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Clinical manifestations and treatment of osteoporotic thoracolumbar vertebral compression fractures Author Harold N Rosen, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Mar 2013. | This topic last updated: mar 1, 2013. INTRODUCTION Osteoporotic fractures (fragility fractures, low-trauma fractures) are those occurring from a fall from a standing height or less, without major trauma such as a motor vehicle accident. Vertebral compression fractures are the most common type of osteoporotic fracture [1]. They often occur at the thoracolumbar junction (T12-L1) because a change in the facets provides less resistance to anteroposterior displacement at this level [2]. Midthoracic (T7-T8) fractures are also common. Fractures may result in limitation of ambulation, depression, loss of independence, and chronic pain. In addition, the presence of a fragility (low-trauma) fracture is an important risk factor for subsequent fracture. This topic card will review the clinical manifestations, diagnosis, and management of acute osteoporotic vertebral compression fractures. The diagnosis and treatment of osteoporosis are reviewed separately. (See "Diagnosis and evaluation of osteoporosis in postmenopausal women" and "Clinical manifestations, diagnosis, and evaluation of osteoporosis in men" and "Overview of the management of osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men".) CLINICAL MANIFESTATIONS Symptoms Most vertebral compression fractures (about two-thirds) are asymptomatic; they are diagnosed as an incidental finding on chest or abdominal x-ray. In some patients, the presence of vertebral fractures may become apparent because of height loss or kyphosis [3]. (See 'Height loss' below and 'Kyphosis' below.) In patients who have a symptomatic vertebral fracture, there is often no history of preceding trauma. The typical patient presents with acute back pain after sudden bending, coughing, or lifting. Occasionally, minor trauma, such as going over speed bumps, may precipitate a fracture [4]. The pain often radiates bilaterally into the anterior abdomen in the distribution of contiguous nerve routes, a so-called "girdle of pain." By contrast, radiation into the legs, as may be seen with a herniated disc, is rare with compression fractures. The pain from a vertebral compression fracture is variable in quality and may be sharp or dull. Sitting and movement often aggravate the discomfort, while muscle spasms may disturb sleep. Acute episodes of pain usually resolve after four to six weeks, but mild pain may persist for up to three months. Severe back pain that persists longer should raise the question of more fractures or another diagnosis. Height loss Height loss is typically asymptomatic and gradual. In addition to osteoporotic compression fractures, height loss can be caused by disc space narrowing, scoliosis, and aging. In one study, historical height loss of >6 cm had a specificity and sensitivity of 94 and 30 percent, respectively, for detection of vertebral fracture [5]. Thus, patients with height loss of <6 cm were less likely to have a vertebral compression fracture. Kyphosis Kyphosis ("dowager hump") may be an indicator of multiple vertebral compression fractures, especially wedge fractures, although kyphosis may occur independently of vertebral abnormalities [6]. Each complete compression fracture causes about 1 cm or more loss in height; loss of more than 4 cm in height is Section Editor Clifford J Rosen, MD Deputy Editor Jean E Mulder, MD

