Medical Management of Osteoporosis and Vertebral Compression Fracture
The medical treatment of a patient with an acute vertebral compression fracture focuses on two issues: 1) the management of the acute fracture addressing both pain relief and rehabilitation and, 2) the assessment and treatment of the underlying osteoporosis.
In the absence of instability or neurologic compromise, medical treatment emphasizes pain relief with limited bedrest, appropriate analgesics, and orthotic support. The hazards of prolonged bedrest in the elderly population is well known -- deconditioning, accelerated bone loss, and co-morbid disease including pneumonia, decubitus ulcers, and disorientation is of particular concern.
In addition to providing pain relief, analgesics and properly fitted bracing may permit earlier ambulation that may help avoid these complications. Many patients require opioid analgesics for adequate pain relief. In the older patient population, associated constipation -- particularly in a bedridden patient -- and cognitive impairment related to opioid therapy are significant concerns. A prophylactic laxative program should be initiated at the same time as the opioid is prescribed. Spouses and other caregivers must be cautioned to observe the patient carefully for cognitive impairment and to provide a protected environment to reduce the risk of a fall.
In selected patients, in-home physical therapy can assist in encouraging early ambulation and mobilization. In many patients, severe pain limiting activity persists for up to three months. As the acute fracture pain subsides, many persons continue to experience mechanical pain, which limits standing or walking time. A carefully supervised rehabilitation program designed to strengthen spinal extensor musculature should be initiated after three or four months.
Evaluation and management of osteoporosis are an integral part of appropriate fracture management. Bone mineral density measurement (BMD) should be performed in persons presenting with a fracture and previously unsuspected bone loss. In all patients, dietary or supplemental calcium and vitamin D intake should be optimized. The National Osteoporosis Foundation recommendations suggest that all women with a spinal fracture and a BMD T score <1 .5 should be treated.
Bisphosphonates (Alendrontate, risedronate, and Etidronate) have been shown to significantly reduce the incidence of new vertebral fractures by almost 50 percent. Significant reduction in hip fracture risk has been demonstrated with these agents as well. Raloxifene, a selective estrogen receptor modulator, has been shown to reduce new vertebral fractures by about 30 percent. No significant reduction in nonvertebral fractures has been demonstrated with this agent. Calcitonin has recently been shown to reduce new vertebral fracture risk by about one-third in women with prevalent vertebral fractures. Clearly, most persons with acute fracture should be considered for aggressive osteoporosis therapy.
