3.1 (−4.00, −2.20) 0.185
Hypertension, n (%) 0.143
 Yes 31 (24%) 24 (18.6%)
 No 51 (39.5%) 23 (17.8%)
Diabetes, n (%) 0.284
 No 76 (58.9%) 40 (31%)
 Yes 6 (4.7%) 7 (5.4%)
Smoking, n (%) 1.000
 No 80 (62%) 46 (35.7%)
 Yes 2 (1.6%) 1 (0.8%)
Alcohol, n (%) 0.381
 No 78 (60.5%) 42 (32.6%)
 Yes 4 (3.1%) 5 (3.9%)
Fracture type, n (%) <0.001
 Compression fracture 78 (60.5%) 30 (23.3%)
 Burst fracture 4 (3.1%) 17 (13.2%)

NPK: non-progressive kyphosis; PK: progressive kyphosis; BMI: body mass index; BMD: bone mineral density; SD: standard deviation; IQR: interquartile range.

3.2 Radiographic outcomes

The preoperative VHL, postoperative VHL difference, VHL improvement rate, VHL at the last follow-up, and VHL difference at the last follow-up in the NPK group were found to be significantly lower than those observed in the PK group (P < 0.05). However, no significant statistical difference was identified between the postoperative VHL of the two groups.

Similarly, the preoperative KA, postoperative KA, postoperative KA difference, KA improvement rate, KA at the last follow-up, and KA difference at the last follow-up in the NPK group were significantly lower than those in the PK group, indicating significant statistical differences (P < 0.05).

Furthermore, the NPK group exhibited statistical differences compared to the PK group in terms of MRI signal change on T2WI (P < 0.001). The NPK group also demonstrated significantly lower proportions of black line signal and IDEC injury than the PK group, with statistical significance (P < 0.001). Additionally, the NPK group displayed a significantly higher proportion of homogeneous high signal compared to the PK group, with statistically significant differences (P < 0.001) (Table 2).

Table 2

Comparison of radiographic data between the two groups

Characteristics NPK group PK group P value
Preoperative VHL, median (IQR) 11.65 (7.10, 17.88) 17.90 (12.45, 28.20) <0.001
Postoperative VHL, mean ± SD 10.70 ± 8.03 12.89 ± 10.51 0.188
Postoperative VHL difference, median (IQR) 1.35 (−2.20, 5.73) 5.9 (−1.05, 12.65) 0.006
VHL improvement rate, median (IQR) 10.83 (−13.16, 48.59) 32.80 (−0.77, 64.06) 0.047
VHL at the last follow-up, mean ± SD 12.73 ± 8.121 18.84 ± 11.05 0.001
VHL difference at the last follow-up, mean ± SD 2.03 ± 5.09 5.95 ± 6.86 0.001
Preoperative KA, mean ± SD 7.54 ± 16.64 22.86 ± 12.34 <0.001
Postoperative KA, mean ± SD 6.68 ± 17.16 18.76 ± 10.52 <0.001
Postoperative KA difference, mean ± SD 0.86 ± 4.68 4.10 ± 4.63 <0.001
KA improvement rate, median (IQR) 1.72 (−16.01, 22.00) 19.62 (4.25, 26.97) 0.003
KA at the last follow-up, mean ± SD 7.27 ± 17.14 30.70 ± 10.49 <0.001
KA difference at the last follow-up, median (IQR) 0.45 (−1.30, 2.88) 11.20 (10.60, 12.15) <0.001
MRI signal changes on T2WI, n (%) <0.001
 A 7 (5.4%) 1 (0.8%)
 B 3 (2.3%) 1 (0.8%)
 C 59 (45.7%) 20 (15.5%)
 D 13 (10.1%) 25 (19.4%)
Black line signal, n (%) <0.001
 No 75 (58.1%) 20 (15.5%)
 Yes 7 (5.4%) 27 (20.9%)
Homogenous high signal, n (%) <0.001
 No 48 (37.2%) 41 (31.8%)
 Yes 34 (26.4%) 6 (4.7%)
IDEC injury, n (%) <0.001
 No 67 (51.9%) 24 (18.6%)
 Yes 15 (11.6%) 23 (17.8%)

NPK: non-progressive kyphosis; PK: progressive kyphosis; VHL: vertebral height loss; KA: kyphosis angle; SD: standard deviation; IQR: interquartile range; T2WI: T2-weighted images; IDEC: intervertebral disc endplate complex.

3.3 Clinical outcomes

Preoperatively, postoperatively, and at the last follow-up, VAS scores of the NPK group were found to be significantly lower than those of the PK group, indicating statistical differences (P < 0.001). Additionally, preoperatively, postoperatively, and at the last follow-up, ODI scores of the NPK group were likewise determined to be significantly lower than those of the PK group (P < 0.05) (Figure 4).

Figure 4 (a) Comparison of VAS scores between the two groups. (b) Comparison of ODI scores between the two groups. *P < 0.05, compared with NPK group; ***P < 0.001, compared with NPK group. VAS: visual analog scale; ODI: Oswestry Disability Index; NPK: non-progressive kyphosis; PK: progressive kyphosis.
Figure 4

(a) Comparison of VAS scores between the two groups. (b) Comparison of ODI scores between the two groups. *P < 0.05, compared with NPK group; ***P < 0.001, compared with NPK group. VAS: visual analog scale; ODI: Oswestry Disability Index; NPK: non-progressive kyphosis; PK: progressive kyphosis.

3.4 Operative outcomes

Operative time, bone cement volume, unilateral or bilateral procedures, bone cement forms, proportion of bone cement leakage, and leakage site were found to be comparable between the two groups (P > 0.05) (Table 3).

Table 3

Comparison of operative data between the two groups

Characteristics NPK PK P value
Operative time (min), median (IQR) 32 (25.5, 40) 30 (25, 39.5) 0.424
Bone cement volume (mL), median (IQR) 6 (6, 6) 6 (5, 6) 0.278
Unilateral or bilateral, n (%) 1.000
 Bilateral 79 (61.2%) 45 (34.9%)
 Unilateral 3 (2.3%) 2 (1.6%)
Bone cement form, n (%) 0.267
 A 7 (5.4%) 2 (1.6%)
 B 22 (17.1%) 7 (5.4%)
 C 46 (35.7%) 34 (26.4%)
 D 7 (5.4%) 4 (3.1%)
Cement leakage, n (%) 0.184
 No 50 (38.8%) 23 (17.8%)
 Yes 32 (24.8%) 24 (18.6%)
Leakage site, n (%) 0.597
 No leakage 50 (38.8%) 23 (17.8%)
 Intervertebral space 6 (4.7%) 6 (4.7%)
 Lateral vertebrae 10 (7.8%) 9 (7%)
 Anterior vertebrae 8 (6.2%) 5 (3.9%)
 Basivertebral foramen 8 (6.2%) 4 (3.1%)

NPK: non-progressive kyphosis; PK: progressive kyphosis; IQR: interquartile range.

