What is the treatment approach for osteoporosis with a lumbar compression fracture?

Treatment of Osteoporosis with Lumbar Compression Fracture

Start with conservative medical management for the first 3 months, including NSAIDs or opioids for pain control, combined with immediate initiation of osteoporosis pharmacotherapy (ibandronate, strontium ranelate, bisphosphonates, or denosumab), and consider vertebral augmentation only if conservative therapy fails after 3 months. 1

Immediate Pain Management (First 4 Weeks)

• Use calcitonin for acute pain relief in the first 4 weeks after fracture identification, as it provides clinically important pain reduction beyond standard analgesics 1, 2
• NSAIDs or opioids are appropriate for pain control, though evidence for specific recommendations is inconclusive 1
• Exercise caution with opioids due to sedation, nausea, decreased physical conditioning, and increased fall risk—particularly problematic in elderly osteoporotic patients 1
• Acetaminophen can be used for mild pain 3

Conservative Management (First 3 Months)

• Most osteoporotic compression fractures resolve spontaneously within 6-8 weeks without intervention 1
• Avoid prolonged bed rest, as it causes 1% bone loss per week (50 times faster than age-related loss), 15% loss of lower extremity strength after just 10 days, and increases risk of decubitus ulcers and deep venous thrombosis 1
• Evidence for bracing is inconclusive and cannot be definitively recommended 1
• Evidence for supervised or unsupervised exercise programs is inconclusive, though some data suggest improvement in symptom and emotional domains at 6-12 months 1

Osteoporosis Pharmacotherapy (Start Immediately)

Begin anti-osteoporosis medication immediately to prevent additional symptomatic fractures:

• Ibandronate and strontium ranelate are specifically recommended for preventing additional symptomatic fractures in patients with existing osteoporotic compression fractures 1
• Bisphosphonates (such as risedronate) are first-line treatments for osteoporosis 4, 3
• Denosumab 60 mg subcutaneously every 6 months is FDA-approved for treatment of osteoporosis in men and postmenopausal women at high risk for fracture 4
• Teriparatide is FDA-approved for postmenopausal women and men with osteoporosis at high risk for fracture, including those who have failed or are intolerant to other therapies 5
• All patients should receive at least 1000 mg calcium and 800 IU vitamin D supplementation daily 4, 3, 2

Interventional Options After Failed Conservative Therapy

Consider vertebral augmentation (vertebroplasty or kyphoplasty) only after 3 months of failed conservative management: 1

When to Offer Vertebral Augmentation:

• Pain refractory to oral medications (NSAIDs or narcotics) after 3 months 1
• Contraindication to pain medications 1
• Requirement for parenteral narcotics or hospital admission 1

Important Controversy:

• The American Academy of Orthopaedic Surgeons recommends AGAINST vertebroplasty based on two Level I studies showing no statistically significant difference compared to sham procedures for pain or function 1
• However, the American College of Radiology and Society of Neurointerventional Surgery support vertebral augmentation based on multiple studies showing benefits in pain intensity, vertebral height, sagittal alignment, functional capacity, and quality of life compared to conservative management 1
• Meta-analyses demonstrate improvements with kyphoplasty versus conventional medical management 1
• Vertebral augmentation is clearly beneficial in the short term and likely beneficial in the long term according to multisociety position statements 1

Alternative Interventional Option:

• L2 nerve root block is an option for treating L3 or L4 compression fractures with acute injury and correlating symptoms 1
• Percutaneous dorsal root ganglion block with steroid at the pathological level and adjacent levels shows dramatic initial pain relief maintained at 1-year follow-up 6

Surgical Consultation Required For:

• Neurologic deficits 1
• Spinal deformity (junctional kyphosis, retropulsion) 1
• Spinal instability 1

Critical Pitfalls to Avoid:

• Do not delay osteoporosis pharmacotherapy—20% risk of another vertebral fracture within 12 months after the first fracture 1
• Avoid prolonged immobilization—causes rapid bone loss and muscle weakness, creating a vicious cycle of deconditioning and increased fracture risk 1
• Do not assume all pain is from the acute fracture—obtain MRI if symptoms change or imaging is >3 months old to identify new fractures 1
• Bone marrow edema on MRI typically resolves within 1-3 months but is not a precise measure of fracture age 1