What are the management options for a vertebral fracture?

Management of Vertebral Fractures

Conservative medical management is the first-line treatment for most vertebral compression fractures, with pain typically resolving spontaneously within 6-8 weeks, while vertebral augmentation should be reserved for patients who fail conservative therapy after 3 months or have contraindications to medical management. 1

Initial Conservative Management (First 3 Months)

Pain Control

• Start with NSAIDs and acetaminophen as first-line analgesics 1, 2
• Use narcotics cautiously and for short-term only due to risks of sedation, nausea, deconditioning, and falls 1
• Apply local analgesic modalities as needed 2, 3
• Most patients experience spontaneous pain resolution within 6-8 weeks even without medication 1

Activity Modification

• Limit bed rest to the acute phase only - prolonged immobilization causes rapid bone loss, muscle weakness, and complications like DVT and pressure ulcers 2
• Encourage early mobilization as tolerated to prevent deconditioning 2
• Consider bracing for comfort improvement, though evidence is limited 1, 2

Rehabilitation Program

• Begin early post-fracture physical training and muscle strengthening 1, 2
• Implement spinal stretching exercises once acute pain subsides 2, 3
• Continue long-term balance training and multidimensional fall prevention 1, 2

Vertebral Augmentation (After Conservative Failure)

Offer vertebral augmentation (vertebroplasty or kyphoplasty) to patients who fail conservative therapy for 3 months. 1

Indications for Earlier Intervention

• Pain refractory to oral medications (NSAIDs or narcotics) 1
• Contraindication to analgesic medications 1
• Requirement for parenteral narcotics or hospital admission 1
• Acute osteoporotic fractures <6 weeks duration may benefit more from early augmentation 1

Evidence Considerations

While two sham-controlled trials showed no benefit, multiple studies demonstrate vertebral augmentation improves pain intensity, vertebral height, sagittal alignment, functional capacity, and quality of life compared to prolonged medical management 1. A multisociety position statement concluded vertebral augmentation is clearly beneficial short-term and likely beneficial long-term 1. The threshold for performing vertebral augmentation has declined given its superiority over prolonged narcotic use 1.

Procedure Selection

• Both vertebroplasty and kyphoplasty are reasonable options for refractory pain 1
• Kyphoplasty may provide additional benefits for vertebral height restoration and sagittal alignment 1
• The age of fracture does not independently affect outcomes - even fractures >12 weeks can benefit 1

Pharmacological Treatment for Fracture Prevention

Calcium and Vitamin D (Universal)

• Calcium 1000-1200 mg/day (diet plus supplementation if needed) 1, 2
• Vitamin D 800 IU/day - reduces non-vertebral fractures by 15-20% and falls by 20% 1, 2
• Avoid high-pulse vitamin D dosing as it increases fall risk 1

Anti-Osteoporotic Medications

Alendronate and risedronate are first-choice agents due to proven efficacy reducing vertebral, non-vertebral, and hip fractures, low cost (generic available), good tolerability, and extensive clinical experience 1

Alternative agents when oral bisphosphonates are not suitable:

• Zoledronic acid (IV) for patients with oral intolerance, dementia, malabsorption, or non-compliance 1
• Denosumab (subcutaneous) for similar indications as zoledronic acid 1
• Teriparatide for very severe osteoporosis as an anabolic option 1

Duration: Typically prescribe for 3-5 years, longer if high risk persists 1

Surgical Consultation Required

Refer immediately for surgical evaluation when:

• Neurologic deficits present 1, 2
• Spinal instability or retropulsion 1, 2
• Spinal deformity (junctional kyphosis) 1
• Questionable etiology requiring open biopsy if percutaneous access not feasible 1

Special Populations

Malignant/Pathologic Fractures

• Obtain biopsy during vertebral augmentation to verify etiology - can detect unsuspected malignancy 1
• Consider radiation oncology consultation for confirmed spinal metastases 1, 2
• Percutaneous thermal ablation reserved for symptomatic spinal metastatic disease 1

Frail Elderly with Comorbidities

• Implement orthogeriatric co-management for patients with multiple comorbidities and polypharmacy 1, 2
• Systematic follow-up improves adherence to osteoporosis treatment (up to 90% in fracture liaison services) 1

Lifestyle Modifications

• Stop smoking - negatively affects BMD and bone quality 1, 2
• Limit alcohol intake - increases fall and fracture risk 1, 2
• Implement fall prevention strategies 1, 2

Critical Pitfalls to Avoid

• Prolonged bed rest - causes rapid bone loss, muscle deconditioning, DVT, and pressure ulcers 2
• Inadequate pain control - leads to immobility and complications 2
• Failing to treat underlying osteoporosis - 15-35% develop subsequent fractures 4, 5
• Delaying vertebral augmentation in appropriate candidates with persistent severe pain beyond 3 months 1
• Missing pathologic fractures - always consider malignancy in atypical presentations 1, 2
• Using high-dose pulse vitamin D - paradoxically increases fall risk 1

Monitoring and Follow-Up

• Assess pain levels, mobility, and analgesic requirements regularly 1, 2
• Monitor for tolerance and adherence to anti-osteoporotic medications 1, 2
• Educate patients to report sudden increases in back pain or new back pain indicating possible new fractures 1, 2
• Repeat fractures are common - prevention with appropriate medical therapy is essential 1, 2