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Section 8: Management of symptomatic osteoporotic vertebral fractures
- 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
- 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).
- 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
- 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).
- When a patient is in pain it may be advisable to initially perform exercise
for back extensors in an unloaded position (Conditional recommendation).
- 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).
- 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).
- 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).
- Analgesia for acute pain is important to allow restoration of function and
mobility but must be used safely 280,
282; (Evidence level IIa).
- 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 283; (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 284.
There is no evidence that salmon calcitonin is an effective treatment for chronic pain associated with
vertebral fractures283; (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
- 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 285; (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.
- Physiotherapist supervised exercise following vertebral fracture improves
pain and physical performance286;
(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 287
; (Evidence level Ia).
- Combining exercise with physiotherapy-delivered education and guidance can
reduce fear of falling and improve psychological symptoms associated with vertebral fractures 163,288;
(Evidence level Ia).
- 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 287
. There is currently no evidence that bracing with soft or rigid external orthoses improves fracture
healing 289. Hence, routine use of bracing for the
treatment of acute or subacute vertebral fractures cannot be recommended (Evidence level Ia).
- 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 287,290;
(Evidence level Ia).
- 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
291; (Evidence level IIb).
- Patients with a recent vertebral fracture have high imminent risk of
further fragility fracture 51; (Evidence level
- If a vertebral fracture is associated with impending or existing
neurological deficits, urgent referral to spinal surgical services is indicated.