3.5 Risk factors for PK after PKP

In the univariate regression analysis, risk factors for PK after PKP included burst fracture, preoperative VHL, preoperative KA, postoperative KA, Type D MRI signal change on T2WI, black line signal, non-homogeneous high signal, and IDEC injury. Subsequently, in the multivariate analysis, the independent risk factors were found to be preoperative KA (OR = 1.26, 95% CI 1.06–1.48, P = 0.008), Type D MRI signal change on T2WI (OR = 18.49, 95% CI 2.73–125.15, P = 0.003), black line signal (OR = 44.00, 95% CI 5.22–370.93, P < 0.001), IDEC injury (OR = 7.86, 95% CI 1.36–45.39, P = 0.021), and postoperative ODI score (OR = 1.18, 95% CI 1.05–1.33, P = 0.004) (Table 4).

Table 4

Univariate and multivariate analysis of risk factors for PK after PKP

Characteristics Univariate analysis Multivariate analysis
Odds ratio (95% CI) P value Odds ratio (95% CI) P value
Fracture type
Compression fracture Reference Reference
Burst fracture 11.05 (3.44–35.52) <0.001 2.19 (0.21–22.80) 0.512
Preoperative VHL 1.06 (1.02–1.09) 0.003 0.93 (0.85–1.02) 0.111
Postoperative VHL 1.03 (0.99–1.07) 0.189
VHL improvement rate 1.001 (0.999–1.003) 0.539
Preoperative KA 1.08 (1.04–1.12) <0.001 1.26 (1.06–1.48) 0.008
Postoperative KA 1.06 (1.03–1.09) <0.001 0.92 (0.80–1.06) 0.234
KA improvement rate 1.000 (0.998–1.002) 0.937
MRI signal change on T2WI
A 0.42 (0.05–3.64) 0.432 1.89 (0.07–53.41) 0.708
B 0.98 (0.10–10.00) 0.989 5.99 (0.24–152.54) 0.278
C Reference Reference
D 5.67 (2.45–13.15) <0.001 18.49 (2.73–125.15) 0.003
Black line signal
No Reference Reference
Yes 14.46 (5.50–38.03) <0.001 44.00 (5.22–370.93) <0.001
Homogenous high signal
No Reference Reference
Yes 0.21 (0.80–0.54) 0.001 0.28 (0.04–1.77) 0.175
IDEC injury
No Reference Reference
Yes 4.28 (1.92–9.53) <0.001 7.86 (1.36–45.39) 0.021
Preoperative VAS score 2.06 (1.36–3.11) <0.001 1.01 (0.30–3.35) 0.986
Preoperative ODI score 1.04 (1.01–1.08) 0.015 0.94 (0.84–1.04) 0.230
Postoperative ODI score 1.13 (1.07–1.20) <0.001 1.18 (1.05–1.33) 0.004

NPK: non-progressive kyphosis; PK: progressive kyphosis; VHL: vertebral height loss; KA: kyphosis angle; T2WI: T2-weighted images; IDEC: intervertebral disc endplate complex; VAS: visual analog scale; ODI: Oswestry Disability Index.

3.6 Nomogram for risk factors of PK after PKP

A nomogram was constructed based on the multivariate analysis of independent risk factors (Figure 5a). The discriminative ability of the model was assessed by plotting the receiver operating characteristic curve (Figure 5b). The area under the curve was calculated to be 0.953 (CI: 0.917–0.989), indicating robust discriminative performance. Calibration curves illustrated the congruence between predicted outcomes and actual results (Figure 5c). The decision curve analysis (DCA) curve was employed to predict the risk of PK using the five risk factors or their combination. The results demonstrated a significant increase in net benefit with the amalgamated nomogram model (Figure 5d). Overall, the model demonstrated feasibility and suitability for prediction (Figure 6).

Figure 5 Nomogram for risk factors of PK after PKP. (a) Nomogram, (b) receiver operating characteristic curve, (c) calibration curve, and (d) DCA curve.
Figure 5

Nomogram for risk factors of PK after PKP. (a) Nomogram, (b) receiver operating characteristic curve, (c) calibration curve, and (d) DCA curve.

Figure 6 Presentation of a typical case in the PK group. A 65-year-old female with an L1 compression fracture due to a fall. (a) and (b) Preoperative X-ray indicating a compression fracture at L1, with a preoperative KA of 39.9° (yellow arrow). (c) Preoperative T2-weighted MRI showing diffuse low signal (Type D, indicated by the yellow arrow). (d) Preoperative MRI suggesting injury to the IDEC both above and below the injured vertebra (yellow arrow). (e) Preoperative STIR MRI indicating a black line signal (yellow arrow). (f) and (g) Postoperative X-ray showing a significant correction in the KA to 33.1°, well-distributed bone cement within the vertebral body, and no apparent leakage. (h) and (i) Last follow-up X-ray revealing an increase in KA to 45.0°, with a difference of 11.9° from the postoperative KA, indicating a significant progression of kyphosis. KA: kyphosis angle; STIR: short tau inversion recovery.
Figure 6

Presentation of a typical case in the PK group. A 65-year-old female with an L1 compression fracture due to a fall. (a) and (b) Preoperative X-ray indicating a compression fracture at L1, with a preoperative KA of 39.9° (yellow arrow). (c) Preoperative T2-weighted MRI showing diffuse low signal (Type D, indicated by the yellow arrow). (d) Preoperative MRI suggesting injury to the IDEC both above and below the injured vertebra (yellow arrow). (e) Preoperative STIR MRI indicating a black line signal (yellow arrow). (f) and (g) Postoperative X-ray showing a significant correction in the KA to 33.1°, well-distributed bone cement within the vertebral body, and no apparent leakage. (h) and (i) Last follow-up X-ray revealing an increase in KA to 45.0°, with a difference of 11.9° from the postoperative KA, indicating a significant progression of kyphosis. KA: kyphosis angle; STIR: short tau inversion recovery.

