The orthopedic surgeon and hospitalist taking care of Mother (she’s 83-years-old) aren’t seeing eye-to-eye on how she should be treated. She has a compression fracture of the spine from osteoporosis. All the discussions have been very cordial but it looks like it might be up to us as the family to cast the deciding vote. What can you tell us about this problem?

The American Academy of Orthopaedic Surgeons (AAOS) has just released Clinical Practice Guidelines (CPGs) for the treatment of symptomatic (painful) spinal compression fractures. A brief summary of these guidelines is presented. These guidelines are based on research, published studies, and the resulting evidence currently available. The AAOS points out that all guidelines are intended to be used as one tool in the treatment decision. All patient characteristics and individual factors must be taken into consideration when making the final decision.

Compression fractures are the most common type of fracture affecting the spine. A compression fracture of a spine bone (vertebra) causes the bone to collapse in height. Compression fractures are commonly the result of osteoporosis (brittle bones).

The majority of patients with compression fractures are treated conservatively (without surgery). Most compression fractures heal within eight weeks with simple remedies of medicine, rest, and a special back brace. Treatment recommendations for bed rest are not supported by enough evidence to make a strong case for or against them. The evidence is said to be weak or inconclusive.

Medications are used to control pain. Although medications can help ease pain, they are not designed to heal the fracture. With pain under control, patients find it easier to get up and move about, avoiding the problems that come from remaining immobile in bed. There is moderate support for acute fractures to be treated in the first four weeks with calcitonin.

Calcitonin is a non-sex, non-steroid hormone. Calcitonin binds to osteoclasts (the bone cells that reabsorb bone). It decreases osteoclast numbers and activity levels. The end result is that it prevents bone from melting away. It doesn’t build up missing bone but it at least keeps the bone that’s there from being broken down and reabsorbed.

Calcitonin is available in a nasal spray and should be used for osteoporotic spinal fractures within five days of the injury. Calcitonin has been shown to relieve pain when tested in four different positions (e.g., in bed, sitting, standing, and walking).

A special back brace, called an orthosis may be prescribed. This type of brace is molded to the patient’s body. It limits spine movement in general, though the brace is usually fashioned to keep patients from bending forward. This protects the fractured vertebral body so it can heal. Patients who wear a brace may be advised to move about but to limit strenuous activities, such as lifting and bending.

Generally, a combination of conservative measures are used in the treatment of this condition. If the patient fails to respond and continues to experience moderate-to-severe pain or pain that limits function, then surgery may be considered.