What is the best course of management for an elderly male patient with a new wedge-shaped compression fracture of the T6 vertebral body, likely due to osteoporosis?

Management of New T6 Vertebral Compression Fracture in an Elderly Male

Begin with conservative medical management including analgesics, limited activity modification, and initiate osteoporosis evaluation and treatment, as this is the standard initial approach for osteoporotic vertebral compression fractures without neurological deficits. 1

Immediate Management (First 4-12 Weeks)

Pain Control

• Acetaminophen, NSAIDs, or opioids should be used for pain management, with careful attention to adverse effects in elderly patients 2
• Calcitonin may be considered specifically for acute pain management during the first 4 weeks after fracture identification 1
• Most vertebral compression fractures demonstrate gradual pain improvement over 2 to 12 weeks with conservative management 1

Activity Modification

• Limited bed rest may be appropriate initially, but prolonged immobilization should be avoided to prevent medical complications 2, 3
• Physical therapy should be initiated as pain allows 2
• Bracing may be considered as part of conservative management 2, 3

Comprehensive Fracture Risk Evaluation (Within 3-6 Months)

Every patient aged 50 years and over with a recent fracture requires systematic evaluation for subsequent fracture risk through a Fracture Liaison Service model, which is the most effective organizational structure. 4

Essential Diagnostic Workup

• DXA scan of lumbar spine and hip to measure bone mineral density 4
• Imaging of the entire spine (radiography or vertebral fracture assessment) to detect additional subclinical vertebral fractures, which are frequent in patients with recent non-vertebral fractures 4
• Laboratory evaluation including serum calcium, albumin, creatinine, thyroid-stimulating hormone, and vitamin D to identify secondary causes of osteoporosis 4
• Falls risk assessment including history of falls in the past year 4

Clinical Risk Factor Assessment

• Age, body mass index, personal and family history of fracture, lifestyle factors, and falls risk should be documented 4
• These factors can be incorporated into fracture risk assessment tools such as FRAX 4

Osteoporosis Treatment Initiation

Pharmacologic osteoporosis therapy should be initiated promptly, as this patient has already sustained a fragility fracture, placing him at very high risk for subsequent fractures. 4

Treatment Options for High-Risk Patients

• Oral or IV bisphosphonates are recommended first-line options 4
• Denosumab, teriparatide/abaloparatide (PTH/PTHrP), or romosozumab are also recommended for patients with new fractures 4
• Calcium and vitamin D supplementation should be provided alongside any osteoporosis medication 4

Critical Consideration

• If denosumab is eventually discontinued, sequential therapy with bisphosphonates must be started 6 to 7 months after the last denosumab dose to prevent rebound vertebral fractures 4

Indications for Vertebral Augmentation

If conservative management fails after 3 months with persistent or worsening pain, vertebral augmentation (vertebroplasty or kyphoplasty) should be considered. 1

Earlier Intervention Warranted If:

• Progressive spinal deformity develops 1
• Worsening symptoms despite medications occur 1
• Pulmonary dysfunction emerges 1
• Patients with severe pain refractory to conservative management are most likely to benefit when offered intervention within 3 weeks 5

Vertebral Augmentation Procedures

• Both vertebroplasty and balloon kyphoplasty provide immediate and considerable improvement in pain and patient mobility 1
• Balloon kyphoplasty may provide better improvement in spinal deformity with correction of kyphotic angle and increased vertebral body height 1
• The age of the fracture does not independently affect vertebroplasty outcomes, with evidence supporting treatment of subacute and chronic painful compression fractures 1

Red Flags Requiring Surgical Referral

Surgical intervention is only indicated for vertebral compression fractures complicated by spinal instability, neurological deficits, or significant spinal cord compression. 1

Absolute Indications for Surgery:

• Neurologic compromise or spinal cord compression requires immediate surgical consultation for decompression and stabilization 6, 7
• Spinal instability (particularly with Spinal Instability Neoplastic Score ≥7 in pathologic fractures) 6

Critical Pitfalls to Avoid

• Do not overlook the possibility of pathologic fracture in patients with risk factors for malignancy; ensure appropriate workup if clinical suspicion exists 1
• Do not delay intervention in patients with progressive deformity or pulmonary dysfunction beyond the 3-month conservative management window 1
• Do not miss neurological deficits on examination, as delays in surgical decompression lead to worse neurological outcomes 7
• Do not forget to address the underlying osteoporosis with pharmacologic therapy, as the fracture itself indicates very high risk for subsequent fractures 4