Secondary Fracture Rate After Vertebral Osteoporotic Compression Fracture Is Decreased by Anti-Osteoporotic Medication but Not Increased by Cement Augmentation

J Bone Joint Surg Am. 2022 Dec 21;104(24):2178-2185. doi: 10.2106/JBJS.22.00469. Epub 2022 Oct 12.


Background: Painful vertebral osteoporotic compression fractures (OCFs) are often treated with cement augmentation, although controversies exist as to whether or not this increases the secondary fracture risk. Prevention of secondary fracture includes treatment of underlying osteoporosis. The purposes of this study were to determine (1) whether cement augmentation increases the rate of secondary fracture compared with nonoperative management, (2) whether anti-osteoporotic medications reduce the rate of secondary fracture, and (3) the rate of osteoporosis treatment with medications following vertebral OCF.

Methods: The PearlDiver database was queried for all patients with a diagnosis of OCF from 2015 to 2019. Patients were excluded if they were <50 years old, had a diagnosis of spinal neoplasm or infection, or underwent lumbar fusion in the perioperative period. Secondary fracture risk was assessed using univariate and multivariate logistic regression analysis, with kyphoplasty, vertebroplasty, anti-osteoporotic medications, age, gender, and Elixhauser Comorbidity Index as variables.

Results: A total of 36,145 patients were diagnosed with an OCF during the study period. Of those, 25,904 (71.7%) underwent nonoperative management and 10,241 (28.3%) underwent cement augmentation, including 1,556 who underwent vertebroplasty and 8,833 who underwent kyphoplasty. Patients who underwent nonoperative management had a secondary fracture rate of 21.8% following the initial OCF, compared with 14.5% in the vertebroplasty cohort and 18.5% in the kyphoplasty cohort, which was not a significant difference on multivariate analysis. In the entire cohort, 2,833 (7.8%) received anti-osteoporotic medications and 33,312 (92.2%) did not. The rate of secondary fracture was 10.1% in patients who received medications and 21.9% in those who did not, which was a significant difference on multivariate analysis (odds ratio = 1.23, p < 0.001).

Conclusions: Cement augmentation did not alter the rate of secondary fracture, whereas anti-osteoporotic medications significantly decreased the risk of subsequent OCF by 19%. Only 7.8% of patients received a prescription for an anti-osteoporotic medication following the initial OCF.

Level of evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

MeSH terms

  • Bone Cements / therapeutic use
  • Fractures, Compression* / etiology
  • Fractures, Compression* / surgery
  • Humans
  • Kyphoplasty*
  • Middle Aged
  • Osteoporosis* / complications
  • Osteoporosis* / drug therapy
  • Osteoporotic Fractures* / etiology
  • Osteoporotic Fractures* / prevention & control
  • Retrospective Studies
  • Spinal Fractures* / etiology
  • Treatment Outcome
  • Vertebroplasty*


  • Bone Cements