Osteoporotic spinal compression fractures

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

anterior column involvement only

1st line – limited bed rest

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1st line –

limited bed rest

Almost all osteoporotic spinal compression fractures are of this type. Spinal stability is not compromised with these fractures.

Most patients experience gradual improvement of pain over 6-12 weeks and are managed with analgesia and 24-48 hours of bed rest, followed by early mobilisation with continued analgesia and temporary use of a thoracolumbar extension orthosis, if required.

Prolonged immobility should be avoided, as this only increases bone loss, frailty, and the risk of subsequent fractures.[11] See Osteoporosis.

Plus – analgesia

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Plus –

analgesia

Treatment recommended for ALL patients in selected patient group

Analgesia is prescribed to reduce pain and encourage mobilisation.[11]

Analgesia should begin with non-opioids such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs). Data from animal studies on the impairment of fracture healing by NSAIDs are inconclusive, and these agents are regularly used clinically for this indication.[67][68] NSAIDs should be used with caution in older people because of increased susceptibility to side effects such as gastrointestinal bleeding and cardiovascular events.[69][70] UK guidelines recommend to consider paracetemol ahead of oral NSAIDs, cyclo-oxygenase-2 (COX-2) inhibitors, or opioids.[57]

If stronger analgesia is required, opioids such as oxycodone can be used in combination with paracetamol. If opioids are used, a laxative should also be prescribed and fluid intake encouraged to prevent constipation, as straining at defecation can cause further fractures. If used chronically, opioids lose potency, induce dependence, raise risk for addiction, and lead to falls and central sensitisation.[11] Opioids are recommended only for very short-term use with acute fractures.

For persistent severe pain, use of centrally-acting therapies including tricyclic antidepressants and gabapentin should be considered after discussion about the potential risks and benefits.[57]

Primary options

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

and

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

diclofenac potassium: 50 mg orally (immediate-release) two to three times daily when required

and

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

oxycodone: 5 mg orally (immediate-release) every 6 hours when required

and

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Tertiary options

amitriptyline: 25-150 mg/day orally given in 1-2 divided doses

gabapentin: 300-1200 mg orally three times daily

Plus – early mobilisation ± orthosis

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Plus –

early mobilisation ± orthosis

Treatment recommended for ALL patients in selected patient group

After an initial short period of bed rest, mobilisation should be encouraged. Recommendations from guidelines vary with regard to bracing. The Bone Health and Osteoporosis Foundation states bracing can be used but there is no evidence that bracing improves physical function or disability.[11] UK guidelines recommend against routine use of bracing (e.g., rigid, dynamic, or soft orthoses) for patients with osteoporotic vertebral fractures and advise that bracing should be avoided in chronic stages post-fracture.[57] However, these guidelines also note that some clinicians believe that the use of a soft brace intermittently in the acute stage may reduce fear or give the patient confidence to mobilise or resume activities.[57] An orthosis may be used temporarily as an aid to control pain, promote fracture consolidation, support posture, improve balance, physical function and quality of life. Patients who are deemed suitable for orthoses are typically instructed to wear orthoses for up to 24 weeks until resolution of pain. Randomised controlled trial data are currently lacking to make evidence-based recommendations.[11] Orthoses should be discarded when no longer required, as prolonged use will encourage further bone loss. Walking aids will help compensate for loss of sagittal balance and impaired proprioception and reduce fall risk.

Plus – long-term osteoporosis prophylaxis

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Plus –

long-term osteoporosis prophylaxis

Treatment recommended for ALL patients in selected patient group

The occurrence of a spinal compression fracture should trigger a review and optimisation of treatment of the underlying osteoporosis.[11]

Supplementing the diet with calcium and vitamin D, reducing alcohol consumption, and stopping smoking are advised to minimise loss of bone mass and maintain skeletal trabeculae microarchitecture and cortical thickness.[94]

Medications such as bisphosphonates significantly reduce the incidence of new vertebral fractures by almost 50%.[43] Other medications of benefit include denosumab, romosozumab, parathyroid hormone analogues (e.g., teriparatide, abaloparatide), and raloxifene.[1][94][95]

