Abstract
BACKGROUND: Optimal management of osteoporotic vertebral compression fractures (OVCFs) remains controversial. This network meta‑analysis (NMA) evaluated the relative efficacy and safety of third‑generation percutaneous vertebral augmentation (TVA), percutaneous kyphoplasty (PKP), percutaneous vertebroplasty (PVP), and non‑surgical management (NSM) in OVCFs. METHODS: A systematic search of PubMed, Embase, the Cochrane Library, and Web of Science was conducted from inception to February 1, 2025, to identify clinical trials comparing ≥ 2 of these interventions. Primary outcomes included pain intensity (Visual Analog Scale [VAS]), functional disability (Oswestry Disability Index [ODI]), quality of life (EQ‑5D), and anterior vertebral body height (AVB). Adverse events, including adjacent vertebral fracture (AVF) and bone cement leakage (BCL), were also assessed. RESULTS: Forty‑six studies (23 RCTs and 23 comparative cohort studies; n = 5,660) were included. Both TVA and PKP yielded greater VAS reductions than NSM at short‑term (≤ 6 months; MD - 1.28 and - 1.37; 95% CI - 1.62 to - 0.93 and - 1.82 to - 0.92) and long‑term (> 6 months; MD - 0.86 and - 0.69; 95% CI - 1.22 to - 0.50 and - 1.20 to - 0.19) follow‑up. TVA outperformed NSM in ODI improvement at short‑term (MD - 6.84; 95% CI - 9.84 to - 3.84) and long‑term (MD - 9.14; 95% CI - 14.64 to - 3.65); PKP surpassed NSM short‑term (MD - 5.59; 95% CI - 9.32 to - 1.86) but was inferior to TVA long‑term (MD 8.34; 95% CI 2.62 to 14.06). Surgical interventions uniformly outperformed NSM in quality‑of‑life gains. TVA and PKP achieved greater AVB restoration than NSM, whereas PVP carried a higher BCL risk compared to TVA and PKP. NSM was associated with the lowest probability of AVF (90.2%). CONCLUSIONS: Although PKP offers the greatest long‑term preservation of AVB, third‑generation TVA appears superior to PVP, PKP, and NSM in improving pain, functional disability, quality of life, and safety in OVCF patients. High‑quality randomized trials with extended follow‑up are required to confirm these findings.