associated with 15 degrees of kyphosis. Practically, however, there are no simple clinical measures of kyphosis and measures of height may be inconsistent due to variabilities in measurement technique and posture. Some potentially useful clinical measurements include the distance from the occiput to the wall (normally 0 cm) and the size of the gap between the costal margin and the iliac crest (normally three finger breadths) [7]. Patients with kyphosis may complain of "getting fat" without any change in weight. They note that their abdomen has become larger, that their clothes do not fit, or that they no longer have a waist. These symptoms are a reflection of the loss of height; the abdominal contents are compressed into less vertical space, causing them to bulge anteriorly. Patients with severe thoracic kyphosis often complain of muscular neck pain, since they must forcefully extend their necks in order to look forward. Restrictive respiratory problems also may become apparent [8]. A costo-iliac impingement syndrome can develop following multiple vertebral fractures. It has been hypothesized that the lowest rib impinges against the iliac crest due to a reduction in the normal distance between the bottom of the rib cage and the top of the iliac crests. This causes pain in the region of the twelfth thoracic vertebra that radiates to the posterior trunk. Patients may also complain of hip pain and, when pressed for details, can pinpoint the sensation to the superior iliac crest. A case report of six patients noted that all had relief of pain following subperiosteal resection of the outer two-thirds of the rib [9]. Clinical consequences The presence of a fragility (low-trauma) fracture is an important risk factor for subsequent fracture. Approximately 19 percent of patients who have a vertebral compression fracture will have another fracture in the next year [10]. In one analysis of the literature, women with preexisting vertebral fractures had approximately four times greater risk of subsequent vertebral fractures than women without prior fractures [11]. The presence of vertebral fractures also predicts future nonvertebral fractures, particularly hip fracture, and this risk increases with the number and severity of prior fractures [12]. (See "Osteoporotic fracture risk assessment", section on 'Personal history of fracture as an adult'.) Functional impairment from vertebral fractures can be as severe as that related to hip fracture, including difficulty bending, lifting, reaching, walking down stairs, or cooking [13,14]. In addition, approximately 75 percent of patients who present with a symptomatic vertebral fracture complain of chronic pain [15,16]. DIAGNOSIS Patients with a suspected acute compression fracture should be evaluated with a plain x-ray of the dorsolumbar spine to confirm the diagnosis. Osteoporosis may lead to several types of vertebral abnormalities, including wedge fractures, biconcave or "codfish" deformities, and compression fractures (figure 1). Radiographic characteristics of compression fractures include anterior wedging of one or more vertebrae with vertebral collapse, vertebral end-plate irregularity, and general demineralization (image 1). Posterior wedging is uncommon and may indicate an underlying destructive lesion. The severity of vertebral fractures may be staged as follows [17]: Grade 1: 20 to 25 percent deformity Grade 2: 25 to 40 percent deformity Grade 3: >40 percent deformity Differential diagnosis Compression fracture may be the first symptom of osteoporosis. It is important to appreciate certain clues that suggest that vertebral fractures might be due to causes other than uncomplicated osteoporosis: Fracture occurring in a person who is not elderly A solitary vertebral fracture in vertebrae higher than T4 is unusual, unless there are also multiple vertebral fractures at lower levels [18] In these settings, other causes of osteopenia (eg, osteomalacia, hyperparathyroidism, granulomatous diseases,

hematologic diseases, infections, or metastatic cancer) should be excluded. (See "Diagnosis and evaluation of osteoporosis in postmenopausal women", section on 'Evaluation'.) Juvenile kyphosis (Scheuermann's disease) and adult or adolescent kyphosis also should be differentiated from compression fractures. The vertebral abnormalities of Scheuermann's disease include end-plate irregularities and wedging of the vertebral body without loss of bone density. (See "Back pain in children and adolescents: Overview of causes", section on 'Scheuermann (juvenile) kyphosis' and "Overview of hyperkyphosis in older persons".) EVALUATION The patient should be assessed for neurologic findings. Neurologic abnormalities may indicate fracture fragments in the spinal canal that demand surgical intervention. In such patients, an urgent MRI or CT scan should be obtained with prompt consultation with a neurosurgeon. An MRI or CT scan may also be considered when further diagnostic information is indicated (by the results of a plain x-ray or blood studies mentioned in the following paragraph), though most patients will not need these imaging studies. A CT scan is helpful in determining potential instability of a wedge fracture [19]. An MRI can indicate the severity and acuity of a fracture, and additionally may provide information on whether there is an underlying malignancy [20]. Patients in whom malignancy is suspected, due to weight loss or other clinical symptoms, should have a complete blood count (CBC), serum alkaline phosphatase, serum and urine protein electrophoresis, and erythrocyte sedimentation rate or C-reactive protein blood test. Radionucleotide bone scan can be performed to evaluate for the presence of metastatic (osteoblastic) bone lesions. Any febrile patient in whom infection is suspected should have a CBC and blood cultures to evaluate for infection. Laboratory evaluation may also be indicated to diagnose secondary causes of osteoporosis such as renal or liver disease, hyperthyroidism, hyperparathyroidism, Cushing's syndrome or subclinical hypercortisolism, early menopause, celiac disease and other forms of malabsorption, idiopathic hypercalciuria, or connective tissue disorders (table 1). For the initial evaluation, we typically measure a CBC, biochemistry profile (calcium, phosphorous, albumin, total protein, creatinine, liver enzymes including alkaline phosphatase, electrolytes), 25-hydroxyvitamin D, and in men, a serum testosterone level. (See "Diagnosis and evaluation of osteoporosis in postmenopausal women", section on 'Initial evaluation' and "Clinical manifestations, diagnosis, and evaluation of osteoporosis in men", section on 'Evaluation'.) Patients who have abnormalities on the initial laboratory testing or who have suspicious findings on history and physical examination may also require additional laboratory tests. (See "Diagnosis and evaluation of osteoporosis in postmenopausal women", section on 'Additional evaluation'.) A DXA bone density study, performed on a non-urgent basis, is preferred for quantitative assessment of bone density. MANAGEMENT Initial management of osteoporotic vertebral compression fractures should include pain control, with resumption of activity as quickly as possible, and physical therapy [21]. When osteoporosis is present, inactivity may result in further loss of bone and new fractures. (See "Treatment of acute low back pain".) Oral analgesics are first-line therapy for the relief of acute pain due to vertebral compression fractures. Options include acetaminophen, ibuprofen, naproxen, or opioids combined with acetaminophen. For patients who do not have adequate pain relief with oral analgesics, we suggest adding nasal calcitonin for a two to four week course, until the patient is able to get started on a more effective osteoporosis treatment regimen. Treatment should be