Oral bisphosphonates (e.g., alendronic acid, ibandronic acid, and risedronate) are recommended by the National Institute for Health and Care Excellence (NICE) for the treatment of osteoporosis.[42] NICE recommends raloxifene and teriparatide as alternative treatment options for secondary prevention of osteoporotic fragility fractures in postmenopausal women who are unable to adhere to the special instructions for the administration of alendronic acid and risedronate, or who have a contraindication to or are intolerant of alendronic acid and risedronate and who also have a combination of T-score, age, and number of independent clinical risk factors for fracture.[96] NICE recommends romosozumab as an option for treating severe osteoporosis in people after menopause who are at high risk of fracture, only if: they have had a major osteoporotic fracture (spine, hip, forearm, or humerus fracture) within 24 months (so are at imminent risk of another fracture).[97]

The European Medicines Agency no longer recommends calcitonin for the treatment of osteoporosis due to an increased risk of various types of cancer in patients using the drug long-term.[46][47] Calcitonin is still approved in the US but is infrequently used and is considered second-line therapy reserved for women in whom alternative treatments are not suitable.[11]

Consider – specialist pain centre referral

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Consider –

specialist pain centre referral

Additional treatment recommended for SOME patients in selected patient group

Some patients with chronic pain may benefit from referral to a multi-disciplinary pain centre.[57] Such centres combine cognitive-behavioural therapy, patient education, supervised exercise, transcutaneous electrical nerve stimulation, acupuncture, specialist walking aids, and other strategies to try to restore normal function. See Chronic pain syndromes.

with severe unrelenting pain

Consider – vertebroplasty/kyphoplasty or open surgical stabilisation

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Consider –

vertebroplasty/kyphoplasty or open surgical stabilisation

Additional treatment recommended for SOME patients in selected patient group

Vertebroplasty and kyphoplasty offer a minimally invasive approach for patients with severe (chronic) pain despite optimal medical and conservative measures. [ ] Vertebroplasty and kyphoplasty are relatively recent techniques that offer a minimally invasive approach to this group of patients.[1] Balloon kyphoplasty and percutaneous vertebroplasty have both been found to be safe and effective surgical procedures for treating osteoporotic vertebral compression fractures in multiple studies with improvements in pain relief and respiratory function.[71][72][73][74][75] Serious complications reported with these procedures include cement pulmonary embolism, osteomyelitis, and epidural cement leak.[11]

UK guidelines from the Royal Osteoporosis Society, published in 2022, recommend to consider referral for vertebroplasty or kyphoplasty for hospitalised patients in whom pain is unremitting after 48 hours and severely compromising activities of daily living and mobility in spite of initiation of therapy and acute pain management, and where there is evidence of vertebral body oedema on MRI imaging.[57]

The American College of Radiology (ACR) recommends in its 2022 guidance to consider percutaneous vertebroplasty or percutaneous balloon kyphoplasty for pain relief and increased mobility.[9] This recommendation is based on a 2014 US multi-society task force of spine interventionalists reporting that percutaneous vertebroplasty and percutaneous balloon kyphoplasty could be considered generally interchangeable techniques for these indications.[9][76]Barr JD, Jensen ME, Hirsch JA, et al. Position statement on percutaneous vertebral augmentation: a consensus statement developed by the Society of Interventional Radiology (SIR), American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS), American College of Radiology (ACR), American Society of Neuroradiology (ASNR), American Society of Spine Radiology (ASSR), Canadian Interventional Radiology Association (CIRA), and the Society of NeuroInterventional Surgery (SNIS). J Vasc Interv Radiol. 2014 Feb;25(2):171-81. Balloon kyphoplasty and percutaneous vertebroplasty are recommended by the ACR for instances of failed non-operative medical therapy.[9] The multi-society panel stated in 2014 that additional factors could inform the choice of technique, such as the degree of compression deformity, the age of fracture, and the presence of neoplastic involvement.[76]Barr JD, Jensen ME, Hirsch JA, et al. Position statement on percutaneous vertebral augmentation: a consensus statement developed by the Society of Interventional Radiology (SIR), American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS), American College of Radiology (ACR), American Society of Neuroradiology (ASNR), American Society of Spine Radiology (ASSR), Canadian Interventional Radiology Association (CIRA), and the Society of NeuroInterventional Surgery (SNIS). J Vasc Interv Radiol. 2014 Feb;25(2):171-81. However, the same task force reconvened in 2019, concluding that routine use of vertebral augmentation is not supported by current evidence. For patients with acutely painful vertebral fractures, the data reviewed by the panel in 2019 demonstrated that percutaneous vertebroplasty provides no demonstrable clinically significant benefit over placebo. There was insufficient evidence to recommend kyphoplasty over non-surgical management.[77] These latest findings are not yet reflected in the ACR guidance.

