Treatment of Osteoporotic Compression Fractures

By John J. Vaughan, MD

Osteoporosis is defined by the World Health Organization as "a disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and an increase in fracture risk."

Osteoporosis affects up to 25 million older men and women in the U.S. each year. The clinical significance of osteoporosis is that affected patients are at increased risk for fractures. These fractures most commonly occur in the hip, spine, and wrist. The estimated lifetime risk of a 50-year-old white woman for a clinically diagnosed compression fracture of a vertebral body is 15.6%.

 

Figure 1 - Lateral lumbar x-ray showing L3 and L4 compression fractures.

Osteoporotic compression fractures can be associated with a great deal of local pain and tenderness (Figure 1). They may also be asymptomatic and diagnosed as an incidental finding on radiographs taken for another reason. Osteoporotic compression fractures may lead to a progressive kyphotic deformity of the spine, but rarely are they associated with neurologic deficits. Frequently, there may be no history of antecedent trauma in a patient with an osteoporotic compression fracture. If there is, it is usually a low-energy injury such as a fall at home.

Once an osteoporotic compression fracture has been diagnosed, it may be necessary to rule out other causes of osteopenia in the elderly patient. The differential diagnosis can include metastatic tumors, infection, and primary spine tumors. These possibilities can usually be ruled out by a careful history and physical examination and by laboratory studies, including a complete blood count, sedimentation rate, calcium and phosphorous levels, and a serum protein electrophoresis to rule out myeloma.

 

Figure 2 - Patient fitted with a CASH brace.

The treatment of osteoporotic compression fractures is in most cases nonoperative. The goals of treatment are to provide pain relief and to prevent further fractures and deformity. For an acute osteoporotic compression fracture, we frequently fit the patient in a brace. This provides for immobilization of the spine, which helps to relieve the pain. Patients in this age group, however, poorly tolerate rigid bracing and seem to do better in a semi-rigid brace. For fractures in the thoracic spine or thoracolumbar junction, we frequently prescribe a CASH brace (Figure 2). For fractures in the lumbar spine, a lumbar corset seems to work well.

We have frequently found it necessary to prescribe analgesics in the acute period after fracture. One must prescribe with caution, however, because older patients frequently have a low tolerance for mood-altering medications.

Bed rest is used only for a short period of time (less than two days) or not at all. Patients are generally mobilized and encouraged to participate in low-impact exercises. This will prevent further osteoporosis caused by disuse.

Finally, with the assistance of the patient's primary care physician, the medical treatment of osteoporosis can be initiated. Such treatment may include calcium supplements, hormone replacements, or newer medications containing alendronate or calcitonin.

Occasionally, a patient with a compression fracture may develop severe intractable pain or neurologic deficit, and surgery may be indicated. Figure 3 shows one such case.

 

 

 

Figure 3A - Postoperative x-ray of a T12 compression that remained extremely painful for a one year period despite bracing, medications, and therapy.

 

Figure 3B - Postoperative x-ray showing vertebral body replacement with a bone graft and posterior stabilization with hooks and rods.

 

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Last Updated: 10/4/03