Nonoperative Management of Osteoporotic Vertebral Fractures

Nonoperative Management of Osteoporotic Vertebral Fractures

The spectrum of osteoporotic vertebral fractures is extremely large, ranging from asymptomatic vertebral wedging, which increases with aging, to acute symptomatic fractures occurring with minimal injury. The quoted prevalence of vertebral fractures depends primarily on the criteria for diagnosis, with some variation from one population to another.1-3

Generally speaking, a 9% to 12% incidence is given for middle-aged women, with a correlation among vertebral fracture prevalence and bone mineral density in the lumbar spine, height loss, and chronic back symptoms.

The male to female ratio also seems quite variable, varying from 2 to 1 in European population to a high of 4 to 1 in patients referred to a metabolic bone disease clinic. Several reports have shown a higher incidence in men aged 45 to 54 in populations exposed to physically demanding activities, which may be due to occupationally related vertebral fractures. The incidence is higher in Caucasians and Asians than in persons of dark skin color.

The factor of risk is an indication as to whether a fracture is likely during a given activity. The factor of risk is the ratio of the force applied to a bone during an activity divided by the force at which the bone fractures. A factor of risk higher than 1 indicates that the bone is overloaded and failure is likely.

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Eastell et al have classified vertebral fractures on the basis of their radiographic appearance. The distribution and type varied between their general population and that of women referred to the clinic with suspected osteoporosis.

Fragility fractures of the spine do not have the same initial impact as fractures of the hip. The disability related to these vertebral fractures is correlated with age and kyphosis, including postural changes and loss of height. When the kyphosis is greater than four standard deviations, chronic pain becomes a significant contributing factor to late disability. Four percent of patients with a vertebral fracture become completely dependent because of the fracture.

As expected, survivorship studies indicate a significant increase in mortality within 1 year of the diagnosis of the insufficiency fracture of the hip. After this point, however, the mortality rate then parallels the age-matched non-fracture group. The mortality rate associated with insufficiency fractures of the vertebrae shows a progressive increase over a much longer period of time, even when controlled for underlying comorbidities. Women with radiographic evidence of vertebral fractures have an increased mortality rate, particularly from pulmonary disease and cancer.

The prevention of vertebral insufficiency fractures parallels those measures for the maintenance of bone mineral density, with special focus on dietary intake of sufficient elemental calcium and vitamin D. Hormone replacement therapy remains controversial. Moderate physical activity in people with osteoporosis may stimulate bone gain and/or decrease bone loss but its effects are an adjunct to other interventions. Other benefits of physical activity are:

  • Reduction of fall risk
  • Decreased pain and improved fitness
  • Overall quality of life8-16

Bisphosphonate may be considered an alternative to ovarian hormone therapy in post-menopausal, osteopenic, or osteoporotic women, especially those who cannot or will not tolerate hormone replacement therapy. It is effective in men with osteoporosis for improving bone mass and preventing fracture. Alendronate therapy significantly decreases the risk of new vertebral fracture in post-menopausal women with osteoporosis who present with a new vertebral fracture. It also decreases the number of days of disability and days of limited activity caused by back pain.17

Many insufficiency fractures that are symptomatic or minimally symptomatic can be treated symptomatically with altered activity and analgesics, with expected improvement over a 1- to 2-month period. Calcitonin has been shown to given significant relief of pain, perhaps more from the release of endogenous opioids than an early direct effect on fracture healing.

Spinal orthoses are not effective for fractures above the T6 level. In acute fractures, pain relief can be obtained by use of a lumbosacral corset or chairback brace. For wedge deformity fractures, a Jewett brace will provide sagittal plane support, which may be important to avoid progression of the wedging. However, fractures contributing to progression of kyphosis have often occurred at different times so that some of the fractures contributing to the deformity may be old and healed.18

The Jewett orthosis is not well tolerated in older patients, is cumbersome to apply, creates a problem for sitting, and is not well tolerated in a patient who already has significant kyphosis.

Fractures caused by axial load, such as biconcave and compression fractures, could be treated by a TLSO within the limitations already mentioned.

