Layout 1 Thematic Section: Advances in Musculoskeletal and Neuromuscular Rehabilitation | Maccarone & Masiero Eur J Transl Myol 34 (3) 12274, 2024 doi: 10.4081/ejtm.2024.12274 Since the World Health Organization (WHO) definition in 1993 describing osteoporosis as a systemic skeletal disease that is related to bone mass loss, there has been great effort towards the development of novel, minimally invasive therapeutic interventions.1-2 Aggregated evidence from pre-clinical and clinical studies have resulted in a better description of this clinical condition.3 Osteoporosis occurs when bone development is slower than its degradation causing instability of the trabecular bone tissue, a process closely associated with fracture rate. Moreover, it has been stated that a substantial loss of approximately 40% of the bone mass is present in more than 50% of cases of insufficiency fractures.4 The Osteoporotic Vertebral Compression Fractures (OVCFs) have been demonstrated to feature a ratio of 30%-50% in individuals older than 50 years old. Considering the ever- growing longevity of the population worldwide, the incidence of OVCFs is expected to rise in the future.5 Existing treatment modalities for the management of OVCFs are either conservative or interventional.6-7 Con- servative treatment includes activity modification, anal- gesics, and exercises aimed at strengthening spine muscular stabilizers. However, failure of conservative management in the context of specific clinical manifesta- tions necessitates interventional management.4,8 Mini- mally Invasive Augmentation (MIVA) procedures, Abstract Aim of this study is to investigate the safety, efficacy and impact on Health-Related Quality of Life (HRQoL) of Vertebroplasty (VP) and Kyphoplasty (KP) in the management of Osteoporotic Vertebral Compression Fractures (OVCFs) in elderly individuals. VP and KP represent Minimally Invasive Vertebral Augmentation (MIVA) procedures that are increasingly implemented for surgical treatment of OVCFs in recent years. These interventions have been associated with minimal traumatization and intraoperative hemorrhage, considerable analgesic effect and rapid postoperative recovery. Seventy-seven (77) consecutive individuals with OVCFs were subjected to VP/KP and recruited in this prospectively designed non-randomized study. Clinical evaluation was performed preoperatively and postoperatively at particular chronic intervals at 1, 6 weeks and at 3, 6, 12 months and 2 years. Assessment was conducted via the standardized Visual Analogue Scale (VAS) and Short-Form 36 (SF-36) Medical Health Survey Questionnaire for pain and HRQoL, respectively. No perioperative complications were observed. All studied indices were demonstrated to present a statistically significant amelioration following overall analysis. Pain intensity measured by the VAS score was depicted to be significantly reduced during the first 3 months, but continuous improvement of all indices of SF-36 and VAS was demonstrated to reach a plateau at 6 months, featuring no further clinical improvement.VP and KP represent safe and efficient options for interventional treatment of OVCFs in elderly and oldest-old patients, improving self-reported symptoms of pain as well as overall HRQoL. Key Words: minimally invasive vertebral augmentation; vertebroplasty; kyphoplasty; osteoporotic vertebral compression fractures; health-related quality of life. Eur J Transl Myol 34 (3) 12274, 2024 doi: 10.4081/ejtm.2024.12274 Vertebroplasty and kyphoplasty in the management of osteoporotic vertebral compression fractures in elderly individuals: evaluation of the health-related quality of life Stylianos Kapetanakis,1,2 Constantinos Chaniotakis,1 Periklis Zavridis,3 Periklis Kopsidas,1 Sotirios Apostolakis,1 Nikolaos Gkantsinikoudis1 1Spine Department and Deformities, Interbalkan European Medical Center, Thessaloniki, Greece; 2Department of Minimally Invasive and Endoscopic Spine Surgery, Athens Medical Center, Athens, Greece; 3Cyprus Pain Clinic, Egkomi, Cyprus. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License (CC BY-NC 4.0) which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. - 50 - Non -co mmerc ial us e o nly Vertebroplasty and kyphoplasty in elderly individuals Eur J Transl Myol 34 (3) 12274, 2024 doi: 10.4081/ejtm.2024.12274 principally represented by Vertebroplasty (VP) and Ky- phoplasty (KP), represent novel and atraumatic proce- dures that gain constant ground for interventional management of OVCFs in the field of spine surgery in re- cent years. These techniques aim to restore the mechanical strength and stability of the vertebral body and to adequ- ately reduce the reported pain whilst also preventing new fractures, being associated with minimal invasiveness and considerable clinical effectiveness in recent literature re- ports.3,9 However, safety and efficacy of MIVA procedures in conjunction with postoperative Health-Related Quality of Life (HRQoL) of operated individuals has not been studied in the ever-aging population yet. This study aims to evaluate the safety, effectiveness and HRQoL alterations post VP and KP in elderly individuals with OVCFs. The demographically authentic national per- spective, in conjunction with the comparative analysis of the studied indices, underscores the originality of this in- vestigation. Materials and Methods Study population and approvals All enrolled patients in this study were diagnosed with OVCFs, meeting all current indications for MIVA proce- dures. All patients were referred to the same senior spine surgeon and all procedures were performed in the same tertiary center. Patients were fully informed about the prin- ciples and aims of this study, agreeing to participate by providing informed written consent. Protection of distinct patients’ rights as well as privacy was strictly warranted during study performance. The study protocol was ap- proved by the Institutional Review Board of involved hos- pital (Interbalkan European Medical Center, Thessaloniki, Greece - Approval Number: 29.09.2018). All aspects of this study were in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans, as defined in 1975 and as revised in 2013. The study inclusion criteria were: i) elderly and oldest-old patients diagnosed with osteoporosis;10 ii) acute onset of back pain emerged passively and actively during the clin- ical examination by the physician with load-dependent character; iii) lack of clinical-radiologic signs of imbal- ance and neurologic deficit in clinical examination; iv) de- tection of clinically referrable OVCFs on plain radiographs, Computed Tomography (CT) scan and Mag- netic Resonance Imaging (MRI) evaluation; v) presence of decreased body vertebrae at a maximum of 50% of the initial normal anatomical aspect of sagittal view. The study exclusion criteria were :i) patients younger than 65 years old; ii) documented previous allergic reactions in Polymethyl methacrylate (PMMA); iii) presence of ac- tive infection, inflammation, hematologic disturbances, and coagulation disorders; iv) the presence of back pain not correlated with imaginary findings; v) presence of in- stability and objective neurological signs at clinical ex- amination and imaging; vi) reduction of the width of the vertebral body by more than 50%. Methods Seventy-seven (77) consecutive individuals with OVCFs were recruited in this prospectively designed non-random- ized study. All patients were subjected to successful VP and/or KP in 2019-2020. The diagnosis was conducted by clinical examination and appropriate imaging evaluations (plain radiographs, CT scans and MRI) preoperatively. The clinical re-evaluation was performed postoperatively at particular chronic intervals at the end of the 1st