eMedicine Specialties > Physical Medicine and Rehabilitation > Therapeutic Modalities

Nonoperative Treatment of Osteoporotic Compression Fractures: Follow-up

Author: Grant Cooper, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, New York-Presbyterian Hospital, The University Hospitals of Columbia and Cornell
Coauthor(s): Julie Lin, MD, Assistant Professor, Department of Rehabilitation Medicine, Weill Medical College of Cornell University; Assistant Attending Physiatrist, Physiatry Department, Hospital for Special Surgery; Joseph M Lane, MD, Professor of Orthopedic Surgery, Weill Medical College of Cornell University; Chief, Metabolic Bone Disease Service, Hospital for Special Surgery
Contributor Information and Disclosures

Updated: May 5, 2009

Follow-up

Further Inpatient Care

  • Inpatient care is not generally required for patients with osteoporotic vertebral compression fractures. However, if neurologic injury has occurred and/or another underlying systemic disease has been detected, inpatient care may be appropriate.

Further Outpatient Care

  • All patients with osteoporosis should be involved in structured, weight-bearing exercises in a physical therapy program to prevent progression of osteoporosis. Balance training programs, particularly Tai Chi Chuan, have been shown to improve balance, which is important in preventing falls.
  • Serial radiographs should be obtained for 1 year following injury to be sure no kyphotic progression occurs.

Inpatient & Outpatient Medications

  • Pain relief is of paramount concern. Pain medications have been discussed and may be used for a short period, typically 1-2 months. However, if pain requiring medication persists for longer than 1 month, vertebroplasty or kyphoplasty should be strongly considered. If pain medications do not provide adequate pain relief during the first month, these procedures should be considered sooner.
  • Anti-osteoporotic medications are essential. Miacalcin may be taken intranasally and has been purported to reduce the pain from compression fractures.

Transfer

  • Transfer to an inpatient facility is indicated in the setting of a patient with pending neurologic compromise and for patients who are unable to care for themselves at home.

Deterrence

  • The key to the prevention of osteoporotic vertebral compression fractures is the prevention of osteoporosis via education of the younger population. By emphasizing a diet high in calcium and vitamin D and encouraging weight-bearing exercise in the adolescent population, the risk of osteoporosis may be minimized. In addition, modifiable risk factors should be addressed. These include smoking, low body weight, low calcium intake, estrogen deficiency (not always easy to modify because of other factors, such as heart disease), alcoholism, and inadequate physical activity. These modifiable activities should be addressed as early as possible.
  • A meta-analysis was performed to evaluate the efficacy of oral supplemental vitamin D in the prevention of hip and other nonvertebral bone fractures in individuals aged 65 years or older. The meta-analysis, which included 12 double-blind, randomized, controlled trials (RCTs) for nonvertebral fractures (n = 42,279) and 8 RCTs for hip fractures (n = 40,886), compared the results obtained from the use of oral vitamin D (with or without calcium) with those derived from the administration of calcium alone and from placebo use. The results indicated that vitamin D offers dose-dependent protection against fractures, with doses of more than 400 IU per day reducing fractures by at least 20% in individuals aged 65 years or older. Calcium supplementation was reported not to have effected the results.16

Complications

  • Progressive kyphosis, additional fractures, and neurologic changes are potential complications. These complications can be minimized with appropriate, expeditious care.

Prognosis

  • The majority of osteoporotic vertebral compression fractures are asymptomatic. Most patients who develop significant back pain from a fracture have resolution of pain without intervention in 6-8 weeks. Many patients do, however, continue to have disabling pain. For these patients, kyphoplasty and vertebroplasty have shown excellent results, substantially relieving pain in approximately 90% of patients.

Patient Education

  • Education of patients is essential in osteoporosis. Good nutrition and weight-bearing exercise may prevent or delay the development of osteoporosis and may reduce the risk of osteoporotic compression fractures. In addition to taking anti-osteoporotic medications, as well as (daily) 1500 mg of elemental calcium and 400 IU of vitamin D, patients should be taught to modify their activities by employing fall-prevention strategies. Patients should also be given the pneumococcal vaccine and undergo yearly influenza vaccinations to reduce their risk of severe coughing. Moreover, they should be instructed in proper weight-bearing exercises and extension exercises.
  • For excellent patient education resources, visit eMedicine's Osteoporosis and Bone Health Center. Also, see eMedicine's patient education articles Osteoporosis, Osteoporosis Medications, and Vertebral Compression Fracture.

Miscellaneous

Medicolegal Pitfalls

  • Osteoporotic vertebral compression fractures require a thorough evaluation for an underlying primary systemic illness, such as a tumor. In men younger than 75 years, compression fractures should mandate an investigation for endocrine or prostate abnormalities.
 


More on Nonoperative Treatment of Osteoporotic Compression Fractures

Overview: Nonoperative Treatment of Osteoporotic Compression Fractures
Differential Diagnoses & Workup: Nonoperative Treatment of Osteoporotic Compression Fractures
Treatment & Medication: Nonoperative Treatment of Osteoporotic Compression Fractures
Follow-up: Nonoperative Treatment of Osteoporotic Compression Fractures
Multimedia: Nonoperative Treatment of Osteoporotic Compression Fractures
References
Further Reading
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References

  1. Freedman BA, Potter BK, Nesti LJ, et al. Osteoporosis and vertebral compression fractures-continued missed opportunities. Spine J. Mar 14 2008;[Medline].

