What is the best approach for managing compression fractures in elderly patients?

Management of Compression Fractures in the Elderly

For elderly patients with osteoporotic vertebral compression fractures, initiate conservative medical management for the first 3 months with analgesics, activity modification, and bracing; reserve percutaneous vertebroplasty for those with persistent severe pain, spinal deformity, or pulmonary dysfunction after this period. 1

Initial Assessment and Imaging

• Obtain plain radiographs or CT to identify the compression fracture initially 1
• Follow with MRI of the spine without IV contrast to assess for bone marrow edema, which indicates acute fracture and helps differentiate from chronic fractures 1
• Look specifically for "red flags" suggesting malignancy: known cancer history, unexplained weight loss, fever, or neurological deficits 1
• If malignancy is suspected, obtain MRI of the complete spine with and without IV contrast 1

Conservative Management (First-Line for 3 Months)

Most symptomatic vertebral compression fractures should be treated conservatively initially, as only one in three vertebral fragility fractures are symptomatic and only 10% require hospitalization 1

Pain Control

• Provide adequate analgesics for pain relief 1
• Consider epidural steroid injections if radicular pain is present 2

Activity Modification and Bracing

• Implement activity modification to reduce mechanical stress on the fractured vertebra 1
• Use bracing to provide external support, though evidence for long-term benefit is limited 1

Early Mobilization and Rehabilitation

• Begin early postfracture physical training and muscle strengthening as soon as pain allows 1
• Implement long-term balance training and multidimensional fall prevention strategies 1
• Avoid prolonged bed rest, which leads to further bone loss and medical complications in elderly patients 3

Indications for Percutaneous Vertebroplasty

Consider vertebroplasty if conservative management fails after 3 months OR if the patient presents with:

• Spinal deformity causing functional impairment 1
• Worsening symptoms despite conservative care 1
• Pulmonary dysfunction from progressive kyphosis 1
• Severe, persistent pain with bone marrow edema on MRI 1

Evidence supporting vertebroplasty: In aged patients (≥70 years) with acute fractures and severe pain, early vertebroplasty provides significantly greater pain relief at all time points (1 week through 1 year) compared to conservative treatment, with improved functional outcomes and fewer complications 4

Contraindications to Vertebroplasty

• If vertebroplasty or surgery is contraindicated, continue medical management indefinitely 1
• Medical management remains the only option for patients who are not surgical or interventional candidates 1

Urgent Surgical Consultation Required

Immediate surgical evaluation is mandatory for:

• Neurological deficits or spinal cord compression 1
• Frank spinal instability 1
• Progressive neurological deterioration (treat with corticosteroids while arranging urgent surgery) 1

Secondary Fracture Prevention (Critical for All Patients)

Every patient aged 50 years and older with a compression fracture must be systematically evaluated for osteoporosis risk 1

Evaluation Components

• DXA scanning of spine and hip 1
• Review clinical risk factors for fractures 1
• Imaging of the spine for additional vertebral fractures 1
• Falls risk assessment 1
• Screening for secondary causes of osteoporosis 1

Pharmacological Treatment

• Initiate bisphosphonate therapy (such as alendronate) for treatment of osteoporosis in postmenopausal women and men with osteoporosis 5
• Use drugs demonstrated to reduce vertebral, non-vertebral, and hip fracture risk 1
• Monitor regularly for tolerance and adherence 1

Non-Pharmacological Interventions

• Ensure adequate calcium and vitamin D intake 1
• Smoking cessation 1
• Limit alcohol intake 1

Multidisciplinary Coordination

• Implement a Fracture Liaison Service (FLS) model with a dedicated coordinator to ensure systematic evaluation and treatment initiation 1
• Coordinate care between orthopedic surgeons, rheumatologists/endocrinologists, geriatricians, and primary care physicians 1
• Provide patient education about disease burden, risk factors, follow-up requirements, and duration of therapy 1

Common Pitfalls to Avoid

• Do not delay imaging with MRI if clinical suspicion exists for acute fracture, as bone marrow edema guides treatment decisions 1
• Do not miss pathologic fractures from malignancy—maintain high suspicion in patients with known cancer or atypical presentations 1
• Do not neglect osteoporosis evaluation and treatment—the risk of subsequent fractures is extremely high without intervention 1
• Do not continue conservative management indefinitely in patients with progressive deformity or persistent severe pain—these patients benefit from vertebroplasty 1, 4