Spinal Compression Fracture

Elderly female with history of osteoporosis, multiple myeloma presents with acute onset midline back pain status post fall. Reports recent coughing, heavy lifting prior to injury. No sensory deficits, focal weakness, clonus on exam.

• Obtain CBC, CMP, 25-hydroxyvitamin D

• Consider MRI if focal neurologic deficits develop

• Schedule DEXA scan to assess future fracture risk

• Pain management

  • Acetaminophen, ibuprofen

  • Administer intranasal calcitonin 200 units (1 spray) in one nostril once daily x 4 weeks

  • Consider tramadol 50 mg q6h for additional pain control

  • DEXA scan T-score indicating osteoporosis:

    • Start alendronate 70 mg once weekly

    • Patient advised to take alendronate in the morning and remain upright for ≥ 30 minutes before any additional PO intake, including medications

Notes

• Risk factors

  • Medical conditions: Osteoporosis, multiple myeloma

  • Fracture generally occurs following coughing, heavy lifting, or fall

• Evaluation

  • Obtain testosterone levels for compression fractures that occur in men

  • MRI indicated for neurologic deficits, e.g. sensory deficits, focal weakness, clonus

• Treatment

  • Calcitonin treats short term pain, i.e. < 4 weeks

  • Bisphosphonates (e.g. alendronate) treat osteoporosis and prevent recurrent fractures

  • Weak evidence for kyphoplasty

  • Strong evidence against vertebroplasty