What is the first-line treatment for lumbar compression fractures in an older adult with osteoporosis after a low-energy fall?

Treatment of Lumbar Compression Fractures in Older Adults with Osteoporosis

Conservative medical management is the first-line treatment for lumbar compression fractures in older adults with osteoporosis, consisting of multimodal analgesia (acetaminophen preferred over NSAIDs/opioids), early mobilization (avoiding prolonged bed rest), and immediate initiation of osteoporosis pharmacotherapy with calcium (1000-1200 mg/day), vitamin D (800 IU/day), and bisphosphonates (alendronate or risedronate), with vertebral augmentation (vertebroplasty or kyphoplasty) reserved for patients with persistent severe pain after 3 months of conservative treatment. 1, 2

Initial Conservative Management (First 3 Months)

Pain Management

• Acetaminophen is the preferred first-line analgesic, particularly in elderly patients with comorbidities such as chronic kidney disease and cardiovascular disease 2
• NSAIDs (ibuprofen or naproxen) can be used but require caution given gastrointestinal, renal, and cardiovascular risks in elderly patients 1
• Opioids should be used judiciously and with extreme caution due to risks of sedation, nausea, deconditioning, and increased fall risk in this population 1, 2
• Calcitonin may be initiated for 4 weeks in acute fractures for additional pain relief 2

Mobilization Strategy

• Avoid prolonged bed rest, as it accelerates bone loss, muscle weakness, and increases risk of deep venous thrombosis 2
• Begin early range-of-motion exercises and physical training to prevent deconditioning 2, 3
• Bracing may be considered as a clinical option, though evidence is inconclusive 2
• Most patients experience spontaneous resolution of pain within 6-8 weeks even without medication 1

Immediate Osteoporosis Treatment (Do Not Delay)

This is critical and must be started immediately, not after waiting to see if pain improves:

• Calcium supplementation (1000-1200 mg/day) and vitamin D (800 IU/day) reduce non-vertebral fractures by 15-20% and falls by 20% 2, 3
• Bisphosphonates (alendronate or risedronate) should be started immediately as first-line therapy to prevent subsequent fractures, as they reduce vertebral, non-vertebral, and hip fractures 2, 3
• Continue bisphosphonates for 3-5 years initially, with longer duration for patients remaining at high risk 2, 3
• For patients with oral intolerance, dementia, malabsorption, or non-compliance, zoledronic acid (intravenous) or denosumab (subcutaneous) are alternatives 2
• Ibandronate and strontium ranelate are additional options for preventing subsequent symptomatic fractures 2

Monitoring for Treatment Failure

The 3-month timepoint is critical for decision-making:

• Patients who achieve significant pain relief with conservative management typically do so by 3 months 1, 2
• Failure of conservative treatment is defined as: pain refractory to oral medications, contraindication to analgesics, or requirement for parenteral narcotics and hospital admission 1
• Recent evidence shows vertebral augmentation is superior to placebo for pain reduction in acute fractures <6 weeks duration, though benefit extends to subacute and chronic fractures 1, 2

Vertebral Augmentation (After 3 Months of Failed Conservative Treatment)

Vertebroplasty or balloon kyphoplasty should be offered to patients with persistent severe pain after 3 months of conservative therapy: 1, 2

• Both procedures are equally effective in substantially reducing pain and disability, with comparable outcomes persisting from 2 to 5 years 2
• Surgical treatment achieves pain relief significantly faster (median 4.5 weeks vs 10 weeks for conservative treatment) 4
• Progression of treated fractures is significantly lower with vertebral augmentation (4.8% vs 29.7% with conservative treatment) 4
• The new fracture rate and adjacent level fracture rate do not differ significantly between surgical and conservative treatment 4
• The main disadvantage is longer hospital stay (median 10 days vs 3 days for conservative treatment) 4

Comprehensive Fracture Risk Assessment

Every patient aged 50 years and over with a lumbar compression fracture must be systematically evaluated for subsequent fracture risk: 1, 3

• Obtain DXA scanning of spine and hip to assess bone mineral density 1, 3
• Perform imaging of the spine (radiography or vertebral fracture assessment) to detect subclinical vertebral fractures 1
• Review clinical risk factors: advanced age, female gender, low body mass index, personal/family history of fracture, falls risk 1
• Identify secondary causes of osteoporosis 1, 3
• Evaluate falls risk through comprehensive assessment including history of falls in the past year 1

Fall Prevention and Lifestyle Modifications

• Implement multidimensional fall prevention programs, which reduce fall frequency by approximately 20% 2
• Address environmental hazards in the home and review medications that may increase fall risk 2
• Stop smoking and limit alcohol intake 2, 3
• Prescribe weight-bearing exercise programs to improve bone mineral density and muscle strength 2
• Continue long-term balance training 2, 3
• Ensure adequate nutritional status, as malnutrition is common in fracture patients 3

Multidisciplinary Approach

• Implement orthogeriatric co-management immediately in frail elderly patients with multiple comorbidities 2
• Establish collaboration between orthopedic surgery, rheumatology/endocrinology, and primary care 2
• Fracture Liaison Service (FLS) is the most effective organizational structure for risk evaluation and treatment initiation, with a dedicated coordinator improving osteoporosis treatment implementation from 26% to 45% within 6 months 1

Indications for Urgent Surgical Consultation

Surgery is the standard of care for pathologic compression fractures complicated by: 1

• Frank spinal instability
• Neurologic deficits (should receive corticosteroid therapy and surgery as soon as possible to prevent further deterioration) 1

Critical Pitfalls to Avoid

• Do not delay osteoporosis treatment while waiting to see if conservative pain management succeeds—bisphosphonates, calcium, and vitamin D should be started immediately regardless of pain management strategy 2, 3
• Avoid high-pulse dosages of vitamin D, as they are associated with increased fall risk 2
• Do not rely solely on pain management without addressing underlying osteoporosis 3
• Avoid delayed mobilization due to fear of pain, as early activity improves outcomes 3
• Do not ignore the high risk of subsequent fractures—secondary fracture risk is highest immediately after the initial fracture 1

Risk Factors for Poor Prognosis with Conservative Treatment

Early identification of these factors may warrant earlier consideration of vertebral augmentation: 5

• Advanced age, previous spine fracture, and steroid medication use 5
• Thoracolumbar involvement, vertebral instability, middle-column injury 5
• Specific MRI signal changes (diffuse low-intensity signals on T2WI, linear black sign on STIR) 5
• Fatty degeneration of paravertebral muscle 5