eMedicine Specialties > Physical Medicine and Rehabilitation > Therapeutic Modalities
Nonoperative Treatment of Osteoporotic Compression Fractures: Treatment & Medication
Updated: May 5, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
The critical element in deciding a treatment regimen is pain and percentage of vertebral collapse. If a patient rates his/her pain as being greater than 4 out of 10 (when 10 equals worst pain imaginable and 0 equals no pain) or the vertebral bodies are collapsed more than 40%, then kyphoplasty or vertebroplasty is indicated as an initial intervention. Other patients may initially attempt more conservative care.
Patients with osteoporotic vertebral compression fractures are usually treated nonoperatively. Heat, massage, analgesic medications, and bed rest may provide symptomatic relief.
Bracing used to be common. However, the use of extension bracing has become controversial because of concerns regarding the placement of increased stress on the posterior elements of the spine.Patients should be treated for their osteoporosis with anti-osteoporotic medications, including second-generation bisphosphonates, as well as (daily) with 1500 mg of elemental calcium and 400 IU of vitamin D.
A structured exercise program is essential and should be tailored to enhance axial muscle strength. Early mobilization should be employed to prevent secondary complications of immobility. Back strengthening exercises may improve kyphotic deformity.8 Back extension exercises should be used preferentially over abdominal flexion exercises.9,10 Weight-bearing exercises are considered the mainstay of therapy to prevent extension of osteoporosis. Crunches and sit-ups should be excluded. Many consider pilates to be an excellent physical exercise regimen. If balance is impaired, Tai Chi Chuan is recommended.
Occupational Therapy
This is primarily used in an inpatient setting.
Recreational Therapy
This is primarily used in an inpatient setting. Along with occupational therapy, recreational therapy is an important component of a patient's transition from an inpatient setting to an outpatient setting.
Medical Issues/Complications
Analgesic medications are often poorly tolerated, especially in an elderly population. Complications from anti-inflammatory and narcotic medications include confusion, increased falling risk, and gastrointestinal symptoms. Bed rest and immobilization result in disuse, osteopenia, and an increased risk of a thromboembolic event. All vertebral compression fractures require a systematic examination to rule out an underlying systemic illness, such as malignancy, infection, or renal or liver disease.
Surgical Intervention
The 2 main minimally invasive surgical procedures are kyphoplasty and vertebroplasty (see Other Treatment).3,4,5,6 More aggressive surgical intervention in an osteoporotic spine is fraught with difficulties. The patient's advanced age, comorbid diseases, and difficulty in securing fixation to weakened osteoporotic bone make surgical intervention an absolute last resort. However, surgical intervention may be required in patients with neurologic impairment, such as paresis, paralysis, saddle anesthesia, or bowel or bladder changes. Surgical intervention may also be required in a patient who is clinically unimproved despite adequate conservative care.
Surgery may be indicated in a patient with radiographic evidence of instability. This is exhibited by ligamentous disruption with potential pending canal compromise or when movement is exhibited on dynamic or motion radiographic examination. The advancement of kyphosis despite adequate conservative care may also be an indication for surgery.
Consultations
- In patients with an underlying systemic disease, appropriate medical consultations are required.
- Consulting a physiatrist is appropriate, and consultation can help to assess functional limitations.
- A rheumatologist is an appropriate consultation for osteoporosis management.
- Consulting an orthopedic surgeon or a neurosurgeon is appropriate if surgery is being considered.11
Other Treatment
Two minimally invasive alternatives that are available for the treatment of osteoporotic vertebral compression fractures include vertebroplasty and kyphoplasty.3,4,5,6
Vertebroplasty was first introduced in France in 1987 and involves the percutaneous injection of polymethylmethacrylate (PMMA) directly into the fractured vertebral body under fluoroscopic guidance.12 This procedure stabilizes the fracture. Substantial pain relief has been noted in the majority of patients treated with this procedure.13 (See images below and Images 3, 6.)
Anterior wedge compression fracture with an intact posterior vertebral cortex.
Vertebroplasty. Anterior wedge compression fracture after fusion of the fracture fragments with polymethylmethacrylate.
Kyphoplasty is a newer percutaneous procedure that addresses the kyphotic deformity as well as the fracture pain. Kyphoplasty involves the percutaneous insertion of an inflatable bone tamp into the fractured vertebral body under fluoroscopic guidance. The bone tamp is then inflated, elevating the endplates and restoring the vertebral body toward its original height. Thick PMMA is then injected in a controlled manner under low pressure into the cavity of the body. The bone tamp is deflated and removed. Kyphoplasty has been shown to provide significant pain relief as well as substantial improvement in the height of the collapsed vertebral body and has been found to reduce the spinal kyphosis. (See images below and Images 2, 7.)
Patients with compression fractures that do not compromise the spinal canal can be treated by means of a kyphoplasty. The use of a percutaneous balloon allows for expansion of the fractured vertebrae. The void created by the balloon is then filled with bone cement.
Fluoroscopic view of a kyphoplasty procedure.
