Association between platelet to lymphocyte ratio and the risk of vertebral fracture in patients with osteoporosis: a systematic review and meta-analysis

Background Vertebral fractures, accounting for 40% of osteoporotic fractures, often lack early clinical symptoms, necessitating improved risk prediction biomarkers. This meta-analysis was the first to evaluate the association between platelet-to-lymphocyte ratio (PLR) and vertebral fracture risk in osteoporosis patients. Methods We systematically searched PubMed, Embase, Web of Science, Cochrane, Wanfang and CNKI (up to July 2025). Odds ratio (OR) and standardized mean difference (SMD) with 95% confidence intervals (CIs) were used for the data synthesis of categorical and continuous variables, respectively. Sensitivity analysis was performed to explore the stability of the results and potential sources of heterogeneity. All analyses were performed using Review Manager 5.4 and STATA 15.0. Results Seven observational studies were included. Categorical data showed significantly higher vertebral fracture risk in high-PLR groups (OR: 1.02; 95% CI: 1.00, 1.03; P = 0.01). Continuous data revealed a significantly higher PLR level in the fracture group compared with the non-fracture group (SMD: 1.78; 95% CI: 0.32, 3.25; P = 0.02). No significant publication bias was detected for either categorical or continuous variables. Sensitivity analyses revealed instability in both categorical and continuous outcomes and found that the Di et al., 2024 and Song et al., 2022-II studies might be the main sources of heterogeneity. Conclusion Elevated PLR is associated with increased vertebral fracture risk in osteoporosis patients, supporting its role as a predictive inflammatory biomarker. However, heterogeneity in study designs and unstable outcomes highlight the need for a standardized PLR cut-off and larger multinational cohorts to validate its clinical utility. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420251137240 , identifier CRD420251137240.