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Conservative Management of Osteoporotic Vertebral Compression Fracture

 

An earlier blog contained a video synopsis of a patient with acute post-traumatic thoracic spine pain that was diagnosed with an Osteoporotic Vertebral Compression Fracture (OVCF). This blog will detail the 6 evidence-based tools that were used to manage this case.

  1. Rule Out Threatening Etiologies

Wise clinicians rule out aggressive causes and end with a benign diagnosis rather than assuming a benign etiology- allowing the prospect of an uncomfortable future discussion. Although OVCF is one potential cause of thoracolumbar pain, clinicians should be cautious to screen for more threatening pathology including neoplasm, hemangioma, aneurysmal bone cyst, multiple myeloma, sarcoma, or metastasis. (3) Some authors suggest that up to 25% of OVCFs may have a malignant origin. (37-41) Clinicians should take into account the location, pattern of collapse, and the patient’s medical history to establish an “index of suspicion”.  In some cases, advanced imaging may be necessary to make a definitive diagnosis. (47,49,50)

  1. Bone Density Screening

Identifying the underlying factor(s) that led to a problem should be a primary goal for any presentation. In this case, the loss of bone density likely contributed to bony collapse. The American Academy of Orthopedic Surgery recommends bone density screening for osteoporosis in all women over age 65 or post-menopausal women with a prior fracture or osteoporosis risk factor. (17). The patient was sent out for bone density screening.

  1. Activity & Exercise

Patients must be educated about ways to avoid pain and maintain mobility. (54) In general, patients should be advised to avoid bed rest and maintain a relatively active lifestyle. (56) Home exercise programs have demonstrated improved quality of life in OVCF patients. (60) Therapeutic exercise has been shown to decrease pain, increase strength, improve endurance, enhance bone density, and minimize the risk of subsequent fracture. (62) The initial focus of home therapy should be improving posture and body mechanics to limit compressive loads. (61) As the patient improves, home rehab should incorporate strength and endurance training. (54) In particular, strengthening exercises should target the spinal extensors. (62) OVCF patients may benefit from the addition of aerobic conditioning and proprioceptive/balance training. (54,62) Resistance training may be even better than weight-bearing aerobic exercise to help maintain bone density. (63)

  1. Calcium & Vitamin D

Nutritional recommendations for managing osteoporosis include daily intake of 800-1000 IU of Vitamin D and 1000-1200mg of Calcium. (64) Patients need to be reminded that the majority of Vitamin D production occurs intrinsically, secondary to UV sunlight exposure. Many patients, particularly seniors, limit sun exposure, creating a problem that is potentially compounded by the proliferation of SPF’s in skincare products. Sun exposure recommendations to ensure adequate Vitamin D production vary based upon season, weather and latitude- ranging from 6-7 minutes mid-day in the summer to 15-29 minutes in the winter. (106,107)

  1. Avoid Traumatizing the Site of Fracture

While soft tissue manipulation and low force techniques to remote segments may prove beneficial, spinal manipulation is contraindicated in the region of a known or suspected compression fracture. (65,67) HVLA manipulation of a fracture site may increase pain and prolong disability. (67)

  1. Know When to Consider Cement Augmentation

Approximately 30% of symptomatic OVCFs do not respond adequately to conservative care. (70,71) Some patients who fail conservative care may require orthopedic/surgical management. (72) Two common surgical treatments for OVCF are percutaneous vertebroplasty (injecting polymethyl methacrylate cement into the fractured vertebra), and balloon kyphoplasty (inflating a balloon to reshape the fractured vertebra followed by cement augmentation). Some studies have demonstrated benefit from these procedures in terms of early pain relief. (24,73-76) Conversely, bone cement is 7-10 times stiffer than the adjacent osteoporotic vertebral bone (77), thereby increasing the risk to adjacent segments. Interestingly, approximately 25% of patients who undergo vertebroplasty will suffer a subsequent OVCF within one year of treatment- with adjacent vertebra being three times more likely to fracture than more distant levels. (18,76,78-82)

One systematic review demonstrated that when compared to patients choosing conservative therapy, OVCF patients undergoing percutaneous vertebroplasty demonstrated greater pain relief up to 1 year post-operatively. (108) Many other vertebroplasty studies have failed to show significantly better long-term outcomes compared with conservative care. (83,84) Studies concerning balloon kyphoplasty fail to support superiority over conservative care. (85-91) Guidelines recommend that patients with stable OVCF should complete 3-4 weeks of conservative care before considering cement augmentation. (92-93,102) Progressive increase in the fracture angle (>10 degrees) and persistent, progressive or debilitating pain may be indications for earlier operative management. (95,96)

Fortunately, most OVCF’s are stable and do not require operative management. The goals of conservative management should include palliative relief, ADL advice to avoid exacerbation, and implementing proactive measures to minimize the risk of future compression. Chiropractic physicians who follow evidence-based guidelines are proficiently equipped to successfully manage the majority of OVCF patients. Visit ChiroUp.com for a complete synopsis of the current chiropractic “best practice” management of OVCF and 90 other conditions.

