Study Design.: A prospective cohort study (Level III). Objective.: To develop and validate a clinical scoring system (Osteoporotic Vertebral Fracture Conservative Treatment Prognosis Score, OVF-CTPS) for predicting the prognosis of conservative treatment in patients with osteoporotic vertebral fractures (OVFs), addressing clinical uncertainty in treatment selection. Summary of Background Data.: OVFs face uncertainty in choosing conservative versus surgical management. Ten percent to 40% of patients have conservative treatment failure ( e.g. , nonunion, collapse). Existing classification systems lack prognostic value, highlighting the need for a practical predictive tool. Methods.: Two hundred one patients with acute OVFs undergoing conservative treatment were prospectively followed for 6 months. Baseline assessments included demographics, pain, quality of life measures, and multimodal imaging (X-ray, CT, and MRI). The primary outcome was conservative treatment failure. Independent predictors were identified using multivariate logistic regression and weighted to create the OVF-CTPS, which was validated using receiver operating characteristic (ROC) analysis. Results.: The conservative treatment failure rate was 29.9%. Six independent predictors were identified: Sugita “bow-shaped” or “concave” type, standing vertebral collapse degree <80%, middle column/posterior wall injury, T2WI “diffuse low” signal, STIR linear black signal, and basivertebral foramen involvement. The OVF-CTPS (range: 0–13) demonstrated excellent predictive performance (AUC=0.918). At an optimal cutoff score of 6, the sensitivity was 91.3% and the specificity was 84.0%. The low-risk group (score <6) had a 96.3% treatment success rate, while the high-risk group (score ≥6) had a success rate of 32.3% Conclusion.: The OVF-CTPS is a validated prognostic tool that integrates fracture morphology, injury severity, and MRI-based perfusion markers. It accurately stratifies patients based on their risk of conservative treatment failure, enabling clinicians to identify low-risk patients suitable for conservative care and high-risk patients who may benefit from early surgical evaluation

Background: Pelvic tilt ratio (PTr), defined as pelvic tilt divided by pelvic incidence, may provide an individualized measure of pelvic retroversion in adult spinal deformity (ASD). However, the spinopelvic muscle characteristics associated with different degrees of pelvic retroversion remain unclear. This study aimed to characterize radiographic, clinical, and spinopelvic muscle features stratified by PTr and to identify muscle parameters independently associated with pelvic retroversion in ASD patients with sagittal imbalance. Methods: Ninety-nine surgically treated ASD patients with preoperative sagittal vertical axis > 50 mm and minimum 2 year follow-up were recruited. Radiographic parameters, patient-reported outcomes, and paraspinal and gluteal muscle parameters were compared across three groups by PTr. LASSO-retained muscle variables, adjusted for age, sex, and body mass index (BMI), were entered into a multivariable linear regression model for PTr. Results: The Large PTr group showed more severe sagittal malalignment, worse preoperative back pain, and greater postoperative radiographic correction. Higher PTr was associated with smaller cross-sectional areas in all three paraspinal muscles, higher erector spinae fat infiltration (ES FIR), and lower gluteus medius fat infiltration (Gmed FIR). LASSO retained multifidus total cross-sectional area (MF TCSA), ES FIR, and Gmed FIR for the final model. In multivariable linear regression, smaller MF TCSA (B = −3.305, P < 0.001), higher ES FIR (B = 0.458, P = 0.024), and lower Gmed FIR (B = −0.883, P = 0.003) were independently associated with greater PTr. Conclusions: In ASD patients with sagittal imbalance, higher PTr was associated with more severe deformity, worse preoperative back pain, and a distinct spinopelvic muscle pattern. Smaller MF TCSA, greater ES FIR, and lower Gmed FIR were independently associated with greater PTr.