Q J Med 2004; 97: 63-74
© Association of Physicians 2004; all rights reserved.
Review |
Acute and long-term management of patients with vertebral fractures
From the 1Department of Medicine (Geriatrics), University of Newcastle upon Tyne, 2Department of Medicine for the Elderly, North Tyneside General Hospital, North Shields, 3Department of Rheumatology, University Hospital of North Durham, Durham, 4Department of Rheumatology, Wansbeck General Hospital, Ashington, 5Department of Rheumatology, Hartlepool General Hospital, 6Department of Rheumatology, James Cook University Hospital, Middlesbrough, 7Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, and 8Department of Geriatric Medicine, South Tyneside District Hospital, South Shields, UK
Symptomatic vertebral fractures are associated with significant morbidity, excess mortality and health and social service expenditure. Up to 20% of patients with an incident vertebral fracture experience a further vertebral fracture within one year. It is therefore important that vertebral fractures are detected early, and treatment considered as soon as possible.
Only a third of vertebral fractures come to medical attention, where they typically present with acute back pain, but other presentations include loss of height and increasing kyphosis. Spine X-rays should then be performed to confirm the diagnosis and exclude other pathology.
Bone density measurements are not essential before starting treatment for osteoporosis in patients with low-trauma vertebral fractures, but may be useful to confirm osteoporosis when there is uncertainty about previous trauma. They may also aid in selecting the most appropriate therapy and monitoring response to treatment.
Up to 30% of women and 55% of men with symptomatic vertebral crush fractures have underlying secondary osteoporosis, where treatment may lead to large increases in bone density. These conditions should therefore be sought by medical history, physical examination and appropriate investigations.
The management of patients with acute vertebral fractures should include measures to reduce pain and improve mobility, as well as starting treatment for osteoporosis. Treatments have now been shown in randomized controlled trials to improve bone density and reduce the incidence of vertebral and non-vertebral fractures in patients with osteoporosis. Choice of treatment will depend on the underlying causes of bone loss, efficacy in any particular situation, cost, patient preference and the potential non-skeletal advantages and disadvantages.
Address correspondence to Dr R.M. Francis, Musculoskeletal Unit, Freeman Hospital, Newcastle upon Tyne, NE7 7DN. e-mail: RMFrancis{at}compuserve.com