4 Discussion

PK after PKP is a not uncommon occurrence in clinical practice, and limited literature exists exploring its potential risk factors. In this retrospective study, an investigation into the possible risk factors for PK following PKP was undertaken, and a nomogram for risk prediction was developed. Among the notable findings, larger preoperative KA, Type D MRI signal change on T2WI, black line signal, IDEC injury, and higher preoperative ODI score were identified as independent risk factors for PK after PKP. The nomogram, based on these factors, predicts the risk of PK, providing valuable insights for clinicians when deciding on treatment strategies.

Wang et al. reported that a greater correction of vertebral height and kyphotic angles constitutes a risk factor for the recurrence of kyphotic deformity after PKP [14]. In our investigation, statistical differences in the improvement rates of VHL and KA were observed between the NPK and PK groups. However, no statistical difference was found in univariate analysis. Nevertheless, a larger preoperative KA was identified as a risk factor for PK following PKP. Chou et al. documented 14 cases of PK after PVP, with an average preoperative KA of 23.67° [22]. In this study, the preoperative KA in the PK group was measured at 22.86°, demonstrating comparability. The plausible explanation is that a larger KA contributes to diminished spinal stability, thereby elevating the risk of PK in subsequent stages [23,24]. Additionally, this study revealed a significantly greater preoperative KA in the PK group (22.86 ± 12.34) compared to the NPK group (7.54 ± 16.64), and the postoperative KA in the PK group (18.76 ± 10.52) remained significantly higher than in the NPK group (6.68 ± 17.16). This observation implies that the kyphotic deformity in patients of the PK group was not fully rectified by PKP, and the residual deformity may serve as a potential factor for the progression of postoperative kyphotic deformity.

Tsujio et al. initially reported the classification of MRI signals on T2WI of OVCFs. They found that patients with diffuse low signal (Type D) were at a higher risk of vertebral collapse compared to those with a high signal [15]. Referring to their classification method, we also classified patients based on MRI signals on T2WI and identified Type D signal change as a risk factor for PK after PKP. It is hypothesized that a more extensive area of low signal on MRI may signify more severe fracture damage, indicating a greater disruption of trabecular bone. Conversely, a high signal may denote localized edema, suggesting relatively less severe damage to trabecular bone.

Characteristic signals, including homogeneous high signal and black line signal, are discernible on MRI STIR images in OVCFs, as initially documented by Omi et al. [16]. Omi also highlighted that non-homogeneous high signal and black line signal are deemed high-risk factors for nonunion of fractures [16]. In this study, the proportion of non-homogeneous high signal in the PK group was notably higher than that in the NPK group. While this distinction exhibited statistical significance in univariate analysis, it did not maintain significance in multivariate analysis. The black line signal was recognized as an independent risk factor for PK after PKP (OR = 44.00). This suggests that, in clinical practice, OVCF patients displaying black line signals should receive heightened attention, prompting a more proactive approach to treatment.

Previous literature has reported that the IDEC injury is a risk factor for the recurrence of kyphosis after PKP surgery [14]. In this study, we also found that IDEC injury is a risk factor for PK after PKP (OR = 7.86). The possible reason is that IDEC injury leads to long-term degeneration of the intervertebral disc, loss of intervertebral space height, and subsequently exacerbates kyphotic deformity.

In this study, we established a nomogram model and each variable included in the nomogram is a relatively easily accessible factor. By calculating the score for each of these five factors, orthopedic surgeons can easily estimate the risk of PK after PKP in patients with OVCFs. For patients assessed with lower risk, PKP remains a safe and effective treatment option. However, for those assessed with higher risk, recommendations may include prolonged bed rest, proactive osteoporosis treatment, and even adjunctive internal fixation.

This study has several limitations that should be acknowledged. The retrospective nature of this single-center analysis may introduce biases in case selection and data completeness, limiting the generalizability of the findings. Additionally, the inclusion criterion of a BMD result of ≤−1.0 SD may affect the applicability of the conclusions, as the World Health Organization’s 1994 criteria require a T-score ≤−2.5 SD for osteoporosis diagnosis, while the 2017 Chinese Guidelines [25] allow for diagnosis based on fragility fractures or T-scores between −2.5 and −1.0 with fractures. Furthermore, the nomogram was developed using data from a single institution, which restricts its applicability across different clinical settings. One parameter was assessed postoperatively, potentially compromising its accuracy in predicting the risk of PK after PKP. Finally, the exclusion of parathyroid hormone (PTH) as a treatment option limits the study. Although PTH is recognized as an effective first-line treatment due to its bone anabolic properties, its use was limited by cost and availability constraints within our patient population. Future research should explore PTH’s role in preventing postoperative complications, such as recurrent fractures and PK, after PKP, as this could enhance treatment strategies for high-risk patients.

5 Conclusions

A larger preoperative KA, Type D MRI signal change on T2WI, black line signal, IDEC injury, and higher preoperative ODI scores were independent risk factors for PK after PKP. An accurate nomogram was developed based on these factors.

Abbreviations

BMD

bone mineral density

BMI

body mass index

DCA

decision curve analysis

IDEC

intervertebral disc endplate complex

IQR

interquartile range

KA

kyphosis angle

MRI

magnetic resonance image

NPK

non-progressive kyphosis

ODI

Oswestry Disability Index

OVCFs

osteoporotic vertebral compression fractures

PK

progressive kyphosis

PKP

percutaneous kyphoplasty

PTH

parathyroid hormone

PVP

percutaneous vertebroplasty

SD

standard deviations

SE

spin echo

STIR

short tau inversion recovery

T2WI

T2-weighted images

VAS

visual analog scale

VHL

vertebral height loss

# Cong Jin and Lei He made equal contributions to this manuscript and were the co-first authors.

tel: +86 575 8822 9063

Acknowledgements

None.

  1. Funding information: This work was supported by the Shaoxing Bureau of Science and Technology (2022KY008), the Zhejiang Provincial Program for the Cultivation of High-Level Innovative Health Talents (YTXX202105), and the Zhejiang Provincial Medicine and Health Technology Plan (2024KY1729).