week, at 6 weeks and at 3, 6, 12 months and 2 years postopera- tively. Clinical assessment was conducted using the stan- dardized Visual Analogue Scale (VAS) in conjunction with the Short Form-36 (SF-36) Health Survey Question- naire in order to assess HRQoL. Surgical technique All surgical operations were performed by the same ex- perienced in Minimally Invasive Spine Surgery surgeon (Stylianos Kapetanakis). All procedures were performed under general anesthesia and under constant fluoroscopic guidance in anteroposterior (AP) and lateral views (two C-ARMs). The level of operation was initially deter- mined by fluoroscopic imaging, and the needle entry point was marked on the patients’ skin located 2-4 cm lateral to the midline. Skin disinfection was subsequently conducted, and sterilization of the area was performed. An incision of less than 1cm with a lancet number 11 was conducted 2-4 cm lateral to the midline (Figure 1). Transpedicular advancement of first trocar with confir- mation of tip in the centre of vertebral body was initially conducted. Subsequently, insertion of Kirschner-wire, removal of first trocar and insertion of second trocar with limited trabecular bone reaming at the center of vertebral body were conducted. This procedure was contralaterally conducted, and, thus, a bipedicular approach in all pa- tients was adopted (Figure 2). Infusion of bone cement (PMMA, 2-4 mL) was subsequently bilaterally per- formed under constant fluoroscopic guidance in AP and lateral views. En bloc removal of working trocars and skin suturing were finally performed. All patients were neurologically evaluated and transferred into the monitoring chamber for one hour and subsequently into the ward. Visual analogue scale VAS is a simple, illustrative method for evaluating various parameters, including pain. A horizontal line of 100 mm was utilized in the present study. Patients were asked to indicate their subjective perception of pain with a mark. The level of minimal clinically significant change was designated to be 9 mm. Other parameters (e.g., sex, age, etiology of pain) were not considered separately.11-12 SF-36 medical health survey questionnaire Short Form-36 (SF-36) Medical Health Survey Question- naire represents a widely used method for evaluating HRQoL after spine surgery.13-14 This questionnaire consists of 36 items evaluating eight parameters reflecting patients’ general health: physical function (PF), role physical (RP), - 51 - Non -co mmerc ial us e o nly Vertebroplasty and kyphoplasty in elderly individuals Eur J Transl Myol 34 (3) 12274, 2024 doi: 10.4081/ejtm.2024.12274 bodily pain (BP), general health (GH), energy, fatigue, and vitality (V), social function (SF), role emotional (RE), and mental health (MH). Each patient was asked to complete the appropriate questionnaire at each regularly scheduled follow-up interval. Responses were collected and con- verted into percentage scales. A higher score is generally associated with enhanced HRQoL. A questionnaire was considered invalid if less than half of the entries were completed.11 Statistical analysis Statistical analysis was conducted using STATISTICA 10.0 (StatSoft 1984–2010) and MATLAB 2016 (The MathWorks, Inc., 2016). Figures were created using MAT- LAB 2016 (The MathWorks Inc., 2016) and Adobe Illus- trator CS3 (Adobe Systems, 2007). For non-parametric variables, Chi-square, Mann-Whitney’s test and Kruskal– Wallis H test and Friedman Analysis of Variance (ANOVA) were used to test for differences between two and multiple groups respectively. When paired data was compared, the Wilcoxon matched-pairs test was imple- mented. Spearman’s correlation coefficient was applied to examine for potential correlations between the parameters. Multiple regression was used to investigate the potential effects of multiple parameters on the outcome measures. In all