What are the treatment options for compression fractures?

Treatment Options for Compression Fractures

For patients with symptomatic osteoporotic vertebral compression fractures, initial management should include calcitonin for 4 weeks in acute cases (0-5 days after onset), along with appropriate analgesics, followed by consideration of bisphosphonates to prevent additional fractures. 1

Initial Management of Acute Compression Fractures

Medication Management

• Calcitonin: Recommended for acute fractures (0-5 days after onset) for a 4-week course

  • Dosage: 200 IU nasal calcitonin daily
  • Benefits: Provides clinically significant pain reduction at 1,2,3, and 4 weeks
  • Side effects: May include mild dizziness 1

• Pain Management:

  • Mild pain: Acetaminophen or NSAIDs
  • Moderate to severe pain: Consider short-term opioids
  • Note: While commonly used, there is insufficient evidence specifically addressing opioid/analgesic efficacy for vertebral compression fractures 1, 2

Prevention of Additional Fractures

• Bisphosphonates: Recommended to prevent additional symptomatic fractures
  • Options include:
    • Alendronate: Indicated for treatment of osteoporosis and has been shown to reduce vertebral fracture risk by 47% 3
    • Risedronate: Alternative option for osteoporosis treatment 4
  • Calcium and Vitamin D supplementation:
    • Calcium: 1000-1200 mg/day
    • Vitamin D: 800 IU/day 5

Physical Interventions

Bracing

• Evidence regarding bracing is inconclusive
• May provide external support and limit painful movements
• Caution: Specific type of brace, age of patient, and fracture level should be considered 1

Exercise and Physical Therapy

• Evidence is inconclusive for supervised or unsupervised exercise programs
• Some studies suggest potential benefits:
  • Improvement in symptoms at 6 and 12 months
  • Improvement in emotional domain at 6 months
  • Improvement in activities of daily living at 12 months 1
• Early introduction of physical training and muscle strengthening is recommended for rehabilitation 5
• Avoid prolonged bed rest due to adverse effects on multiple organ systems 5

Interventional Procedures

Nerve Blocks

• L2 nerve root block is an option for treating patients with L3 or L4 compression fractures 1

Vertebral Augmentation

• Vertebroplasty: Not recommended based on high-quality evidence

  • Two level I studies showed no statistically significant difference between vertebroplasty and sham procedure 1

• Kyphoplasty: May be considered for patients who fail conservative management

  • Provides rapid pain relief and structural reinforcement
  • Reserved for patients not responsive to conservative therapy 6, 2

Special Considerations

Spinal Instability Assessment

• The Spinal Instability Neoplastic Score (SINS) should be used to assess spinal stability 5
• Immediate surgical intervention is indicated for patients with neurological deficits or spinal instability 5

Malignant Compression Fractures

• Require different management approach
• MRI is the preferred imaging technique for diagnosis
• May require immediate high-dose dexamethasone followed by urgent neurosurgical consultation 5

Treatment Algorithm

1. Acute phase (0-5 days after onset):

   • Calcitonin for 4 weeks
   • Appropriate analgesics based on pain severity
   • Limited activity but avoid prolonged bed rest

2. Subacute phase (1-4 weeks):

   • Start bisphosphonates to prevent additional fractures
   • Calcium and vitamin D supplementation
   • Consider bracing (though evidence is inconclusive)

3. Chronic phase (>4 weeks):

   • Continue bisphosphonate therapy
   • Gradual increase in physical activity and targeted exercise
   • Consider vertebral augmentation only if conservative management fails

4. For refractory pain:

   • Consider L2 nerve root block for L3/L4 fractures
   • Evaluate for vertebral augmentation if conservative measures fail after 4-6 weeks

Pitfalls and Caveats

• Avoid prolonged bed rest which can lead to deconditioning and complications
• Be cautious with long-term opioid use due to risk of dependence
• Monitor for bisphosphonate side effects including osteonecrosis of the jaw and atypical femoral fractures
• Vertebroplasty, despite being commonly performed, is not supported by high-quality evidence
• Distinguish between osteoporotic and malignant compression fractures, as management differs significantly