Osteoporotic vertebral compression fractures are a commonly encountered clinical problem. Although the majority of patients with this injury experience a benign and self-limited course of gradually resolving pain, a significant number continue to experience chronic pain and disability. In evaluating a patient with a vertebral compression fracture, the differential diagnosis must consider not only osteoporosis, but also various causes of osteomalacia, endocrinopathy, and malignancy. Accumulation of multiple compression fractures and increased thoracolumbar kyphosis are associated with a poor prognosis. Multiple medical treatments--including hormone replacement therapy, calcitonin, and bisphosphonates--are effective in maintaining or increasing bone mass and reducing the risk of compression fracture. Conventional treatment in the form of pain medication, activity limitation, and occasionally bracing is effective in returning most patients to their previous level of functioning. When therapies fail, patients may be considered for minimally invasive treatments such as vertebroplasty or kyphoplasty. Surgery, although enormously challenging because of poor underlying health status and structurally weak bone, may be the last resort for a small percentage of patients experiencing progressive deformity or neurologic deficit.