cases, the level of statistical significance was p<.05. The Bonferroni correction for multiple comparisons was used accordingly in post-hoc analyses. Results In total, 77 patients were included in the study. Demo- graphic characteristics of enrolled individuals are presented in Table 1. All patients were subjected to VP/KP. No intra- operative complications were observed, and all patients were discharged on the same day. Furthermore, all patients successfully completed the intended 2-year follow-up. Studying the functional improvement of patients, a statis- tically significant difference in the self-reported question- naire was observed in all individual indices of SF-36. Pain intensity measured by the VAS score was also found to feature a significant reduction (Table 2). Post-hoc analysis of the various follow-up time periods re- vealed a continuous improvement of all indices of SF-36 over the entire follow-up period (Figure 3). On the other hand, VAS was demonstrated to reach a plateau at 6 months featuring no further clinical improvement (Table 3). In further correlation analysis, the improvement in all in- dices was found to be irrespective of age (p >0.19) (Table 4). When comparing the early versus late inter- vention groups, the difference in the various indices be- tween preoperative and two years of postoperative - 52 - Figure 1. Two incisions of less than 1 cm (each one- bilateral), 2-4 cm lateral to the midline. The first and the second trocars. Figure 2. The bipedicular approach. Infusion of bone cement (bilaterally) was performed under C- ARM guidance. Non -co mmerc ial us e o nly Vertebroplasty and kyphoplasty in elderly individuals Eur J Transl Myol 34 (3) 12274, 2024 doi: 10.4081/ejtm.2024.12274 assessment was found to be statistically significant for PF (U1,77 = 497.5, p = 0.01), RP (U1,77 = 546.5, p < 0.05) and GH (U1,77 = 490.5, p = 0.01) of SF-36. When examin- ing age, gender and time-lapse from fracture to treatment collectively as predictors of outcome measure, multiple regression analysis demonstrated a main effect of time for PF (b=-0.25), RP (b=-0.33) and GH (b=-0.23) at a level of p<0.05. - 53 - Table 1. Demographics of patients included in the present study. Number of patients 77 Age mean (SD) 75.87 (7.116) Age median (Min-max) 76 (65-88) Male (%) 23 (29.8%) Mean age male (SD) 75.65 (7.374) Mean age female (SD) 75.96 (7.116) Figure 3. The changes in the value of the various parameters (PF, GH and VAS score), at each follow- up. Table 2. Statistical results of overall ANOVA analy- sis of recorded values in studied indices PF F=0.99, P<0.001 RP F=0.99, P<0.001 BP F=0.99, P<0.001 GH F=0.98, P<0.001 V F=0.99, P<0.001 SF F=0.99, P<0.001 RE F=0.98, P<0.001 MH F=0.99, P<0.001 VAS F=0.94, P<0.001 Table 3. Results from Wilcoxon matched pairs test comparing each index at two successive time points of assessment. Level of significance follow- ing Bonferonni correction was p<0.008. PFpreop Vs PFpostop Z=7.62, p<0.008 PFpostop Vs PF1w Z=7.62, p<0.008 PF1w Vs PF6w Z=7.62, p<0.008 PF6w Vs PF3mo Z=7.62, p<0.008 PF3mo Vs PF6mo Z=7.62, p<0.008 PF6mo Vs PF12mo Z=7.62, p<0.008 PF12mo Vs PF2yrs Z=5.645, p<0.008 RPpreop Vs RPpostop Z=7.62, p<0.008 RPpostop Vs RP1w Z=7.62, p<0.008 RP1w Vs RP6w Z=7.62, p<0.008 RP6w Vs RP3mo Z=7.62, p<0.008 RP3mo Vs RP6mo Z=7.62, p<0.008 RP6mo Vs RP12mo Z=7.62, p<0.008 RP12mo Vs RP2yrs Z=5.086, p<0.001 BPpreop Vs BPpostop Z=7.62, p<0.008 BPpostop Vs BP1w Z=7.62, p<0.008 BP1w Vs BP6w Z=7.62, p<0.008 BP6w Vs BP3mo Z=7.62, p<0.008 BP3mo Vs BP6mo Z=7.62, p<0.008 BP6mo Vs BP12mo Z=6.09, p<0.008 BP12mo Vs BP2yrs Z=5.51, p<0.001 GHpreop Vs GHpostop Z=7.62, p<0.008 GHpostop Vs GH1w Z=7.62, p<0.008 GH1w Vs GH6w Z=7.62, p<0.008 GH6w Vs GH3mo Z=7.62, p<0.008 GH3mo Vs GH6mo Z=7.62, p<0.008 GH6mo Vs GH12mo Z=5.77, p<0.008 To be continued on next page Non -co mmerc ial us e o nly Vertebroplasty and