Introduction
Vertebral compression fractures (VCFs) represent the most common osteoporotic fractures, arising from the structural collapse of a vertebral body [1,2]. They most frequently affect the thoracic and lumbar spine and typically occur following minimal or no trauma in individuals with underlying skeletal fragility. Globally, VCFs account for more than 1.4 million new cases annually, contributing significantly to morbidity, disability, and healthcare costs associated with osteoporosis in older adults [3,4]. In the United States, over 700,000 VCFs are diagnosed each year, although the true incidence is likely higher due to underdiagnosis and the frequent absence of acute symptoms [1,2,4,5]. Although often linked to low-energy or atraumatic mechanisms, these injuries are not benign. Beyond acute pain, VCFs can lead to progressive kyphotic deformity, impaired mobility, decreased pulmonary function, heightened risk of subsequent fragility fractures, and higher mortality [3,5]. Despite this burden, VCFs continue to be underrecognized and undertreated, particularly when symptoms are attributed to nonspecific back pain or when underlying osteoporosis remains unaddressed [6,7].
VCFs are particularly frequent among postmenopausal females owing to age-related bone loss, but males who sustain these fractures often experience poorer outcomes [4,6]. The prevalence of VCFs increases with advancing age and varies geographically, reflecting disparities in osteoporosis screening, lifestyle factors, and access to care [7,8].
The clinical impact of VCFs extends well beyond localized pain, encompassing kyphotic deformity, impaired mobility, compromised pulmonary function, and a substantially elevated risk of subsequent fractures and premature mortality [6,9,10]. Nevertheless, VCFs remain underdiagnosed and inconsistently managed. Current treatment options range from conservative therapy to percutaneous vertebral augmentation procedures, including vertebroplasty and balloon kyphoplasty, although evidence about long-term efficacy remains inconclusive [11,12]. Differences in diagnostic access, procedural intervention, and osteoporosis management persist across sociodemographic lines [13,14]. The clinical challenge in VCF care has shifted from acknowledging that these fractures are common to optimizing their evaluation and management. In practice, key areas of uncertainty [8,9] include differentiating acute symptomatic osteoporotic fractures from chronic deformities or pathologic collapse, identifying patients most likely to benefit from vertebral augmentation, and defining the role of anti-osteoporotic pharmacotherapy in secondary fracture prevention after a vertebral fragility event [3,10,11]. These issues are particularly relevant in older adults with substantial comorbidity, variable fracture morphology, and increased susceptibility to recurrent fracture, functional decline, and delayed treatment escalation [12-14].
Given their high prevalence, clinical complexity, and impact on quality of life, a comprehensive review of VCFs is warranted. This narrative review synthesizes current evidence on the epidemiology, pathophysiology, diagnosis, management, and healthcare disparities related to VCFs, highlighting treatment outcomes, advances in imaging and risk prediction, and emerging strategies for fracture prevention and secondary care. Hence, this narrative review examines clinically relevant areas of uncertainty in VCF care, focusing on diagnostic evaluation, treatment selection, vertebral augmentation, and secondary fracture prevention, emphasizing areas of ongoing controversies where management remains nuanced and where evolving evidence may help inform patient-centered management.
Methods Literature Search Strategy
Relevant peer-reviewed literature was identified through PubMed and Google Scholar databases to identify peer-reviewed articles published between January 2000 and December 2024. Search terms included “vertebral compression fracture,” “osteoporosis,” “vertebroplasty,” “kyphoplasty,” “spinal fracture diagnosis,” “VCF mortality,” “bone mineral density,” and “fragility fractures.” Studies published in English and focusing on adult populations were prioritized.
Priority was provided to systematic reviews, meta-analyses, randomized controlled trials, and guidelinebased publications from high-impact journals. To provide a broader clinical context, relevant narrative reviews and large-scale cohort studies were also included. Articles were screened for relevance in key areas, including epidemiology, risk factors, diagnostic imaging, treatment outcomes, disparities in care, and emerging technologies such as artificial intelligence (AI) and fracture risk prediction tools.
