Evaluating the Outcomes of Vertebral Biopsies Performed in Osteoporotic vertebral fractures: A Systematic Review and Meta-Analysis

Purpose Osteoporotic vertebral fractures (OVFs) are common among older adults and are generally treated conservatively. However, some patients initially diagnosed with benign OVFs may have underlying malignancies—such as metastatic solid tumors or hematologic cancers—that mimic osteoporotic fractures radiographically. This study aimed to determine the pooled prevalence of unsuspected malignancy in patients initially diagnosed with OVFs through a systematic review and meta-analysis. Methods A systematic literature search of the PubMed database was conducted through March 2025 in accordance with PRISMA guidelines. Studies were included if they involved adults with presumed osteoporotic vertebral fractures who underwent vertebral biopsy or histopathological evaluation. Pooled prevalence estimates of unsuspected malignancies were calculated using a random-effects model. The risk of bias in included studies was assessed using the Newcastle-Ottawa Scale. Results Twelve studies involving 3,229 patients met the inclusion criteria. The pooled prevalence of unsuspected malignancy among presumed OVF cases was 8.00% (95% CI: 5.43–10.6%). Subgroup analysis showed that 4.87% (95% CI: 2.30–7.44%) had metastatic solid tumors, while 2.62% (95% CI: 1.31–3.94%) had multiple myeloma. No biopsy-related complications were reported. Moderate to substantial heterogeneity was observed across studies. Conclusion Approximately one in twelve patients with an initial diagnosis of benign OVF may have an underlying malignancy. Vertebral biopsy is a safe and valuable diagnostic tool, particularly in cases with atypical clinical or radiologic features, to facilitate early cancer detection and appropriate oncologic intervention.