To put vertebral augmentation (eg, vertebroplasty) into perspective, the etiology and outcomes of vertebral fractures are reviewed. There is considerable debate about which criteria should be used to define a vertebral fracture because there is no consistent relation between symptoms and the degree of vertebral deformity. However, it is the more significant vertebral body deformities that are most closely associated with frequent or severe back pain, and the referrals for vertebral augmentation come mainly from this subset of patients. In addition to their vertebral fractures, these patients typically have osteoporosis or elevated bone turnover, and they are at greatly increased risk of subsequent fractures as a result of falling or, more often, excessive spinal loads from activities of everyday living. Additional risk factors for new vertebral fractures include the number and severity of vertebral deformities at baseline. Moreover, new fractures are most likely in nearby vertebrae, and they occur more frequently in the mid-thoracic or thoracolumbar regions of the spine. Interestingly, these are also the characteristics of the subsequent fractures of contiguous vertebrae considered by some to represent a complication of vertebral augmentation, yet they characterize vertebral fracture risk even in untreated patients. Vertebral fractures are very common among older men and postmenopausal women; they are associated with substantial morbidity and mortality; and they may have a devastating impact on the patient's quality of life. Vertebral augmentation may be able to help many of these patients, although opportunities exist to optimize management strategies with respect to the other factors that influence long-term outcomes in this patient population.