There are no clear guidelines as to which fractures are not amenable to nonoperative measures. The main indications for consideration of more invasive treatment are fractures remaining symptomatic or becoming increasingly symptomatic after the 4- to 8-week interval, or perhaps fractures that have an intraosseus vacuum phenomenon.

Reprinted with permission from the February/March 2006 issue of COA Bulletin

References

  1. Black DM, Palermo L, Nevitt MC, Genant HK, Christensen L, Cummings SR, 1999. “Defining incident vertebral deformity: a prospective comparison of several approaches. The Study of Osteoporotic Fractures Research Group.” J Bone Miner Res 14 (1): 90-101
  2. Sauer P, Leidig G, Minne HW, Duckeck G, Schwarz W, Siromachkostov L, Ziegler R, 1991. “Spine deformity index (SDI) versus other objective procedures of vertebral fracture identification in patients with osteoporosis: a comparative study.” J Bone Miner Res 6 (3): 227-38
  3. Kiel D, 1995. “Assessing vertebral fractures. National Osteoporosis Foundation Working Group on Vertebral Fractures.” J Bone Miner Res 10 (4): 518-23
  4. Melton LJ, 1997. “Epidemiology of spinal osteoporosis.”Spine (Phila Pa 1976)22 (24 Suppl):2S-11S
  5. Myers ER, Wilson SE, 1997. “Biomechanics of osteoporosis and vertebral fracture.”Spine (Phila Pa 1976)22 (24 Suppl): 25S-31S
  6. Eastell R, Cedel SL, Wahner HW, Riggs BL, Melton LJ, 1991. “Classification of vertebral fractures.”J Bone Miner Res 6(3):207-15
  7. Ettinger B, Black DM, Nevitt MC, Rundle AC, Cauley JA, Cummings SR, Genant HK, 1992. “Contribution of vertebral deformities to chronic back pain and disability. The Study of Osteoporotic Fractures Research Group.”J Bone Miner Res 7(4):449-56 
  8. Hanley DA, Josse RG, 1996. “Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 1. Introduction.”CMAJ 155(7):921-3
  9. Sturtridge W, Lentle B, Hanley DA, 1996. “Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 2. The use of bone density measurement in the diagnosis and management of osteoporosis.”CMAJ 155(7):924-9
  10. Josse RG, 1996. “Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 3. Effects of ovarian hormone therapy on skeletal and extraskeletal tissues in women.”CMAJ 155(7):929-34
  11. Murray TM, 1996. “Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 4. Calcium nutrition and osteoporosis.”CMAJ 155(7):935-9
  12. Prior JC, Barr SI, Chow R, Faulkner RA, 1996. “Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 5. Physical activity as therapy for osteoporosis.”CMAJ 155(7):940-4
  13. Hodsman A, Adachi J, Olszynski W, 1996. “Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 6. Use of bisphosphonates in the treatment of osteoporosis.”CMAJ 155(7):945-8
  14. Murray TM, Ste-Marie LG, 1996. “Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 7. Fluoride therapy for osteoporosis.”CMAJ 155(7):949-54
  15. Jones G, Hogan DB, Yendt E, Hanley DA, 1996. “Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 8. Vitamin D metabolites and analogs in the treatment of osteoporosis.”CMAJ 155(7):955-61
  16. Siminoski K, Josse RG, 1996. “Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 9. Calcitonin in the treatment of osteoporosis.”CMAJ 155(7):962-5
  17. Nevitt MC, Thompson DE, Black DM, Rubin SR, Ensrud K, Yates AJ, Cummings SR, 2000. “Effect of alendronate on limited-activity days and bed-disability days caused by back pain in postmenopausal women with existing vertebral fractures. Fracture Intervention Trial Research Group.”Arch Intern Med 160(1):77-85
  18. Patwardhan AG, Li SP, Gavin T, Lorenz M, Meade KP, Zindrick M, 1990. “Orthotic stabilization of thoracolumbar injuries. A biomechanical analysis of the Jewett hyperextension orthosis.”Spine (Phila Pa 1976) 15(7):654-61
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