What is the best course of treatment for a 9-year-old male with back pain radiating to the lower back after exercising, who has a history of a grade 2 vertical compression fracture and deformity, was previously treated with prednisone, and has normal reflexes, sensation, and vitamin D levels?

Management of Vertebral Compression Fracture in a 9-Year-Old Male

The best treatment for this 9-year-old male with back pain and history of grade 2 vertebral compression fracture is conservative management with calcium and vitamin D supplementation, lifestyle modifications, and appropriate pain control, rather than pharmacologic osteoporosis treatments or invasive procedures.

Clinical Assessment

• The patient presents with:
  • Back pain radiating to lower back after exercise
  • History of grade 2 vertical compression fracture with deformity on x-ray
  • Previous treatment with prednisone (no longer taking it)
  • Normal neurological examination (reflexes and sensation)
  • Vitamin D level of 35 ng/mL (adequate)
  • No bladder incontinence
  • History of trauma 10 years ago

Treatment Recommendations

First-Line Management

• Calcium and vitamin D supplementation
  • Calcium: 1,000-1,200 mg/day
  • Vitamin D: 600-800 IU/day to maintain serum level ≥20 ng/mL 1
  • Current vitamin D level of 35 ng/mL is adequate but should be maintained

Lifestyle Modifications

• Balanced diet
• Weight-bearing and resistance training exercises appropriate for age
• Maintaining appropriate weight
• Avoiding high-impact activities during acute pain phase 1, 2

Pain Management

• Age-appropriate analgesics for pain control
• Consider short-term activity modification during acute pain episodes
• Avoid prolonged bed rest as it can lead to further bone loss and deconditioning

Monitoring

• Regular clinical fracture risk assessment every 12 months
• Follow-up imaging to monitor fracture healing and potential development of deformity
• Monitor growth and development 1

Rationale for Treatment Approach

1. Age-specific considerations: The ACR guidelines for glucocorticoid-induced osteoporosis specifically recommend against BMD testing and pharmacologic treatments for children with a history of glucocorticoid use 1

2. Prior steroid exposure: While the patient has a history of prednisone use (which increases fracture risk), he is no longer taking it, reducing ongoing risk 1

3. Normal vitamin D level: The current level of 35 ng/mL is adequate, but continued supplementation is important for bone health 1, 2

4. Absence of neurological deficits: The patient has normal reflexes and sensation, indicating no spinal cord compression that would necessitate surgical intervention 1, 2

Important Considerations

• Vertebral augmentation procedures (vertebroplasty/kyphoplasty) are not recommended for this pediatric patient as they are primarily indicated for adults with persistent pain despite conservative management 1

• Bisphosphonates and other osteoporosis medications are not routinely recommended for children unless there are exceptional circumstances (multiple fractures, severe osteoporosis) 1

• Calcium and vitamin D supplementation has been shown to prevent bone loss in patients with history of corticosteroid use 3

• The absence of bladder incontinence and normal neurological examination suggests that this is a stable fracture without neurological compromise 1, 2

Follow-up Plan

• Reassess pain and function in 4-6 weeks
• If pain persists beyond 6 weeks despite conservative management, consider additional imaging to evaluate for fracture healing 1
• Monitor for development of new fractures or progression of deformity
• Assess growth and development at regular intervals

Caution

• Avoid prolonged use of NSAIDs as they may impair bone healing
• Systemic corticosteroids should be avoided as they have been associated with worse outcomes in back pain and can further compromise bone health 4, 5
• If pain worsens or new neurological symptoms develop, urgent reassessment is needed to rule out progression of fracture or new pathology