  2. Prather H, Watson JO, Gilula LA. Nonoperative management of osteoporotic vertebral compression fractures. Injury. Sep 2007;38 Suppl 3:S40-8. [Medline].

  3. Chiras J, Depriester C, Weill A, et al. [Percutaneous vertebral surgery. Technics and indications]. J Neuroradiol. Jun 1997;24(1):45-59. [Medline]. [Full Text].

  4. Karlsson MK, Hasserius R, Gerdhem P, et al. Vertebroplasty and kyphoplasty: new treatment strategies for fractures in the osteoporotic spine. Acta Orthop. Oct 2005;76(5):620-7. [Medline]. [Full Text].

  5. Lin JT, Lane JM. Nonmedical management of osteoporosis. Curr Opin Rheumatol. Jul 2002;14(4):441-6. [Medline].

  6. Phillips FM. Minimally invasive treatments of osteoporotic vertebral compression fractures. Spine. Aug 1 2003;28(15):S45-53. [Medline].

  7. Lane JM, Russell L, Khan SN. Osteoporosis. Clin Orthop Relat Res. Mar 2000;139-50. [Medline].

  8. Sinaki M, Itoi E, Wahner HW, et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone. Jun 2002;30(6):836-41. [Medline].

  9. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. Oct 1984;65(10):593-6. [Medline].

  10. Huntoon EA, Schmidt CK, Sinaki M. Significantly fewer refractures after vertebroplasty in patients who engage in back-extensor-strengthening exercises. Mayo Clin Proc. Jan 2008;83(1):54-7. [Medline]. [Full Text].

  11. Skedros JG, Holyoak JD, Pitts TC. Knowledge and opinions of orthopaedic surgeons concerning medical evaluation and treatment of patients with osteoporotic fracture. J Bone Joint Surg Am. Jan 2006;88(1):18-24. [Medline].

  12. Tanigawa N, Komemushi A, Kariya S, et al. Relationship between cement distribution pattern and new compression fracture after percutaneous vertebroplasty. AJR Am J Roentgenol. Dec 2007;189(6):W348-52. [Medline]. [Full Text].

  13. He SC, Teng GJ, Deng G, et al. Repeat vertebroplasty for unrelieved pain at previously treated vertebral levels with osteoporotic vertebral compression fractures. Spine. Mar 15 2008;33(6):640-7. [Medline].

  14. McDonald RJ, Trout AT, Gray LA, et al. Vertebroplasty in multiple myeloma: outcomes in a large patient series. AJNR Am J Neuroradiol. Jan 17 2008;[Medline]. [Full Text].

  15. Lin WC, Cheng TT, Lee YC, et al. New vertebral osteoporotic compression fractures after percutaneous vertebroplasty: retrospective analysis of risk factors. J Vasc Interv Radiol. Feb 2008;19(2):225-31. [Medline].

  16. [Best Evidence] Bischoff-Ferrari HA, Willett WC, Wong JB, et al. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med. Mar 23 2009;169(6):551-61. [Medline].

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Keywords

compression fracture, osteoporosis, back pain, spine surgery, kyphoplasty, vertebroplasty, kyphosis, compression fractures, spine fracture, vertebral fracture, spinal fracture, osteoporosis fracture, osteoporosis spine, vertebral fractures, vertebral compression fracture, spine fractures, osteoporotic, spinal fractures, wedge fracture, osteoporotic vertebral compression fractures, diminished bone density, wedge-shaped compression fractures, acquired kyphosis, bone density loss, central crush fracture

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Contributor Information and Disclosures

Author

Grant Cooper, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, New York-Presbyterian Hospital, The University Hospitals of Columbia and Cornell
Grant Cooper, MD is a member of the following medical societies: Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Julie Lin, MD, Assistant Professor, Department of Rehabilitation Medicine, Weill Medical College of Cornell University; Assistant Attending Physiatrist, Physiatry Department, Hospital for Special Surgery
Julie Lin, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Joseph M Lane, MD, Professor of Orthopedic Surgery, Weill Medical College of Cornell University; Chief, Metabolic Bone Disease Service, Hospital for Special Surgery
Joseph M Lane, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of University Professors, American Federation for Aging Research, American Orthopaedic Association, American Society for Bone and Mineral Research, Association of Bone and Joint Surgeons, Medical Society of the State of New York, Musculoskeletal Tumor Society, National Osteoporosis Foundation, North American Spine Society, and Orthopaedic Research Society
Disclosure: P & G; Roche; Lilly: Aventis: Novartis: Spinewave; biomimetics; Zimmer; DFine; Innovative Solutions; Honoraria Speaking and teaching

Medical Editor

Everett C Hills, MD, MS, Medical Director, Penn State Hershey Rehabilitation Hospital, Assistant Professor of Orthopaedics and Rehabilitation, Assistant Professor of Neurology, Penn State Milton S. Hershey Medical Center and Penn State University College of Medicine
Everett C Hills, MD, MS is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Congress of Rehabilitation Medicine, American Medical Association, American Society of Neurorehabilitation, Association of Academic Physiatrists, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD, Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center
Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association
Disclosure: Nothing to disclose.

 
 
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