In the outpatient setting, the National Institute for Health and Care Excellence (NICE) in the UK recommends in its 2013 guideline that percutaneous vertebroplasty and percutaneous balloon kyphoplasty (without stenting) are both options for treating osteoporotic vertebral compression fractures in patients who have severe ongoing pain after a recent, unhealed vertebral fracture despite optimal pain management, and in patients in whom the pain has been confirmed to be at the level of the fracture by physical examination and imaging.[78]

Vertebroplasty involves the injection of bone cement into the vertebral body under fluoroscopic guidance and can be performed as a 1-day or overnight procedure. The mechanism of pain relief is mainly from fracture stabilisation, although thermal and chemical ablation of the nerve endings in the vertebral body may also contribute.[1]

Individual studies and one meta-analysis suggest that a specific population may benefit from vertebral augmentation: older inpatients (mean age >80 years), with comorbidity (≥2 comorbid conditions), high pain scores on a visual analogue scale (>7), and whose fractures are difficult to manage with non-surgical treatments.[83][84][85]

With kyphoplasty, an inflatable bone tamp is first inserted percutaneously into the collapsed vertebral body under fluoroscopic guidance. The endplates are then elevated as the tamp is inflated. The fracture is then fixed by the injection of bone cement in a manner similar to vertebroplasty.[1] Both procedures seem to be equally effective, but kyphoplasty seems to be safer than vertebroplasty.[86] Generally, indisputable evidence in favour of or against the effectiveness of cement injection is still lacking.[91]

The optimal timing of surgical intervention remains unclear. Percutaneous vertebral augmentation guidelines suggest that, ideally, patients should present within 4 months of the fracture (as measured by the onset of pain) and have at least 3 weeks of failure of conservative treatment before undergoing vertebroplasty.[90] Intervention may, however, be considered within days of a painful fracture in patients at high risk for bed-rest complications including thrombophlebitis, deep vein thrombosis, pneumonia, and pressure ulcer.[90]

Open surgical treatment of the osteoporotic spine is challenging and tends to be reserved for those cases where less-invasive approaches have not provided a satisfactory result.

with significant deformity (e.g., >30° of kyphosis)

Consider – open surgical reconstruction ± vertebroplasty/kyphoplasty

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Consider –

open surgical reconstruction ± vertebroplasty/kyphoplasty

Additional treatment recommended for SOME patients in selected patient group

Significant deformity is an indication for open surgical reconstruction, with or without vertebroplasty or kyphoplasty at the time of open surgery.

It is often difficult to achieve reliable fixation, and bone grafts frequently subside into the weak osteoporotic bone.[1] Careful patient selection is critical to achieving satisfactory results. Pre-operative health status must be carefully considered when deciding whether open surgery is a viable option.[1]

Anterior, posterior, or combined anterior and posterior approaches can be used, depending on the exact configuration of the fracture(s). The aim is to eliminate motion by enabling the fractured vertebra to fuse to the adjacent vertebrae by using a combination of bone graft, screws, and plates. Extension osteotomy of the spine may be considered to compensate for loss of sagittal balance but is associated with high complication rates. [Figure caption and citation for the preceding image starts]: Pre-operative sagittal T2-weighted magnetic resonance imaging showing osteoporotic spinal compression fractures of L1,2,4Personal collection of Nasir A. Quraishi [Citation ends]. com.bmj.content.model.Caption@31f9aed8 [Figure caption and citation for the preceding image starts]: Anteroposterior and lateral x-ray images of patient with osteoporotic spinal compression fractures of L1,2,4 following kyphoplastyPersonal collection of Nasir A. Quraishi [Citation ends].

multiple column involvement

1st line – strict bed rest

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1st line –

strict bed rest

Rarely, osteoporotic compression fractures can involve the middle and/or posterior spinal columns in addition to the anterior column. These types of fractures are potentially unstable.

Patients are placed on strict bed rest and given analgesia while definitive treatment is planned.

Plus – analgesia

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Plus –