What are potential treatment options for osteoporotic compression fractures

The goal of treatment is rapid return to baseline functional status, while limiting possible complications. Traditionally, osteoporotic compression fractures were treated nonoperatively except in unusual cases where the fracture was associated with neurologic compromise or extreme spinal instability. Rationale for this approach included the finding that a certain percentage of these fractures were associated with mild symptoms that improved over time. In addition, surgical treatment in this population is complicated by surgical morbidity due to associated medical comorbidities and implant complications due to poor fixation in osteoporotic bone using traditional surgical techniques. Over the past decade, studies have shown that, although some patients with compression fractures improve without intervention, up to two thirds may experience intense pain 1 year after their injury. This led to current treatment approaches that include analgesics, spinal orthoses, and medications (calcium, vitamin D, bisphosphonates) to prevent the next compression fracture by treating the underlying cause of osteoporosis. Administration of nasal calcitonin (200 IU [International Units]) for 4 weeks following an acute fracture has shown benefit in reducing pain. Minimally invasive vertebral augmentation provides an additional treatment option. Decision making is based on fracture-related factors (i.e. acuity, morphology) and patient-related factors including a medical comorbidities, pain level, ability to comply with treatment, and patient preference. Selection of a specific treatment option is tempered by realistic expectations and goals regarding the specific intervention in the context of the best available medical evidence regarding treatment effectiveness and outcomes (Table 66-1).

Table 66-1. Treatment Options for Osteoporotic Vertebral Body Compression Fractures

MEDICAL TREATMENT OPTIONS

SURGICAL TREATMENT OPTIONS

Analgesic Medication

Minimally Invasive Vertebral Body Augmentation

• Vertebroplasty

• Kyphoplasty

Spinal Orthoses

Traditional Maximally Invasive Spine Surgery

• Anterior Approaches

• Posterior Approaches

• Combined Anterior and Posterior Approach o Single Incision o Separate Anterior and Posterior Incisions

Rehabilitation Approaches

• Weight-bearing Exercise

• Fall Prevention Program

Hybrid Approaches

• Vertebral body augmentation combined with laminectomy

• Vertebral body augmentation combined with laminectomy and posterior spinal instrumentation

Osteoporosis Medications

• Anticatabolics o Bisphosphonates o Hormone replacement o Selective estrogen modulators o Calcitonin

• Anabolics o Teriparatide

Special Procedures

• Pedicle subtraction osteotomy o Burst fractures with canal compromise

• Vertebral column resection o Salvage revision for complex deformity

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