What is the best treatment approach for a patient with multiple chronic thoracic compression fractures and kyphosis?

Treatment Approach for Multiple Chronic Thoracic Compression Fractures with Kyphosis

There is insufficient evidence to recommend any specific treatment for patients with multiple chronic thoracic compression fractures and kyphosis, as no single approach has demonstrated clear superiority for improving morbidity, mortality, or quality of life outcomes. 1

Initial Management

• Pharmacological management should include calcium and vitamin D supplementation as baseline treatment for underlying osteoporosis 1
• Bisphosphonates should be considered first-line therapy for treating the underlying osteoporosis and may resolve bone pain while improving vertebral bone mineral density 1
• For patients with refractory bone pain or worsening bone mineral density despite bisphosphonate therapy, anti-RANKL monoclonal antibodies (e.g., denosumab) can be considered as second-line therapy 1

Pain Management Options

• Medical management remains a cornerstone of treatment for painful compression fractures when interventional procedures are contraindicated or not preferred 1
• Facet joint injections may provide significant pain relief in selected patients, as facet joints can be abnormally stressed due to increased thoracic flexion moment in compression fractures 2
• Low-dose radiation therapy (10-30 Gy) may be considered for uncontrolled pain in cases where compression fractures are associated with malignancy 1

Interventional Procedures

• Vertebral augmentation procedures (vertebroplasty or kyphoplasty) may be considered for patients with persistent pain despite conservative management 1
• The timing of vertebral augmentation remains debated, with some evidence suggesting benefit for patients who have not achieved sufficient pain relief after 3 months of conservative treatment 1
• Studies comparing vertebroplasty and kyphoplasty have shown inconsistent results, with some suggesting kyphoplasty may provide better correction of spinal deformity and vertebral height, potentially leading to superior functional recovery 1
• For middle thoracic regions (T5-T8), balloon kyphoplasty through an extrapedicular approach has shown effectiveness with low complication rates 3

Surgical Considerations

• For severe thoracic kyphosis, staged vertebral augmentation with osteotomies may be considered in selected patients, though this approach is complex 4
• Surgical consultation is helpful for prescribing and supervising immobilization devices 1

Risk Factors for Progressive Deformity

• Patients over 60 years of age, those with osteoporosis/osteopenia, fractures located at the thoracolumbar junction, and solitary fractures are at higher risk for increased compression and kyphosis over time 5
• These high-risk patients may require closer follow-up to monitor for progression 5

Important Caveats

• The evidence base for treating symptomatic osteoporotic spinal compression fractures is limited, with a paucity of high-quality research studies 1
• Radiographic fracture assessment is not a reliable surrogate measure of symptomatic fracture; the presence of a fracture on imaging does not necessarily correlate with the source of back pain 1
• Long-term prospective studies on the natural history of osteoporotic spinal insufficiency fractures are needed 1
• Fracture parameters such as type, location, and degree of kyphosis have been suggested as clinically important but have not been adequately studied 1