  2. Author contributions: C.J. and L.H. conceived the design of the original study; C.J. and L.H. performed all the operations; C.J. and W.Q.H. conducted statistical analysis and drafted the manuscript; W.H., J.W.Z., and X.C. were involved with interpretation of data and critical revision of the manuscript. All authors read and approved the final manuscript.

  3. Conflict of interest: The authors declare that they have no conflict of interest.

  4. Data availability statement: The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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Received: 2024-08-24
Revised: 2024-11-02
Accepted: 2024-11-10
Published Online: 2024-12-09

© 2024 the author(s), published by De Gruyter

This work is licensed under the Creative Commons Attribution 4.0 International License.

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  167. Detection of serum FOXM1 and IGF2 in patients with ARDS and their correlation with disease and prognosis
  168. Rhein promotes skin wound healing by activating the PI3K/AKT signaling pathway
  169. Differences in mortality risk by levels of physical activity among persons with disabilities in South Korea
  170. Review Articles
  171. Cutaneous signs of selected cardiovascular disorders: A narrative review
  172. XRCC1 and hOGG1 polymorphisms and endometrial carcinoma: A meta-analysis
  173. A narrative review on adverse drug reactions of COVID-19 treatments on the kidney
  174. Emerging role and function of SPDL1 in human health and diseases
  175. Adverse reactions of piperacillin: A literature review of case reports
  176. Molecular mechanism and intervention measures of microvascular complications in diabetes
  177. Regulation of mesenchymal stem cell differentiation by autophagy
  178. Molecular landscape of borderline ovarian tumours: A systematic review
  179. Advances in synthetic lethality modalities for glioblastoma multiforme
  180. Investigating hormesis, aging, and neurodegeneration: From bench to clinics
  181. Frankincense: A neuronutrient to approach Parkinson’s disease treatment
  182. Sox9: A potential regulator of cancer stem cells in osteosarcoma
  183. Early detection of cardiovascular risk markers through non-invasive ultrasound methodologies in periodontitis patients
  184. Advanced neuroimaging and criminal interrogation in lie detection
  185. Maternal factors for neural tube defects in offspring: An umbrella review
  186. The chemoprotective hormetic effects of rosmarinic acid
  187. CBD’s potential impact on Parkinson’s disease: An updated overview
  188. Progress in cytokine research for ARDS: A comprehensive review
  189. Utilizing reactive oxygen species-scavenging nanoparticles for targeting oxidative stress in the treatment of ischemic stroke: A review
  190. NRXN1-related disorders, attempt to better define clinical assessment
  191. Lidocaine infusion for the treatment of complex regional pain syndrome: Case series and literature review
  192. Trends and future directions of autophagy in osteosarcoma: A bibliometric analysis
  193. Iron in ventricular remodeling and aneurysms post-myocardial infarction
  194. Case Reports
  195. Sirolimus potentiated angioedema: A case report and review of the literature
  196. Identification of mixed anaerobic infections after inguinal hernia repair based on metagenomic next-generation sequencing: A case report
  197. Successful treatment with bortezomib in combination with dexamethasone in a middle-aged male with idiopathic multicentric Castleman’s disease: A case report
  198. Complete heart block associated with hepatitis A infection in a female child with fatal outcome
  199. Elevation of D-dimer in eosinophilic gastrointestinal diseases in the absence of venous thrombosis: A case series and literature review
  200. Four years of natural progressive course: A rare case report of juvenile Xp11.2 translocations renal cell carcinoma with TFE3 gene fusion
  201. Advancing prenatal diagnosis: Echocardiographic detection of Scimitar syndrome in China – A case series
  202. Outcomes and complications of hemodialysis in patients with renal cancer following bilateral nephrectomy
  203. Anti-HMGCR myopathy mimicking facioscapulohumeral muscular dystrophy
  204. Recurrent opportunistic infections in a HIV-negative patient with combined C6 and NFKB1 mutations: A case report, pedigree analysis, and literature review
  205. Letter to the Editor
  206. Letter to the Editor: Total parenteral nutrition-induced Wernicke’s encephalopathy after oncologic gastrointestinal surgery
  207. Erratum
  208. Erratum to “Bladder-embedded ectopic intrauterine device with calculus”
  209. Retraction
  210. Retraction of “XRCC1 and hOGG1 polymorphisms and endometrial carcinoma: A meta-analysis”
  211. Corrigendum
  212. Corrigendum to “Investigating hormesis, aging, and neurodegeneration: From bench to clinics”
  213. Corrigendum to “Frankincense: A neuronutrient to approach Parkinson’s disease treatment”
  214. Special Issue The evolving saga of RNAs from bench to bedside - Part II
  215. Machine-learning-based prediction of a diagnostic model using autophagy-related genes based on RNA sequencing for patients with papillary thyroid carcinoma
  216. Unlocking the future of hepatocellular carcinoma treatment: A comprehensive analysis of disulfidptosis-related lncRNAs for prognosis and drug screening
  217. Elevated mRNA level indicates FSIP1 promotes EMT and gastric cancer progression by regulating fibroblasts in tumor microenvironment
  218. Special Issue Advancements in oncology: bridging clinical and experimental research - Part I
  219. Ultrasound-guided transperineal vs transrectal prostate biopsy: A meta-analysis of diagnostic accuracy and complication rates
  220. Assessment of diagnostic value of unilateral systematic biopsy combined with targeted biopsy in detecting clinically significant prostate cancer
  221. SENP7 inhibits glioblastoma metastasis and invasion by dissociating SUMO2/3 binding to specific target proteins
  222. MARK1 suppress malignant progression of hepatocellular carcinoma and improves sorafenib resistance through negatively regulating POTEE
  223. Analysis of postoperative complications in bladder cancer patients
  224. Carboplatin combined with arsenic trioxide versus carboplatin combined with docetaxel treatment for LACC: A randomized, open-label, phase II clinical study
  225. Special Issue Exploring the biological mechanism of human diseases based on MultiOmics Technology - Part I
  226. Comprehensive pan-cancer investigation of carnosine dipeptidase 1 and its prospective prognostic significance in hepatocellular carcinoma
  227. Identification of signatures associated with microsatellite instability and immune characteristics to predict the prognostic risk of colon cancer
  228. Single-cell analysis identified key macrophage subpopulations associated with atherosclerosis
https://doi.org/10.1515/med-2024-1107
Schlagwörter für diesen Artikel
risk factors; kyphosis; kyphoplasty; osteoporotic fractures; nomograms
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Artikel in diesem Heft