aimed at the underlying disease. With osteoporosis, for example, medications, such as bisphosphonates, raloxifene, or PTH, may lead to increased bone mass and a reduction in the rate of new fractures [22]. (See "Overview of the management of osteoporosis in postmenopausal women".) Provide relief from pain The patient should be informed that fractures may take up to three months to heal and that pain will diminish gradually. Acute pain requires non-opioid or opioid analgesics and may require some limitation of activity. Lying in the 90/90 rest position may be helpful (picture 1). Patients should resume physical activity as quickly as possible. Oral analgesics Oral analgesics are the first-line therapy for the relief of acute pain due to vertebral compression fractures. Acetaminophen (650 mg four times daily or 1 g three times daily), ibuprofen (400 to 600 mg four times daily), or naproxen (220 to 500 mg twice daily) is commonly used. There are no randomized trials evaluating oral analgesics in patients with vertebral compression fractures. Studies in animals suggest that nonsteroidal antiinflammatory drugs (NSAIDs) may adversely impact fracture healing, but there are inconclusive data from human studies to determine if healing is impaired with NSAIDs, such as ibuprofen and naproxen. Animal data suggest that the highly selective cyclooxygenase-2 inhibitors (eg, celecoxib) interfere with fracture healing, and there is agreement that highly selective cyclooxygenase-2 inhibitors should be avoided for early pain control. (See "Overview of selective COX-2 inhibitors", section on 'Possible effect on fracture healing'.) Some UpToDate authors and editors prefer to avoid all NSAIDs in the setting of acute fracture, whereas other experts do not feel that the short-term use (less than a few weeks) of ibuprofen or naproxen is contraindicated [23]. The risk of NSAIDs needs to be considered carefully in older adults, especially elderly individuals with multiple comorbidities. Potential adverse effects of NSAIDS are reviewed separately. (See "Nonselective NSAIDs: Overview of adverse effects".) If opioids are required, we suggest initiating treatment with an opioid combined with acetaminophen. A laxative generally also is given to prevent straining at defecation, which can cause further fractures. Potential adverse effects of opioids are reviewed separately. (See "Overview of the treatment of chronic pain", section on 'Opioids'.) Calcitonin Calcitonin is not a first-line agent for the treatment of osteoporosis because it causes the least increase in bone mineral density of any agent currently used. Nevertheless, in some small randomized trials, calcitonin hastened the relief of pain from vertebral fractures, and it can be a useful adjunct to traditional analgesics in the acute setting (figure 2). Nasal calcitonin, 200 units (one spray) once daily alternating nostrils, may be more effective than the intramuscular preparation (figure 3). (See "Calcitonin in the prevention and treatment of osteoporosis", section on 'Bone pain'.) Because calcitonin is more expensive than NSAIDs or acetaminophen, we do not usually use calcitonin for initial pain management. However, for patients who do not have adequate pain relief with oral analgesics, we suggest adding nasal calcitonin for a two to four week course or until the patient is able to get started on a more effective osteoporosis treatment regimen, such as alendronate [24]. Bisphosphonates Oral bisphosphonates, such as alendronate, may provide pain relief over time, but they do not provide acute pain relief from the existing fracture. In one small trial, intravenous pamidronate provided pain relief in patients with acute painful osteoporotic vertebral compression fracture [25]. However, intravenous pamidronate has not been shown to be more effective than calcitonin [26]. Bisphosphonates are the treatment of choice for the long-term management of osteoporosis. (See "Bisphosphonates in the management of osteoporosis in postmenopausal women".) Parathyroid hormone Parathyroid hormone (PTH) 1-34 may be another option for women with a new vertebral fracture. PTH 1-34 reduces the severity and incidence of new spine fractures and has been shown to reduce back pain in some clinical trials. (See "Parathyroid hormone therapy for osteoporosis", section on 'Back pain'.)

