Surgical approaches, techniques and knowledge gaps in the management of osteoporotic vertebral fractures in the thoracic and lumbar spine: A Narrative review.

Osteoporotic vertebral fractures (OVF) represent a growing clinical challenge due to population aging and the increasing prevalence of osteoporosis. Surgical management of OVF differs substantially from that of traumatic vertebral fractures in younger patients and requires careful consideration of fracture morphology, stability, and patient-related factors. A wide range of surgical techniques is currently available, yet clear treatment algorithms remain limited. A non-systematic narrative review of the literature was performed using PubMed, Scopus, and Google Scholar, supplemented by manual reference screening. The review focuses on contemporary surgical strategies for thoracic and lumbar OVF, with particular emphasis on fracture morphology as defined by the AO Spine-DGOU Osteoporotic Fracture (OF) classification and its implications for treatment selection. Minimally invasive cement augmentation techniques, including vertebroplasty and kyphoplasty, are primarily indicated for stable fracture patterns and provide effective pain relief and early mobilization. Posterior fixation strategies range from short-to long-segment constructs, with stability increasing as construct length increases, particularly in osteoporotic bone. Cement augmentation of pedicle screws significantly improves implant anchorage and reduces mechanical complications. Hybrid stabilization, combining posterior instrumentation with vertebral body augmentation, offers circumferential stabilization with favourable mid-term outcomes and reduced invasiveness compared with combined anterior-posterior surgery. Combined anterior-posterior reconstruction remains the most biomechanically robust option for selected patients with severe instability, neurological deficits, or structural collapse, although its use is limited by patient frailty and surgical morbidity. Surgical treatment of osteoporotic vertebral fractures encompasses a spectrum of techniques tailored to fracture morphology, biomechanical demands, and patient condition. Cement augmentation is suitable for less unstable fractures, whereas posterior fixation-often augmented or combined with hybrid strategies-is preferred in more complex patterns. Individualized treatment selection based on fracture classification and patient factors remains essential to optimize outcomes while minimizing complications.