Objective To investigate the necessity, feasibility, and postoperative effects of balloon-expandable vertebroplasty treatment for old osteoporotic thoracolumbar compression fractures in the elderly. Methods Retrospective analysis of 238 patients treated with balloon-expandable vertebroplasty for osteoporotic thoracolumbar compression fractures from July 2003 to March 2009, including 51 cases (21.4%) of old fractures, 19 men and 32 women, aged 61-82 years, average 65.5 years, with a medical history of 1-15 months, average 6.8 months. Preoperatively, all thoracolumbar frontal and lateral X-rays, CT and MRI (T1W1, T2W1, STIR) were performed, and vertebral fractures T7-L4 were found, with more than 2 fractures in 12 cases, accounting for 23.5% of the lesioned vertebrae that matched the clinical symptoms and signs were all treated with the aforementioned surgery. The surgery was still managed as a fresh fracture, with surgery in the prone position, under local anesthesia, unilateral or bilateral puncture, expansion using a balloon, and injection of an appropriately viscous bone cement. The preoperative and postoperative anterior height of the injured spine and change in Cobb’s angle were measured based on X-rays, and the preoperative and postoperative posterior thoracic convexity or anterior lumbar convexity change in Coob’s angle was measured, and the VAS and Oswestry dysfunction index (ODI) scores were used to evaluate the treatment effect and analyze the complications. Results All groups were able to move to the ground 1-2 days after surgery and were hospitalized for 3-7 days, with a mean of 5 days. At follow-up 3-51 months, mean 12.4 months, all patients showed significant improvement in postoperative pain, VAS score decreased from 8.9 preoperatively to 2.3 postoperatively, Oswestry score decreased from 68 preoperatively to 22, and the final follow-up VAS score and Oswestry score were 2. 6 and 27, respectively, and all patients showed recovery of vertebral body height and Coob angle on postoperative X-ray The postoperative X-rays showed an increase in anterior vertebral height of 0-5 mm and a decrease in the Cobb’s angle of 0-25 degrees, with a mean of 10 degrees. Sagittal radiographs showed varying degrees of improvement in the physiological curvature of the spine and a reduction in kyphosis of 5-25 degrees, with an average of 15 degrees. There were 8 cases (15.7%) with different degrees of cement leakage in the whole group, and there was no spinal canal leakage, no lower limb nerve complications, and no pulmonary embolism or death. Conclusion The MRI examination can detect the “fresh” manifestation of leakage in the old osteoporotic thoracolumbar old compression fractures which are difficult to heal for a long time, and it is of great value to clarify the diagnosis and guide the treatment. Posterior percutaneous balloon expansion kyphoplasty is one of the effective methods to treat old osteoporotic thoracolumbar compression fractures in the elderly, which can rapidly restore and stabilize the injured spine and improve the quality of life of the elderly, and the balloon technique can reduce the occurrence of serious complications such as cement leakage.