The incidence of osteoporotic vertebral fractures (OVFs) has risen along with the elderly population’s longer life expectancy. The most typical osteoporotic fracture is a vertebral fracture. OVFs are commonly treated conservatively; nonetheless, it can be difficult to manage complicated cases that require surgery. OVFs can lead to poor activities of daily living (ADL), subsequent fractures (which are four times more common), pulmonary problems (which are three times more common), and increased mortality (15% increase) [1-4]. The presence of an OVF is a major predictor of morbidities, such as back pain, spine deformities, and a decline in quality of life (QOL) [5]. The clinical practice guidelines (11 recommendations) were developed by the American Academy of Orthopedic Surgeons; there was only one strong and one moderate evidences; the remaining nine recommendations were weak or inconclusive [6]. A 2017 review of clinical recommendations for OVF found that diagnostic and treatment advice was frequently contradictory. Because there are now few studies with level I evidence available for review and few of the best OVF management guidelines, more work is needed to raise the standard of the majority of guidelines [7-11]. The purpose of this review was to provide an up-to-date summary of the available evidence on OVF management. Because they are the most common, thoracic and lumbar OVFs were the focus of this review. Cervical OVFs were excluded from this review.

The acute pain of a new OVF is usually relieved after 6–12 weeks [12]. The most common course of treatment for a patient with an acute OVF is a conservative manner. It focuses on pain management through short-term bed rest, analgesic medicine, anti-osteoporotic medication, exercise (physiotherapy), and a brace (spinal orthosis). Because conservative treatment is highly beneficial and should be actively practiced in general, it has remained a successful primary therapeutic approach even if there are no conclusive results.

There have been numerous studies published on vertebral augmentation (VA), which includes kyphoplasty (KP) and vertebroplasty (VP). Fourteen randomized controlled trials investigating the role of VA have been published and over 4,000 articles on VP alone. Despite this, there is still disagreement regarding the effectiveness of VA. Although reaching a firm conclusion is challenging, it is widely accepted that the VA group demonstrated a pain-reduction effect when compared with the control group during the acute phase, but there was no discernible difference in the long-term follow-up results. VA has several advantages, including local anesthesia, mechanical stabilization with cement injection, and analgesic effect from the thermal reaction of polymethyl methacrylate (PMMA) cement [33]. According to several studies, treating local kyphosis and relieving pain with VA may have significantly improved sagittal imbalance [34]. The position statement was presented by American Society spinal intervention groups, which also emphasized the multiple AEs of bed rest, including muscle weakness, pressure sores, and deep vein thrombosis [35]. Patients with osteoporotic burst fractures (OBF) are the subject of several studies. VA reported one case of a patient with OBF who had a poor general condition but no neurologic deficit and received a satisfactory outcome [36]. Short segment fixation combined VA (hybrid procedure) has been introduced as a different treatment approach for OBF [37]. However, because these studies have limited surgical indications, then VA should be performed through a comprehensive evaluation for vertebral instability to avoid serious complications. Several papers proposed VA as an alternative treatment option for intravertebral cleft or vertebral osteonecrosis, but a large number of other studies reported a high failure rate (Fig. 2) [38]. An intravertebral cleft or vertebral instability may be the primary cause of a delayed neurologic deficit and a pain determinant. These results suggest that stabilization therapy has important implications [39]. VA recently showed positive outcomes in mid and long-term periods, and it has been demonstrated to be a cost-effective alternative to conservative treatment in studies conducted in a variety of healthcare settings [40,41]. A meta-analysis suggested facet joint block may be considered complementary to VA in the management of residual back pain, but it may not be effectively used as an alternative therapy [42]. Despite numerous studies pointing to the benefits of VA, there is high heterogeneity across each of these trials, which is the main reason why the evidence is not completely accepted [43]. As a result, clinicians found it challenging to apply the findings to standard clinical practice.

