Osteoporotic vertebral compression fracture (OVCF) is one of the most common fragility fractures in elderly patients with osteoporosis and may result in acute pain, limited mobility, progressive spinal kyphosis, recurrent fractures, and increased mortality. Although clinical guidelines and expert consensus on the diagnosis and treatment of OVCF have been continuously updated, several key controversies remain in clinical practice. These include the timing and sequential use of perioperative anti-osteoporotic medications, early identification of patients at extremely high risk of vertebral recollapse and appropriate timing of surgical intervention, individualized strategies for bone cement volume and adjacent vertebral prophylactic augmentation during vertebral augmentation, treatment conversion criteria when residual MRI bone marrow edema is inconsistent with clinical symptoms, and early prevention of acute bone loss after fracture. This expert review focuses on these unresolved issues and proposes that OVCF management should shift from merely relieving pain and reinforcing the fractured vertebra to a risk-stratified strategy covering preoperative assessment, intraoperative decision-making, and postoperative follow-up. Preoperatively, bone mineral density, fracture acuity, vertebral height loss, kyphotic progression, and bone metabolic status should be carefully evaluated, and anti-osteoporotic therapy should be initiated immediately after diagnosis. Intraoperatively, bone cement injection should be individualized according to treatment goals, fracture morphology, and mechanical stability requirements. During postoperative or conservative follow-up, decisions regarding continued observation or treatment escalation should be based on pain changes, dynamic radiographic findings, MRI features, and systemic risk factors. Establishing a continuous management pathway of “early diagnosis-risk stratification-individualized intervention-long-term refracture prevention” may help improve the standardization and precision of OVCF treatment