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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.


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About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman


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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