Medication Summary
Oral medications are useful in patients with lumbar fractures for many reasons. The initial goal for most patients is pain relief. In geriatric patients, the goal of pain relief must be balanced by the potential adverse effects of some of the stronger pain medications. Often, the strongest pain medications can cause severe disorientation, respiratory depression, and constipation.
The second goal is to prevent further osteoporosis in these patients. A variety of agents may be used for this purpose, including parathyroid hormone, antiosteoporotic agents, bisphosphonates, and selective estrogen modulators.
Patients with spinal cord injuries need many different medications to assist with their rehabilitation and daily function (eg, to treat spasticity or autonomic dysreflexia).
Ohtori et al found that an L2 spinal nerve block may provide temporary relief of low back pain from acute osteoporotic lumbar vertebral fractures. [32] In a randomized, controlled study, 60 patients with acute L3 or L4 osteoporotic vertebral fractures received 1.5 mL of 1% lidocaine in a spinal nerve root block or a subcutaneous injection. Patients who received the L2 block showed greater improvement in pain relief, as measured by the visual analog scale score, at 1 hour, 1 week, and 2 weeks after treatment (P < .05). From 1 month to 4 months after treatment, however, significant pain-score differences between the groups no longer existed (P >.05). The authors concluded that, although L2 spinal nerve blocks had no long-term effects on pain and social function, they provided effective pain relief for 2 weeks.
However, a retrospective study by Huang et al reported that in patients with lumbar osteoporotic compression fractures, percutaneous dorsal root ganglion block provides immediate and prolonged pain relief when conservative treatment has failed or residual pain exists follow vertebroplasty. Dramatic pain relief was achieved on the first day, with improvement still significant at 1-year follow-up. [33]
Analgesics
Class Summary
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained fractures or other trauma.
Acetaminophen with codeine (Tylenol with codeine)
A centrally acting analgesic, often appropriate in elderly patients with moderate back pain.
Oxycodone (OxyContin, OxyIR, Roxicodone)
Reserved for patients with more severe back pain from their fracture; can be given in short- or long-acting form.
Acetaminophen (Tylenol, Panadol, Feverall)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Tramadol hydrochloride (Ultram, Ultram ER)
Centrally acting analgesics. Although mode of action is not completely understood, from animal tests, at least 2 complementary mechanisms appear applicable: binding of parent and M1 metabolite to micro-opioid receptors and weak inhibition of reuptake of norepinephrine and serotonin.
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for relief of moderate to severe pain.
Hydromorphone (Dilaudid)
Potent semisynthetic opiate agonist similar in structure to morphine. Approximately 7-8 times as potent as morphine on mg-to-mg basis with shorter or similar duration of action.
Fentanyl (Duragesic)
A synthetic opioid that is 75-200 times more potent with much shorter half-life than morphine sulfate. Has less hypotensive effects and is safer in patients with hyperactive airway disease than morphine because of minimal-to-no associated histamine release. By itself, it causes little cardiovascular compromise, although addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.
Highly lipophilic and protein-bound. Prolonged exposure leads to accumulation in fat and delays weaning process.
Consider continuous infusion because of short half-life.
Parenteral form is DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia and during immediate postoperative period.
Excellent choice for pain management and sedation of short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone.
After initial parenteral dose, subsequent parenteral doses should not be titrated more frequently than q3h or q6h thereafter.
Transdermal form is used only for chronic pain conditions in opioid-tolerant patients. When using transdermal dosage form, most patients are controlled with 72-h dosing intervals; however, some require dosing intervals of 48 h.
Morphine sulfate (Roxanol, MSIR, MS Contin)
DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.
Tramadol 37.5 mg /APAP 325 mg (Ultracet)
Centrally acting pain medication that combines tramadol hydrochloride with acetaminophen. Clinical trials demonstrated that the combination offers better pain relief over either medication alone. Indicated for the short-term (5 days or less) management of acute pain.
Parathyroid hormones, recombinant
Class Summary
Promote new bone formation on trabecular and cortical (periosteal and/or endosteal) bone surfaces by preferential stimulation of osteoblastic activity over osteoclastic activity.
Teriparatide (Forteo)
Recombinant human parathyroid hormone rhPTH(1-34), which has identical sequence to 34 N-terminal amino acids (biologically active region) of 84-amino acid human parathyroid hormone. Acts as endogenous parathyroid hormone, thus regulating calcium and phosphate metabolism in bone and kidney. Works primarily to stimulate new bone by increasing number and activity of osteoblasts (bone-forming cells). Additional physiological actions include regulation of bone metabolism, renal tubular reabsorption of calcium and phosphate, and intestinal calcium absorption. When administered with calcium and vitamin D, teriparatide increases bone mineral density and decreases risk of fractures in patients with osteoporosis.
Antiosteoporotic agents
Class Summary
Used to prevent worsening of osteoporosis and occasionally can reverse the process.
Calcitonin (Miacalcin, Osteocalcin)
Administered most often intranasally. Advantage is that it also can relieve some of the back pain associated with fracture.
Bisphosphonates
Class Summary
Analogs of pyrophosphate that act by binding to hydroxyapatite in bone matrix, thereby inhibiting dissolution of crystals. Prevent osteoclast attachment to bone matrix and osteoclast recruitment and viability.
Alendronate (Fosamax)
A bisphosphonate that acts as a specific inhibitor of osteoclast-mediated bone resorption. Patients should be upright and not lie down for 30 min after taking medication.
Selective estrogen modulators
Class Summary
May act like estrogen to prevent bone resorption.
Raloxifene hydrochloride (Evista)
Selective estrogen receptor modulator that decreases bone loss.
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Anteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture.
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Fluoroscopic view of a kyphoplasty procedure.
