Section 8: Management of symptomatic osteoporotic vertebral fractures

Recommendations

  1. Administer analgesia orally rather than parenterally whenever possible. Pain should be regularly reviewed, and analgesia titrated up or down according to pain intensity and side effects, with use of the weakest effective agent for the shortest possible time (Strong recommendation).
  2. Avoid use of non-steroidal anti-inflammatory drugs (NSAIDs) in older people, but, if used, co-prescribe a proton-pump inhibitor, and monitor for gastro-intestinal, renal and cardiovascular side-effects (Strong recommendation).
  3. Prescribe appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, whenever opioid therapy is used in older people (Strong recommendation).
  4. It is recommended that exercise programmes following vertebral fracture include progressive muscle strengthening activity, including back extensor muscle strengthening and/or endurance exercise (Strong recommendation).
  5. When a patient is in pain it may be advisable to initially perform exercise for back extensors in an unloaded position (Conditional recommendation).
  6. Provide clear and prompt guidance on how to adapt movements involved in day-to-day living, including how exercises can help with posture and pain, to patients with painful vertebral fractures (Strong recommendation).
  7. Ensure prompt secondary fracture prevention is started following a fracture, with follow-up through fracture liaison services for all postmenopausal women, and men age 50 years and older, with a newly diagnosed vertebral fracture (Strong recommendation).

Evidence summary

  1. Vertebral fractures can cause acute and chronic pain, height loss, spinal deformity and altered body shape, functional impairment, and reduced health-related quality of life 14; (Evidence level Ia).
  2. Analgesia for acute pain is important to allow restoration of function and mobility but must be used safely 294, 296; (Evidence level IIa).
  3. In patients admitted to hospital, salmon calcitonin given for up to 4 weeks (50-100IU daily given subcutaneously or intramuscularly), has been shown to be an effective adjunctive analgesic for pain, experienced at rest or when walking, associated with acute (within 10 days of) vertebral fracture 297; (Evidence level IIa). However, side-effects (mainly flushing and gastro-intestinal disturbance) are common. Of note long-term use may be associated with an increased risk of cancer 298. There is no evidence that salmon calcitonin is an effective treatment for chronic pain associated with vertebral fractures297; (Evidence level Ia). Of note, in the SPC, calcitonin is indicated for the prevention of acute bone loss due to sudden immobilisation such as in patients with recent osteoporotic fractures, rather than for the management of pain.
  4. A single, small, randomised double-blind, controlled trial found 30mg intravenous pamidronate, given within 21 days of acute vertebral fracture, to be more effective than placebo in reducing pain 299; (Evidence level IIb). Of note in the SPC, pamidronate is indicated for the treatment of conditions associated with increased osteoclast activity, rather than for the management of pain.
  5. Physiotherapist supervised exercise following vertebral fracture improves pain and physical performance300; (Evidence level Ib). In the presence of pain it may be advisable to initially perform exercise for back extensors in an unloaded position, such as supine 301 ; (Evidence level Ia).
  6. Combining exercise with physiotherapy-delivered education and guidance can reduce fear of falling and improve psychological symptoms associated with vertebral fractures 171,302; (Evidence level Ia).
  7. For patients with painful vertebral fractures, there is low quality evidence suggesting that spinal bracing using soft or rigid external orthoses for 2 hours a day over 6 months may improve pain and trunk muscle strength 301 . There is currently no evidence that bracing with soft or rigid external orthoses improves fracture healing 303. Hence, routine use of bracing for the treatment of acute or subacute vertebral fractures cannot be recommended (Evidence level Ia).
  8. The current evidence does not support the routine use of percutaneous vertebroplasty or balloon kyphoplasty for the treatment of painful osteoporotic vertebral fractures, as these procedures do not show consistent patient benefit 301,304; (Evidence level Ia).
  9. In older women with vertebral fractures and chronic back pain stable for 6 months or more, a small randomised controlled has shown electrical nerve stimulation, administered as inferential therapy or horizontal therapy five days a week for two weeks, can improve pain over 14 weeks 305; (Evidence level IIb).
  10. Patients with a recent vertebral fracture have high imminent risk of further fragility fracture 51; (Evidence level IIb).
  11. If a vertebral fracture is associated with impending or existing neurological deficits, urgent referral to spinal surgical services is indicated.