A total of 12 consecutive patients (mean age 71 years) with a total of 19 osteoporotic vertebral compression fractures underwent postural and balloon vertebral fracture reduction in Department of Orthopedics, Dongguan People's Hospital between March 2007 and December 2008, including 8 females. Preoperative standing and lateral radiographs of the fractured vertebrae were compared with prone cross-table lateral radiographs. Following positional manipulation, patients underwent a unilateral balloon kyphoplasty. Postoperative standing radiographs were evaluated for the percentage of height restoration related to positioning and balloon kyphoplasty. In the middle portion of the vertebrae, the percentage available for restoration with extension positioning was 10.4% (median 11.1%) and after balloon kyphoplasty was 57.0% (median 62.2%); the difference was statistically significant (P < 0.001). Kyphoplasty provided an additional 46.6% of the height available for restoration from the positioning alone. With operative positioning, 51.2% of vertebral compression fractures had >10% restoration of the central portion of the vertebral body, whereas 90.7% of fractures improved at least 10% following balloon kyphoplasty (P < 0.002). Although this study supports the concept that many vertebral compression fractures can be treated with positioning, balloon kyphoplasty enhanced the height reduction 4.5-fold over the positioning maneuver alone and accounted for over 80% of the ultimate reduction. Moreover, kyphoplasty is superior in most cases to the positioning maneuver alone in height restoration.