What is the conservative management for an elderly female patient with a history of osteoporosis and a previous lumbar fracture, presenting with pain at a higher level without neurological deficits?

Conservative Management for Elderly Female with Osteoporotic Vertebral Compression Fracture

For this elderly female patient with osteoporosis, a previous lumbar fracture, and new pain at a higher level without neurological deficits, conservative management should consist of limited bed rest (less than 2 weeks), analgesics with calcitonin for 4 weeks if acute, external bracing, early mobilization, and immediate initiation of bisphosphonate therapy to prevent subsequent fractures. 1, 2, 3

Initial Management Phase (First 3 Weeks)

Pain Control

• Calcitonin 200 IU (nasal or suppository) for 4 weeks provides clinically important pain reduction at 1,2,3, and 4 weeks in acute presentations 3
• NSAIDs as first-line analgesics for mild to moderate pain 2, 3
• Opioids may be used cautiously for severe breakthrough pain, but avoid prolonged use due to risks of sedation, falls, and deconditioning 3

Activity Modification

• Limit bed rest to less than 2 weeks to prevent complications including bone mass loss, muscle strength loss, deep venous thrombosis, and cardiovascular/respiratory deconditioning 1, 2
• Permit slow, regular walking starting with 10-minute periods, gradually increasing duration 3
• Allow range-of-motion exercises and light calisthenics that generate 40-70% of maximum oxygen consumption 3

External Support

• Thoracolumbosacral orthosis (TLSO) or Jewett brace to provide stability and reduce pain during initial healing 2
• Surgical consultation may be helpful for prescribing and supervising immobilization devices 1

Critical Monitoring

• Perform complete neurological examination immediately and monitor for any development of neurological symptoms, as this would necessitate urgent surgical intervention 3
• Monitor for sudden increase or new back pain indicating potential new fracture 2

Osteoporosis Treatment (Initiate Immediately)

First-Line Pharmacotherapy

Given her history of previous lumbar fracture, this patient is at extremely high risk for subsequent fractures and requires immediate anti-osteoporotic therapy. 1

• Bisphosphonates (specifically alendronate) are first-line therapy, reducing vertebral fracture risk by 47-48% and hip fracture risk by 51% 4
• Alendronate 10 mg daily or 70 mg weekly reduces the risk of experiencing multiple vertebral fractures by 87-90% 4
• For elderly patients with immobility and comorbidities, anti-osteoporotic treatment can be started even without a DXA scan 1

Supplementation

• Calcium 1000-1200 mg/day 3
• Vitamin D 800 IU/day (avoid high pulse dosages which increase fall risk) 3

Rehabilitation Phase (2-8 Weeks)

Early Mobilization

• Initiate physical therapy as soon as pain allows to prevent complications of prolonged bed rest 2
• Focus on core strengthening exercises 2
• Training in proper body mechanics 2
• Gradual return to activities with moderate intensity as perceived appropriate 3

Decision Point at 3 Weeks

The VERTOS II trial demonstrated that patients who achieve sufficient pain relief with conservative management typically do so by 3 months. 1

Continue Conservative Management If:

• Pain is adequately controlled
• Patient is mobilizing appropriately
• No neurological deficits develop
• No significant spinal deformity or pulmonary dysfunction

Consider Vertebral Augmentation (Vertebroplasty or Kyphoplasty) If:

• Persistent severe pain after 3 weeks of conservative management 1, 3
• Development of spinal deformity or pulmonary dysfunction 3
• Patient has contraindication to surgery but ongoing pain with edema on MRI 3

Important caveat: Studies comparing vertebroplasty to sham procedures show that while there may be clinically important pain relief at 24 hours, by 6 weeks the effect becomes less clinically important, and after 6 weeks there is no statistically or clinically important difference. 1 This supports a conservative approach initially.

Long-Term Management (8-24 Weeks and Beyond)

Continued Fracture Prevention

• Continue bisphosphonate therapy long-term, as alendronate shows continued BMD increases through 5 years of treatment 4
• Progressive rehabilitation program to restore function and prevent deconditioning 2
• Patient education regarding proper body mechanics and activities to avoid 2

Follow-Up Monitoring

• Regular assessment of pain levels and functional status 2
• Monitor for adjacent level fractures, which are common in patients with underlying osteoporosis 2
• Women with severe vertebral fractures have 3.4 times the risk of hip fracture and 12.6 times the risk of new vertebral fractures 5

Critical Pitfalls to Avoid

• Prolonged bed rest leading to deconditioning, bone loss, and increased mortality risk 3
• Overuse of narcotics causing sedation, falls, and decreased physical conditioning 3
• Failing to initiate anti-osteoporotic therapy immediately in a patient with a previous fracture 1
• Missing unstable fractures by performing inadequate neurological examination 3
• Delaying mobilization beyond 2 weeks 1, 2

When to Abandon Conservative Management

Immediate surgical referral is required for:

• Any neurological deficits 3
• Frank spinal instability 3
• Failure of conservative management at 3 months with persistent severe pain 1, 3

The multidisciplinary approach should include orthogeriatric consultation, especially for frail elderly patients, as optimal care in all phases has important effects on clinical outcomes including mobility and quality of life. 1