References

  1. American Academy of Orthopedic Surgeons Position Statement: Osteoporosis/ Bone Health in Adults as a National Public Health Priority. Accessed 8/15/15 http://www.aaos.org/about/papers/position/1113.asp
  2. Melton LJ. Epidemiology of spinal osteoporosis. Spine 1989;22: 2–11.
  3. Andrew L Sherman et al. Lumbar Compression Fractures Accessed 6/18/2015 http://emedicine.medscape.com/article/309615-overview#a5
  4. Weninger, P., Schultz, A., Hertz, H., 2009. Conservative manage- ment of thoracolumbar and lumbar spine compression and burst fractures: functional and radiographic outcomes in 136 cases treated by closed reduction and casting. Arch. Orthop. Trauma Surg. 129 (2), 207e219
  5. Sundaresan N, Rosen G, Boriani S. Primary malignant tumors of the spine. Orthop Clin North Am. 2009 Jan. 40(1):21-36,
  6. Alexandru D, William SO. Evaluation and Management of Vertebral Compression Fractures Perm J. 2012 Fall; 16(4): 46–51.
  7. Wood KB et al. Management of Thoracolumbar Spine Fractures. Spine. 14 (2014) 145-164
  8. Haczynski J, Jakimiuk A. Vertebral fractures: a hidden problem of osteoporosis. Med Sci Monit. 2001 Sep-Oct;7(5):1108–17.
  9. Patel U, Skingle S, Campbell GA, Crisp AJ, Boyle IT. Clinical profile of acute vertebral compression fractures in osteoporosis. Br J Rheumatol. 1991;30:418–421.
  10. Kinoshita T, Ebara S, Kamimura M, et al. Nontraumatic lumbar vertebral compression fracture as a risk factor for femoral neck fractures in involutional osteoporotic patients. J Bone Miner Metab 1999;17: 201–5.
  11. Kaufman JD. Osteoporosis: bone density tests. American Academy of Orthopaedic Surgeons Bulletin 1999;47(Aug):3.
  12. Melton LJ. Epidemiology of spinal osteoporosis. Spine 1997;22: 2S–11S.
  13. Stock H, Schneider A, Strauss E. Osteoporosis: a disease in men. Clin Orthop Relat Res 2004;425:143–51.
  14. Lane JM, Nydick M. Osteoporosis: current modes of prevention and treatment. J Am Acad Orthop Surg 1999;7:19–31.
  15. Ross PD, Davis JW, Epstein RS, Wasnich RD. Pre-existing fractures and bone mass may predict vertebral fracture incidence in women. Ann Intern Med 1991;114:919–23.
  16. NOF issues guide to osteoporosis. American Academy of Orthopae- dic Surgeons Bulletin 1998;46(Dec):6.
  17. Srinidhi Nagaraja et al. Vertebroplasty increases compression of adjacent IVDs and vertebrae in osteoporotic spines The Spine Journal 13 (2013) 1872–1880
  18. Sran, M.M., Robinovitch, S.N., 2008. Preventing fall-related vertebral fractures: effect of floor stiffness on peak impact forces during backward falls. Spine 33 (17)
  19. Kim DH, Vaccaro AR. Osteoporotic Compression Fracture of the Spine; current options and considerations for treatment. Spine Journal 6 (2006) 479-487
  20. Sebastion D. Lower thoracic syndrome – A differential screen for back pain following vertical compression injury: A case report. Journal of Bodywork and Movement Therapies. October 2014 Volume 18, Issue 4, Pages 545–552
  21. Rao RD, Singrakhia MD. Painful osteoporotic vertebral fracture. J Bone Joint Surg 2003; 85A(10):2010–22.
  22. Gibson JE, Pilgram TK, Gilula LA. Response of nonmidline pain to percutaneous vertebroplasty. AJR Am J Roentgenol. 2006 Oct. 187(4):869-72.
  23. Rao RD, Singrakhia MD. Painful osteoporotic vertebral fracture. J Bone Joint Surg 2003; 85A(10):2010–22.
  24. Jensen ME, Evans AJ, Mathis JM, et al. Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. AJNR Am J Neuroradiol 1997;18(10):1897–904.
  25. Bostrom MPG, Lane JM. Augmentation of osteoporotic vertebral bodies. Spine 1997;22: 38S–42S.
  26. Glaser DL, Kaplan FS. Osteoporosis: definition and clinical presentation. Spine 1997;22:125–65.
  27. Langdon J, Way A, Heaton S, Bernard J, Molloy S. Vertebral compression fractures – new clinical signs to aid diagnosis. Annals of The Royal College of Surgeons of England. 2010;92(2):163-166.
