Background <p>The mOF score shows promise as a reliable tool to guide treatment decisions of osteoporotic vertebral fractures (OVFs). However, the prognostic value is lacking. This study aims to assess the prognostic value of the mOF score considering clinical and radiological outcomes in accordance with compliant or non-compliant management.</p> Methods <p>A retrospective cohort study included all patients aged ≥50 years and diagnosed with acute thoracolumbar OVF between 2017 and 2021. Final treatment was compared with the recommendations according to the mOF score. Clinical and radiological outcome variables were pairwise compared in each group of treatment recommendation.</p> Results <p>Final analysis included 482 patients. 81.95% received non-surgical management. Overall, the accuracy rate was 75.1%. The mOF score achieved a sensitivity of 24.7% and a specificity of 86.4% for surgical management prediction (AUC 0.55). In patients with surgical treatment recommendations, compliant management was associated with a significantly lower rate of fracture progression than non-compliant management (11% against 45%, <i>p</i> = 0.019), and lower decline in independent living status (0% compared with 10.6%, <i>p</i> = 0.311). In patients with non-surgical treatment recommendations, non-compliant management was associated with better results in radiological progression (<i>p</i> &lt; 0.001), pain relief (<i>p</i> &lt; 0.001), and the need for further therapy due to poor evolution (<i>p</i> = 0.088).</p> Conclusions <p>The mOF score demonstrated limited predictive capacity in discriminating the actual received treatment in our cohort. The surgical recommendation was meaningful, identifying better outcomes in patients compliant with the recommendation; for the non-surgical recommendations, vertebral augmentation still may provide a better outcome than conservative bracing and analgesics.</p>