What is the best treatment for a spine fracture in osteoporosis?

Best Treatment for Osteoporotic Spine Fractures

For acute osteoporotic vertebral compression fractures (0-5 days from onset), initiate calcitonin 200 IU nasal spray or suppository daily for 4 weeks to achieve rapid pain relief, combined with bisphosphonates (alendronate or risedronate) to prevent future fractures, along with calcium 1000-1200 mg/day and vitamin D 800 IU/day. 1, 2, 3

Acute Phase Management (0-5 Days)

Calcitonin is the cornerstone of acute symptomatic relief:

• Administer calcitonin 200 IU nasal spray or suppository daily for 4 weeks in neurologically intact patients presenting within 0-5 days of symptom onset 2, 3
• This provides clinically significant pain reduction at 1,2,3, and 4 weeks 1, 2
• Alternative dosing: 100 IU subcutaneously or intramuscularly every other day 3
• Side effects are mild, primarily dizziness 2, 3

Concurrent fracture prevention therapy must be initiated immediately:

• Start bisphosphonates (alendronate or risedronate) as first-line pharmacologic treatment based on high-certainty evidence for reducing vertebral, non-vertebral, and hip fractures 1
• These agents have favorable tolerability, low cost, and extensive clinical experience 1

Essential Adjunctive Therapy

All patients require:

• Calcium 1000-1200 mg/day 1, 3
• Vitamin D 800 IU/day, which reduces non-vertebral fractures and falls by 15-20% 1

Intermediate Management (Beyond 4 Weeks)

For persistent pain:

• L2 nerve root block is an option for persistent pain at L3 or L4 vertebral compression fractures 2
• Bracing and exercise programs have insufficient evidence to support routine use 4, 2

For prevention of additional symptomatic fractures:

• Continue bisphosphonates (ibandronate is specifically recommended for patients with existing vertebral compression fractures) 2
• Monitor bone mineral density yearly while on treatment 3

Alternative First-Line Options

For patients with specific contraindications or intolerance:

• Zoledronic acid (intravenous bisphosphonate) for patients with oral intolerance, dementia, malabsorption, or non-compliance 1
• Denosumab for postmenopausal females with contraindications to bisphosphonates or refractory bone pain despite bisphosphonate therapy 1

Vertebral Augmentation Considerations

The evidence does NOT support routine vertebral augmentation:

• The American Academy of Orthopaedic Surgeons makes a strong recommendation against vertebroplasty for treating osteoporotic compression fractures 2
• Kyphoplasty shows no difference in pain outcomes compared to vertebroplasty at 3 days and 6 months 4
• Current evidence does not support routine use of vertebral augmentation over conservative treatment 5, 6
• The guideline explicitly states inability to recommend for or against any specific treatment, reflecting the paucity of high-quality evidence 4

Surgical Indications (15-35% of Patients)

Surgery is reserved for specific complications:

• Unstable fractures with ongoing collapse 5, 6
• Persistent intractable back pain despite conservative management 5, 6
• Severely collapsed vertebra causing neurologic deficit 5, 6
• Progressive kyphosis or chronic pseudarthrosis 5, 6
• When surgery is required, polymethylmethacrylate reinforcement combined with screw fixation is necessary to anchor implants in severely osteoporotic bone 7

Critical Monitoring and Duration

Bisphosphonate therapy:

• Prescribe for 3-5 years initially, longer in patients who remain at high risk 1
• Monitor for osteonecrosis of the jaw and atypical femoral fractures (risk increases with longer duration) 1
• Monitor renal function with chronic use 1

Calcitonin therapy:

• If bone mineral density falls more than 4% per year over two successive years, switch to bisphosphonate 3
• After stopping calcitonin, restart if yearly BMD falls more than 4% 3

Very High-Risk Patients

For patients at very high fracture risk:

• Consider anabolic agents (teriparatide or romosozumab) as these significantly enhance fracture healing and reduce mortality risk 1, 5, 6

Common Pitfalls to Avoid

• Do not delay bisphosphonate initiation while waiting for acute pain to resolve—start immediately alongside calcitonin 1
• Do not pursue vertebroplasty routinely—the strong recommendation is against it 2
• Do not forget calcium and vitamin D supplementation—these are essential adjuncts, not optional 1, 3
• Do not assume radiographic fracture equals symptomatic fracture—clinical correlation is essential as radiographic assessment is not a reliable surrogate for symptomatic fracture 4