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vertebral compression fracture

Etiology: - osteoporosis - glucocorticoid use - trauma * vertebral compression fracture makes a clinical diagnosis of osteoporosis regardless of T-score from bone mineral density measurement [7] Clinical manifestations: - lower thoracic or lumbar spine a) abrupt onset of severe pain b) pain worsens with sitting or standing* c) pain sometimes relieved by lying down d) point tenderness over the spine at the fracture site e) absence of any neurologic abnormalities * symptoms less position dependent than with spinal stenosis [7] Complications: - nerve compression & radiculopathy [7] - vertebral augmentation (vertebroplasty or kyphoplasty) not associated with secondary fracture (but of questionable value) [13] Differential diagnosis: - ischiogluteal bursitis - pain relieved by standing & walking Management: 1) bedrest, analgesia, & mobilization as tolerated - patients with severe pain may benefit from 2 weesk of bedrest [12] - avoid prolonged bedrest [14] - acetaminophen is 1st line [14] - use NSAIDs cautiously in elderly with adequate renal function & low risk of upper GI bleed [14] - opiates if other options fail [14] 2) cibacalcin (calcitonin) may diminish pain 3) pamidronate 30 mg IV QD for 3 days may diminish pain [4] 4) hospitalization maybe required to control pain [4] 5) pain generally improves over several weeks 6) treatment for osteoporosis indicated [7] - bisphosponate contraindicated with renal failure (eGFR < 35 ml/min) - denosumab may be alternative in patients with renal impairment 7) percutaneous vertebroplasty a) beneficial only within 3 weeks of fracture & only for fractures at T11-L2 [8] b) not recommended for 1st line treatment [3] c) not useful [4] - no better than sham treatment for osteoporotic vertebral compression fractures < 9 weeks duration [9] 8) kyphoplasty unproven [4] 9) back braces are ineffective [6] - they may be cumbersome & can irritate the skin 10) physical therapy for chronic back pain

Related

kyphoplasty (balloon kyphoplasty) osteoporosis vertebroplasty

General

vertebral fracture; spine fracture

References

  1. UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  2. Kao D, UCLA Multicampus Program in Geriatric Medicine & Gerontlology 2001
  3. Staples MP et al Effectiveness of vertebroplasty using individual patient data from two randomised placebo controlled trials: Meta-analysis. BMJ 2011 Jul 12; 343:d395 PMID: 21750078 - Wilson DJ. Vertebroplasty for vertebral fracture: On the basis of current evidence, cannot be recommended as the first line treatment. BMJ 2011 Jul 12; 343:d3470 PMID: 21750076
  4. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  5. Esses SI, McGuire R, Jenkins J et al American Academy of Orthopaedic Surgeons clinical practice guideline on: the treatment of osteoporotic spinal compression fractures. J Bone Joint S - Esses SI, McGuire R, Jenkins J et al The treatment of symptomatic osteoporotic spinal compression fractures. J Am Acad Orthop Surg. 2011 Mar;19(3):176-82. PMID: 21368099
  6. Kim H-J et al. Comparative study of the treatment outcomes of osteoporotic compression fractures without neurologic injury using a rigid brace, a soft brace, and no brace: A prospective randomized controlled non-inferiority trial. J Bone Joint Surg Am 2014 Dec 3; 96:1959 PMID: 25471910 http://jbjs.org/content/96/23/1959
  7. Medical Knowledge Self Assessment Program (MKSAP) 17, 18. American College of Physicians, Philadelphia 2015, 2018
  8. Clark W, Bird P, Gonski P, Diamond TH et al. Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR): A multicentre, randomised, double-blind, placebo-controlled trial. Lancet 2016 Aug 17; PMID: 27544377 - Hirsch JA, Chandra RV. Resurrection of evidence for vertebroplasty? Lancet 2016 Aug 17 PMID: 27544375
  9. Firanescu CE et al Vertebroplasty versus sham procedure for painful acute osteoporotic vertebral compression fractures (VERTOS IV): randomised sham controlled clinical trial. BMJ 2018;361:k1551 PMID: 29743284 Free full text https://www.bmj.com/content/361/bmj.k1551 - Davies E No more vetebroplasty for acute vertebral compression fractures? BMJ 2018;361:k1756 PMID: 29743282 https://www.bmj.com/content/361/bmj.k1756
  10. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  11. After the Vertebral Fracture http://www.osteo.org/newfile.asp?doc=r206i&doctitle=After+the+Vertebral+Fracture&doctype=HTML+Fact+Sheet
  12. Funayama T et al. Therapeutic effects of conservative treatment with 2-week bed rest for osteoporotic vertebral fractures: A prospective cohort study. J Bone Joint Surg Am 2022 Oct 19; 104:1785 PMID: 36005391 https://journals.lww.com/jbjsjournal/Abstract/2022/10190/Therapeutic_Effects_of_Conservative_Treatment_with.3.aspx
  13. Mills ES et al. Secondary fracture rate after vertebral osteoporotic compression fracture is decreased by anti-osteoporotic medication but not increased by cement augmentation. J Bone Joint Surg Am 2022 Dec 21; 104:2178 PMID: 36223482 https://journals.lww.com/jbjsjournal/Abstract/2022/12210/Secondary_Fracture_Rate_After_Vertebral.6.aspx
  14. NEJM Knowledge+ Endocrinology