  1. Research Articles
  2. EDNRB inhibits the growth and migration of prostate cancer cells by activating the cGMP-PKG pathway
  3. STK11 (LKB1) mutation suppresses ferroptosis in lung adenocarcinoma by facilitating monounsaturated fatty acid synthesis
  4. Association of SOX6 gene polymorphisms with Kashin-Beck disease risk in the Chinese Han population
  5. The pyroptosis-related signature predicts prognosis and influences the tumor immune microenvironment in dedifferentiated liposarcoma
  6. METTL3 attenuates ferroptosis sensitivity in lung cancer via modulating TFRC
  7. Identification and validation of molecular subtypes and prognostic signature for stage I and stage II gastric cancer based on neutrophil extracellular traps
  8. Novel lumbar plexus block versus femoral nerve block for analgesia and motor recovery after total knee arthroplasty
  9. Correlation between ABCB1 and OLIG2 polymorphisms and the severity and prognosis of patients with cerebral infarction
  10. Study on the radiotherapy effect and serum neutral granulocyte lymphocyte ratio and inflammatory factor expression of nasopharyngeal carcinoma
  11. Transcriptome analysis of effects of Tecrl deficiency on cardiometabolic and calcium regulation in cardiac tissue
  12. Aflatoxin B1 induces infertility, fetal deformities, and potential therapies
  13. Serum levels of HMW adiponectin and its receptors are associated with cytokine levels and clinical characteristics in chronic obstructive pulmonary disease
  14. METTL3-mediated methylation of CYP2C19 mRNA may aggravate clopidogrel resistance in ischemic stroke patients
  15. Understand how machine learning impact lung cancer research from 2010 to 2021: A bibliometric analysis
  16. Pressure ulcers in German hospitals: Analysis of reimbursement and length of stay
  17. Metformin plus L-carnitine enhances brown/beige adipose tissue activity via Nrf2/HO-1 signaling to reduce lipid accumulation and inflammation in murine obesity
  18. Downregulation of carbonic anhydrase IX expression in mouse xenograft nasopharyngeal carcinoma model via doxorubicin nanobubble combined with ultrasound
  19. Feasibility of 3-dimensional printed models in simulated training and teaching of transcatheter aortic valve replacement
  20. miR-335-3p improves type II diabetes mellitus by IGF-1 regulating macrophage polarization
  21. The analyses of human MCPH1 DNA repair machinery and genetic variations
  22. Activation of Piezo1 increases the sensitivity of breast cancer to hyperthermia therapy
  23. Comprehensive analysis based on the disulfidptosis-related genes identifies hub genes and immune infiltration for pancreatic adenocarcinoma
  24. Changes of serum CA125 and PGE2 before and after high-intensity focused ultrasound combined with GnRH-a in treatment of patients with adenomyosis
  25. The clinical value of the hepatic venous pressure gradient in patients undergoing hepatic resection for hepatocellular carcinoma with or without liver cirrhosis
  26. Development and validation of a novel model to predict pulmonary embolism in cardiology suspected patients: A 10-year retrospective analysis
  27. Downregulation of lncRNA XLOC_032768 in diabetic patients predicts the occurrence of diabetic nephropathy
  28. Circ_0051428 targeting miR-885-3p/MMP2 axis enhances the malignancy of cervical cancer
  29. Effectiveness of ginkgo diterpene lactone meglumine on cognitive function in patients with acute ischemic stroke
  30. The construction of a novel prognostic prediction model for glioma based on GWAS-identified prognostic-related risk loci
  31. Evaluating the impact of childhood BMI on the risk of coronavirus disease 2019: A Mendelian randomization study
  32. Lactate dehydrogenase to albumin ratio is associated with in-hospital mortality in patients with acute heart failure: Data from the MIMIC-III database
  33. CD36-mediated podocyte lipotoxicity promotes foot process effacement
  34. Efficacy of etonogestrel subcutaneous implants versus the levonorgestrel-releasing intrauterine system in the conservative treatment of adenomyosis
  35. FLRT2 mediates chondrogenesis of nasal septal cartilage and mandibular condyle cartilage
  36. Challenges in treating primary immune thrombocytopenia patients undergoing COVID-19 vaccination: A retrospective study
  37. Let-7 family regulates HaCaT cell proliferation and apoptosis via the ΔNp63/PI3K/AKT pathway
  38. Phospholipid transfer protein ameliorates sepsis-induced cardiac dysfunction through NLRP3 inflammasome inhibition
  39. Postoperative cognitive dysfunction in elderly patients with colorectal cancer: A randomized controlled study comparing goal-directed and conventional fluid therapy
  40. Long-pulsed ultrasound-mediated microbubble thrombolysis in a rat model of microvascular obstruction
  41. High SEC61A1 expression predicts poor outcome of acute myeloid leukemia
  42. Comparison of polymerase chain reaction and next-generation sequencing with conventional urine culture for the diagnosis of urinary tract infections: A meta-analysis
  43. Secreted frizzled-related protein 5 protects against renal fibrosis by inhibiting Wnt/β-catenin pathway
  44. Pan-cancer and single-cell analysis of actin cytoskeleton genes related to disulfidptosis
  45. Overexpression of miR-532-5p restrains oxidative stress response of chondrocytes in nontraumatic osteonecrosis of the femoral head by inhibiting ABL1
  46. Autologous liver transplantation for unresectable hepatobiliary malignancies in enhanced recovery after surgery model
  47. Clinical analysis of incomplete rupture of the uterus secondary to previous cesarean section
  48. Abnormal sleep duration is associated with sarcopenia in older Chinese people: A large retrospective cross-sectional study
  49. No genetic causality between obesity and benign paroxysmal vertigo: A two-sample Mendelian randomization study
  50. Identification and validation of autophagy-related genes in SSc
  51. Long non-coding RNA SRA1 suppresses radiotherapy resistance in esophageal squamous cell carcinoma by modulating glycolytic reprogramming
  52. Evaluation of quality of life in patients with schizophrenia: An inpatient social welfare institution-based cross-sectional study
  53. The possible role of oxidative stress marker glutathione in the assessment of cognitive impairment in multiple sclerosis
  54. Compilation of a self-management assessment scale for postoperative patients with aortic dissection
  55. Left atrial appendage closure in conjunction with radiofrequency ablation: Effects on left atrial functioning in patients with paroxysmal atrial fibrillation
