Background: Osteoporotic vertebral fractures (OVFs) cause pain, deformity, and functional decline, requiring effective treatments. While teriparatide is widely used, evidence on romosozumab in OVFs remains limited. This study compared radiologic, bone mineral density (BMD), and clinical outcomes between romosozumab and teriparatide.

Methods: We analyzed 62 patients with single-level OVFs treated between January 2022 and December 2023, including a prospective romosozumab cohort (n = 34) and a retrospective teriparatide cohort (n = 28). Patients received romosozumab or teriparatide for six months, followed by denosumab. Radiologic parameters (Cobb’s angle [CA], vertebral wedge angle [VWA], and vertebral body heights) were assessed up to 12 months. Lumbar spine and femur BMD were measured at baseline and 12 months. Pain was evaluated using the numeric rating scale (NRS), and disability by the Oswestry Disability Index (ODI).

Results: Baseline demographics and fracture distribution were similar. At 12 months, romosozumab group showed trends toward smaller CA (18.2° vs. 21.5°) and VWA (15.1° vs. 19.1°), and better preservation of vertebral height, although differences were not significant. Lumbar spine BMD increased more with romosozumab (0.065 vs. 0.051 g/cm², p = 0.110), whereas femur BMD was higher with teriparatide (0.614 vs. 0.563 g/cm², p = 0.046). Both groups had marked pain reduction (−4.07 vs. −3.87, p = 0.967). ODI improvement was greater with teriparatide (−40.5% vs. −26.7%, p = 0.020).

Conclusion: Both agents provided comparable radiologic outcomes and pain relief. Romosozumab showed a tendency toward better maintenance of spinal alignment and vertebral height, suggesting potential radiologic advantages in OVFs.