kyphoplasty in elderly individuals Eur J Transl Myol 34 (3) 12274, 2024 doi: 10.4081/ejtm.2024.12274 Discussion Osteoporosis represents a persistent age-related disease considered responsible for fracture incidence in 50% of fe- males and 20% of male gender during their lifetime.15 More specifically, OVCFs represent a critical disabling factor for elderly individuals associated with restriction of mobility, degraded HRQoL and increased morbidity and mortality.3 Back pain is the principal complaint of patients with OVCFs and is described as severe in the vast majority of affected individuals. Other clinical manifestations of OVCFs include radicular pain (due to compression of neu- rovascular structures), myelopathy, and acute cauda equina syndrome as well as the appearance of psychosocial phe- nomena, all of which are associated with considerable mor- bidity and even mortality. Early diagnosis of OVCFs is crucial to avoid mechanical complications such as post- traumatic kyphosis and alterations in body posture, in con- junction with the enhancement of physical strength, mobility and performance.4,16 VP and KP represent well-established procedures that can lead to further reduction of fractures and avoidance of a new OVCF.17 The need for localizing the fractured verte- bral body by performing profile (lateral) and anteroposte- rior (face) X-ray is prominent. The combination of two image converters (C- ARM) decreases the operation time, aids accurate needle insertion, and regulates cement ap- plication. VP was first described in 1987 by Galibert et al. and followed by Chiras et al. as the main surgical proce- dure for OVCFs while KP was described as an alternative method for the treatment of the OVCFs in 2002.18-20 Since then, the two procedures have been acknowledged and studied by many surgeons. The main difference between the KP and VP surgical techniques is that the first allows fracture reduction by insertion of controlled inflatable bal- loon catheter resulting in better morphological reshaping of vertebral body.4-5,17,21 Several studies have been conducted to evaluate HRQoL changes in patients with OVCFs before and after MIVA procedures conduction. For this purpose, different question- naires have been employed in order to measure this change, with the most common being SF-36 and VAS scores for pain improvement.3, 22- 23 Wang et al., in their meta-analysis of the literature, includ- ing 8 studies (845 patients) compared HRQoL changes be- tween patients who underwent VP and KP for single-level OVCFs.24 Results demonstrated that both procedures were safe and effective. The authors also concluded that KP is superior to VP regarding short-term pain relief, injected cement volume, improvement of short- and long-term ky- photic angle, and has a lower cement leakage rate, being albeit associated with a higher material cost and longer operation time.24 Similar observations were made in the systematic review and meta-analysis by Zhao et al., in ad- dition to KP being associated with a lower incidence of new fractures.25 The EVOLVE trial (2019) was the first large multicenter prospective study evaluating HRQoL after balloon kypho- plasty in 354 patients with both osteoporotic and neoplas- tic VCFs. HRQoL was assessed using Numerical Rating Scale (NRS) for back pain, Oswestry Disability Index - 54 - Table 3. Continued from previous page. GH12mo Vs GH2yrs Z=5.4, p<0.008 Vpreop Vs Vpostop Z=7.62, p<0.008 Vpostop Vs V1w Z=7.62, p<0.008 V1w Vs V6w Z=7.62, p<0.008 V6w Vs V3mo Z=7.62, p<0.008 V3mo Vs V6mo Z=7.62, p<0.008 V6mo Vs V12mo Z=6.27, p<0.008 V12mo Vs V2yrs Z=6.09, p<0.008 SFpreop Vs SFpostop Z=7.62, p<0.008 SFpostop Vs SF1w Z=7.62, p<0.008 SF1w Vs SF6w Z=7.62, p<0.008 SF6w Vs SF3mo Z=7.62, p<0.008 SF3mo Vs SF6mo Z=7.62, p<0.008 SF6mo Vs SF12mo Z=6.21, p<0.008 SF12mo Vs SF2yrs Z=5.08, p<0.008 REpreop Vs REpostop