Muscle relaxants There are no clinical trials evaluating the efficacy of non-benzodiazepine skeletal muscle relaxants (eg, cyclobenzaprine, methocarbamol) for the relief of pain in patients with osteoporotic vertebral compression fractures. Although these medications have been shown to be modestly more effective than placebo for short-term relief of non-specific acute low back pain, they have significant adverse effects in older adults, and we do not recommend using them. (See "Treatment of acute low back pain", section on 'Centrally-acting skeletal muscle relaxants'.) Bracing Although there are limited clinical data evaluating the efficacy of back bracing for improving pain and mobility in patients with osteoporotic compression fractures, braces are commonly used for the acute management of such fractures [20,27]. This practice may be due to randomized trial data suggesting benefit in patients with traumatic vertebral compression fractures [28]. "Chair back" braces, designed to support the lumbar spine, provide limited benefit, are expensive, and cannot be used while sitting. Thus, we do not typically recommend bracing for the management of pain in patients with osteoporotic compression fractures. If used, braces should be discarded when no longer needed, since they promote immobility of the spine and the potential for disuse osteoporosis. Vertebroplasty and kyphoplasty Vertebroplasty and kyphoplasty involve the percutaneous injection of bone cement under fluoroscopic guidance into a collapsed vertebra. Kyphoplasty also involves the introduction of inflatable bone tamps into the fractured vertebral body for elevation of the endplates prior to fixation of the fracture with bone cement [29]. These procedures are performed in an outpatient setting, although the optimal timing related to fracture acuity is unclear [30,31]. The potential short-term benefit for both procedures is improvement in pain, whereas potential long-term benefits include prevention of recurrent pain at the treated level(s), limitation or reversal of height loss and spinal deformity, and improved functional capability. Indirect comparisons based upon outcomes from case series indicate that both procedures provide equivalent pain relief, with more improvement in functionality and a suggestion of fewer adverse events (pulmonary emboli and neurologic sequelae) with balloon kyphoplasty [32,33]. In the only randomized trial comparing the two procedures, 100 patients with osteoporotic compression fracture were randomly assigned to vertebroplasty or kyphoplasty [34]. There was no difference in pain scores between the treatment groups at three days and six months [34]. The postoperative increase in vertebral body height (0.91 versus 0.31 cm) and the reduction in kyphotic wedge angle (8 versus 3 degrees) were significantly greater in the kyphoplasty group. Short-term placebo-controlled (sham procedure) trials of vertebroplasty in patients with osteoporotic compression fractures have not shown a significant benefit in reducing pain [35,36]. In addition, a systematic review of eight trials comparing vertebral augmentation (seven trials vertebroplasty, one trial kyphoplasty) with placebo or standard medical care showed significant improvement in pain from baseline in both the treatment and control groups at 1, 3, and 12 months [37]. In the six trials that did not use a sham procedure (four of the six were funded by the device manufacturers), the reduction in pain at one month was better with vertebral augmentation than controls. However, the two sham-controlled trials, which provide the highest quality of evidence, did not show benefit of vertebroplasty over control. A subsequent meta-analysis of six trials (five vertebroplasty, one kyphoplasty) reported similar findings [38]. Although the mean difference in the pain visual analog scale was statistically significant favoring vertebral augmentation (mean difference 0.73, 95% CI 0.35-1.10, and 0.58, 95% CI 0.19-0.97 for early [<12 weeks] and late [6 to 12 months] time points, respectively), the sham-controlled trials did not show a significant benefit of vertebral augmentation over control [38]. These trials are discussed in more detail below. (See 'Efficacy of vertebroplasty' below and 'Efficacy of kyphoplasty' below.) Additional trials evaluating kyphoplasty, particularly compared with a sham procedure, are required. There are no trials that address long-term (beyond two years) benefits. In an industry-sponsored review of a Medicare database with 858,978 patients who had vertebral fracture, operative management with vertebroplasty or kyphoplasty was associated with a 37 percent lower mortality than non-operative management [39]. However, this was not a randomized study, and there are likely unmeasured patient characteristics that account for the observed difference. In addition, patients who received operative management might have been cared for more aggressively