Etiology and Risk Profile
VCFs arise from the interplay between skeletal fragility and mechanical loading. Osteoporotic VCFs result when low-energy stresses, such as bending, lifting, or falling, exceed the diminished structural integrity of weakened vertebral bodies. Deterioration of trabecular bone microarchitecture, compromised bone mineral density, and cortical thinning increase susceptibility to fracture, especially in the thoracolumbar region [1,2,14,15].
Although osteoporosis accounts for most VCFs in older adults, these fractures may also result from high-energy trauma or pathologic processes like metastatic disease or infection. Traumatic VCFs occur more frequently in younger individuals and are typically associated with motor vehicle collisions or falls from height, whereas malignancy-related fractures occur when tumor infiltration compromises vertebral structural integrity [15]. Major risk factors include advanced age, female sex, low bone mass, prior fragility fracture, glucocorticoid use, smoking, and comorbidities such as chronic kidney disease, rheumatoid arthritis, etc. that impair bone quality or increase fall risk [1,7]. Among these factors, a previous vertebral fracture, especially among postmenopausal females, is a particularly strong predictor of future fractures, underscoring the significance of recognizing VCFs as markers of ongoing skeletal fragility [1,5,13-16].
Morbidity and Mortality
VCFs impose a considerable burden of morbidity and mortality, especially in older adults [14]. Although sometimes perceived as less severe than hip fractures, VCFs are increasingly recognized as sentinel fragility events associated with accelerated functional decline, loss of independence, and premature death [5,8,9]. Complications of untreated VCFs include chronic pain, progressive sagittal imbalance, restrictive lung disease, and physical deconditioning, all of which contribute to functional decline and a heightened risk of mortality [8,15]. Emerging evidence indicates that a history of VCF independently predicts poorer functional recovery after total hip arthroplasty, highlighting the systemic impact of spinal fragility [16].
A large Medicare cohort reported a 1-year mortality rate of approximately 15% after VCF, with significantly worse outcomes among patients with delayed treatment or multimorbidity; most fractures occurred without major trauma, and the mean patient age was over 75 years [9]. Consistent with these findings, a Korean nationwide analysis demonstrated elevated 30-day and 1-year mortality rates across all age groups, particularly among individuals older than 75 years [4]. Hospital-based studies have further identified frailty, comorbidities, and delayed presentation as key determinants of postfracture mortality [6,16-19]. These findings underscore that VCFs are associated with substantial morbidity and should not be regarded as benign radiographic findings [17]. In addition to acute and chronic pain, these fractures may contribute to kyphotic deformity, impaired mobility, loss of independence, decreased pulmonary function, and elevated risk of future fragility fractures [5,6,12]. Their clinical consequences extend beyond the spine, as vertebral fragility is increasingly recognized as an indicator of systemic physiological vulnerability in older adults [12,13].
Mortality after VCF is considerable, with a large Medicare cohort reporting a 1-year mortality rate of approximately 15% after VCF, with worse outcomes among older patients and those with a higher burden of comorbidities [5]. More recent population-based studies have similarly demonstrated elevated short-and long-term mortality after VCF, particularly among older adults and those with delayed treatment or frailty-related risk factors [12,13,18]. This increased mortality risk is likely driven by multiple factors, reflecting the effects of immobility, progressive sagittal deformity, pulmonary dysfunction, sarcopenia, and recurrent falls and fractures over time [13,19,20].
Collectively, these findings support the recognition of VCFs as sentinel fragility events rather than isolated mechanical injuries. Appreciation of their broader clinical significance is important because it informs subsequent decisions regarding diagnostic evaluation, treatment selection, and secondary fracture prevention.
Compared with other fragility fractures, the mortality burden associated with VCFs is often underestimated, largely due to their often insidious presentations and the perception that spinal fractures are less consequential than hip fractures [18,19]. However, accumulating evidence indicates that VCFs may be associated with mortality rates comparable to, or in some cases exceeding, those observed after hip fractures, particularly in the presence of chronic cardiopulmonary disease, malignancy, or systemic frailty [8,18-20].