The indications for vertebroplasty include stabilization of painful osteoporotic vertebral fractures, painful vertebra due to metastases or multiple myeloma, Kümmell disease, and painful vertebral hemangioma.14 Indications for kyphoplasty include painful or progressive osteoporotic and osteolytic vertebral compression fractures. Neither procedure should be performed on more than 3 levels at a single time. Contraindications and precautions for vertebroplasty include sepsis, coagulopathy, posterior vertebral body wall deficiency or fracture, inadequate intra-operative visualization of the fracture, anatomic variant limiting vertebral body access, neurologic compromise related to the fracture, and localized spine infection.
Partial or complete relief of pain symptoms is experienced by 60-100% of patients within 72 hours following vertebroplasty. This improvement has been noted to persist for at least 4 years. Kyphoplasty is a newer procedure with shorter follow-up available. However, one study found that in 1439 patients with 2194 vertebral fractures, 90% of vertebral fractures had significant pain relief within 2 weeks of kyphoplasty. In addition to pain relief, kyphoplasty has been shown to produce a 70-97% reversal of kyphotic deformity in patients.
Complications from vertebroplasty include radiculopathy, rare cement leakage into the epidural space (necessitating surgical decompression), and frequent, asymptomatic leakage of PMMA into the perivertebral veins.3,4,5,6 This leakage has prompted concern about potential embolization of PMMA to the lungs via the venous system. Kyphoplasty uses much lower pressure to inject the cement and has been shown to have a lower rate of intravenous and transcortical leakage of contrast. However, research indicates that kyphoplasty and vertebroplasty can increase the risk of adjacent vertebral body fracture. This risk remains under active investigation.15
When kyphoplasty has been performed within 1 month of fracture, easier endplate elevation and restoration of vertebral body height has been observed. Current care emphasizes conservative medical care for approximately 1-2 months. Earlier kyphoplasty or vertebroplasty may be more appropriate when analgesic medications are insufficient for pain relief or in patients with significant kyphosis. Patients with fractures at the thoracolumbar junction may also benefit from early kyphoplasty, because this fracture location is prone to produce more significant kyphosis. However, the potential risk of future adjacent body compression fracture should be taken into consideration.
Medication
Oral medications have many roles in the treatment of patients with osteoporotic vertebral compression fractures. Pain relief is often the initial goal. Patients with osteoporosis need to be placed on anti-osteoporotic medications. As always, the benefits of the medications need to be weighed against the adverse effects. Anti-inflammatory medications may produce gastrointestinal adverse effects. Strong analgesic medications may cause confusion, disorientation, increased risk of falling, constipation, and respiratory depression.
Analgesic medications
Essential for providing initial pain relief.
Acetaminophen (Tylenol, Feverall, Panadol, Aspirin Free Anacin)
Indicated for mild to moderate pain. DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or those who are taking PO anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects of acetaminophen; co-administration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible following various dose levels in people with long-term alcoholism; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose
Tramadol (Ultram)
Inhibits ascending pain pathways; alters perception and response to pain. Inhibits re-uptake of norepinephrine and serotonin.
Adult
50-100 mg PO q4-6h; not to exceed 400 mg/d
Pediatric
Not established
Drug levels decrease with carbamazepine use; co-administration with opiates, sedatives, and alcohol increases CNS depression
Documented hypersensitivity; opioid dependency; concurrent use of MAOIs or use within previous 14 d; use of SSRIs, TCAs, or opioids; acute alcohol intoxication
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause dizziness, nausea, constipation, sweating, and/or pruritus; additive sedation with alcohol and TCAs; adjust dose in liver disease, myxedema, hypothyroidism, or hypo-adrenalism; caution in pregnant patients, patients breastfeeding, or patients with seizures; abrupt discontinuation may precipitate opioid withdrawal symptoms; development of tolerance or dependency with extended use; co-administration with opiates, hypnotics, sedatives, and alcohol increases CNS depression
Acetaminophen with codeine (Tylenol #3)
Indicated for the treatment of mild to moderate pain.
Adult
30-60 mg/dose PO based on codeine content q4-6h or 1-2 tab q4h; not to exceed 4 g/d of acetaminophen
Pediatric
0.5-1 mg/kg/dose PO based on codeine q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
Toxicity of codeine increases with CNS depressants, tricyclic antidepressants, MAOIs, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics
Rifampin can reduce analgesic effects of acetaminophen; co-administration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity of acetaminophen
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates, because this substitution may result in acute opiate withdrawal symptoms; caution in severe renal or hepatic dysfunction
Hepatotoxicity with acetaminophen possible following various dose levels in people with long-term alcoholism; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose
Oxycodone (OxyContin, Roxicodone, OxyIR)
Indicated for the relief of moderate to severe pain. Reserved for patients with more severe back pain.
Adult
Immediate release: 5-10 mg PO q4-6h prn pain
Controlled release: 10-20 mg PO bid with less fluctuation in pain level
Pediatric
Not established
Phenothiazines may antagonize analgesic effects; MAOIs, general anesthesia, CNS depressants, and tricyclic antidepressants may increase toxicity
Documented hypersensitivity; documented history of drug abuse or dependence; use while driving or operating heavy machinery
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D (fetal risk shown in humans; use only if benefits outweigh risk to fetus) if used for prolonged periods or in high dosages; caution in impaired renal function, impaired liver function, GI motility disorder, prostatic hypertrophy, biliary disease, hypotension, head injury, increased intracranial pressure, or impaired pulmonary function or in elderly patients
Anti-osteoporotic agents
Needed to prevent progression of osteoporosis.