than the non-operative group. We do not recommend vertebroplasty or kyphoplasty for the acute management of pain due to osteoporotic compression fractures. In most patients with osteoporotic vertebral compression fracture, the acute pain resolves gradually over four to six weeks and completely resolves within three months [40]. In some patients, the pain may persist beyond three months (sometimes due to paraspinal spasm). These modalities have not been adequately evaluated for the treatment of chronic pain. Vertebroplasty or kyphoplasty for the treatment of malignancy associated vertebral compression fractures is reviewed elsewhere. (See "Treatment of the complications of multiple myeloma", section on 'Kyphoplasty and vertebroplasty' and "Psychological, rehabilitative, and integrative therapies for cancer pain".) Efficacy of vertebroplasty In observational studies, vertebroplasty reduced pain in patients with osteoporotic vertebral compression fractures [41-44]. In unblinded randomized trials comparing vertebroplasty with pain management, there was greater improvement in pain immediately after vertebroplasty (one day) but not at two weeks [45], three months [46], or 12 months [47,48]. In one trial, the improvement in pain after vertebroplasty was significant at one day, one month, and one year [49]. However, the trial was not blinded and the observed results may be attributed, in part, to a placebo response and to biased patient-reported outcomes (patients who received vertebroplasty exaggerated reported pain relief because of prior expectations by patient and/or investigator) [50]. In addition, more than half of the patients who initially qualified for the study had spontaneous reduction or resolution of pain (mean pain score <5) during screening and therefore were not eligible for inclusion in the study. In two short-term, blinded trials comparing vertebroplasty with a sham procedure, there was no immediate or delayed benefit of vertebroplasty [35,36,51]. One of these trials compared vertebroplasty to a simulated procedure without cement in 131 patients who had one to three painful osteoporotic vertebral compression fractures [36]. The primary outcomes were pain intensity during the previous 24 hours and disability, measured by the modified Roland-Morris Disability Questionnaire. The improvement in pain and disability scores was similar in both groups at all time points (three days, two weeks, one month). In both groups, the greatest improvement occurred within three days of the procedure and was maintained at one month. In these two trials, patients assigned to the sham procedures received the same subcutaneous and periosteal anesthetic as those assigned to the full vertebroplasty procedure. The anesthetic, rather than the vertebroplasty procedure itself, may account for some of the immediate pain relief noted in unblinded trials [36,52]. In addition, the cross-over rate in these trials was fairly high, which could account for the negative findings. Based upon the available data, we do not recommend vertebroplasty for pain reduction in patients with osteoporotic compression fractures. This recommendation is consistent with the American Academy of Orthopaedic Surgeons Guideline on The Treatment of Osteoporotic Spinal Compression Fractures [53]. Efficacy of kyphoplasty In observational studies, kyphoplasty reduced pain in patients with osteoporotic vertebral compression fractures [30,54-56]. Data from randomized trials are limited. In the largest trial to date, 300 patients with one to three acute vertebral fractures were randomly assigned to balloon kyphoplasty versus nonsurgical care (not a sham procedure as in the above vertebroplasty trials) [57]. After one month, patients assigned to kyphoplasty had greater improvement in the short-form (SF)-36 physical component summary scale, a validated quality of life measurement. However, after 12 and 24 months, the difference in improvement between the two groups was no longer significant [57,58]. The changes in pain (SF-36 bodily pain) and quality of life (EuroQuol selfreport) scores, predefined secondary endpoints, were statistically significant (favoring kyphoplasty) at all time points, but the differences between treatment groups at 24 months were small and, without a sham procedure, of uncertain clinical significance [58]. Adverse effects Vertebroplasty and kyphoplasty are not without risk. Short-term complications occur predominantly due to extravasation of the cement and may include increased pain and damage from heat or pressure to the spinal cord or nerve roots [59], and rarely cement embolization [60]. Extravasation has been reported in 11 to 73 percent of vertebroplasty procedures [61], and less commonly with kyphoplasty.