The mechanisms underlying these adverse outcomes are multifactorial. Acute immobility predisposes patients to venous thromboembolism, pneumonia, and urinary infections [11,21], while progressive kyphosis may impair pulmonary mechanics and reduce physiological reserve [19,22]. Moreover, chronic pain and reduced mobility can accelerate sarcopenia and elevate the risk of subsequent falls and fractures [5,17].
Timely recognition and management are essential. Several studies suggest that early initiation of osteoporosis treatment and, in certain cases, vertebral augmentation may reduce complications and improve survival [11,18,21]. VCFs are not benign events; rather, they signal broader physiological vulnerability and warrant proactive, multidisciplinary care focused on fracture prevention, functional preservation, and mortality reduction.
Diagnosis
Accurate diagnosis of VCFs requires thorough clinical evaluation supported by appropriate imaging. A detailed history should evaluate the mechanism of injury, presence or absence of trauma, symptom duration, and history of prior fractures, malignancy, or systemic disease. Particular attention should be given to red-flag features, such as progressive neurological deficits or signs of infection, which may indicate underlying malignancy or osteomyelitis [20-23].
Physical examination should assess spinal tenderness, postural alignment, and range of motion, including flexion, extension, and lateral bending. It should also include a focused neurologic evaluation encompassing lower extremity motor strength, dermatomal sensory testing, and deep tendon reflexes. However, clinical examination alone may be insufficient to differentiate benign osteoporotic fractures from malignancy-associated VCFs, and further evaluation with advanced imaging modalities, such as magnetic resonance imaging (MRI) or positron emission tomography (PET)/computed tomography (CT), is typically required [24].
Accurate diagnosis of VCFs begins with meticulous clinical assessment and targeted imaging. The history should address symptom onset, mechanism of injury, presence or absence of trauma, prior fragility fractures, and any history of malignancy, infection, or systemic disease [21-23]. Red-flag features, such as progressive neurologic deficits, constitutional symptoms, or clinical concern for infection, should be carefully evaluated, as these findings may indicate a pathologic or infectious etiology rather than an isolated osteoporotic fracture [24,25].
Physical examination should evaluate focal spinal tenderness, overall alignment, functional limitation, and neurological status. However, clinical findings alone are often insufficient to distinguish an acute osteoporotic fracture from chronic vertebral deformities or malignant vertebral collapse [26]. In these settings, advanced imaging plays a key role. MRI is particularly valuable for confirming fracture acuity, whereas CT and, in selected cases, PET/CT can help delineate posterior wall involvement, canal compromise, or features suggestive of neoplastic or infectious pathology [26,27]. Table 1 summarizes the roles, strengths, and limitations of commonly employed imaging modalities.
Imaging Modalities
Plain radiographs (X-rays)
Plain radiography is often the initial imaging modality due to its wide availability and can identify overt vertebral height loss or wedge deformities. However, they lack the sensitivity for detecting acute fractures and cannot reliably demonstrate bone marrow edema [25].
CT
CT is useful for assessing cortical bone, posterior wall disruption, and fracture morphology, especially in the context of trauma evaluation or surgical planning. It is less reliable for differentiating benign from malignant fractures [17].
MRI
MRI, particularly short tau inversion recovery (STIR) and T2-weighted sequences, is highly sensitive for detecting bone marrow edema and distinguishing acute from chronic fractures. It also provides detailed assessment of spinal canal compromise, epidural extension, or neoplastic infiltration and is particularly helpful in the setting of osteoporotic burst fractures [26].
Advanced modalities (diffusion weighted MRI and fluorodeoxyglucose PET/CT)
Diffusion-weighted MRI demonstrates high specificity for identifying malignant lesions, whereas fluorodeoxyglucose PET/CT provides metabolic information that is useful in oncologic cases. Both modalities are valuable in distinguishing benign osteoporotic fractures from malignant vertebral involvement [26-29].