Z=7.62, p<0.008 REpostop Vs RE1w Z=7.62, p<0.008 RE1w Vs RE6w Z=7.62, p<0.008 RE6w Vs RE3mo Z=7.62, p<0.008 RE3mo Vs RE6mo Z=7.62, p<0.008 RE6mo Vs RE12mo Z=5.71, p<0.008 RE12mo Vs RE2yrs Z=5.37, p<0.008 MHpreop Vs MHpostop Z=7.62, p<0.008 MHpostop Vs MH1w Z=7.62, p<0.008 MH1w Vs MH6w Z=7.62, p<0.008 MH6w Vs MH3mo Z=7.62, p<0.008 MH3mo Vs MH6mo Z=7.62, p<0.008 MH6mo Vs MH12mo Z=6.33, p<0.008 MH12mo Vs MH2yrs Z=5.30, p<0.008 VASpreop Vs VASpostop Z=7.62, p<0.008 VASpostop Vs VAS1w Z=7.62, p<0.008 VAS1w Vs VAS6w Z=7.62, p<0.008 VAS6w Vs VAS3mo Z=4.62, p<0.008 VAS3mo Vs VAS6mo Z=4.62, p<0.008 VAS6mo Vs VAS12mo - VAS12mo Vs VAS2yrs - Non -co mmerc ial us e o nly Vertebroplasty and kyphoplasty in elderly individuals Eur J Transl Myol 34 (3) 12274, 2024 doi: 10.4081/ejtm.2024.12274 (ODI) andShort Form-36 Questionnaire Physical Compo- nent Summary (SF-36v2 PCS and EuroQol-5-Domain (EQ-5D). Results showed that KP is a safe procedure with the improvement of all primary endpoints in all times of follow-up.3 In another study, Nikoobakht et al. analyzed HRQoL and pain using the VAS for pain and SF-12 on 54 patients who had previously undergone conservative management for VCFs. A statistically significant improvement was observed after KP (p<0.001), which continued to improve until the endpoint of the study at twelve months after the operation.23 In general, MIVA procedures are considered safe and ef- ficient options for the treatment of VCFs. Moreover, re- sults regarding pain after intervention with either VP or KP as measured by the VAS score plateaued after six months of follow-up in our study, while in the aforemen- tioned investigation by Nikoobakht et al. VAS score con- tinued to improve for twelve months.23 This could be attributed to the fact that we only included patients with OVCFs, meaning our sample is more consistent than the aforementioned studies. As for SF-36, our results are in line with the already existing literature with the benefit of a longer follow-up time. Major complications after VP and KP are rare, with severe complications occurring in approximately 8% of patients following KP and VP according to existing literature.26 Some of the most common major complications described after the two procedures are cement leakage and emer- gence of adjacent OVCF. In our study, no major compli- cations were observed, suggesting the safety of the two procedures.24 To our knowledge, this is the first prospective study in global literature for patients with OVCFs with an extensive follow-up time of two years. In this study, two of the most commonly used questionnaires for HRQoL were employed to determine the primary outcome: the pain VAS score and the SF-36 for the overall functionality and quality of life of patients. The latter was chosen in order to perform a more multifaceted evaluation of our individuals. Limitations of this study include the small sample size, the relatively lim- ited follow-up duration, and the fact that this is not a ran- domized control trial. In view of these limitations, future researchers could work towards these directions. Conclusions VP and KP in this study were demonstrated to be safe and efficient options for interventional treatment of OVCFs in elderly patients, improving self-reported symptoms of pain as well as overall HRQoL. Neverthe- less, further randomized controlled trials with greater number of enrolled individuals and more extended fol- low-up intervals are required in order to exclude safer conclusions about the precise utility of these techniques in interventional management of OVCFs. Furthermore, a more detailed categorization of patients based on os- teoporosis and co-existing underlying comorbidities is required, so any confounders that may falsely affect the outcome of interventions on general HRQoL could be mitigated. List of acronyms HRQoL: Health-Related Quality of Life. VP: