What is the treatment for an active female in her late 70s with a T12 vertebral body fracture?

Treatment of T12 Vertebral Body Fracture in an Active Female in Her Late 70s

Most symptomatic vertebral compression fractures in elderly patients should be managed conservatively with analgesics, activity modification, and bracing, as only about 10% require hospitalization for pain. 1

Initial Management Approach

Conservative Treatment (First-Line)

• Begin with adequate pain management using multimodal analgesia, prioritizing non-opioid analgesics to minimize complications 1
• Implement activity modification to reduce pain while maintaining mobility within tolerable limits 1, 2
• Consider bracing for symptomatic relief and spinal support, though two-thirds of patients experience spontaneous pain resolution within 4-6 weeks 1, 3
• Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation for bone healing 1

The EULAR/EFORT guidelines emphasize that appropriate treatment requires a balanced approach between operative and non-operative management, with careful consideration of the patient's functional status and fracture characteristics. 1

When to Consider Vertebral Augmentation

Indications for Kyphoplasty/Vertebroplasty

• Persistent severe back pain refractory to conservative management after 4-6 weeks 3, 4
• Presence of bone marrow edema on MRI indicating acute fracture 3, 4
• Optimal timing is within 3 weeks of symptom onset for best outcomes 3
• Most patients report immediate, durable pain relief with these procedures 3

Important Caveat

Standard percutaneous vertebroplasty/kyphoplasty is not routinely recommended if there is posterior cortical compromise with bony retropulsion into the spinal canal or neurological deficits, though open kyphoplasty may be considered in highly selected cases 5

Comprehensive Multidisciplinary Management

Immediate Assessment Requirements

• Systematically evaluate for risk of subsequent fractures given her age >50 years 1
• Obtain DXA scanning of spine and hip to assess bone mineral density 1
• Review clinical risk factors and identify secondary causes of osteoporosis 1
• Evaluate falls risk through comprehensive assessment 1

Rehabilitation Protocol

• Initiate early physical training and muscle strengthening to prevent deconditioning 1
• Implement spinal stretching exercises as pain permits 2
• Continue long-term balance training and multidimensional fall prevention strategies 1
• Encourage return to ordinary activities within pain-limited tolerance 2

Pharmacological Fracture Prevention

Prescribe anti-osteoporosis medication using drugs demonstrated to reduce vertebral, non-vertebral, and hip fracture risk. 1

First-Line Pharmacotherapy Options

• Alendronate or risedronate are preferred first-choice agents due to tolerability, low cost (generic availability), and extensive clinical experience 1
• These bisphosphonates reduce vertebral, non-vertebral, and hip fractures in primary analyses 1
• Alternative options include zoledronic acid (intravenous) or denosumab (subcutaneous) for patients with oral intolerance, malabsorption, or non-compliance 1, 6
• Denosumab reduces new vertebral fractures by 68% at 3 years (7.2% placebo vs 2.3% treatment) 6

Treatment Duration and Monitoring

• Typically prescribe for 3-5 years initially, with longer duration for patients remaining at high risk 1
• Regularly monitor for tolerance and adherence, as long-term compliance is often poor 1

Lifestyle Modifications

• Stop smoking and limit alcohol intake 1
• Ensure adequate nutritional status, as malnutrition is common in fracture patients 1
• Maintain adequate calcium and vitamin D intake throughout treatment 1

Patient Education

Educate about disease burden, risk factors for fractures, follow-up requirements, and expected duration of therapy. 1

• Explain that vertebral fractures are robust predictors of future fractures requiring ongoing management 7
• Discuss expected recovery timeline and warning signs requiring medical attention 4

Critical Pitfalls to Avoid

• Do not delay fracture risk assessment and osteoporosis treatment, as this patient has already sustained a fragility fracture indicating high risk for subsequent fractures 1
• Avoid delayed mobilization due to fear of pain, as early activity improves outcomes 1, 2
• Do not rely solely on pain management without addressing underlying osteoporosis 1, 7
• Recognize that the T12 location (thoracolumbar junction) is a common site for vertebral fractures and warrants careful evaluation 1, 7