Introduction: Various classifications for osteoporotic vertebral fractures (OVFs) have been introduced to enhance patient care and facilitate clinical communication. However, there is limited evidence of their effectiveness in predicting vertebral collapse, and very few studies have compared this association across different classification systems. This study aims to investigate the association between OVF categories, according to the most widely used classification systems, and vertebral collapse. Patients and Methods: A retrospective single-center study was conducted involving patients diagnosed with acute OVFs at the emergency department of a tertiary-level academic hospital with a minimum follow-up of 6 months. Vertebral fractures were independently classified by two radiologists according to several classification systems, including those proposed by Genant, Sugita, the German Society for Orthopedics and Trauma (DGOU), and the AO Spine. Associations between vertebral collapse and OVF classification systems were analyzed using bivariate and logistic regression analyses. Results: This study included 208 patients (82.7% females; mean age of 72.6 ± 9.2 years). The median follow-up time was 15 months, with L1 being the most common fracture site (47.6%). The most frequent OVF types observed, according to Genant’s morphological, Genant’s quantitative, Sugita ’s, DGOU’s, and AO Spine’s classifications, were biconcave (50%), grade 0.5 (47.6%), bow-shaped (61.5%), OF2 (74%), and A1 (61.5%), respectively. All classifications, except for Genant’s quantitative system, were significantly associated with vertebral collapse in bivariate analyses. Logistic regression analyses showed a significant association (p = 0.002) between the AO Spine classification and vertebral collapse, with 85.7% of A4 fractures developing collapse on follow-up. Conclusions: The AO Spine classification showed the highest predictive capacity for vertebral collapse. Specifically, A4 fracture types showed a very high risk of vertebral collapse, confirming the need for non-conservative management of these fractures. Further multicentric and prospective studies are warranted to confirm these findings.