Biomarkers and Risk Stratification Tools
Laboratory markers, including bone-specific alkaline phosphatase and 25-hydroxyvitamin D, may assist in diagnostic evaluation in ambiguous cases and support osteoporosis management planning [30]. A comparative summary of these modalities is presented in Table 1 [17,20,23,25,26,28,30].
Plain radiographs are typically the initial imaging study due to their ready availability and ability to detect vertebral height loss, wedge deformity, or more advanced collapse [28]. However, their limited capacity to determine fracture acuity and inability to demonstrate bone marrow edema restrict their utility in distinguishing acute symptomatic fractures from chronic deformities [26,29].
CT is particularly useful for delineating fracture morphology, cortical disruption, posterior wall involvement, and retropulsion, especially in cases of suspected instability or when surgical planning is required. However, despite its excellent osseous detail, CT is less reliable than MRI in assessing fracture acuity or differentiating benign osteoporotic collapse from malignant vertebral involvement [29].
MRI is the most informative modality when the diagnosis is uncertain or when management decisions require confirmation of fracture acuity. STIR and T2-weighted sequences can detect bone marrow edema, enabling differentiation of acute from chronic fractures [26]. MRI is also valuable in assessing canal compromise, posterior ligamentous involvement, epidural extension, and imaging features suggestive of neoplasm or infection [30].
In selected cases, advanced imaging may further refine diagnostic assessment. Diffusion-weighted MRI enhances characterization of malignant vertebral lesions, while fluorodeoxyglucose-PET/CT may be useful when metastatic disease or other pathologic processes are suspected [26,27]. However, these modalities are generally adjunctive rather than first-line investigations and are most valuable when conventional imaging does not reliably distinguish osteoporotic fracture from malignant or infectious vertebral collapse [30].
Management
Management of vertebral compression fractures
Management of VCFs should be individualized according to pain severity, fracture morphology, neurological status, and comorbidities [5,11,14,31]. Early diagnosis and tailored treatment are essential to prevent immobility-related complications, particularly in older adults [14,15,19]. These approaches are consistent with established clinical guidelines that emphasize early risk stratification, fracture stabilization, and osteoporosis management to enhance outcomes in patients with VCFs [32].
Management of VCFs should be individualized according to pain severity, fracture acuity and morphology, neurological status, functional limitation, and comorbidities [6,10,16,31]. In most patients without neurological deficit or structural instability, treatment is initially conservative, whereas more invasive approaches are considered for refractory pain, progressive deformity, or neurological compromise [10,31]. Because these fractures often reflect a fragility event rather than isolated mechanical injury, evaluation of underlying osteoporosis and initiation of secondary fracture prevention are essential components of management [7,16]. A treatment algorithm summarizing this approach is presented in Fig. 1.
Nonoperative management
Initial nonoperative management
Conservative treatment remains the mainstay for most patients, especially those with stable fractures and manageable pain [10,33]. It comprises analgesia, short-term bracing, early mobilization, physical therapy, and osteoporosis-specific pharmacotherapy [5,23,34]. Although brief bed rest may occasionally be required, prolonged immobility is associated with increased risk of thromboembolism, pneumonia, and functional deterioration [17,21].
Bracing with thoracolumbar orthoses may offer short-term structural support and pain relief, although its long-term benefit remains uncertain [11]. Early physical therapy emphasizing postural correction, spinal extension exercises, and balance training mitigates fall risk and supports functional recovery [20-22,35].
Pharmacologic management focuses on both acute pain and fracture prevention. Nonsteroidal anti-inflammatory drugs and acetaminophen are first-line agents, while opioids are reserved for severe or refractory pain [17]. Treatment of underlying osteoporosis is crucial; although bisphosphonates are widely used, anabolic agents like teriparatide may accelerate fracture healing and reduce the risk of refracture in high-risk populations [13,14]. Despite established clinical guidelines, adherence to osteoporosis treatment remains suboptimal, especially in underserved populations [12,13].
