Osteoporosis: The Renascent Impact of Vertebral Fractures—A Narrative Review of Diagnosis, Risk Stratification, and Integrated Management

Osteoporotic vertebral fractures (OVFs) are the most common osteoporotic fracture type and remain substantially underdiagnosed despite their diagnostic, prognostic, and therapeutic importance. This review examines OVFs as sentinel events in osteoporosis, emphasizing their role in diagnosis, fracture-risk stratification, treatment selection, and secondary fracture prevention. This narrative review synthesizes evidence from contemporary clinical practice guidelines, epidemiological studies, randomized controlled trials, systematic reviews, meta-analyses, and selected observational studies addressing imaging and artificial-intelligence-assisted detection. References were selected based on clinical relevance, methodological rigor, and recency, in keeping with the conventions of a focused narrative review rather than a systematic review. OVFs frequently occur without classic osteoporosis-range bone mineral density and often remain clinically silent or incidentally detected. Nevertheless, they independently predict future vertebral, hip, and non-OVFs, particularly during the early post-fracture period. Vertebral fracture assessment on dual-energy X-ray absorptiometry (DXA), opportunistic CT screening, standardized radiology reporting, and AI-assisted detection may improve case finding. Management should combine acute pain control, rehabilitation, appropriate use of vertebral augmentation in selected patients, pharmacological osteoporosis therapy, and structured secondary prevention. Patients with recent or multiple OVFs often meet criteria for high or very-high fracture risk and may benefit from anabolic-first or sequential therapy strategies. Fracture Liaison Services provide a system-level model to close the diagnosis and treatment gap. Recognizing OVFs as actionable markers of skeletal fragility is essential for reducing subsequent fracture burden.