There have been several case reports of pulmonary embolization of the cement [60]. Pulmonary emboli were noted on chest radiography in approximately 5 percent of patients in one series of 65 procedures and in 23 percent of patients in a series of 78 procedures [62,63]. None of the radiographically detected embolic events produced symptoms. In one of these studies, cement leakage into the inferior vena cava was the only significant risk factor for developing pulmonary cement embolism [63]. Pyogenic spondylitis and osteomyelitis may occur, but are rare in experienced hands [64,65]. Possible long-term complications include local acceleration of bone resorption caused by the treatment itself or by foreign body reaction at the cement bone interface, and increased risk of fracture in treated or adjacent vertebrae through changes in mechanical forces. Polymethylmethacrylate (PMMA) cement is not as bio-inert as initially considered and has been associated with bone necrosis surrounded by fibrotic tissue, foreign body reaction, and neovascularization [66]. The cement reaction might also predispose to adjacent new vertebral fractures. Retrospective reviews of patients treated with vertebroplasty found a high rate of new vertebral fractures [67-70]. In a population-based retrospective cohort study of patients with previous vertebral compression fracture, 48 patients who received vertebroplasty or kyphoplasty were compared with 164 patients who did not. Treated patients had a significantly greater risk of subsequent vertebral compression fractures than the comparison group (odds ratios 6.8, 95% CI 1.7-26.9, and 2.9, 95% CI 1.1-7.9, for secondary fractures occurring within 90 and 360 days of the procedure, respectively) [71]. In the majority of the randomized trials described above, which were not designed to assess the frequency of new or worsening vertebral fractures, the incidence of new fractures was not significantly different in the vertebroplasty/kyphoplasty group from that of controls [35,38,49,57]. However, in one trial, there was an increase in new vertebral fracture in the vertebroplasty group (29 new fractures in 17 of 64 patients treated with vertebroplasty compared with eight fractures in 8 of 61 patients treated conservatively, OR 2.78, 95% CI 1.02-7.62) [48]. Most new vertebral fractures were adjacent to the vertebroplasty procedure (82 versus 27 percent in the conservative group). Exercise An exercise program can be initiated when pain has diminished. Exercise has beneficial effects on bone mineral density in premenopausal and postmenopausal women, and may also be beneficial in men. Exercise regimens in elderly patients who have had a vertebral fracture have been shown to decrease the use of analgesics and improve quality of life in some, but not all, studies [72-74]. (See "Overview of the management of osteoporosis in postmenopausal women" and "Epidemiology and etiology of osteoporosis in men", section on 'Physical activity and strength'.) Aquatic therapy is an excellent means of pain management in our experience. Use of the Arthritis Foundation aquatic program hastens the relief of pain and can also lead to early resumption of activity; begin as soon as patients can tolerate the movements. Hyperextension exercises may relieve pain and prevent kyphosis (figure 4) [75]; we use this routinely in elderly patients with osteoporosis. The posterior pelvic tilt is another useful exercise (figure 5). Treatment for osteoporosis Antiresorptive therapy with bisphosphonates or other osteoporosis therapy should be part of the treatment plan. Unfortunately, the majority of patients with spine, hip and distal radius fractures do not receive evaluation and treatment for underlying osteoporosis. (See "Overview of the management of osteoporosis in postmenopausal women", section on 'Medical intervention after fracture' and "Treatment of osteoporosis in men" and "Bisphosphonates in the management of osteoporosis in postmenopausal women".) Lifestyle factors Lifestyle changes are essential. Smoking is a risk factor for osteoporosis. Alcohol abuse in the elderly increases the risk of falling. Daredevil acts that predispose to fracture (eg, parachuting, trampoline exercise), sedentary inactivity, a low calcium diet, and tobacco use are important considerations for change. (See "Osteoporotic fracture risk assessment" and "Overview of the management of osteoporosis in postmenopausal women", section on 'Nonpharmacologic therapy' and "Calcium and vitamin D supplementation in osteoporosis".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade

reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Basics topics (see "Patient information: Vertebral compression fracture (The Basics)" and "Patient information: Kyphosis in adults (The Basics)") SUMMARY AND RECOMMENDATIONS Although the majority of osteoporotic vertebral compression fractures are asymptomatic, some patients present with acute back pain after sudden bending, coughing, or lifting. (See 'Clinical manifestations' above.) The evaluation of an osteoporotic compression fracture includes assessment for neurologic findings, which may necessitate further imaging and surgical consult, and laboratory evaluation to assess for malignancy (such as multiple myeloma) and secondary causes of osteoporosis. (See 'Evaluation' above.) The management of an acute osteoporotic vertebral compression fracture includes pain control and treatment of the underlying osteoporosis. (See 'Management' above.) Oral analgesics are first-line therapy for the relief of acute pain due to vertebral compression fractures. Options include acetaminophen, ibuprofen, naproxen, or opioids combined with acetaminophen. The risks of NSAIDs and opioids need to be considered carefully in older adults, especially elderly individuals with multiple comorbidities. (See 'Oral analgesics' above.) For patients who do not have adequate pain relief with oral analgesics, we suggest adding nasal calcitonin (Grade 2B). (See 'Calcitonin' above and "Calcitonin in the prevention and treatment of osteoporosis", section on 'Bone pain'.) We recommend not using vertebroplasty for the acute management of pain associated with osteoporotic compression fractures (Grade 1B). We suggest not using kyphoplasty for the acute management of pain associated with osteoporotic compression fractures (Grade 2C). (See 'Vertebroplasty and kyphoplasty' above.) We suggest not using skeletal muscle relaxants for the acute management of pain in patients with osteoporotic compression fractures (Grade 2C). (See 'Muscle relaxants' above and 'Bracing' above.) If bracing is used to relieve pain, braces should be discarded as soon as possible, since they promote immobility of the spine and the potential for disuse osteoporosis. (See 'Bracing' above.) For the long-term management of osteoporosis in patients with osteoporotic compression fractures, we recommend treatment with a pharmacologic agent (Grade 1A). (See "Overview of the management of osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men".) ACKNOWLEDGMENT The author and UpToDate would like to acknowledge Dr. Robert P Sheon, who contributed to earlier versions of this topic review. Use of UpToDate is subject to the Subscription and License Agreement. Topic 7775 Version 19.0

GRAPHICS
Types of osteoporotic vertebral fracture

Schematic representation of the different types of vertebral fracture seen in osteoporosis. The central depression with the biconcave or codfishing appearance occurs because the edges of the vertebrae, being supported by the outer walls of the vertebrae, are stronger than the central part. In comparison, the anterior aspect of the vertebral body collapses more than the posterior aspect with a wedge fracture, while the entire vertebral body collapses down with a compression fracture.

