What are the treatment options for compression fracture pain?

From the Guidelines

Treatment for compression fracture pain should prioritize a multidisciplinary approach, including conservative management with medications and physical measures, and considering interventional procedures like vertebroplasty or kyphoplasty for persistent pain, as supported by recent guidelines 1.

Conservative Management

Conservative management is often the first line of treatment and includes:

• Over-the-counter medications like acetaminophen (Tylenol) at 500-1000mg every 6 hours or NSAIDs such as ibuprofen (Advil, Motrin) at 400-800mg every 6-8 hours, with caution in elderly patients due to gastrointestinal and cardiovascular risks.
• Prescription medications may include muscle relaxants like cyclobenzaprine (5-10mg three times daily) for associated muscle spasms, or in cases of severe pain, short-term opioids such as hydrocodone/acetaminophen (5/325mg every 4-6 hours as needed).
• Physical measures: brief rest (1-3 days) followed by gradual activity resumption, application of ice or heat for 15-20 minutes several times daily, and wearing a back brace for temporary support.

Interventional Procedures

For persistent pain, interventional procedures like vertebroplasty or kyphoplasty may be considered, where bone cement is injected into the fractured vertebra to stabilize it and provide pain relief, as shown to be effective in recent studies 1.

Long-term Management

Long-term management should include calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) supplementation, along with treatment for underlying osteoporosis if present, to prevent future fractures, as recommended by guidelines 1.

Key Considerations

• The timing of when to consider interventional procedures like vertebroplasty or kyphoplasty has been debated, but recent evidence suggests considering these options for patients who have not received sufficient pain relief by 3 months with conservative treatment 1.
• The choice between vertebroplasty and kyphoplasty should be based on individual patient factors and the specific characteristics of the fracture, with kyphoplasty potentially offering superior functional recovery in some cases 1.

From the FDA Drug Label

Oxycodone hydrochloride tablets are an opioid agonist indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate The treatment options for compression fracture pain include opioid analgesics such as oxycodone, which is indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate 2.

• Key points:
  • Oxycodone is used for severe pain
  • Alternative treatments should be considered before using oxycodone
  • Oxycodone has risks of addiction, abuse, and misuse, even at recommended doses
• Important consideration: Alendronate may help reduce the risk of new vertebral fractures, but it is not a treatment for pain itself 3.

From the Research

Treatment Options for Compression Fracture Pain

• Conservative therapy with bracing and narcotic analgesics is often the initial treatment approach for compression fracture pain, but it may not always provide significant improvement 4.
• Percutaneous vertebroplasty, which involves the injection of polymethylmethacrylate into the fractured vertebra, has been shown to eliminate pain and reduce the need for narcotic analgesics in some patients 4.
• Kyphoplasty, a similar procedure that involves the use of a balloon to expand the fractured vertebra before injecting cement, has also been found to be effective in reducing pain and improving function in patients with osteoporotic compression fractures 5.
• Intrathecal infusion of bupivacaine with or without buprenorphine has been used to relieve intractable pain in patients with vertebral compression fractures caused by osteoporosis, with satisfactory pain relief achieved in some patients 6.
• Vertebral body augmentation, including vertebroplasty and balloon tamp reduction, may be considered for patients with chronic pain beyond 2 months 7.
• Open surgical management with decompression and stabilization is typically reserved for patients with neural compression and progressive deformity with neurologic deficits 7.

Comparison of Treatment Options

• A study comparing the efficacy and safety of balloon kyphoplasty, percutaneous vertebroplasty, and non-surgical treatment for osteoporotic vertebral compression fractures found that all three treatments had their own advantages and disadvantages, and the choice of treatment depended on various factors, including the patient's condition and medical history 8.
• Another study found that kyphoplasty and vertebroplasty had a high acceptance and use rate, with 95% improvement in pain and significant improvement in function following treatment by either of these percutaneous techniques 5.

Considerations for Treatment

• The treatment of osteoporotic compression fractures should focus on pain control and maximizing functional outcome, with thorough differential diagnosis and appropriate evaluation and medical treatment of underlying osteoporosis 7.
• The role of surgical treatment remains controversial and should be reserved for patients who fail initial non-surgical management options 7.
• The choice of treatment should be individualized based on the patient's specific condition, medical history, and preferences, with consideration of the potential risks and benefits of each treatment option 5, 7.