Vertebroplasty. KP: Kyphoplasty. OVCFs: Osteoporotic Vertebral Compression Fractures. MIVA: Minimally Invasive Vertebral Augmentation. VAS: Visual Analogue Scale. SF-36: Short-Form 36. WHO: World Health Organization. CT: Computed Tomography. MRI: Magnetic Resonance Imaging. PMMA: Polymethyl methacrylate. AP: Anteroposterior. PF: Physical Function. RP: Role Physical. BP: Bodily Pain. GH: General Health. V: Vitality. SF: Social Function. RE: Role emotional. MH: Mental Health. ANOVA: Analysis Of Variance. NRS: Numerical Rating Scale. ODI: Oswestry Disability Index. PCS: Physical Component Summary. EQ-5D: EuroQol-5-Domain. Contributions SK, CC, PK, SA, NG, conception and design, analysis and interpretation of data, drafting the article and critical re- vision of article for important intellectual content, final approval of the version to be published, agreement to be accountable for all aspects of the work; PV, analysis and interpretation of data, drafting the article and critical re- vision of article for important intellectual content, final - 55 - Table 4. Spearman rank order correlation coefficients. No values were found to be statistically significant at the level of p<0.05. AGE PF_DIF RP_DIF BP_DIF GH_DIF V_DIF SF_DIF RE_DIF MH_DIFVAS_DIF TIME AGE 1,000 0,018 -0,142 -0,149 0,131 0,128 0,0239 0,031 -0,014 -0,021 0,193 Non -co mmerc ial us e o nly Vertebroplasty and kyphoplasty in elderly individuals Eur J Transl Myol 34 (3) 12274, 2024 doi: 10.4081/ejtm.2024.12274 approval of the version to be published, agreement to be accountable for all aspects of the work. Conflict of interest The authors declare no conflict of interest. Funding This research did not receive any specific grant from fund- ing agencies in the public, commercial, or not-for-profit sectors. Ethics approval The study protocol was approved by the Institutional Re- view Board of Interbalkan European Medical Center, Thessaloniki, Greece (Approval Code: 29.09.2018). The study is conformed with the Helskinki Declaration of 1964, as revised in 2013, concerning human and animal rights. Informed consent All patients participating in this study signed a written in- formed consent form for participating in this study. Availability of data and materials All data generated or analyzed during this study are in- cluded in this published article. Corresponding author Stylianos N. Kapetanakis, Orthopaedic Surgeon-Spine Surgeon, Spine Department and Deformities, Interbalkan European Medical Center, Thessaloniki, Greece. Tel.: +306972707384 - Fax: +302541067200. ORCID ID: 0000-0001-6276-2447 E-mail: stkapetanakis@yahoo.gr Constantinos Chaniotakis ORCID ID: 0000-0002-8935-5566 E-mail: kostas_chanio1994@hotmail.com Periklis Zavridis ORCID ID: 0000-0002-8368-6946 E-mail: pzavridis@painclinic.com.cy Periklis Kopsidas E-mail: periklis.kop@gmail.com Sotirios Apostolakis ORCID ID: 0000-0003-4179-2916 E-mail: sotapostolakis@gmail.com Nikolaos Gkantsinikoudis ORCID ID: 0000-0001-7868-6880 E-mail: nikgkantsinikoudis@gmail.com References 1. Lane JM, Russell L, Khan SN. Osteoporosis. Clin Or- thopRelat Res 2000;372:139-50. 2. Link TM, Majumdar S. Osteoporosis imaging. Radiol Clin North Am 2003;41:813-39. 3. Beall DP, Chambers MR, Thomas S, et al. Prospective and multicenter evaluation of outcomes for quality of life and activities of daily living for balloon kypho- plasty in the treatment of vertebral compression frac- tures: the EVOLVE trial. Neurosurgery 2019;84: 169-78. 4. Chmielnicki M, Prokop A, Kandziora F, Pingel A. 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Disclaimer All claims expressed in this article are solely those of the authors and do not necessarily represent those of their af- filiated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Submitted: 11 January 2024. Accepted: 12 June 2024. Early access: 8 August 2024. - 57 - Non -co mmerc ial us e o nly