To whom do you refer a patient with a new diagnosis of osteoporosis and a lumbar compression fracture?

Referral for New Osteoporosis Diagnosis with Lumbar Compression Fracture

Patients with a new diagnosis of osteoporosis and a lumbar compression fracture should be referred to an osteoporosis specialist (clinical endocrinologist or rheumatologist) or a Fracture Liaison Service if available, with additional referrals to orthopedic surgery/neurosurgery or interventional radiology based on specific clinical features. 1, 2

Primary Referral Pathway

Osteoporosis Specialist or Fracture Liaison Service (First-Line Referral)

All patients who experience fragility fractures should be considered for referral to an osteoporosis specialist or a fracture liaison team. 1 This is explicitly recommended by the AACE Guidelines and represents the most effective organizational structure for comprehensive osteoporosis management. 1

The Fracture Liaison Service model has proven superior effectiveness compared to simpler interventions, with RCTs demonstrating that 45% of patients receive appropriate management within 6 months versus only 26% in control groups. 1 The coordinator (typically a specialized nurse working under supervision of an endocrinologist, rheumatologist, or orthopedic surgeon) manages identification, investigation, and treatment initiation. 1

Additional Specialist Referrals Based on Clinical Features

Immediate Orthopedic Surgery or Neurosurgery Referral Required For:

• Neurological deficits - requires immediate referral 2, 3
• Spinal instability - urgent surgical evaluation needed 2, 3
• Severe and worsening pain despite 3 months of conservative management 2
• Significant spinal deformity or progressive kyphosis 2

Interventional Radiology Referral Appropriate For:

• Persistent pain after 3 months of conservative management - consider percutaneous vertebral augmentation 2
• Spinal deformity with worsening symptoms or pulmonary dysfunction - candidates for vertebral augmentation 2

Pain Management Referral For:

• Persistent pain despite initial analgesic therapy 2
• Consideration of L2 nerve root blocks if pain persists 2

Conservative Management Without Referral

Patients can be managed conservatively without specialist referral if they meet ALL of the following criteria: 2

• No neurological deficits
• No spinal instability
• No significant spinal deformity
• Within first 3 months post-fracture with improving symptoms
• No "red flags" suggesting pathologic fracture

Essential Initial Workup Before or Concurrent with Referral

Imaging Requirements:

• MRI of spine without IV contrast (or CT without contrast if MRI contraindicated) to assess fracture characteristics and exclude pathologic causes 2
• Complete spine MRI with and without contrast if malignancy suspected 2

Laboratory Evaluation:

A contributing factor for osteoporosis is identified in 32% to 85% of previously undiagnosed patients with fragility fractures, necessitating comprehensive workup to exclude secondary causes. 1

Pain Management:

Calcitonin should be initiated for the first 4 weeks, as it demonstrates clinically important pain reduction in acute compression fractures. 2

Special Populations Requiring Specialist Referral

Premenopausal Women and Men Under 50:

These patients require further evaluation by a specialist, as the majority of fragility fractures in this population are due to underlying disease. 1 While evaluation can be undertaken in primary care in some countries, referral to a specialized center is appropriate for complex cases. 1

Additional AACE Criteria for Specialist Referral:

• Unexpectedly low BMD or unusual features (young age, unexplained artifacts on bone density tests, abnormal alkaline phosphatase or phosphorus levels) 1
• Osteoporosis with concurrent metabolic bone disease (hyperthyroidism, hyperparathyroidism, hypercalciuria, elevated prolactin) 1
• Conditions complicating management (decreased kidney function, hyperparathyroidism, malabsorption) 1
• Recurrent fractures or continued bone loss while receiving therapy 1

Common Pitfalls to Avoid

The "treatment gap" remains unacceptably high - many patients with osteoporotic fractures never receive appropriate osteoporosis evaluation or treatment. 4 Orthopedic surgeons, who are often the first clinicians to see these patients, frequently do not routinely consider osteoporosis management. 4, 5, 6, 7

Always rule out pathologic fractures - if there is any suspicion of malignancy, complete spine MRI with contrast and potential biopsy are indicated. 2

Reassess patients at 4-6 weeks to evaluate response to initial treatment, and consider additional imaging if symptoms persist beyond 8 weeks to rule out fracture progression or new fractures. 2