What is the recommended treatment for an elderly female with mild kyphotic changes, chronic wedge deforming of T12, and chronic compression of T9 and T11, presenting with lumbar and right hip pain?

Treatment Approach for Elderly Female with Chronic Thoracic Compression Fractures and Pain

Begin with conservative medical management including calcium, vitamin D supplementation, and bisphosphonates as first-line therapy, reserving vertebral augmentation only for patients with persistent severe pain after 3 months of optimized conservative treatment. 1

Initial Conservative Management

Pharmacological therapy forms the foundation of treatment:

• Start bisphosphonates immediately as first-line therapy to treat underlying osteoporosis, which may resolve bone pain while improving vertebral bone mineral density 1
• Provide calcium and vitamin D supplementation as baseline treatment for the underlying osteoporotic process 1
• Use analgesics for pain control, including NSAIDs and potentially short-term opioids if needed, though prolonged bed rest should be avoided due to rapid bone loss (1% per week) and muscle strength decline (15% loss in just 10 days) 2, 3
• Consider calcitonin nasal spray specifically for acute fracture pain 4

Physical therapy and mobilization are critical:

• Implement a structured physical therapy program focusing on maintaining mobility and preventing deconditioning 4
• Avoid prolonged bed rest, which causes bone resorption markers to increase within 2 days and leads to 50 times more rapid bone loss than normal age-related decline 2
• Most vertebral compression fractures show gradual pain improvement over 2-12 weeks with conservative treatment 2

When Conservative Treatment Fails

Consider vertebral augmentation (vertebroplasty or kyphoplasty) if:

• Pain persists after 3 months of optimized conservative management 2, 1
• The VERTOS II trial demonstrated that 40% of conservatively treated patients had no significant pain relief after 1 year despite higher-class prescription medications 2
• Vertebral augmentation provides earlier pain relief (30 days vs 116 days with conservative treatment) 5

Important caveats about vertebral augmentation:

• The American Academy of Orthopaedic Surgeons explicitly states there is a paucity of good quality research supporting these procedures 2, 4
• Radiographic fracture assessment is not a reliable surrogate for symptomatic fracture—imaging findings do not necessarily correlate with pain source 2, 1, 4
• Studies comparing kyphoplasty to vertebroplasty show no clinically important benefit in pain management at 12 months 2, 4
• The age of fracture (chronic vs acute) does not independently affect vertebral augmentation outcomes 2

Addressing the Kyphotic Deformity

The 26-degree kyphosis requires specific consideration:

• Kyphotic deformity with wedge compression fractures increases stress on adjacent vertebrae, creating bimodal stress peaks in midthoracic vertebrae and superior adjacent levels 6
• Higher kyphosis angles (>10 degrees) correlate with worse pain and functional outcomes 7
• Surgical correction is reserved exclusively for: patients with neurologic deficits, progressive spinal deformity with instability, or spinal cord compression 2
• For this patient with 26-degree kyphosis but no neurologic deficits, surgical correction is not indicated 2

Managing the Right Hip Pain

Evaluate whether hip pain is related to spinal pathology:

• Kyphotic deformity shifts the center of gravity anteriorly, potentially causing compensatory postural changes affecting the hip 8, 9
• The hip pain may represent referred pain from lumbar pathology or compensatory mechanical stress
• Address with targeted physical therapy focusing on posture correction and hip strengthening 4

Second-Line Osteoporosis Management

If bisphosphonates fail or are contraindicated:

• Consider anti-RANKL monoclonal antibodies (denosumab) as second-line therapy for refractory bone pain or worsening bone mineral density 1, 4

Critical Pitfalls to Avoid

Do not proceed with vertebral augmentation without:

• Documenting failure of at least 3 months of optimized conservative management 2, 1
• Confirming bone mineral density testing to quantify osteoporosis severity 4
• Ensuring the radiographic fractures correlate clinically with the patient's pain pattern 2, 1, 4

Recognize that:

• Approximately 1 in 5 patients with osteoporotic vertebral fractures develop chronic back pain regardless of treatment 2
• Once a vertebral fracture occurs, there is a 20% risk of another fracture within 12 months 2
• Cement leakage occurs commonly with vertebral augmentation procedures, with rare but serious complications including pulmonary embolism 5, 4