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

Treatment of Compression Fractures in Older Adults with Osteoporosis

Initiate bisphosphonate therapy (alendronate or risedronate) immediately alongside calcitonin for acute pain relief, with calcium and vitamin D supplementation as essential adjuncts. 1

Acute Phase Management (0-5 Days Post-Injury)

Start calcitonin immediately for rapid pain control in neurologically intact patients presenting within 0-5 days of symptom onset 1, 2:

• Calcitonin 200 IU nasal spray or suppository daily for 4 weeks provides clinically significant pain reduction at 1,2,3, and 4 weeks 1, 2
• Side effects are generally mild (dizziness) 2

Initiate bisphosphonates immediately—do not delay while waiting for acute pain to resolve 1:

• Alendronate or risedronate are first-line pharmacologic treatments 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
• Alendronate specifically inhibits osteoclast activity without impairing bone formation, leading to progressive gains in bone mass 3

Essential adjunctive therapy that must not be forgotten 1:

• Calcium 1000-1200 mg/day 1
• Vitamin D 800 IU/day 1
• These reduce non-vertebral fractures and falls by 15-20% 1

Intermediate Management (Beyond 4 Weeks)

For persistent pain at L3 or L4 vertebral compression fractures, L2 nerve root block is an option 1, 2

Continue bisphosphonate therapy to prevent additional symptomatic fractures 1:

• Ibandronate is specifically recommended for patients with existing vertebral compression fractures 1, 2
• Bisphosphonates should be prescribed for 3-5 years initially, longer in patients who remain at high risk 1

Monitor bone mineral density yearly while on treatment 1

Bracing and exercise programs have insufficient evidence to support routine use 1, 2

Alternative First-Line Options

For patients with specific contraindications or intolerance to oral bisphosphonates 1:

• Zoledronic acid (intravenous bisphosphonate) may be considered 1
• Denosumab may be considered 1

Very High-Risk Patients

For patients at very high fracture risk, anabolic agents (teriparatide or romosozumab) may be considered to significantly enhance fracture healing and reduce mortality risk 1

Vertebral Augmentation: Strong Recommendation Against

The American Academy of Orthopaedic Surgeons makes a strong recommendation AGAINST vertebroplasty for treating osteoporotic compression fractures 1, 2

Kyphoplasty shows no difference in pain outcomes compared to vertebroplasty at 3 days and 6 months 1

Critical Monitoring Requirements

Monitor renal function with chronic use of bisphosphonates 1

Monitor for complications 1:

• Osteonecrosis of the jaw
• Atypical femoral fractures

Switch from calcitonin to bisphosphonate if bone mineral density falls more than 4% per year over two successive years 1

Special Considerations for Glucocorticoid-Induced Osteoporosis

For patients on chronic glucocorticoids (≥7.5 mg/day prednisone equivalent) 4, 3:

• Alendronate is indicated for treatment of glucocorticoid-induced osteoporosis 3
• If a new fracture occurs after ≥12 months of initial osteoporosis treatment, oral or IV bisphosphonates, raloxifene, PTH/PTHrP, denosumab, or romosozumab are all conditionally recommended 4

Common Pitfalls to Avoid

Do not delay bisphosphonate initiation—start immediately alongside calcitonin, not after acute pain resolves 1

Do not pursue vertebroplasty routinely—there is a strong recommendation against it 1

Do not forget calcium and vitamin D supplementation—these are essential adjuncts, not optional 1

Do not discontinue therapy without sequential planning if using denosumab, PTH/PTHrP, or romosozumab—these require transition to anti-resorptive therapy to prevent rebound vertebral fractures 4