  28. Lee YL, Yip KM. The osteoporotic spine. Clin Orthop 1996;323: 91–7.
  29. McGill S. Low Back Disorders: Evidence-based Prevention and Rehabilitation. Human Kinetics, 2007. p. 192
  30. Heggeness MH. Spine fracture with neurological deficit in osteoporosis. Osteoporos Int. 1993 Jul;3(4):215–21
  31. Papa JA. Conservative management of a lumbar compression fracture in an osteoporotic patient: a case report. J Can Chiropr Assoc. 2012 Mar; 56(1): 29–39.
  32. NIH Osteoporosis and Related Bone Diseases National Resource Center. Bone Mass Measurement: What the Numbers Mean. January 2012
  33. Sebastion D. Lower thoracic syndrome – A differential screen for back pain following vertical compression injury: A case report. Journal of Bodywork and Movement Therapies. October 2014 Volume 18, Issue 4, Pages 545–552
  34. Park DK, Munns J, Singh K. Spinal Metastatic Disease: Current Treatment Algorithms. Contemporary Spine Surgery. 2010 Jan;11(1):1-6.
  35. Gilbert RW, Kim JH, Posner JB. Epidural spinal cord compression from metastatic tumor: diagnosis and treatment. Ann Neurol. 1978 Jan;3(1):40-51.
  36. Kim SH, Smith SE, Mulligan ME. Hematopoietic tumors and metastases involving bone. Radiol Clin North Am. 2011 Nov;49(6):1163-83.
  37. Griffith JF, Guglielmi G. Vertebral fracture. Radiol Clin North Am. 2010 May;48(3):519-29.
  38. Yuh WT, Quets JP, Lee HJ, Simonson TM, Michalson LS, Nguyen PT, Sato Y, Mayr NA, Berbaum KS. Anatomic distribution of metastases in the vertebral body and modes of hematogenous spread. Spine (Phila Pa 1976). 1996 Oct 1;21(19):2243-50.
  39. O’Donnell P. Metastatic Cancer of Bone. OrthoBullets. http://www.orthobullets.com/pathology/8045/metastatic-cancer-of-bone Accessed 8/18/15.
  40. Poe LB, MRI Web Clinic: pathologic fractures Radsource. April, 2012, obtained from radsourceus\pathologic-fractures on 7/12/15.)
  41. Dai LY, Yao WF, Cui YM, Zhou Q. Thoracolumbar fractures in patients with multiple injuries: diagnosis and treatment-a review of 147 cases. J Trauma 2004;56:348–55.
  42. Keene JS. Radiographic evaluation of thoracolumbar fractures. Clin Orthop 1984;216:58–64.
  43. Lucas TS, Einhorn TA. Osteoporosis: the role of the orthopaedist. J Am Acad Orthop Surg 1993;1:48–56.
  44. Kim DH and Vacarro AR. Osteoporotic compression fractures of the spine; current options and considerations for treatment The Spine Journal 6 (2006) 479–487
  45. Cicala D et al. Atraumatic vertebral compression fractures: differential diagnosis between benign osteoporotic and malignant fractures by MRI. Musculoskeletal Surgery. August 2013, Volume 97, Issue 2 Supplement, pp 169-179
  46. Baker LL et al. Benign versus pathologic compression fractures of vertebral bodies: assessment with conventional spin-echo, chemical-shift, and STIR MR imaging. RSNA Radiology Feb 1990 Volume 174, Issue 2.
  47. Hauser CJ, Visvikis G, Hinrichs C, et al. Prospective validation of computed tomographic screening of the thoracolumbar spine
  48. Faciszewski T, Kiernan F, Rao R. Treatment of osteoporotic vertebral compression fractures. In: Spivak JM, Connolly PJ, editors. Orthope- dic Knowledge Update, Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2006.
  49. Prather H. Conservative Care for Patients with Osteoporotic Vertebral Compression Fractures Phys Med Rehabil Clin N Am 18 (2007) 577–591
  50. Wood K, Butterman G, Mehbod A, et al. Operative compare with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective, randomized study. J Bone Joint Surg Am 2003;85:773–81.
  51. Mumford J, Weinstein JN, Spratt KF, et al. Thoracolumbar burst fractures. The clinical efficacy and outcome of nonoperative man- agement. Spine 1993;18:955–70.
  52. Cantor JB, Lebwohl NH, Garvey T, et al. Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine 1993;18:971–6.
