What is the management approach for osteoporotic compression fractures?

Management of Osteoporotic Compression Fractures

For patients with symptomatic osteoporotic vertebral compression fractures, calcitonin should be administered for 4 weeks as first-line treatment, followed by bisphosphonates or denosumab for long-term management to prevent additional fractures. 1

Initial Management (Acute Phase: 0-5 days)

• Calcitonin therapy is recommended for patients presenting with an acute osteoporotic spinal compression fracture (0-5 days after injury or symptom onset) who are neurologically intact 1
• Nasal calcitonin (200 IU) or calcitonin suppositories (200 IU) have been shown to reduce pain at 1,2,3, and 4 weeks in a clinically significant manner 1
• Side effects of calcitonin are generally mild and may include dizziness 1
• No strong recommendations exist for or against bed rest, complementary/alternative medicine, or specific opioids/analgesics in the acute phase 1

Intermediate Management (Beyond 4 Weeks)

• For persistent pain at L3 or L4 vertebral compression fractures, an L2 nerve root block is a treatment option 1, 2
• Bracing has insufficient evidence to make a strong recommendation, as studies have not adequately reported age or fracture level 1
• Exercise programs (supervised or unsupervised) have inconclusive evidence for efficacy 1
• For patients with persistent pain beyond 2 months, consider referral for interventional procedures 3

Long-term Management and Prevention of Additional Fractures

• Ibandronate and strontium ranelate are recommended options to prevent additional symptomatic fractures in patients with existing vertebral compression fractures 1
• Denosumab (60 mg subcutaneously every 6 months) is strongly supported by evidence for preventing subsequent fractures in patients with osteoporotic vertebral compression fractures 4, 5
  • Persistent denosumab users show significantly lower risk of developing subsequent osteoporotic fractures compared to bisphosphonate users or non-persistent denosumab users 5
  • Discontinuation of denosumab is associated with significantly increased risk of subsequent fractures and mortality (HR 3.12,95% CI 2.22-4.38) 5
• All patients should receive calcium (at least 1000 mg) and vitamin D (800-1000 IU) supplementation daily 4

Interventional Procedures

• The American Academy of Orthopaedic Surgeons (AAOS) makes a strong recommendation against vertebroplasty for treating osteoporotic compression fractures 1
• Kyphoplasty may be considered as a weak recommendation for symptomatic fractures in neurologically intact patients 1
• Despite the AAOS recommendation, some research suggests percutaneous vertebroplasty may provide prompt pain relief and rapid rehabilitation compared to conservative therapy in the first 24 hours (53% reduction in pain scores, p=0.0001) 6
• Long-term outcomes (6 weeks and 6-12 months) appear similar between vertebroplasty and conservative treatment 6

Special Considerations

• For compression fractures at L3 or L4 levels, referred abdominal pain may occur due to involvement of the L2 nerve root 2
• Surgical management with decompression and stabilization should be reserved only for rare patients with neural compression and progressive deformity with neurologic deficits 3
• Approximately 25% of women over age 50 will suffer vertebral compression fractures, with an annual incidence of approximately 700,000 in the United States 7
• About 75-80% of cases respond to conservative outpatient management, leaving 20-25% of patients who may require more aggressive intervention 8

Treatment Algorithm

1. Acute phase (0-5 days): Calcitonin 200 IU daily for 4 weeks + calcium/vitamin D supplementation 1
2. Persistent pain (>4 weeks): Consider L2 nerve root block for L3/L4 fractures 1, 2
3. Chronic pain (>2 months): Consider referral for kyphoplasty evaluation 1, 3
4. Long-term management: Initiate denosumab 60 mg subcutaneously every 6 months or bisphosphonates, with strong emphasis on treatment adherence 4, 5