Background: The rising incidence of vertebral body fractures, vertebral infections and metastatic disease increases the need for diagnostic modalities with high specificity. Biopsy remains essential, yet comparative data on CT-guided versus intraoperative percutaneous fluoroscopy-guided biopsy are limited. Methods: This retrospective study compared two cohorts biopsied for spinal lesions between April 2015 and April 2024: CT-guided biopsy (n = 62), and intraoperative percutaneous biopsy (n = 154). Groups were analyzed for demographic and clinical characteristics, and diagnostic yield was defined by the conclusiveness of the primary biopsy; statistical comparisons were performed using Fisher’s exact test. Results: CT-guided biopsy yielded conclusive results in 46 of 62 cases (74.2%), whereas intraoperative, fluoroscopy-guided biopsy was conclusive in 41 of 154 cases (26.6%), representing a statistically significant difference (p < 0.001). In analogy, propensity score matching (1:1) resulted in similar significant (p < 0.001) results (CT-guided group vs. intraoperative, fluoroscopy-guided group: 86.7% vs. 35.6%) Conclusions: CT-guided biopsy demonstrated a substantially higher rate of conclusive results compared with intraoperative biopsy in this cohort. Further studies with larger and more balanced cohorts are needed to strengthen clinical recommendations.

Background/Objectives: Vertebral fractures (VFs) often remain clinically unrecognized. We estimated the prevalence of previously unrecognized VFs among older adults presenting with major nonvertebral fragility fractures and explored associated clinical characteristics. Methods: This single-center prospective observational study enrolled 49 consecutive patients aged ≥60 years presenting with low-energy proximal femur, proximal humerus, or distal radius fractures between January 2023 and January 2024. Standardized thoracolumbar radiographs were evaluated using a combined modified algorithm-based qualitative and Genant semiquantitative approach. FRAX probabilities were calculated without bone mineral density. Associations were examined in exploratory unadjusted analyses. Results: Previously unrecognized VFs were found in 22/49 patients (44.9%; Wilson 95% CI, 31.9–58.7%), comprising 34 fractures. The most frequently affected levels were L2 (10/34) and T12 (8/34). A prior fracture history was associated with newly detected VFs in exploratory analysis (p = 0.002). Mean FRAX major osteoporotic fracture probability without bone mineral density was 16.66 ± 10.59% in patients with and 9.72 ± 7.80% in those without a newly identified VF (mean difference 6.94 percentage points; 95% CI, 1.45–12.43; p = 0.011). Conclusions: Previously unrecognized VFs were frequent in this small, predominantly hip-fracture cohort. The findings suggest a potential diagnostic gap and justify larger studies assessing targeted vertebral imaging in secondary fracture prevention; they do not establish a benefit from universal screening.