  53. Shen WJ, Shen YS. Nonsurgical treatment of three-column thoraco- lumbar junction burst fractures without neurologic deficit. Spine 1999;24:412–5.
  54. Papaioannou A, Adachi JD,Winegard K,et al. Efficacy of home based exercise for improving quality of life among elderly women with symptomatic osteoporosis-related vertebral fractures. Osteoporos Int 2003;14:677–82
  55. Akuthota V, Nadler SF. Core strengthening. Arch Phys Med Rehabil 2004;85(3 Suppl 1): S86–92
  56. Sinaki M,Itoi E,Wahner HW,et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone 2002;30(6): 836–41
  57. Layne JE, Nelson ME. The effects of progressive resistance training on bone density: a review. Med Sci Sports Exerc 1999;31(1):25–30.
  58. National Osteoporosis Foundation. Calcium and Vitamin D: What You Need to Know. http://nof.org/calcium Accessed July 16, 2015.
  59. Gatterman MI. Chiropractic management of spine related disorders. Baltimore, USA: Williams and Wilkins; 1990. Complications of and contraindications to spinal manipulative therapy; pp. 55–69. [chapter 4].
  60. Papa JA. Conservative management of a lumbar compression fracture in an osteoporotic patient: a case report. J Can Chiropr Assoc. 2012 Mar; 56(1): 29–39.
  61. Papaioannou A, Watts NB, Kendler DL, et al. Diagnosis and management of vertebral fractures in elderly adults. Am J Med 2002;113:220–8.
  62. Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing ver- tebral fractures. Fracture Intervention Trial Research Group. Lancet 1996;348:1535–41.
  63. Wasnich U. Vertebral fracture epidemiology. Bone 1996;18:1791–6.
  64. Melton LJ III. Epidemiology of vertebral fractures in women. Am J Epidemiol 1989;129:1000–11.
  65. Kanis JA, Johnell O. The burden of osteoporosis. J Endocrinol Invest 1999;22:583–8.
  66. Evans AJ, Jensen ME, Kip KE, et al. Vertebral compression fractures: pain reduction and improvement in functional mobility after percuta- neous polymethylmethacrylate vertebroplasty retrospective report of 245 cases. Radiology 2003;226:366–72.
  67. Alvarez L, Alcaraz M, Perez-Higueras A, et al. Percutaneous vertebroplasty: functional improvement in patients with osteoporotic compression fractures. Spine 2006;31:1113–8.
  68. Diamond TH, Champion B, Clark WA. Management of acute osteoporotic vertebral fractures: a nonrandomized trial comparing percutaneous vertebroplasty with conservative therapy. Am J Med 2003;114: 257–65.
  69. Chosa K, Naito A, Awai K. Newly developed compression fractures after percutaneous vertebroplasty: comparison with conservative treatment. Jpn J Radiol 2011;29:335–41.
  70. Boger A, Heini P, Markus W, Schneider E. Adjacent vertebral failure after vertebroplasty: a biomechanical study of low-modulus PMMA cement. Eur Spine J 2007;16:2118–25.
  71. Voormolen MHJ, Lohle PNM, Juttmann JR, et al. The risk of new osteoporotic vertebral compression fractures in the year after percutaneous vertebroplasty. J Vasc Interv Radiol 2006;17:71–6.
  72. Trout AT, Kallmes DF, Kaufmann TJ. New fractures after vertebroplasty: adjacent fractures occur significantly sooner. AJNR Am J Neuroradiol 2006;27:217–33.
  73. Kim SH, Kang HS, Choi JA, Ahn JM. Risk factors of new compression fractures in adjacent vertebrae after percutaneous vertebroplasty. Acta Radiol 2004;45:440–5.
  74. Lin EP, Ekholm S, Hiwatashi A, Westesson PL. Vertebroplasty: cement leakage into the disc increases the risk of new fracture of adjacent vertebral body. AJNR Am J Neuroradiol 2004;25:175–80.
  75. Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 2009;361:569–79.
  76. Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 2009;361:557–68.
  77. Liu JT, Liao WJ, Tan WC, et al. Balloon kyphoplasty versus vertebroplasty for treatment of osteoporotic vertebral compression fracture: a prospective, comparative, and randomized clinical study. Osteo- poros Int 2010;21:359–64.