Thoracolumbar vertebral compression fractures

Radiographic features of spinal osteoporosis include wedging of the vertebra anteriorly with vertebral collapse (arrows), vertebral end-plate irregularity, and general demineralization.
Courtesy of Toledo Hospital.

Secondary causes of osteoporosis

Drugs
Glucocorticoids Immunosuppressants (cyclosporine) Antiseizure medications (particularly phenobarbital and phenytoin) GnRH agonists and antagonists Heparin Cancer chemotherapy

Marrow-related disorders
Amyloidosis Hemochromatosis Hemophilia Leukemia Lymphoma Mastocytosis Multiple myeloma Pernicious anemia Sarcoidosis Sickle cell anemia Thalassemia

Endocrine disorders
Acromegaly Adrenal atrophy in Addison's disease Cushing's syndrome Eating disorders Endometriosis Hyperparathyroidism Hyperprolactinemia Hyperthyroidism Hypogonadism (primary or secondary) Diabetes mellitus

Organ transplantation
Bone marrow Heart Kidney Liver Lung

Gastrointestinal disease/nutritional disorders

Alcohol-related liver disease Celiac disease Chronic active hepatitis Chronic cholestatic disease Gastrectomy Inflammatory bowel disease Jejunoileal bypass Malabsorption syndromes Pancreatic insufficiency Parenteral nutrition Primary biliary cirrhosis Severe liver disease Vitamin D and/or calcium deficiency

Miscellaneous causes
Ankylosing spondylitis Chronic obstructive pulmonary disease Congenital porphyria Epidermolysis bullosa Hemophilia Idiopathic hypercalciuria Idiopathic scoliosis Multiple sclerosis Rheumatoid arthritis

Genetic disorders
Hypophosphatasia Osteogenesis imperfecta Homocystinuria due to cystathionine deficiency

Reproduced with permission from: Fitzpatrick LA. Secondary causes of osteoporosis. Mayo Clin Proc 2002; 77:454. Copyright 2002 Mayo Foundation.

90/90 rest position

The 90/90 rest position for patients with low back pain is achieved by lying on a flat surface and flexing both hips and knees to 90 degrees.

By permission from Sheon, RP, Moskowitz, RW, Goldberg, VM. Soft Tissue Rheumatic Pain: Recognition, Management, Prevention, 3rd ed, Williams & Wilkins, Baltimore 1996.

Nasal calcitonin improves bone pain

Effect of intranasal salmon calcitonin (sCT) or placebo on the intensity of spontaneous bone pain (score from 0 to 20) in women with recent osteoporotic spinal fractures. Salmon calcitonin led to a more rapid reduction in pain.

Data from Gennari, C, Agnusdei, D, Camporeale, A, Calcif Tissue Int 1991; 49 Suppl 2:S9.

Nasal versus intramuscular calcitonin for bone pain

Effect of salmon calcitonin (sCT) on spontaneous bone pain in patients with recent osteoporotic fractures treated with either intranasal (100 Int. Units) or intramuscular (100 Int. Units) calcitonin. The intranasal calcitonin led to more effective pain relief.
Data from Gennari, C, Agnusdei, D, Camporeale, A, Calcif Tissue Int 1991; 49(Suppl 2):S9.

Hyperextension exercise

The patient should lie face down on the floor or on a firm bed with a pillow under the abdomen and hips. The arms should be resting at the sides. The chin should be held in or neutral. The patient should inhale and raise the head, neck, chest (as a block), and arms a few inches from the floor. Hold for five seconds. Repeat five to ten times.

Posterior pelvic tilt

The posterior pelvic tilt is a basic maneuver in back rehabilitation. The abdominal and gluteal muscles are contracted to flatten the lumbar spine. This position is held for 5 to 10 seconds and can be repeated frequently.
Reproduced with permission from Sheon, RP, Moskowitz, RW, Goldberg, VM. Soft Tissue Rheumatic Pain: Recognition, Management, Prevention, 3rd ed, Williams & Wilkins, Baltimore 1996.

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