Background: Cement-augmented fenestrated pedicle screws enhance fixation strength in osteoporotic spine surgery but may increase cement-related complications when extensively used. This prospective study evaluated the clinical and radiological outcomes of posterior spinal fusion using selective cement-augmented fenestrated pedicle screws combined with transpedicular bone grafting in severe osteoporotic vertebral fractures.

Methods: Twenty-two patients (5 men and 17 women), aged 66.4 ± 5.9 years, with severe osteoporotic vertebral fractures classified as OF4 or OF5 according to the AO Spine–DGOU Osteoporotic Fracture classification, were prospectively enrolled. All patients underwent posterior spinal fusion between March 2021 and December 2024, in which cement-augmented fenestrated pedicle screws were selectively applied at the uppermost and lowermost instrumented vertebrae, combined with transpedicular bone grafting into the fractured vertebra. Clinical outcomes were assessed using the visual analog scale (VAS) and neurologic status based on the Frankel grading system. Radiological evaluation included measurement of local kyphotic angle and computed tomography–based assessment of fusion status at 12 months postoperatively.

Results: The mean operative time was 142 ± 10.8 minutes, with a mean blood loss of 380.7 ± 63.6 mL. The mean VAS score improved from 7.9 preoperatively to 2.6 at final follow-up. All patients with neurologic deficits showed improvement of at least one Frankel grade. The mean local kyphotic angle improved from 28.7° preoperatively to 14.0° postoperatively and was maintained at 16.6° at final follow-up. No screw loosening or pull-out was observed. Cement leakage occurred in four cases without clinical symptoms. Solid bony fusion was achieved in all cases. The mean follow-up duration was 31.9 months (range, 12–56 months).

Conclusion: Selective cement-augmented fenestrated pedicle screws combined with transpedicular bone grafting in posterior spinal fusion provide favorable clinical and radiological outcomes, achieve reliable fusion, and may reduce cement-related complications in severe osteoporotic vertebral fractures. Keywords: Osteoporotic vertebral fracture; Fenestrated pedicle screw; Cement augmentation; Transpedicular bone grafting; Posterior spinal fusion