What is the management and treatment for patients with compression fractures?

Management of Compression Fractures

Initial conservative medical management for 3 months is the primary approach for osteoporotic vertebral compression fractures without neurological deficits, with vertebral augmentation procedures reserved for patients who fail to achieve adequate pain relief during this period. 1, 2

Initial Conservative Management (First 3 Months)

Pain Control

• Calcitonin should be considered for acute pain management within the first 4 weeks after fracture identification, as it provides clinically important pain reduction 2
• NSAIDs are effective for back pain relief in compression fractures for assessment periods of 2-12 weeks 1
• Opioid analgesics may be used for moderate to severe pain, with controlled or extended-release formulations (morphine, codeine, oxycodone) providing effective relief for 1-9 weeks 1, 3
• Acetaminophen is appropriate for mild pain 3

Activity Modification and Bracing

• Avoid prolonged immobilization, which worsens bone loss and muscle weakness 2
• Physical therapy should focus on maintaining mobility, strengthening core and back muscles, and improving posture 2
• Bracing may be considered, though evidence is limited to specific brace types 1

Underlying Osteoporosis Treatment

• Bisphosphonates (such as alendronate) are first-line treatment for osteoporosis and have demonstrated significant reduction in vertebral fracture incidence (48% relative risk reduction) 4, 3
• Supplemental calcium and vitamin D should be provided 1, 3
• Denosumab is an alternative first-line agent 3

Vertebral Augmentation (After Failed Conservative Management)

Timing and Indications

• Consider vertebral augmentation if adequate pain relief is not achieved by 3 months of conservative management 1, 2
• Studies suggest patients who have not received sufficient pain relief by 3 months with conservative treatment are appropriate candidates 1
• Vertebral augmentation provides immediate and considerable improvement in pain and patient mobility 1

Important Caveat About Vertebroplasty

The American Academy of Orthopaedic Surgeons recommends against vertebroplasty for osteoporotic compression fractures based on two Level I sham-controlled trials showing no statistically significant difference in pain or function 1. However, this strong recommendation conflicts with other evidence showing benefit.

Kyphoplasty vs Vertebroplasty

• Both kyphoplasty and balloon kyphoplasty are equally effective in substantially reducing pain and disability 1
• Kyphoplasty provides superior improvement in spinal deformity with better vertebral height restoration and less cement leakage compared to vertebroplasty 1
• The improvement in spinal deformity with kyphoplasty provides superior functional recovery compared with vertebroplasty 1
• Observational studies indicate both procedures provide effective relief for 6-12 months 1

Benefits of Vertebral Augmentation

• Prevents secondary sequelae including decreased bone mineral density, muscle strength loss with immobility, increased deep venous thrombosis risk, and cardiovascular/respiratory deconditioning 1
• Improves pulmonary function in patients with compression fractures through improved alignment and decreased pain 1
• Reduces hospitalization rates in patients with baseline vertebral fractures 4

Special Populations

Malignancy-Related Compression Fractures

• Biopsy is required to confirm cancer diagnosis before treatment 1
• Radiation therapy is reserved for spinal metastatic disease causing pain, neurologic compromise, or risk of neurologic compromise 1
• Vertebroplasty/kyphoplasty for refractory pain associated with vertebral compression fractures in selected patients with systemic mastocytosis 1

Refractory Cases

• For patients with refractory bone pain not responding to bisphosphonates, consider PEG-interferon-alfa or denosumab (anti-RANKL monoclonal antibody) 1
• Vertebroplasty/kyphoplasty for refractory pain in selected patients 1

Surgical Consultation

Indications for Surgical Referral

• Neurologic deficits or neural compression 5
• Progressive spinal deformity with neurologic deficits 5
• Spinal instability 1
• Failure of medical management with worsening symptoms despite medications 1

Surgical Options

• Open surgical management with decompression and stabilization is reserved for rare patients with neural compression and progressive deformity 5
• Posterior decompression and fixation or anterior decompression and reconstruction may be required if neurological deficits are present 3

Common Pitfalls to Avoid

• Do not withhold treatment for 3 months in patients with severe, disabling pain - earlier vertebral augmentation may be appropriate in select cases 1
• Do not ignore underlying osteoporosis treatment - fracture management alone without addressing bone health leads to future fractures 5
• Do not use prolonged bed rest - this accelerates bone loss and muscle deconditioning 2
• Recognize that the age of fracture does not independently affect vertebroplasty outcomes - subacute and chronic painful compression fractures can benefit from treatment 1