Initial Management of Vertebral Fractures
Conservative medical management is the first-line treatment for most vertebral compression fractures, consisting of pain control, limited bed rest, appropriate rehabilitation, and osteoporosis treatment to prevent subsequent fractures. 1
Immediate Management
- Initial treatment should focus on pain control with appropriate analgesics, including acetaminophen, NSAIDs, and if necessary, short-term narcotic medications 1, 2
- Limited bed rest (avoiding prolonged immobilization) is recommended as prolonged bed rest can lead to rapid bone loss (1% per week), muscle strength decline (15% after just 10 days), and increased risk of complications such as decubitus ulcers and deep vein thrombosis 1
- Bracing may be used for comfort and to improve stability during the healing phase 1, 3
- Early mobilization should be encouraged as tolerated to prevent complications of immobility 1
Rehabilitation Approach
- An appropriate rehabilitation program should include early post-fracture physical training and muscle strengthening 1
- Long-term continuation of balance training and multidimensional fall prevention is essential 1
- Early identification of individual goals and needs is crucial before developing the rehabilitation plan 1
- Spinal stretching exercises should be incorporated as pain allows 3
Pharmacological Management
Pain Management
- Short-term analgesics to control acute pain 1, 2
- Calcitonin may be considered for acute pain relief 2
- Special caution is needed when prescribing medications to elderly patients due to potential adverse effects 2
Osteoporosis Treatment
- Calcium supplementation (1000-1200 mg/day) and vitamin D (800 IU/day) are recommended 1
- Bisphosphonates (alendronate, risedronate) are first-choice agents for preventing subsequent fractures 1
- Alendronate has demonstrated a 47% relative risk reduction in new vertebral fractures in patients with previous vertebral fractures 4
- For patients with oral intolerance, dementia, malabsorption, or non-compliance, zoledronic acid (intravenous) or denosumab (subcutaneous) are alternatives 1
- For very severe osteoporosis, anabolic agents such as teriparatide may be considered 1
When to Consider Vertebral Augmentation
- Vertebral augmentation (vertebroplasty or kyphoplasty) should be considered in patients with:
- The VERTOS II trial suggested that patients who have not received sufficient pain relief by 3 months with conservative treatment may be candidates for vertebral augmentation 1
Special Considerations
- For pathologic vertebral fractures due to malignancy, a multidisciplinary approach including interventional radiology, surgery, and radiation oncology consultation is recommended 1
- In cases of neurological deficits, spinal instability, or cord compression, surgical consultation is necessary 1
- Orthogeriatric co-management is recommended for frail elderly patients with multiple comorbidities and polypharmacy 1
Prevention of Subsequent Fractures
- Patient education about the burden of the disease, risk factors for fractures, follow-up, and duration of therapy is essential 1
- Non-pharmacological measures include smoking cessation, limiting alcohol intake, and fall prevention strategies 1
- Regular monitoring for medication tolerance and adherence is important for long-term success 1
- Systematic follow-up as part of a structured fracture liaison service can improve adherence to therapy 1
Common Pitfalls to Avoid
- Prolonged bed rest leading to deconditioning, bone loss, and increased risk of complications 1
- Inadequate pain control leading to immobility and further complications 1
- Failure to address underlying osteoporosis, increasing risk of subsequent fractures 1
- Delaying vertebral augmentation in appropriate candidates with persistent pain 1
- Not considering pathologic fractures that may require different management approaches 1