What are the treatment options for compression fracture pain?

Treatment Options for Compression Fracture Pain

Minimally invasive spinal procedures such as kyphoplasty may be used for the treatment of pain related to vertebral compression fractures, while calcitonin is recommended for acute pain management in the first 4 weeks after fracture. 1

First-Line Treatment Options

Pharmacological Management

1. Calcitonin

   • Recommended for acute compression fracture pain (0-5 days after injury) for a 4-week duration 1
   • Provides clinically significant pain relief at 1,2,3, and 4 weeks 1
   • Available as nasal spray (200 IU) or suppositories (200 IU) 1
   • Side effects include mild dizziness 1
   • Most effective for acute pain; not effective for chronic pain beyond 6 months 2

2. NSAIDs

   • Effective for back pain relief for periods of 2-12 weeks 1
   • Should be considered for pain management in compression fractures 1

3. Analgesics/Opioids

   • May be necessary for severe pain, though specific evidence for compression fractures is limited 1
   • Controlled or extended-release opioid therapy can provide effective pain relief for back pain 1
   • Common side effects include nausea, vomiting, and constipation 1

Non-Pharmacological Approaches

1. Early Mobilization

   • Recommended once acute pain is controlled 3
   • Helps prevent complications of prolonged bed rest 3, 4

2. Orthoses/Bracing

   • May provide temporary pain relief in acute phase 3
   • Evidence regarding specific types of braces is limited 1

3. Exercise Programs

   • Recommended after acute pain control is achieved 3
   • Can improve function and quality of life 3
   • May improve symptoms and emotional domains at 6-12 months 1

Second-Line Treatment Options

Minimally Invasive Procedures

1. Kyphoplasty

   • May be used for pain related to vertebral compression fractures 1
   • Observational studies show effective pain relief for 6-12 months 1
   • Should be considered when conservative measures fail 5

2. Vertebroplasty

   • Not recommended based on high-quality evidence 1
   • Two level I studies showed no statistically significant difference compared to sham procedures in pain relief or function 1

Interventional Pain Management

1. Nerve Blocks

   • L2 nerve root block may be an option for L3 or L4 compression fractures 1
   • Limited evidence for efficacy 1

2. Intrathecal Therapy

   • In refractory cases, intrathecal bupivacaine with or without buprenorphine may provide relief 6
   • Should be considered only after failure of conventional treatments 6

Prevention of Future Fractures

1. Bisphosphonates

   • Alendronate reduces the risk of new vertebral fractures by 47% in patients with previous vertebral fractures 7
   • Reduces risk of clinical vertebral fractures by 54% 7
   • Recommended for prevention of additional fractures 1

2. Calcium and Vitamin D

   • Recommended as supplementation (calcium 1000-1200 mg/day, vitamin D 800 IU/day) 8

Treatment Algorithm

1. Acute Phase (0-4 weeks):

   • Calcitonin for 4 weeks (200 IU daily) 1
   • NSAIDs for pain control 1
   • Temporary bracing/orthosis for pain relief 3
   • Early mobilization as pain allows 3

2. Subacute Phase (4-12 weeks):

   • Transition from calcitonin to other analgesics as needed
   • Begin structured exercise program 1, 3
   • Consider L2 nerve root block for persistent L3/L4 fracture pain 1

3. Chronic Phase (>12 weeks with persistent pain):

   • Consider kyphoplasty if conservative measures fail 1, 5
   • Avoid vertebroplasty due to lack of proven benefit 1
   • For refractory cases, consider intrathecal therapy 6

4. Throughout Treatment:

   • Bisphosphonates to prevent future fractures 1, 7
   • Calcium and vitamin D supplementation 8

Important Considerations and Pitfalls

• Vertebroplasty should be avoided despite its popularity, as high-quality evidence shows no benefit over sham procedures 1
• Calcitonin is effective only for acute pain management and should not be continued for chronic pain 2
• Bed rest should be minimized to prevent complications like deconditioning, deep vein thrombosis, and pneumonia 4
• The evidence for bracing is limited; when used, it should be for temporary pain relief only 1, 3
• Patients with neurological deficits require immediate surgical evaluation and are not candidates for conservative management alone 8