  56. Effect of anterior femoral cortical notch grade on postoperative function and complications during TKA surgery: A multicenter, retrospective study
  57. Clinical characteristics and assessment of risk factors in patients with influenza A-induced severe pneumonia after the prevalence of SARS-CoV-2
  58. Analgesia nociception index is an indicator of laparoscopic trocar insertion-induced transient nociceptive stimuli
  59. High STAT4 expression correlates with poor prognosis in acute myeloid leukemia and facilitates disease progression by upregulating VEGFA expression
  60. Factors influencing cardiovascular system-related post-COVID-19 sequelae: A single-center cohort study
  61. HOXD10 regulates intestinal permeability and inhibits inflammation of dextran sulfate sodium-induced ulcerative colitis through the inactivation of the Rho/ROCK/MMPs axis
  62. Mesenchymal stem cell-derived exosomal miR-26a induces ferroptosis, suppresses hepatic stellate cell activation, and ameliorates liver fibrosis by modulating SLC7A11
  63. Endovascular thrombectomy versus intravenous thrombolysis for primary distal, medium vessel occlusion in acute ischemic stroke
  64. ANO6 (TMEM16F) inhibits gastrointestinal stromal tumor growth and induces ferroptosis
  65. Prognostic value of EIF5A2 in solid tumors: A meta-analysis and bioinformatics analysis
  66. The role of enhanced expression of Cx43 in patients with ulcerative colitis
  67. Choosing a COVID-19 vaccination site might be driven by anxiety and body vigilance
  68. Role of ICAM-1 in triple-negative breast cancer
  69. Cost-effectiveness of ambroxol in the treatment of Gaucher disease type 2
  70. HLA-DRB5 promotes immune thrombocytopenia via activating CD8+ T cells
  71. Efficacy and factors of myofascial release therapy combined with electrical and magnetic stimulation in the treatment of chronic pelvic pain syndrome
  72. Efficacy of tacrolimus monotherapy in primary membranous nephropathy
  73. Mechanisms of Tripterygium wilfordii Hook F on treating rheumatoid arthritis explored by network pharmacology analysis and molecular docking
  74. FBXO45 levels regulated ferroptosis renal tubular epithelial cells in a model of diabetic nephropathy by PLK1
  75. Optimizing anesthesia strategies to NSCLC patients in VATS procedures: Insights from drug requirements and patient recovery patterns
  76. Alpha-lipoic acid upregulates the PPARγ/NRF2/GPX4 signal pathway to inhibit ferroptosis in the pathogenesis of unexplained recurrent pregnancy loss
  77. Correlation between fat-soluble vitamin levels and inflammatory factors in paediatric community-acquired pneumonia: A prospective study
  78. CD1d affects the proliferation, migration, and apoptosis of human papillary thyroid carcinoma TPC-1 cells via regulating MAPK/NF-κB signaling pathway
  79. miR-let-7a inhibits sympathetic nerve remodeling after myocardial infarction by downregulating the expression of nerve growth factor
  80. Immune response analysis of solid organ transplantation recipients inoculated with inactivated COVID-19 vaccine: A retrospective analysis
  81. The H2Valdien derivatives regulate the epithelial–mesenchymal transition of hepatoma carcinoma cells through the Hedgehog signaling pathway
  82. Clinical efficacy of dexamethasone combined with isoniazid in the treatment of tuberculous meningitis and its effect on peripheral blood T cell subsets
  83. Comparison of short-segment and long-segment fixation in treatment of degenerative scoliosis and analysis of factors associated with adjacent spondylolisthesis
  84. Lycopene inhibits pyroptosis of endothelial progenitor cells induced by ox-LDL through the AMPK/mTOR/NLRP3 pathway
  85. Methylation regulation for FUNDC1 stability in childhood leukemia was up-regulated and facilitates metastasis and reduces ferroptosis of leukemia through mitochondrial damage by FBXL2
  86. Correlation of single-fiber electromyography studies and functional status in patients with amyotrophic lateral sclerosis
  87. Risk factors of postoperative airway obstruction complications in children with oral floor mass
  88. Expression levels and clinical significance of serum miR-19a/CCL20 in patients with acute cerebral infarction
  89. Physical activity and mental health trends in Korean adolescents: Analyzing the impact of the COVID-19 pandemic from 2018 to 2022
  90. Evaluating anemia in HIV-infected patients using chest CT
  91. Ponticulus posticus and skeletal malocclusion: A pilot study in a Southern Italian pre-orthodontic court
  92. Causal association of circulating immune cells and lymphoma: A Mendelian randomization study
  93. Assessment of the renal function and fibrosis indexes of conventional western medicine with Chinese medicine for dredging collaterals on treating renal fibrosis: A systematic review and meta-analysis
  94. Comprehensive landscape of integrator complex subunits and their association with prognosis and tumor microenvironment in gastric cancer
  95. New target-HMGCR inhibitors for the treatment of primary sclerosing cholangitis: A drug Mendelian randomization study
  96. Population pharmacokinetics of meropenem in critically ill patients
  97. Comparison of the ability of newly inflammatory markers to predict complicated appendicitis
  98. Comparative morphology of the cruciate ligaments: A radiological study
  99. Immune landscape of hepatocellular carcinoma: The central role of TP53-inducible glycolysis and apoptosis regulator
  100. Serum SIRT3 levels in epilepsy patients and its association with clinical outcomes and severity: A prospective observational study
  101. SHP-1 mediates cigarette smoke extract-induced epithelial–mesenchymal transformation and inflammation in 16HBE cells
  102. Acute hyper-hypoxia accelerates the development of depression in mice via the IL-6/PGC1α/MFN2 signaling pathway
  103. The GJB3 correlates with the prognosis, immune cell infiltration, and therapeutic responses in lung adenocarcinoma
  104. Physical fitness and blood parameters outcomes of breast cancer survivor in a low-intensity circuit resistance exercise program
  105. Exploring anesthetic-induced gene expression changes and immune cell dynamics in atrial tissue post-coronary artery bypass graft surgery
  106. Empagliflozin improves aortic injury in obese mice by regulating fatty acid metabolism
  107. Analysis of the risk factors of the radiation-induced encephalopathy in nasopharyngeal carcinoma: A retrospective cohort study
  108. Reproductive outcomes in women with BRCA 1/2 germline mutations: A retrospective observational study and literature review