For most patients with stable VCFs and tolerable pain, conservative treatment remains the first-line approach [9]. This approach typically involves pain control with analgesics, short-term reduction in activity, early mobilization, selective bracing, and physical therapy [3,32].
Analgesic management is typically stepwise, beginning with acetaminophen or nonsteroidal anti-inflammatory drugs when appropriate, with short-course opioids reserved for severe or refractory pain [13]. Although brief activity restriction may be required early after fracture, prolonged bed rest should be avoided, as it is associated with deconditioning, thromboembolic events, pulmonary complications, and functional decline, particularly in older adults [13,22].
Bracing may offer short-term pain relief and mechanical stabilization in selected patients, although its long-term benefit remains uncertain [10]. Physical therapy is generally initiated once acute pain is controlled and emphasizes mobilization, posture, balance, and functional recovery while decreasing fall risk [19,21,33]. A VCF should also trigger assessment for underlying skeletal fragility, as untreated osteoporosis contributes to recurrent fractures and ongoing morbidity [7,11,16].
Vertebral augmentation: indications, outcomes, and controversy
Vertebral augmentation techniques, including vertebroplasty and balloon kyphoplasty, may be considered in patients with MRI-confirmed acute fractures who have persistent severe pain despite an initial trial of conservative treatment [10,32,34]. Both procedures involve percutaneous cement augmentation, while kyphoplasty additionally attempts partial restoration of vertebral height before cement injection [34]. In appropriately selected patients, augmentation has been associated with improved short-term pain relief and functional recovery compared with nonoperative management alone [10,35].
The role of vertebral augmentation remains complex. While randomized trials and meta-analyses demonstrate short-term benefit in selected patients, long-term outcomes are less clearly defined, and complications such as cement leakage, adjacent-level fracture, and embolic phenomena must be considered [3,10,31]. Although symptomatic cement embolic events are rare, asymptomatic pulmonary cement emboli may be detected more frequently on postoperative imaging, with reported incidence varying according to surveillance protocol and imaging modality used [36,37]. These considerations underscore the importance of careful patient selection, particularly based on fracture acuity, symptom severity, radiographic findings, and inadequate response to initial conservative therapy [6,35,38]. A summary of treatment strategies, including their indications, benefits, and limitations, is provided in Table 2.
Operative management: surgical stabilization and decompression
Recent evidence suggests that vertebral augmentation may offer superior pain relief and mitigate the risk of subsequent fractures compared with orthotic management alone [36]. Vertebral augmentation techniques, including vertebroplasty or balloon kyphoplasty, are typically considered in patients with MRI-confirmed bone edema and persistent pain after 2–4 weeks of conservative therapy [11,17,33]. Both procedures involve percutaneous cement injection for stabilization, with kyphoplasty additionally allowing partial restoration of vertebral height before cement placement [37]. Compared with bracing, vertebral augmentation has been demonstrated to provide superior pain relief and lower refracture rates in selected patients [28].
Randomized trials and meta-analyses have exhibited short-term improvements in pain and function following vertebral augmentation [33,36]. However, the long-term benefit remains unclear in light of the risks, including cement leakage, adjacent fractures, and rare embolic events [10,11,31]. A critical review and meta-analysis of randomized controlled trials highlighted the increased risk of new vertebral fractures and serious adverse effects after vertebroplasty, underscoring the need for careful patient selection [38,39]. Nonetheless, large series suggested that overall complication rates remain low among experienced surgeons [31,40], and appropriate patient selection is critical to minimize complications [34,36].
Surgical decompression and stabilization are reserved for individuals with neurological impairments, spinal canal compromise, or progressive deformity. In patients with osteoporotic burst fractures and delayed neurological symptoms, posterior instrumentation and decompression can restore stability and improve neurological outcomes [41,42]. For malignancy-related VCFs, vertebral body stenting combined with decompression and augmentation may relieve cord compression and enhance mobility [43].
