Diagnosis and Management of Vertebral Compression Fractures

 


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Am Fam Physician. 2016 Jul 1;94(1):44-50.

Author disclosure: No relevant financial affiliations.

Vertebral compression fractures (VCFs) are the most common complication of osteoporosis, affecting more than 700,000 Americans annually. Fracture risk increases with age, with four in 10 white women older than 50 years experiencing a hip, spine, or vertebral fracture in their lifetime. VCFs can lead to chronic pain, disfigurement, height loss, impaired activities of daily living, increased risk of pressure sores, pneumonia, and psychological distress. Patients with an acute VCF may report abrupt onset of back pain with position changes, coughing, sneezing, or lifting. Physical examination findings are often normal, but can demonstrate kyphosis and midline spine tenderness. More than two-thirds of patients are asymptomatic and diagnosed incidentally on plain radiography. Acute VCFs may be treated with analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, narcotics, and calcitonin. Physicians must be mindful of medication adverse effects in older patients. Other conservative therapeutic options include limited bed rest, bracing, physical therapy, nerve root blocks, and epidural injections. Percutaneous vertebral augmentation, including vertebroplasty and kyphoplasty, is controversial, but can be considered in patients with inadequate pain relief with nonsurgical care or when persistent pain substantially affects quality of life. Family physicians can help prevent vertebral fractures through management of risk factors and the treatment of osteoporosis.

Vertebral compression fractures (VCFs) are the most common complication of osteoporosis, affecting more than 700,000 Americans annually.1 Patients with VCFs account for 66,000 physician office visits and 45,000 to 70,000 hospitalizations each year, with one-half requiring skilled nursing facility care.2 Fracture risk increases with age; in the United States, four out of 10 white women older than 50 years will experience a hip, spine, or vertebral fracture in their lifetime.2 Women with one or more VCFs have a 1.2-fold greater age-adjusted mortality rate compared with women without fractures, with the risk of death increasing with the number of fractures.3 Fracture-related deaths occur after the fracture, often from pulmonary disease or cancer.3,4 Furthermore, patients report a lower quality of life at 12 and 24 months after a fracture.2 The estimated direct annual health care cost of managing osteoporotic spine and hip fractures is $10 billion to $15 billion.5

WHAT IS NEW ON THIS TOPIC: VERTEBRAL COMPRESSION FRACTURES

Two randomized controlled trials comparing vertebroplasty with a sham procedure in patients with acute or chronic vertebral compression fractures found no benefit in pain reduction, function, or quality of life.

Patients with vertebral compression fractures should not undergo vertebroplasty unless they continue to have debilitating pain or substantial functional limitations after at least three weeks of conservative therapy.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A trial of conservative therapy should be offered to patients with vertebral compression fractures.

C

13, 17, 18, 21

Percutaneous vertebral augmentation can be considered in patients who have inadequate pain relief with nonsurgical care or when persistent pain substantially affects quality of life.

C

13, 15, 17, 21

Patients with vertebral compression fractures should be evaluated for osteoporosis, and preventive therapy should be initiated if necessary.

C

6, 22, 41


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A trial of conservative therapy should be offered to patients with vertebral compression fractures.

C

13, 17, 18, 21

Percutaneous vertebral augmentation can be considered in patients who have inadequate pain relief with nonsurgical care or when persistent pain substantially affects quality of life.

C

13, 15, 17, 21

Patients with vertebral compression fractures should be evaluated for osteoporosis, and preventive therapy should be initiated if necessary.

C

6, 22, 41


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Risk Factors

Risk factors for VCFs include osteopenia, osteoporosis, older age, a history of VCFs or falls, inactivity, use of corticosteroids (more than 5 mg daily for three months) or

The Authors

show all author info

JASON McCARTHY, MD, is a faculty physician at the David Grant Medical Center Family Medicine Residency Program, Travis Air Force Base, Calif....

AMY DAVIS, MD, is a faculty physician at the David Grant Medical Center Family Medicine Residency Program.

The authors thank Pamela M. Williams, MD; Kathy Holder, MD; and Regina Rowell for their assistance with the manuscript.

Author disclosure: No relevant financial affiliations.

Address correspondence to Jason McCarthy, MD, David Grant Medical Center, 101 Bodin Cir., Travis Air Force Base, CA 94535 (e-mail: jason.mccarthy.6@us.af.mil). Reprints are not available from the authors.

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