Purpose of Review <p>Osteoporosis is a systemic skeletal disease that presents unique challenges in spine surgery due to decreased bone mass, poor bone quality, and increased risk of fractures. This review aims to synthesize current understanding of osteoporosis in the context of spinal procedures, emphasizing the pathophysiology, diagnostic challenges, perioperative considerations, and evolving management strategies.</p> Recent Findings <p>Despite high prevalence, osteoporosis remains underdiagnosed and undertreated in surgical candidates, with preoperative bone mineral density (BMD) screening often overlooked. Recent evidence underscores the importance of optimizing bone health preoperatively through pharmacologic therapies, which includes bisphosphonates, denosumab, and anabolic agents like teriparatide and romosozumab. Furthermore, surgical innovations such as cement augmentation and biomechanically optimized pedicle screw techniques are thoroughly discussed. New modalities, such as CT-based Hounsfield unit assessments and finite element analysis, offer improved preoperative evaluation of bone quality.</p> Summary <p>Successful spine surgery outcomes in osteoporotic patients require a multidisciplinary approach that integrates early screening, targeted pharmacologic treatment, lifestyle modifications, and advanced surgical planning. Addressing osteoporosis comprehensively improves implant fixation, reduces complications like pseudoarthrosis and junctional failures, and enhances overall patient quality of life.</p>