  109. Evaluation of upper airway ultrasonographic measurements in predicting difficult intubation: A cross-section of the Turkish population
  110. Prognostic and diagnostic value of circulating IGFBP2 in pancreatic cancer
  111. Postural stability after operative reconstruction of the AFTL in chronic ankle instability comparing three different surgical techniques
  112. Research trends related to emergence agitation in the post-anaesthesia care unit from 2001 to 2023: A bibliometric analysis
  113. Frequency and clinicopathological correlation of gastrointestinal polyps: A six-year single center experience
  114. ACSL4 mediates inflammatory bowel disease and contributes to LPS-induced intestinal epithelial cell dysfunction by activating ferroptosis and inflammation
  115. Affibody-based molecular probe 99mTc-(HE)3ZHER2:V2 for non-invasive HER2 detection in ovarian and breast cancer xenografts
  116. Effectiveness of nutritional support for clinical outcomes in gastric cancer patients: A meta-analysis of randomized controlled trials
  117. The relationship between IFN-γ, IL-10, IL-6 cytokines, and severity of the condition with serum zinc and Fe in children infected with Mycoplasma pneumoniae
  118. Paraquat disrupts the blood–brain barrier by increasing IL-6 expression and oxidative stress through the activation of PI3K/AKT signaling pathway
  119. Sleep quality associate with the increased prevalence of cognitive impairment in coronary artery disease patients: A retrospective case–control study
  120. Dioscin protects against chronic prostatitis through the TLR4/NF-κB pathway
  121. Association of polymorphisms in FBN1, MYH11, and TGF-β signaling-related genes with susceptibility of sporadic thoracic aortic aneurysm and dissection in the Zhejiang Han population
  122. Application value of multi-parameter magnetic resonance image-transrectal ultrasound cognitive fusion in prostate biopsy
  123. Laboratory variables‐based artificial neural network models for predicting fatty liver disease: A retrospective study
  124. Decreased BIRC5-206 promotes epithelial–mesenchymal transition in nasopharyngeal carcinoma through sponging miR-145-5p
  125. Sepsis induces the cardiomyocyte apoptosis and cardiac dysfunction through activation of YAP1/Serpine1/caspase-3 pathway
  126. Assessment of iron metabolism and iron deficiency in incident patients on incident continuous ambulatory peritoneal dialysis
  127. Tibial periosteum flap combined with autologous bone grafting in the treatment of Gustilo-IIIB/IIIC open tibial fractures
  128. The application of intravenous general anesthesia under nasopharyngeal airway assisted ventilation undergoing ureteroscopic holmium laser lithotripsy: A prospective, single-center, controlled trial
  129. Long intergenic noncoding RNA for IGF2BP2 stability suppresses gastric cancer cell apoptosis by inhibiting the maturation of microRNA-34a
  130. Role of FOXM1 and AURKB in regulating keratinocyte function in psoriasis
  131. Parental control attitudes over their pre-school children’s diet
  132. The role of auto-HSCT in extranodal natural killer/T cell lymphoma
  133. Significance of negative cervical cytology and positive HPV in the diagnosis of cervical lesions by colposcopy
  134. Echinacoside inhibits PASMCs calcium overload to prevent hypoxic pulmonary artery remodeling by regulating TRPC1/4/6 and calmodulin
  135. ADAR1 plays a protective role in proximal tubular cells under high glucose conditions by attenuating the PI3K/AKT/mTOR signaling pathway
  136. The risk of cancer among insulin glargine users in Lithuania: A retrospective population-based study
  137. The unusual location of primary hydatid cyst: A case series study
  138. Intraoperative changes in electrophysiological monitoring can be used to predict clinical outcomes in patients with spinal cavernous malformation
  139. Obesity and risk of placenta accreta spectrum: A meta-analysis
  140. Shikonin alleviates asthma phenotypes in mice via an airway epithelial STAT3-dependent mechanism
  141. NSUN6 and HTR7 disturbed the stability of carotid atherosclerotic plaques by regulating the immune responses of macrophages
  142. The effect of COVID-19 lockdown on admission rates in Maternity Hospital
  143. Temporal muscle thickness is not a prognostic predictor in patients with high-grade glioma, an experience at two centers in China
  144. Luteolin alleviates cerebral ischemia/reperfusion injury by regulating cell pyroptosis
  145. Therapeutic role of respiratory exercise in patients with tuberculous pleurisy
  146. Effects of CFTR-ENaC on spinal cord edema after spinal cord injury
  147. Irisin-regulated lncRNAs and their potential regulatory functions in chondrogenic differentiation of human mesenchymal stem cells
  148. DMD mutations in pediatric patients with phenotypes of Duchenne/Becker muscular dystrophy
  149. Combination of C-reactive protein and fibrinogen-to-albumin ratio as a novel predictor of all-cause mortality in heart failure patients
  150. Significant role and the underly mechanism of cullin-1 in chronic obstructive pulmonary disease
  151. Ferroptosis-related prognostic model of mantle cell lymphoma
  152. Observation of choking reaction and other related indexes in elderly painless fiberoptic bronchoscopy with transnasal high-flow humidification oxygen therapy
  153. A bibliometric analysis of Prader-Willi syndrome from 2002 to 2022
  154. The causal effects of childhood sunburn occasions on melanoma: A univariable and multivariable Mendelian randomization study
  155. Oxidative stress regulates glycogen synthase kinase-3 in lymphocytes of diabetes mellitus patients complicated with cerebral infarction
  156. Role of COX6C and NDUFB3 in septic shock and stroke
  157. Trends in disease burden of type 2 diabetes, stroke, and hypertensive heart disease attributable to high BMI in China: 1990–2019
  158. Purinergic P2X7 receptor mediates hyperoxia-induced injury in pulmonary microvascular endothelial cells via NLRP3-mediated pyroptotic pathway
  159. Investigating the role of oviductal mucosa–endometrial co-culture in modulating factors relevant to embryo implantation
  160. Analgesic effect of external oblique intercostal block in laparoscopic cholecystectomy: A retrospective study
  161. Elevated serum miR-142-5p correlates with ischemic lesions and both NSE and S100β in ischemic stroke patients
  162. Correlation between the mechanism of arteriopathy in IgA nephropathy and blood stasis syndrome: A cohort study
  163. Risk factors for progressive kyphosis after percutaneous kyphoplasty in osteoporotic vertebral compression fracture
