What is the recommended treatment for an older adult with a history of osteoporosis and spinal deformity suffering from dorsalgia due to kyphosis?

Treatment for Dorsalgia Due to Kyphosis in Older Adults with Osteoporosis

Begin with conservative medical management including calcium and vitamin D supplementation, bisphosphonates for underlying osteoporosis, and analgesics for pain control; if pain persists beyond 3 months despite optimal medical therapy, consider vertebral augmentation (vertebroplasty or kyphoplasty) for symptomatic compression fractures. 1

Initial Conservative Management

Osteoporosis Treatment (Foundation of Care)

• Initiate bisphosphonates as first-line therapy to treat underlying osteoporosis, which may resolve bone pain while improving vertebral bone mineral density 1
• Provide calcium and vitamin D supplementation as baseline pharmacological management 1
• If refractory bone pain or worsening bone mineral density occurs despite bisphosphonate therapy, consider anti-RANKL monoclonal antibodies (denosumab) as second-line therapy 1

Pain Management

• Medical management with analgesics remains the cornerstone when interventional procedures are contraindicated or not preferred 1
• Conservative management should include analgesics, bed rest (limited duration), back braces, physical therapy, and rehabilitation 2
• Most vertebral compression fractures show gradual improvement in pain over 2 to 12 weeks with variable return of function 3

Physical Therapy and Exercise

• Implement a structured physical therapy program with supervised back exercises initially 2
• Unsupervised back exercises at home can be recommended after initial instruction by a physical therapist 3
• Strongly avoid spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis due to risk of spine fractures, spinal cord injury, and paraplegia 3

Timing for Interventional Procedures

When to Consider Vertebral Augmentation

• Consider vertebral augmentation if patients have not achieved sufficient pain relief after 3 months of conservative treatment 3, 1
• The VERTOS II trial demonstrated that 40% of conservatively treated patients had no significant pain relief after 1 year, with the majority who achieved relief doing so by 3 months 3
• Vertebral augmentation shows immediate and considerable improvement in pain and patient mobility compared to conservative therapy 3

Benefits of Vertebral Augmentation

• Prevents secondary sequelae including decreased bone mineral density and muscle strength from immobility, increased risk of deep venous thrombosis, and deconditioning of cardiovascular and respiratory muscles 3
• Improves pulmonary function in patients with vertebral compression fractures through improved alignment and decreased pain 3
• Studies show vertebral augmentation is superior to placebo for pain reduction in acute osteoporotic fractures 3

Vertebroplasty vs. Kyphoplasty

• Both procedures are equally effective in substantially reducing pain and disability 3
• Kyphoplasty may provide superior functional recovery due to better improvement in spinal deformity with extension of the kyphotic angle and increased vertebral body height 3, 1
• Kyphoplasty demonstrates less cement leakage compared to vertebroplasty 3
• The age of the fracture (acute vs. chronic) does not independently affect outcomes of vertebral augmentation 3

Surgical Consultation Indications

When Surgery is Necessary

• Reserve surgical intervention for patients with neurologic deficits, significant spinal deformity (junctional kyphosis, retropulsion), or spinal instability 3
• Surgical consultation is helpful for prescribing and supervising immobilization devices 3, 1
• Elective spinal osteotomy is generally not recommended for severe kyphosis due to perioperative mortality of 4% and permanent neurologic sequelae of 5% 3
• Consider spinal osteotomy only in highly selected patients with severe kyphosis who lack horizontal vision causing major physical and psychological impairments, and only at specialized centers with extensive surgical experience 3

Important Clinical Caveats

Diagnostic Considerations

• Radiographic fracture assessment is not a reliable surrogate measure of symptomatic fracture—the presence of a fracture on imaging does not necessarily correlate with the source of back pain 3, 1, 2
• Bone mineral density testing is required to confirm osteoporosis diagnosis and quantify severity 2
• Approximately 1 in 5 patients with osteoporotic vertebral compression fractures will develop chronic back pain 3

Evidence Limitations

• The American Academy of Orthopaedic Surgeons explicitly notes that the paucity of good quality research studies has limited the strength of recommendations for treating symptomatic osteoporotic spinal compression fractures 3, 1, 2
• Fracture parameters such as type, location, and degree of kyphosis have been suggested as clinically important but have not been adequately studied 1

Spinal Deformity Considerations

• Spinal deformity may be defined as 15% kyphosis, 10% scoliosis, 10% dorsal wall height reduction, or vertebral body height loss >20% 3
• Spinal deformity associated with vertebral compression fractures can contribute to impaired mobility, physical functioning, pulmonary dysfunction, and increased mortality 3, 4