  78. Yang H, Wang G, Liu J, et al. Balloon kyphoplasty in the treatment of osteoporotic vertebral compression fracture nonunion. Orthopedics 2010;33:24.
  79. Dixon RG, Mathis JM. Vertebroplasty and kyphoplasty: rapid pain relief for vertebral compression fractures. Curr Osteoporos Rep 2004;2:111–5.
  80. Mathis JM, Ortiz AO, Zoarski GH. Vertebroplasty versus kypho- plasty: a comparison and contrast. AJNR Am J Neuroradiol 2004;25:840–5.
  81. Chen JK, Lee HM, Shih JT, et al. Combined extraforaminal and intradiscal cement leakage following percutaneous vertebroplasty. Spine 2007;32:E358–62.
  82. Park SY, Modi HN, Suh SW, et al. Epidural cement leakage through pedicle violation after balloon kyphoplasty causing paraparesis in osteoporotic vertebral compression fractures—a report of two cases. J Orthop Surg Res 2010;5:54.
  83. Longo UG, Loppini M, Denaro L, et al. Conservative management of patients with an osteoporotic vertebral fracture: a review of the litera- ture. J Bone Joint Surg Br 2012;94:152–7.
  84. Klazen CA, Lohle PN, de Vries J, et al. Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomized trial. Lancet 2010;376: 1085–92.
  85. Hwan Mo Lee et al. Comparative analysis of clinical outcomes in patients with osteoporotic vertebral compression fractures (OVCFs): conservative treatment versus balloon kyphoplasty The Spine Journal 12 (2012) 998–1005
  86. Frost HM. The evolution of osteoporosis therapy. Orthop Clin North Am 1981;12:649–69.
  87. Mehta JS, Reed MR, McVie JL, Sanderson PL. Weight-bearing radiographs in thoracolumbar fractures. Spine 2004;29:564–7.
  88. Gibson LJ. The mechanical behavior of cancellous bone. J Biomech 1985;18:317–28.
  89. Recker R. Continuous treatment of osteoporosis: current status. Orthop Clin North Am 1981;12:611.
  90. Black D, Schwartz A, Ensrud K et al, “Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-Term Extension (FLEX): a randomized trial,” JAMA 2006; 296:2927-2938.
  91. Black D, Reid I, Boonen S et al. “The effect of 3 versus 6 years of zoledronic acid treatment in osteoporosis: a randomized extension to the HORIZON-Pivotal Fracture Trial (PFT),” J Bone Miner Res 2012; 27:243-254.
  92. Schwartz A, Bauer D, Cummings S et al, “Efficacy of continued alendronate for fractures in women with and without prevalent vertebral fracture: the FLEX trial,” J Bone Miner Res 2010 ;25:976-982.
  93. Marcea Whitaker M et al. Bisphosphonates for Osteoporosis — Where Do We Go from Here? N Engl J Med 2012; 366:2048-2051
  94. Haczynski J, Jakimiuk A. Vertebral fractures: a hidden problem of osteoporosis. Med Sci Monit. 2001 Sep-Oct;7(5):1108–17.
  95. Papa JA. Conservative management of a lumbar compression fracture in an osteoporotic patient: a case report. J Can Chiropr Assoc. 2012 Mar; 56(1): 29–39.
  96. McGraw JK, Cardella J, Barr JD, et al. Society of Interventional Radiology quality improvement guidelines for percutaneous vertebroplasty. J Vasc Interv Radiol 2003;14:827–31.
  97. Tania Winzenberg T, van der Meri I, Mason RS, Nowson C, Jones G. Vitamin D and the musculoskeletal health of older adults. Vol. 41, No. 3, March 2012. Pages 92-99.
  98. Gies P, Roy C, Javorniczky J, Henderson S, Lemus-Deschamps L, Driscoll C. Global Solar UV Index: Australian measurements, forecasts and comparison with the UK. Photochem Photobiol 2004;79:32–9. 
  99. Mattie R, et al. Comparing percutaneous vertebroplasty and conservative therapy for treating osteoporotic compression fractures in the thoracic and lumbar spine: A systematic review and meta-analysis. J Bone Joint Surg Am. 2016 Jun 15;98 (12):1041-51.

 

About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman

DC, CCSP, DACO

Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as President of the executive board.

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