What is the best course of treatment for an older adult with a history of osteoporosis presenting with a compression fracture?

Treatment of Osteoporotic Compression Fractures in Older Adults

For older adults with osteoporotic compression fractures, initiate conservative management with calcitonin for acute pain control (first 4 weeks), bisphosphonates for fracture prevention, and calcium/vitamin D supplementation, reserving vertebral augmentation only for patients with persistent severe pain after 3 months of failed medical management. 1, 2, 3

Acute Phase Management (0-4 Weeks)

Pain Control

• Calcitonin should be administered for 4 weeks in neurologically intact patients presenting within 0-5 days of symptom onset or identifiable injury, as it provides clinically important pain reduction at 1,2,3, and 4 weeks 1
• Nasal calcitonin 200 IU is the typical formulation, with mild dizziness as the primary side effect 1
• Analgesics and opioids have insufficient evidence for formal recommendation, though they remain clinical options when needed 1

Activity Modification

• Evidence for bed rest is insufficient to make a recommendation for or against its use 1
• Most vertebral compression fractures demonstrate gradual pain improvement over 2-12 weeks with natural healing 3, 4

Osteoporosis Treatment to Prevent Future Fractures

First-Line Pharmacotherapy

• Bisphosphonates (such as alendronate) are first-line therapy for treating underlying osteoporosis and preventing additional symptomatic fractures 2, 5
• Alendronate increases bone mass and reduces the incidence of vertebral compression fractures in postmenopausal women 5
• The medication works by inhibiting osteoclast activity, reducing bone resorption by 50-70% while allowing bone formation to exceed resorption 5

Baseline Supplementation

• Calcium and vitamin D supplementation should be initiated as baseline treatment for all patients with osteoporotic compression fractures 2

Second-Line Options

• Ibandronate and strontium ranelate are alternative options to prevent additional symptomatic fractures 1
• Denosumab (anti-RANKL monoclonal antibody) can be considered for patients with refractory bone pain or worsening bone mineral density despite bisphosphonate therapy 2

Reassessment at 4-6 Weeks and Beyond

Conservative Management Continuation

• Two-thirds of patients experience spontaneous pain resolution within 4-6 weeks 4
• Medical management remains the cornerstone for stable fractures without neurological deficits 3, 6

Bracing Considerations

• Evidence for bracing is inconclusive, with only one Level II study of unclear generalizability regarding age, fracture level, and brace type 1, 6

Exercise Programs

• Insufficient evidence exists to recommend for or against supervised or unsupervised exercise programs 1, 6
• One study showed some benefit in symptom and emotional domains at 6-12 months, but no improvement in physical function 6

Interventional Procedures (After 3 Months of Failed Conservative Management)

Indications for Vertebral Augmentation

• Vertebroplasty or kyphoplasty should be considered only after failure of medical management with worsening symptoms at 3 months 2, 3
• Earlier intervention may be warranted for spinal deformity, worsening symptoms despite medications, or pulmonary dysfunction 3
• Patients most likely to benefit are those with severe pain refractory to nonoperative management who receive intervention within 3 weeks of persistent symptoms 4

Procedure Selection

• Both vertebroplasty and kyphoplasty provide immediate and considerable improvement in pain and patient mobility 3
• Kyphoplasty may provide better correction of spinal deformity with improved kyphotic angle and vertebral body height 2, 3
• The age of the fracture does not independently affect vertebroplasty outcomes, with evidence supporting treatment of subacute and chronic painful fractures 3

Important Caveat About Vertebroplasty

• The AAOS guideline from 2011 strongly recommended against vertebroplasty based on Level I evidence showing no benefit over sham procedure 6
• However, more recent ACR guidance (reflected in 2025 summaries) suggests vertebral augmentation may be considered after 3 months of failed conservative treatment 2, 3
• This represents evolving evidence and practice patterns over time

Surgical Referral Indications

Immediate Surgical Consultation Required

• Any neurological deficits mandate immediate orthopedic or neurosurgical consultation 6
• Spinal instability on imaging requires immediate surgical evaluation 6
• Spinal cord compression requires urgent surgical decompression 6
• Progressive kyphosis or significant spinal deformity should prompt surgical referral 6

Specific Nerve Block Option

• L2 nerve root block is an option for treating acute compression fractures at L3 or L4 in neurologically intact patients 1

Critical Pitfalls to Avoid

Pathologic Fractures

• Always rule out pathologic fractures with MRI, especially in patients with known malignancy or atypical presentations 3, 6
• Radiographic fracture presence does not necessarily correlate with the source of back pain 2

Delayed Intervention

• Do not delay intervention in patients with progressive deformity or pulmonary dysfunction 3
• Conversely, avoid premature vertebral augmentation before 3 months of conservative management in stable patients 2, 3

Duration of Bisphosphonate Therapy

• Patients at low risk for fracture should be considered for drug discontinuation after 3-5 years of use 5
• All patients on bisphosphonate therapy require periodic re-evaluation of the need for continued treatment 5

Ineffective Interventions

• Electrical stimulation lacks evidence for benefit in treating chronic vertebral compression fractures 6
• Complementary and alternative medicines have insufficient data to support their use 1