Post-procedure rehabilitation is critical for optimizing recovery. Tailored physical therapy programs that focus on core stabilization, postural correction, and fall prevention have been demonstrated to improve functional outcomes and decrease recurrence [22,35]. Additionally, recent economic analyses have indicated that vertebral augmentation, when applied to appropriately selected patients, may be cost-effective by shortening hospital length of stays, improving mobility, and reducing long-term care dependency [13,36].
Surgical decompression and stabilization are often reserved for patients with neurological deficits, spinal canal compromise, progressive deformity, or fractures associated with instability. In osteoporotic burst fractures with delayed neurological symptoms, posterior decompression and instrumentation may help restore stability and enhance neurological outcomes [39,40]. In pathologic fractures associated with malignancy, decompression combined with stabilization or vertebral body reconstruction may also be required to relieve neural compression and preserve mobility [41].
Prevention and Public Health Implications
Secondary fracture prevention and system-level gaps in care
A VCF should be regarded as a sentinel fragility event prompting systemic examination of underlying osteoporosis and initiation of secondary fracture prevention when appropriate [42]. Although dual-energy X-ray absorptiometry remains the standard for determining bone mineral density, osteoporosis remains underdiagnosed and undertreated following VCF, including in populations at particularly high risk of recurrent fracture [6,7]. Fracture-risk tools such as FRAX may further support risk stratification, especially when bone mineral density alone does not fully reflect clinical risk [16]. AI-based models have shown potential in fracture prediction and diagnostic precision. Algorithms that incorporate clinical, demographic, and radiologic variables may enable earlier intervention and individualized management [43]. Integration of AI tools into electronic health records and imaging workflows could facilitate real-time clinical decision-making [44].
Post-fracture treatment gaps persist, as many patients with VCF do not receive timely osteoporosis evaluation or pharmacologic therapy despite the increased risk of subsequent fracture and continuous functional decline [7,10]. Antiresorptive agents, such as bisphosphonates, are foundational in secondary fracture prevention, while anabolic therapies are considered in selected high-risk patients [42,45]. More recently, romosozumab has emerged as an additional option for patients at very high fracture risk, although its use should remain individualized and informed by patient-specific risk profiles, treatment sequencing, and potential contraindications [2,46].
Beyond pharmacotherapy, persistent system-level inadequacies impact timely diagnosis, treatment initiation, and longitudinal follow-up after VCF. Racial, socioeconomic, and geographical disparities continue to limit access to osteoporosis screening, vertebral augmentation, and guideline-directed post-fracture treatment [11,12,46]. Fracture liaison services (FLSs) have emerged as one of the most practical approaches for bridging these gaps, enhancing post-fracture evaluation, increasing treatment initiation and adherence, and lowering recurrent fracture risk in a cost-effective manner [7,11,46].
Adjunctive strategies such as fall-risk assessment, rehabilitation, and patient education remain important but are most effective when integrated into a larger secondary prevention framework rather than when applied in isolation. Collectively, these data support a transition from episodic fracture management toward coordinated longitudinal care after VCF.
Preventing VCFs requires a coordinated strategy that targets upstream risk factors, optimizes secondary prevention, and ensures equitable access to care. Public health frameworks should prioritize early detection of osteoporosis, fall risk mitigation, timely imaging, and institutional improvements to address care gaps.
Osteoporosis detection and post-fracture management
Osteoporosis is the primary underlying risk factor for VCFs, yet it is frequently underdiagnosed and undertreated. Although dual-energy X-ray absorptiometry is the gold standard for determining bone mineral density, its utilization in high-risk populations, including older males and underserved communities, remains suboptimal [5,13]. Clinical techniques such as the FRAX algorithm (Osteoporosis Research Ltd, London, UK) help identify patients at high risk of fracture, even when bone mineral density thresholds are not fulfilled [14].
Post-fracture osteoporosis care is particularly inadequate. Studies have revealed that fewer than half of patients with VCFs obtain appropriate diagnostic evaluation or pharmacologic treatment for underlying bone disease, resulting in a missed opportunity for secondary prevention [11]. First-line treatment with bisphosphonates or anabolic agents such as teriparatide may minimize recurrence, particularly when initiated early in high-risk individuals [12,13].
