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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.
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