What is the diagnosis and treatment for a vertebral compression fracture?

From the Guidelines

The diagnosis of a vertebral compression fracture typically involves a combination of clinical evaluation, imaging studies, and sometimes, a bone density test, with treatment prioritizing pain management, stabilization, and prevention of further fractures, as supported by the most recent evidence from 1 and 1.

Diagnosis

The diagnosis of a vertebral compression fracture is primarily based on:

• Clinical presentation, including sudden onset of back pain
• Imaging studies such as X-rays, CT scans, or MRI to confirm the fracture
• Bone density tests to assess for osteoporosis, a common underlying cause

Treatment

Treatment options vary depending on the severity of the fracture and the patient's overall health but generally include:

• Pain management with medications such as acetaminophen or NSAIDs, as recommended by 1 and 1
• Use of a back brace for stabilization and pain relief
• Limited bed rest, typically 1-3 days, to avoid worsening bone density
• Physical therapy focusing on core strengthening exercises once acute pain subsides
• For severe cases or those with neurological symptoms, procedures like vertebroplasty or kyphoplasty may be necessary, with evidence from 1 suggesting these procedures can provide significant pain relief and improved functional outcomes

Prevention

Prevention of further fractures is crucial and includes:

• Calcium and vitamin D supplementation, as recommended by 1
• Weight-bearing exercises
• Osteoporosis medications if appropriate, with alendronate and risedronate being first-choice agents due to their efficacy and tolerability, as noted in 1

Key Considerations

• The timing of when to consider vertebroplasty or kyphoplasty is debated, but evidence from 1 suggests that patients who have not received sufficient pain relief by 3 months with conservative treatment may be candidates for these procedures
• The choice between vertebroplasty and kyphoplasty depends on various factors, including the severity of the fracture and the patient's overall health, with both procedures showing comparable effectiveness in reducing pain and disability, as found in 1 and 1

From the FDA Drug Label

To assess the effects of alendronate sodium on the incidence of vertebral fractures (detected by digitized radiography; approximately one third of these were clinically symptomatic), the U. S. and Multinational studies were combined in an analysis that compared placebo to the pooled dosage groups of alendronate sodium (5 or 10 mg for three years or 20 mg for two years followed by 5 mg for one year) There was a statistically significant reduction in the proportion of patients treated with alendronate sodium experiencing one or more new vertebral fractures relative to those treated with placebo (3.2% vs. 6.2%; a 48% relative risk reduction). A reduction in the total number of new vertebral fractures (4.2 vs. 11. 3 per 100 patients) was also observed.

The diagnosis of a vertebral compression fracture is typically made by X-ray or other imaging techniques. The treatment for a vertebral compression fracture may include alendronate sodium, which has been shown to reduce the incidence of new vertebral fractures in patients with osteoporosis.

• Key benefits of alendronate sodium in treating vertebral compression fractures include:
  • Reduction in the proportion of patients experiencing one or more new vertebral fractures
  • Reduction in the total number of new vertebral fractures
  • Statistically significant reductions in fracture incidence at three years 2

From the Research

Diagnosis of Vertebral Compression Fracture

• Vertebral compression fractures can be diagnosed using plain radiographs, while computed tomography and magnetic resonance imaging may be required to evaluate for a malignant cause or if there are neurological deficits on examination 3
• Magnetic resonance imaging is also the modality of choice to determine if the fracture is acute vs chronic in nature 3
• Patients with an acute VCF may report abrupt onset of back pain with position changes, coughing, sneezing, or lifting, and physical examination findings are often normal, but can demonstrate kyphosis and midline spine tenderness 4

Treatment of Vertebral Compression Fracture

• Primary treatment of osteoporosis includes consideration of underlying metabolic abnormalities and provision of supplemental calcium/vitamin D in conjunction with bisphosphonates or calcitonin, or both 5
• Acute osteoporotic vertebral compression fracture management includes bracing, analgesics, and functional restoration 5
• Patients with chronic pain beyond 2 months may be appropriate candidates for vertebral body augmentation, ie, vertebroplasty or balloon tamp reduction 5
• Pain control can be achieved with acetaminophen or nonsteroidal anti-inflammatory drugs for mild pain or opioids and/or calcitonin for moderate to severe pain 6
• Bisphosphonates and denosumab are the first-line treatments for osteoporosis 6
• Vertebroplasty and kyphoplasty are reserved for patients who have not found symptomatic relief through conservative methods and are effective in achieving pain relief 6
• Calcium and vitamin D supplementation can have a protective and therapeutic effect 6
• Management of OVCFs must be combined with multiple approaches, including appropriate exercises and activity modification, medication with different mechanisms of action, and minimally invasive surgical interventions such as vertebroplasty and kyphoplasty 6