Limited Impact of Short-Term Osteoporosis Medication on Vertebral Height Loss in the Acute Phase of Osteoporotic Vertebral Compression Fractures: A 3-Month Longitudinal Analysis

<i>Background and Objectives</i>: The optimal pharmacological strategy to mitigate progressive vertebral collapse during the acute phase of osteoporotic vertebral compression fractures (OVCFs) remains a subject of debate. This initial 3-month window is the most critical period for evaluating the structural stability of the fracture, as the majority of progressive height loss occurs before solid bone union is achieved, directly influencing the decision to continue conservative management or transition to surgical intervention. <i>Materials and Methods</i>: In this retrospective study, 123 patients were allocated to control (<i>n</i> = 26), denosumab (<i>n</i> = 35), teriparatide (<i>n</i> = 30), or romosozumab (<i>n</i> = 32) groups. Treatment choice was non-randomized, driven by clinical pragmatism and patient preference. Serial changes in vertebral compression rate (VCR) and pain (VAS) were analyzed over 3 months using linear mixed models (LMMs) specifically adjusted for baseline imbalances in initial VCR. <i>Results</i>: In the unadjusted analysis, DMAB appeared to show a slower progression of compression compared to the control group. However, after adjusting for the initial VCR, no significant structural benefit was observed in any medication group (<i>p</i> > 0.05), with all groups showing small effect sizes (Cohen's d < 0.4). In contrast, unstable fracture morphology was identified as the most potent driver of vertebral collapse (β = 2.758, 95% CI: 1.51-4.01, <i>p</i> < 0.001). Clinically, the RM group showed significantly lower overall pain levels throughout the follow-up period compared to the control group (<i>p</i> = 0.014). <i>Conclusions</i>: Short-term osteoporosis medication does not significantly mitigate vertebral collapse during the acute phase of OVCFs. Practically, these findings suggest that unstable fracture morphology and the baseline VCR-reflecting a potential 'floor effect' where less initially collapsed vertebrae may undergo more significant progression-are more informative predictors of acute collapse than medication choice. Consequently, early imaging-based risk stratification is crucial to identify patients at high risk for progressive deformity, regardless of their pharmacological regimen.