Although VA has low reported complication rates in general, it is important to discuss the serious nature of these problems (2% in KP and 3.9% in VP) [44]. The likelihood of major AEs, including infection, neural tissue damage, thecal sac compression, pulmonary embolism, and respiratory failure, was identified in five trials (821 VP cases). Cement extravasation is a common severe complication. In 473 VA cases, 87.5% for VP and 49.2% for KP were found [45]. In comparison with 1.6% to 3.0% for VP, two meta-analyses determined that the symptomatic leakage rate for KP is between 0% and 0.3% [46]. Precautions have been suggested to reduce the risk of cement leakage, including (1) careful preoperative evaluation, (2) a total cement injection volume less than or equal to the void left by the balloon, (3) a small volume of cement (0.2–0.5 mL) each time, (4) regular evaluation by fluoroscopic imaging, (5) use of high-viscosity cement in a doughy state, and (6) injection time of 3–4 minutes after cement mixing [36].

Re-fractures (VA index level) or subsequent fractures (adjacent level) have also been mentioned as a cause for concern [47]. Risk factors for index level re-fracture include intravertebral cleft and severe kyphosis, increased psoas muscle fatty infiltration, thoracolumbar level, solid lump cement distribution pattern, and higher restoration of body height [48,49]. A common complication is adjacent-segment fracture (ASF), which has a risk of 2% to 23% in KP and up to 52% in VP. The majority of ASFs were observed within two months of VA [50]. The following are hypotheses regarding the potential causes of the rising ASF rate. By increasing the stiffness of the cemented vertebra, it is possible to produce 35 times harder and 12 times stiffer than those in the control group. Unusual loading distribution can result in a 13%–18% increase in adjacent-level pressure [51]. Until recently, the impact of VA on later ASF was not well understood. According to some authors, restoring sagittal balance and physiologic loading by VA may reduce ASF, which was primarily caused by underlying osteoporosis and altered mechanical load caused by spinal deformity [52]. Although this is still debatable, it is possible to conclude that VA has no effect on the likelihood of future fractures. To overcome ASF, prophylactic VP for the adjacent level was attempted. It was suggested that adjacent levels be given a mechanical property gradient by injecting cement based on the findings of various investigations [53,54]. However, its preventive effects have not been completely confirmed.

After randomized studies were published in 2009 demonstrating that the VA was not superior to a sham treatment [8,9], numerous studies have been published that contradict the positive effects of VA. There have also been debate and worldwide concern about study design and results [55]. Because of the controversy surrounding its use in OVFs, the 2018 ASBMR Task Force Report stated that existing research does not support the routine use of VA. Patients should be made aware of the evidence when it is presented [32]. Based on the findings to date, the impact of VA cannot be determined definitively. Only in a small percentage of non-responders to conservative treatment is VA performed properly to anticipate early pain management while accounting for major complications. Because the potential advantages of VA are unknown until more robust data are available, they should not be routinely provided to OVF patients.

Approximately 15%–35% of patients will experience persistent pain, decreased pulmonary function, spinal deformity, and neurological deficits that will necessitate surgical intervention [56,57].

It has been reported that sarcopenia and osteoporosis play an important role in the treatment of OVF. Several studies reported a significant correlation between vertebral instability and cross-sectional area (CSA) of erector lumbar muscles [92]. In a study on subsequent OVF, the most important issue in OVF management, CSA of the psoas muscle could be used as a standalone diagnostic tool of sarcopenia, and sarcopenia was an independent risk factor for subsequent OVF after VA [93]. These studies emphasized that muscle status, such as sarcopenia, has a superior meaning than traditional BMD [92,93]. Sarcopenia was also associated with decreased implant longevity and was identified as the primary cause of implant failures and complications in OVF patients treated with spinal fixation. The authors concluded that measuring the skeletal muscle area using an axial computed tomography of the lumbar spine might help to prevent implant-related complications via early detection and treatment of sarcopenia [94].

The role of artificial intelligence in the management of OVF is also gradually expanding. In the medical imaging field, a deep learning approach based on convolutional neural network (CNN) has gained attention, and the constructed model demonstrated high sensitivity, specificity, and accuracy with an area under the curve (AUC) of 0.949 in detecting acute OVF using magnetic resonance images. This study concluded that the performance of the CNN was comparable with that of two spine surgeons [95]. Machine learning algorithms can also be used to predict nonunion after OVF. The authors proposed extreme gradient boosting (AUC=0.845) and random forest (AUC=0.860) models as more effective predictors with good performance than conventional methods [96].

According to the available literature, there are still no standard methods for managing OVFs. The majority of guidelines should be improved, which will necessitate increased efforts using multimodal strategies, such as conservative and surgical treatment, VA, and medications that treat osteoporosis and promote fracture healing.