Unilateral extrapedicular vs. bilateral transpedicular percutaneous kyphoplasty in osteoporotic vertebral compression fractures: an exploratory systematic review and meta-analysis

Background Severe osteoporotic vertebral compression fractures (OVCFs) may require uniform and symmetrical cement distribution to achieve adequate biomechanical stability. Evidence for the unilateral extrapedicular approach (UEA) in percutaneous kyphoplasty (PKP) is limited. This study compares the safety and efficacy of UEA vs. bilateral transpedicular approach (BTA) in PKP for OVCFs. Methods Prospective and retrospective studies comparing UEA and BTA in PKP were identified through searches of Web of Science, PubMed, Embase, Scopus, and the Cochrane Library. Studies published through January 2026 were included. The study was performed using R version 4.5.1 with the meta package. Results Four studies, including 394 OVCF patients, were analyzed. UEA-PKP and BTA-PKP demonstrated comparable efficacy in Oswestry Disability Index score, Visual Analog Scale score, kyphotic correction, and vertebral height restoration. However, relative to BTA-PKP, UEA-PKP results in shorter operative duration (MD = −8.43, 95% CI: −10.90 to −5.96), reduced radiation exposure (MD = −7.23, 95% CI: −11.31 to −3.15), lower cement volume (MD = −0.94, 95% CI: −1.57 to −0.32), and is associated with lower cement leakage rate (OR = 0.49, 95% CI: 0.28–0.85). Conclusion UEA-PKP may offer safety advantages while maintaining similar efficacy compared with BTA-PKP. However, these findings should be interpreted as exploratory, as they are based exclusively on a limited number of retrospective cohort studies.