Complications of Vertebroplasty in Adults: Incidence, Etiology, and Therapeutic Strategies—A Comprehensive, Systematic Literature Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This systematic review provides a comprehensive analysis of vertebroplasty complications across 15 studies encompassing approximately 8,500 patients. The authors successfully compile complication rates and present a thorough categorization of adverse events. While the methodology is sound and the results section is well-structured, the discussion section requires substantial revision to maximize the clinical utility of this work.

The discussion section, while containing valuable information, fails to adequately translate the systematic review findings into actionable clinical guidance. Several critical issues need addressing:

1. Lack of Clinical Decision Framework The discussion does not provide clear guidance on how practitioners should use these complication data for patient selection and informed consent. Consider developing decision trees for different clinical scenarios, and specific recommendations for high-risk populations
2. Insufficient Practice Optimization Recommendations While the authors mention "meticulous technique," they should elaborate on training requirements and learning curve considerations. Also, specific technical modifications to reduce complications, or equipment or procedural innovations that have demonstrated benefit may be mentioned. Eg, when should high viscocity cement be used? When should vertebroplasty be preferred over kyphoplasty based on complication profiles?

I recommend reorganizing the discussion into the following sections:

• Clinical Decision-Making Framework (Patient selection criteria based on complication risk, Guidelines for when to proceed, modify approach, or defer treatment)
• Complication Prevention and Technical Optimization
• Management of Complications
• Informed Consent and Risk Communication
• Future Research Priorities

(Page 10, Line 204-205) For the section on Adjacent-level fractures and repeat PVP management, which represents an important clinical scenario with potentially distinct complication profiles compared to primary procedures. The authors should consider  seeking reference that specifically examine complications and outcomes in this clinical context

This recent study provides valuable data on the safety profile and clinical outcomes of repeated vertebroplasty procedures, which directly addresses the management strategy mentioned in their discussion.

Author Response

Comment 1: Clinical Decision-Making Framework (Patient selection criteria based on complication risk, Guidelines for when to proceed, modify approach, or defer treatment)

Response 1: Added a new “Clinical Decision-Making Framework” section with a decision matrix (Table 3) guiding patient selection and individualized risk stratification.

Comment 2:  Insufficient Practice Optimization Recommendations 

Response 2: Expanded “Complication Prevention & Technical Optimization” to detail training requirements (≥25 supervised cases), learning curve, and equipment innovations (steerable cannulas, pressure feedback). We clarify indications for high-viscosity cement and when kyphoplasty may be preferred based on leak profiles.

 

Comment 3 Discussion reorganization

Response 3: Reformatted discussion into the five requested subsections to enhance actionable guidance

 

Comment 4: Adjacent-level fractures and repeat PVP management

Response 4 : Cited recent registry data (Jensen et al. 2016) on repeat PVP outcomes and integrated targeted management strategies.

Reviewer 2 Report

Comments and Suggestions for Authors

This is a useful systematic review on an important topic due to actual epidemiology of vertebral fractures, meaning complications of vertebroplasty in adults. First of all, besides the importance of the subject, some other strenghts should be mentioned, including comprehensive literature coverage (2009–2024), with over 8,500 patients, structured methodology and the fact that it covers both osteoporotic and neoplasic indications.

Some points to consier

• Introductions is too short and it mainly discusses about vertebroplasty but very little about epiemiology of vertebral fractures. This aspect would be very important in order to point the importance of the subject. Consequently, information found on rows 36-37 should be expanded and references added
• Article is classified as systematic review, but partially met PRISMA standards. While the authors followed several basic steps of a systematic review—such as protocol registration, database search, eligibility criteria, and data extraction—they failed to fully execute key methodological components, including bias assessment, quantitative synthesis, and critical appraisal. As such, this article would be better described as a narrative literature review with systematic elements, rather than a fully compliant systematic review
• Some diacussion about included publication bias should be added
• Some tables (like Table 1) inconsistently present complication rates (e.g., mixing per-patient and per-level data). This makes direct comparisons between studies difficult.
• Lack of visually tools - while Figure 2 is helpful, the article could benefit from more high-yield summary visuals like a complication risk matrix, evidence strength table, or decision-making algorithm.
• Some of the cited studies are quite old (and yes, I understand that used method of treatment is not new), but  some published registries data should be added
  •  

Author Response

Comment 1: Introduction Expanded

Response 1: Added epidemiology of vertebral fractures with prevalence and impact data, citing two large registry studies.

Comment 2: Review Classification

Response 2: Clarified in Methods that our work is a “systematic narrative review” to align with PRISMA elements executed

Comment 3: Table Consistency

Response 3: Reformatted Table 1 to present all complication rates per patient for comparability.

Comment 4: Decision tool

Response 4: Proposed a decision matrix through an evidence-strength table summarizing level of evidence for each complication.

Comment 5: Registry Data

Response 5: Added Saracen & Kotwica (2016) and Ebeling et al. (2019) to include large-scale registry and task-force findings.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

No futher comments. My suggestions were resolved