The latest article in our Clinical Practice series, “Vertebral Fractures,” comes from Drs. Kristine Ensrud and John Schousboe at the University of Minnesota.
Vertebral fractures of the thoracic and lumbar spine account for an estimated 700,000 of the 1.5 million osteoporotic fractures occurring annually in the United States. These fractures are usually identified clinically when a patient presents with back pain, and a spinal radiograph is interpreted as showing a fracture of a vertebral body, most commonly in the thoracolumbar transition zone or midthoracic region.
• What are the risk fractures for incident vertebral fractures?
In addition to older age, clinical risk factors for incident vertebral fractures include prior fracture, history of one or more falls, inactivity, current smoking, use of systemic glucocorticoids (the risk increases with increasing cumulative exposure), certain chronic medical conditions (e.g., chronic obstructive pulmonary disease, seropositive rheumatoid arthritis, and Crohn’s disease), and a low body-mass index.
• What treatments are most effective to manage the pain associated with acute vertebral fracture?
Nonsteroidal antiinflammatory drugs, analgesics (including narcotics and tramadol), transdermal lidocaine, and agents used to relieve neuropathic pain (e.g., tricyclic antidepressants) are commonly used. Narcotics are often required temporarily to facilitate mobility and avoid prolonged bed rest. Small, randomized, placebo-controlled trials suggest that calcitonin (administered by intramuscular injection or as a nasal spray) may modestly reduce pain associated with acute vertebral fracture.
Table 1. Medications for Reducing the Risk of Fracture in Postmenopausal Women with Prevalent Vertebral Fractures.
Morning Report Questions
Q: Is treatment with calcium and vitamin D effective to reduce subsequent fractures?
A: All current guidelines for the management of osteoporosis recommend adequate intake of calcium (greater than/equal to 1000 mg per day) and vitamin D (greater than/equal to 600 IU per day). However, no placebo- controlled, randomized trial has shown that there is a reduced risk of incident radiographic or clinical vertebral fractures with the use of calcium alone, vitamin D alone, or calcium combined with vitamin D.
Q: What treatments are recommended to reduce the risk of both vertebral and non-vertebral fractures in patients with osteoporosis?
A: Treatment with bisphosphonates (including alendronate, risedronate, and zoledronic acid; no data are available for ibandronate), lasofoxifene, strontium, denosumab, and teriparatide, has been shown to reduce the risk of both vertebral and nonvertebral fractures.