What is the Best Treatment for Painful Osteoporotic Compression Fractures of the Spine?

What is the Best Treatment for Painful Osteoporotic Compression Fractures of the Spine? Posted By:
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Pop quiz: What is the best method of treatment for osteoporotic compression fractures of the spine?
  • Nonsurgical treatment (NST)
  • Balloon kyphoplasty (BK)
  • Percutaneous vertebroplasty (PVP)
    • Your 85-year-old maternal grandmother loses her balance and falls backward, landing on her buttocks. She develops increasing pain in her low- and mid-back, and can barely get up to a standing position. Her pain is unbearable; she is self-managing with acetaminophen and ibuprofen with little relief. Her daughter calls in to the office to ask for something stronger. You recommend evaluation in the ER.

      An X-ray shows mild wedging of three vertebra: T-7, T-8, and L-1. Two look acute and one appears old. An MRI shows edema consistent with recent fracture of L-1 and T-7. There is an old T-8 wedge compression with no edema. The patient is admitted for pain control and inability to ambulate.

      Her daughter calls you to render an opinion about what to do next. You appropriately decline because she is a family member.

      However, you have just read the Osteoporosis International February 2019 meta-analysis on the "best" treatments for grandma. The meta-analysis has reviewed 1057 studies, 15 of which were suitable for analysis. Treatment comparisons reviewed three options, two of which were procedure related, and the third a conservative approach. A Bayesian network approach was used to find the "best".

      Ranked first for pain relief and return to function was PVP. However, NST ranked first for prevention of adjacent fracture above and below the affected vertebra. BK was the best intervention for decreasing the risk of subsequent vertebral fracture or re-fracture at the break.

      In the late 90s and early 2000s, calcitonin was in use especially for painful osteoporotic compression fractures of the spine. Interventional procedures were not in common use at that time for this diagnosis. We employed a reduced dose (by 50%) of injectable calcitonin to avoid nausea and facial flushing. It appeared to improve pain (for reasons that are unclear) and decrease time to mobility while avoiding side effects. Non-procedural conservative management such as this was supported by a systematic review of controlled trials in Osteoporosis International in 2005. At that time, standard management was 4 weeks of injectable calcitonin while PT was started as early as tolerated. Maximum mobilization varied but was commonly 3 to 4 months. Pain reduction started in the first few days and continued improving with the use of calcitonin.

      What I fear is that the potential for pain reduction with newer interventions will obscure the more important question of how to prevent the next fracture. The old adage of "fractures beget fractures" continues to be the norm. As PAs and NPs, we need to take up the cause of getting these patients diagnosed and treated before the compression fracture occurs.

      References
      • Knopp JA, Diner BM, Blitz M, Lyritis GP, Rowe BH. Calcitonin for treating acute pain of osteoporotic vertebral compression fractures: a systematic review of randomized, controlled trials. Osteoporos Int. 2005;16:1281-90.
      • Zhu RS, Kan SL, Ning GZ. Which is the best treatment of osteoporotic vertebral compression fractures: balloon kyphoplasty, percutaneous vertebroplasty, or non-surgical treatment? A Bayesian network meta-analysis. Osteoporos Int. 2019;30:287-298.

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      Filed under: Rheumatology

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