Fall prevention and functional risk reduction
Falls represent the most common precipitating event for osteoporotic VCFs. Older adults with impaired balance, sarcopenia, visual deficits, or polypharmacy are at particularly high risk [22,35]. Fall prevention strategies, including strength and balance training, home hazard modification, medication review, and vitamin D supplementation, have been shown to reduce fracture incidence [22]. Frailty is an independent risk factor for VCF occurrence and associated adverse outcomes, reinforcing the importance of early frailty assessment and fall prevention interventions in older adults [44].
Community-based interventions and national public health initiatives aimed at reducing fall risk have the potential to decrease both fracture-related morbidity and downstream healthcare utilization [6,35]. Functional rehabilitation following fracture, including spine-focused physical therapy, also plays a key role in restoring mobility and preventing future injury.
Diagnostic timelines and imaging access
Delays in diagnostic imaging, specialist referral, or treatment initiation after symptom onset may lead to progressive deformity, chronic pain, and a higher mortality rate [11,21]. Early MRI is the most sensitive modality for identifying acute VCFs and distinguishing them from chronic or malignant compression fractures [45]. Expanding access to MRI and specialized radiology expertise in acute care settings is essential to facilitate prompt diagnosis and effective triage.
Addressing disparities and enhancing system-level coordination
Significant racial, socioeconomic, and geographical disparities continue to impact the diagnosis and management of VCFs. Patients from racial and ethnic minority groups as well as those living in low-resource communities are less likely to receive osteoporosis screening, vertebral augmentation procedures, or guideline-directed pharmacologic therapy [12,46]. These disparities have important clinical implications. In a large population-based cohort, Gold et al. [8] reported that older adults with osteoporotic vertebral fractures experienced a 35%–40% higher adjusted risk of all-cause mortality than matched controls, even after adjustment for age, sex, and comorbidity burden.
Addressing these inequities will require policy reforms and targeted outreach programs. FLS have emerged as cost-effective models of coordinated care that improve post-fracture treatment adherence, lower refracture rates, and mitigate healthcare costs [12,13,35]. Integrating FLS into hospitals and outpatient settings can improve care continuity through multidisciplinary collaboration among the departments of geriatrics, endocrinology, and orthopedics.
Educational and public health initiatives
Patient and provider education plays a key role in fracture prevention. Initiatives focused on increasing awareness of osteoporosis, fracture risk, and treatment options can encourage early care-seeking behavior and enhance adherence to prescribed therapy [14]. At the healthcare system level, incorporating FLS into hospitals and clinics has been shown to enhance postfracture evaluation rates and reduce the incidence of secondary fractures [6,12,13]. FLS programs have demonstrated high cost effectiveness by reducing refracture rates and long-term healthcare expenditures while improving treatment initiation and adherence [32].
Future Directions
Despite growing recognition of the clinical and public health burden linked to VCFs, key knowledge gaps remain in treatment optimization, long-term outcomes, and equitable access to care. Emerging technologies and evolving care models offer promising opportunities to address these limitations.
Significant knowledge gaps persist in the management of VCFs, particularly regarding patient selection for vertebral augmentation, comparative long-term outcomes, and the optimal role of pharmacologic therapy following fracture [40]. Future studies should aim to define which patients derive the greatest benefit from augmentation, clarify the duration of effect beyond short-term pain relief, and evaluate novel procedural approaches and biomaterials that may improve safety and structural durability [32].
Additional efforts are needed to strengthen secondary fracture prevention after VCF. Despite established treatment strategies, osteoporosis remains underdiagnosed and undertreated following fragility fracture, and system-level gaps continue to limit timely initiation of therapy and longitudinal follow-up [7]. Future efforts should prioritize coordinated post-fracture care models, including FLSs, to improve treatment initiation, adherence, and long-term risk reduction. Prospective studies and real-world data are essential to clarify long-term outcomes related to pain, function, recurrent fracture, and mortality [13,20,22].