  164. Predictive role of neuron-specific enolase and S100-β in early neurological deterioration and unfavorable prognosis in patients with ischemic stroke
  165. The potential risk factors of postoperative cognitive dysfunction for endovascular therapy in acute ischemic stroke with general anesthesia
  166. Fluoxetine inhibited RANKL-induced osteoclastic differentiation in vitro
  167. Detection of serum FOXM1 and IGF2 in patients with ARDS and their correlation with disease and prognosis
  168. Rhein promotes skin wound healing by activating the PI3K/AKT signaling pathway
  169. Differences in mortality risk by levels of physical activity among persons with disabilities in South Korea
  170. Review Articles
  171. Cutaneous signs of selected cardiovascular disorders: A narrative review
  172. XRCC1 and hOGG1 polymorphisms and endometrial carcinoma: A meta-analysis
  173. A narrative review on adverse drug reactions of COVID-19 treatments on the kidney
  174. Emerging role and function of SPDL1 in human health and diseases
  175. Adverse reactions of piperacillin: A literature review of case reports
  176. Molecular mechanism and intervention measures of microvascular complications in diabetes
  177. Regulation of mesenchymal stem cell differentiation by autophagy
  178. Molecular landscape of borderline ovarian tumours: A systematic review
  179. Advances in synthetic lethality modalities for glioblastoma multiforme
  180. Investigating hormesis, aging, and neurodegeneration: From bench to clinics
  181. Frankincense: A neuronutrient to approach Parkinson’s disease treatment
  182. Sox9: A potential regulator of cancer stem cells in osteosarcoma
  183. Early detection of cardiovascular risk markers through non-invasive ultrasound methodologies in periodontitis patients
  184. Advanced neuroimaging and criminal interrogation in lie detection
  185. Maternal factors for neural tube defects in offspring: An umbrella review
  186. The chemoprotective hormetic effects of rosmarinic acid
  187. CBD’s potential impact on Parkinson’s disease: An updated overview
  188. Progress in cytokine research for ARDS: A comprehensive review
  189. Utilizing reactive oxygen species-scavenging nanoparticles for targeting oxidative stress in the treatment of ischemic stroke: A review
  190. NRXN1-related disorders, attempt to better define clinical assessment
  191. Lidocaine infusion for the treatment of complex regional pain syndrome: Case series and literature review
  192. Trends and future directions of autophagy in osteosarcoma: A bibliometric analysis
  193. Iron in ventricular remodeling and aneurysms post-myocardial infarction
  194. Case Reports
  195. Sirolimus potentiated angioedema: A case report and review of the literature
  196. Identification of mixed anaerobic infections after inguinal hernia repair based on metagenomic next-generation sequencing: A case report
  197. Successful treatment with bortezomib in combination with dexamethasone in a middle-aged male with idiopathic multicentric Castleman’s disease: A case report
  198. Complete heart block associated with hepatitis A infection in a female child with fatal outcome
  199. Elevation of D-dimer in eosinophilic gastrointestinal diseases in the absence of venous thrombosis: A case series and literature review
  200. Four years of natural progressive course: A rare case report of juvenile Xp11.2 translocations renal cell carcinoma with TFE3 gene fusion
  201. Advancing prenatal diagnosis: Echocardiographic detection of Scimitar syndrome in China – A case series
  202. Outcomes and complications of hemodialysis in patients with renal cancer following bilateral nephrectomy
  203. Anti-HMGCR myopathy mimicking facioscapulohumeral muscular dystrophy
  204. Recurrent opportunistic infections in a HIV-negative patient with combined C6 and NFKB1 mutations: A case report, pedigree analysis, and literature review
  205. Letter to the Editor
  206. Letter to the Editor: Total parenteral nutrition-induced Wernicke’s encephalopathy after oncologic gastrointestinal surgery
  207. Erratum
  208. Erratum to “Bladder-embedded ectopic intrauterine device with calculus”
  209. Retraction
  210. Retraction of “XRCC1 and hOGG1 polymorphisms and endometrial carcinoma: A meta-analysis”
  211. Corrigendum
  212. Corrigendum to “Investigating hormesis, aging, and neurodegeneration: From bench to clinics”
  213. Corrigendum to “Frankincense: A neuronutrient to approach Parkinson’s disease treatment”
  214. Special Issue The evolving saga of RNAs from bench to bedside - Part II
  215. Machine-learning-based prediction of a diagnostic model using autophagy-related genes based on RNA sequencing for patients with papillary thyroid carcinoma
  216. Unlocking the future of hepatocellular carcinoma treatment: A comprehensive analysis of disulfidptosis-related lncRNAs for prognosis and drug screening
  217. Elevated mRNA level indicates FSIP1 promotes EMT and gastric cancer progression by regulating fibroblasts in tumor microenvironment
  218. Special Issue Advancements in oncology: bridging clinical and experimental research - Part I
  219. Ultrasound-guided transperineal vs transrectal prostate biopsy: A meta-analysis of diagnostic accuracy and complication rates
  220. Assessment of diagnostic value of unilateral systematic biopsy combined with targeted biopsy in detecting clinically significant prostate cancer
  221. SENP7 inhibits glioblastoma metastasis and invasion by dissociating SUMO2/3 binding to specific target proteins
  222. MARK1 suppress malignant progression of hepatocellular carcinoma and improves sorafenib resistance through negatively regulating POTEE
  223. Analysis of postoperative complications in bladder cancer patients
  224. Carboplatin combined with arsenic trioxide versus carboplatin combined with docetaxel treatment for LACC: A randomized, open-label, phase II clinical study
  225. Special Issue Exploring the biological mechanism of human diseases based on MultiOmics Technology - Part I
  226. Comprehensive pan-cancer investigation of carnosine dipeptidase 1 and its prospective prognostic significance in hepatocellular carcinoma
  227. Identification of signatures associated with microsatellite instability and immune characteristics to predict the prognostic risk of colon cancer
  228. Single-cell analysis identified key macrophage subpopulations associated with atherosclerosis
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Heruntergeladen am 5.11.2025 von https://www.degruyterbrill.com/document/doi/10.1515/med-2024-1107/html?lang=de
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