A 78-year-old woman is brought to the emergency department after experiencing a sudden, sharp pain in her mid-back while reaching into her dryer to fold laundry. She denies any falls or direct trauma. Her medical history is significant for osteoporosis, for which she was prescribed alendronate, though she discontinued it two years ago due to gastroesophageal reflux. On physical examination, there is point tenderness over the T12 spinous process. Neurological examination reveals 5/5 strength in all muscle groups of the lower extremities, intact sensation to light touch in all dermatomes, and symmetric 2+ patellar and Achilles reflexes. Plain radiography of the thoracic spine reveals a loss of approximately 30% of the anterior height of the T12 vertebral body compared to the posterior height.
Which of the following is the most appropriate initial management for this patient?
The correct answer is:
B) Early mobilization and non-opioid analgesics
This patient is presenting with an acute vertebral compression fracture, the most common complication of osteoporosis. These fractures often occur with minimal or no trauma (e.g., coughing, lifting, or bending). The classic radiographic finding is an anterior wedge fracture, where the anterior height of the vertebral body is reduced while the posterior height is relatively preserved. In the absence of neurological deficits, which are rare because the spinal canal is usually not compromised) the most appropriate initial management is conservative therapy. This includes early mobilization to prevent complications of immobility like DVT or pneumonia, physical therapy, and pain management with non-opioid analgesics (e.g., NSAIDs or acetaminophen).
Answer choice A: Calcitonin nasal spray, is incorrect. While intranasal calcitonin has some analgesic properties specifically for the bone pain associated with acute vertebral compression fracture, it is considered a second-line or adjunctive treatment. It is not the primary initial management strategy compared to mobilization and standard analgesics.
Answer choice C: Kyphoplasty, is incorrect. Kyphoplasty and vertebroplasty are percutaneous procedures involving the injection of bone cement into the vertebral body. While they may be considered for patients with debilitating pain that fails to improve with conservative management, they are not indicated as the first-line therapy in the acute setting for an uncomplicated fracture.
Answer choice D: Strict bed rest for 2 weeks, is incorrect. Prolonged bed rest is contraindicated in the elderly, as it rapidly leads to muscle atrophy, pressure ulcers, and a further decrease in bone mineral density. It also significantly increases the risk of venous thromboembolism.
Answer choice E: Thoracolumbosacral orthosis (TLSO) brace, is incorrect. While bracing can be used for more unstable spinal fractures or for pain control in some patients, it is generally not required for stable osteoporotic wedge fractures and can be poorly tolerated by elderly patients. It has not been shown to improve long-term outcomes in typical compression fractures.
Key Learning Point
Vertebral compression fractures are a hallmark of osteoporosis and typically present with localized point tenderness after minimal trauma. In the absence of neurological compromise, initial management is conservative, focusing on pain control and early mobilization to prevent the complications of immobility.