Advancements in treatment and rehabilitation
Although vertebral augmentation and pharmacologic therapies remain key components of VCF management, further research is needed to refine procedural indications, optimize patient selection, and compare the long-term outcomes of available treatment strategies [33,39]. Novel biomaterials, injectable biologics, and spinal stabilization techniques may lower the incidence of complications and improve durability. Structured rehabilitation programs after VCFs, including targeted physical therapy protocols and spine-specific exercise regimens, warrant further investigation to determine their impact on recovery, mobility, and fall risk [22,35].
Personalized risk stratification
AI-based models have demonstrated considerable potential for improving fracture prediction and diagnostic precision. Algorithms that incorporate clinical, demographic, and radiologic variables may enable earlier intervention and support more individualized management [45]. Incorporation of AI tools into electronic health records and imaging workflows could enhance real-time clinical decision-making [27].
Closing gaps in osteoporosis care
Despite well-established guidelines, osteoporosis remains underdiagnosed and undertreated, especially after fragility fractures. Addressing this gap will require the implementation of FLS, the incorporation of automated alerts within electronic health systems, and telehealth-based osteoporosis care models to improve adherence, reduce treatment gaps, and prevent recurrence [13,32].
Addressing health disparities
Persistent disparities in access to diagnostic evaluation, pharmacologic therapy, and surgical care disproportionately impact racial and socioeconomically marginalized populations [12,46]. Interventions to address these inequities will require a multifaceted approach that includes culturally tailored education, community-based healthcare strategies, and structural policy reforms aimed at enhancing insurance coverage and care accessibility [6,18].
Longitudinal data and real-world evidence
Prospective cohort studies and registry-based research are essential to better define the natural history of VCFs, evaluate the durability of current treatment approaches, and characterize their long-term effects on pain, function, and mortality [17,19,21]. Real-world evidence will be instrumental in informing value-based care frameworks, shaping future guidelines, and assessing the cost-effectiveness of multidisciplinary strategies.
Conclusions
VCFs are highly prevalent fragility injuries that are associated with substantial consequences beyond acute pain, including deformity, functional decline, recurrent fracture risk, and increased mortality. Accurate diagnosis and individualized treatment selection are therefore essential. While nonoperative care remains the initial approach for most stable fractures, vertebral augmentation may provide meaningful short-term benefits in appropriately selected patients. Surgical stabilization is generally reserved for patients with mechanical instability, progressive deformity, or neurologic compromise.
Importantly, a VCF should be viewed as a sentinel event that prompts evaluation of the underlying osteoporosis and initiation of secondary fracture prevention. Greater emphasis on a coordinated approach to diagnosis, treatment selection, and post-fracture care may improve outcomes and help reduce the long-term burden associated with VCFs.
VCFs are a prevalent yet underrecognized cause of morbidity and mortality, particularly in older adults. They are associated with acute pain, progressive spinal deformity, functional decline, and increased short- and long-term mortality. Despite their significant consequences, VCFs remain inconsistently diagnosed and managed, reflecting both clinical uncertainty and continuing deficiencies in care delivery.
VCF outcomes are influenced by patient demographic characteristics, comorbidities, fracture characteristics, and timeliness of intervention. Although conservative treatment remains the cornerstone of care, vertebral augmentation and surgical stabilization can enhance outcomes when appropriately applied.
Emerging technologies, such as the FRAX algorithm and AI-driven predictive models, hold promise for improving risk stratification and personalizing treatment. Examples include deep learning systems capable of detecting and grading vertebral fractures on radiographs and opportunistic CT imaging, as well as machine learning models that combine clinical factors with imaging-derived bone metrics to estimate future fragility fracture risk. Addressing disparities in care access and expanding multidisciplinary, evidence-based models of care will be required to improve outcomes across diverse populations. As the global burden of VCFs grows, coordinated efforts in clinical research, healthcare policy, and public health are critical to reducing care gaps and enhancing long-term patient outcomes.
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