Calcitonin (Miacalcin, Osteocalcin)
Administered intranasally. Inhibits osteoclastic bone resorption. May relieve back pain associated with fracture. Decreases overall fracture incidence by 37%. No benefit for hip fracture.
Adult
1 spray/d into alternate nostrils
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hypocalcemia may occur; examine urine sediment during prolonged therapy
Bisphosphonates
Analogues of pyrophosphate. Act by binding to hydroxyapatite in bone matrix, thereby inhibiting the dissolution of crystals. Prevent osteoclast attachment to the bone matrix and osteoclast recruitment and viability.
Alendronate sodium (Fosamax)
Commonly used as first-line therapy for osteoporosis. A bisphosphonate that acts as a specific inhibitor of osteoclast-mediated bone resorption. Patients should be upright while taking medication and not lie down for 30 min after taking medication to prevent esophageal problems.
Adult
70 mg PO qwk
Pediatric
Not established
None reported
Documented hypersensitivity; abnormalities of the esophagus; inability to sit upright or stand for at least 30 min; hypocalcemia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in upper GI disease; must be taken at least 30 min before first food, drink, or medication of the day; medication should be taken with large amounts of water; not recommended for patients with renal insufficiency; if patient is hypocalcemic, hypocalcemia must be corrected prior to medication
Selective estrogen receptor modulators
May act like estrogen to prevent bone resorption.
Raloxifene hydrochloride (Evista)
Selective estrogen receptor modulator that decreases bone loss. Decreases risk of spine fracture by approximately 40%. No benefit for hip fracture.
Adult
60 mg PO qd
Pediatric
Not established
May decrease prothrombin time when administered concurrently with warfarin; co-administration with cholestyramine may decrease absorption of raloxifene
Documented hypersensitivity; breastfeeding; pregnancy; planned pregnancy; DVT or history of DVT; concurrent HRT or OCP (use is not recommended)
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Not associated with an increased risk of breast cancer; reactions include hot flashes, leg cramps, insomnia, arthralgia, depression, dyspepsia, leg cramps, sinusitis, nausea, cough, weight gain, and rash; concomitant use with estrogen replacement medication not recommended
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 |
| « Previous Page | Next Page » |
References
Freedman BA, Potter BK, Nesti LJ, et al. Osteoporosis and vertebral compression fractures-continued missed opportunities. Spine J. Mar 14 2008;[Medline].
Prather H, Watson JO, Gilula LA. Nonoperative management of osteoporotic vertebral compression fractures. Injury. Sep 2007;38 Suppl 3:S40-8. [Medline].
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].
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].
Lin JT, Lane JM. Nonmedical management of osteoporosis. Curr Opin Rheumatol. Jul 2002;14(4):441-6. [Medline].
Phillips FM. Minimally invasive treatments of osteoporotic vertebral compression fractures. Spine. Aug 1 2003;28(15):S45-53. [Medline].
Lane JM, Russell L, Khan SN. Osteoporosis. Clin Orthop Relat Res. Mar 2000;139-50. [Medline].
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].
Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. Oct 1984;65(10):593-6. [Medline].
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].
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].
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].
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].
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].
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].
[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].
Further Reading
Related eMedicine topics:
Fracture, Cervical Spine
Kyphosis
Lower Cervical Spine Fractures and Dislocations
Lumbar Compression Fracture
Lumbar Spine Fractures and Dislocations
Osteoporosis [Orthopedic Surgery]
Osteoporosis [Pediatrics: General Medicine]
Osteoporosis (Primary)
Osteoporosis (Secondary)
Percutaneous Vertebroplasty
Thoracic Spine, Trauma
Vertebral Fracture
Vertebroplasty and Kyphoplasty, Percutaneous
Clinical guidelines:
ACR Appropriateness Criteria® low back pain. American College of Radiology - Medical Specialty Society. 1996 (revised 2005). 7 pages. [NGC Update Pending] NGC:004786
ACR Appropriateness Criteria® osteoporosis and bone mineral density. American College of Radiology - Medical Specialty Society. 1998 (revised 2007). 12 pages. NGC:005990
Clinical trials:
Addressing Vertebral Osteoporosis Incidentally Detected to Prevent Future Fractures (AVOID Fracture)
Comparison of Balloon Kyphoplasty and Vertebroplasty in Subacute Osteoporotic Vertebral Fractures (OSTEO+6)
Comparison of Balloon Kyphoplasty, Vertebroplasty and Conservative Management in Acute Osteoporotic Vertebral Fractures (OSTEO-6)
Denosumab Fracture Intervention Randomized Placebo Controlled Trial in Japanese Patients With Osteoporosis (DIRECT)
The Effect of PTH(1-84) or Alendronate on Reduction of Back Pain in Postmenopausal Women With an Osteoporosis Related Vertebral Fracture(s) (FP-005-IM)
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
