Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care
Diagnosis and Treatment of Adults with Osteoporotic Vertebral Fractures
Summary of Questions & Recommendations
Natural History Clinical Questions | Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence |
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Natural History Question 1: For patients with osteoporotic vertebral compression fractures managed without augmentation or surgery, what is the risk of development of long-term sequelae of vertebral compression fractures (eg, spinal deformity, respiratory compromise, gastrointestinal tract dysfunction, physical, and psychological functional impairment)? | In adults with osteoporotic vertebral compression fractures treated without augmentation or surgery, there is fair evidence to suggest that decline occurs in functional status and activities of daily living.
Grade of Recommendation: B
In adults with osteoporotic vertebral compression fractures treated without augmentation or surgery, there is poor quality evidence that there may be progressive kyphosis and loss of vertebral body height.
Grade of Recommendation: C
In adults with osteoporotic vertebral compression fractures treated without augmentation or surgery, there is poor quality evidence that there may be significant medical morbidity associated with the fracture.
Grade of Recommendation: C
In adults with osteoporotic vertebral compression fractures treated without augmentation or surgery, there is poor quality evidence that patients are at risk of additional fractures.
Grade of Recommendation: C |
Natural History Question 2: For patients with acute osteoporotic vertebral compression fractures managed without augmentation or surgery, what is the expected time to resolution of pain? | In adults with osteoporotic vertebral compression fractures treated without augmentation or surgery, there is fair evidence to suggest that significant pain improvement will occur. Time course to improvement is variable from three months to one year. In some studies, the time may be overstated due to the interval of follow-up and the time to improvement may vary due to different medical therapies.
Grade of Recommendation: B |
Natural History Question 3: For patients with acute osteoporotic vertebral compression fractures managed without augmentation or surgery, what is the risk of persistent long-term (>6 months) pain? | In adults with osteoporotic vertebral compression fractures treated without augmentation or surgery, there is fair evidence to suggest that a significant percentage of patients will have persistent long-term (greater than 6 months) pain (VAS >3). Most studies suggest approximately a third of patients (ranging from 10-40%).
Grade of Recommendation: B |
Natural History Question 4: For patients with osteoporotic vertebral compression fractures, are rates of morbidity and mortality different for those managed with augmentation or surgery versus those managed without? | There is fair evidence to suggest that the new fracture rates are not different in adults with osteoporotic vertebral compression fractures treated with augmentation or surgery as compared to medical treatment.
Grade of Recommendation: B
There is conflicting evidence that precludes making a recommendation on rates of morbidity and mortality for adults with osteoporotic vertebral compression fractures managed with augmentation or surgery compared to those managed without.
Grade of Recommendation: I
There is conflicting evidence that precludes making a recommendation for or against the impact of augmentation or surgery versus medical treatment on rate of medical complications in adults with osteoporotic vertebral compression fractures.
Grade of Recommendation: I |
Natural History Question 5: For patients with osteoporotic vertebral compression fractures managed without augmentation or surgery, are there specific variables that increase the risk for refracture of the same or other vertebral levels? | There is insufficient evidence to make a recommendation for or against the impact of diabetes, smoking, NSAIDS, low FIM score, presentation of multiple fractures, or low segmental cobb angle on risk for refracture of the same or other vertebral level in adults with osteoporotic vertebral compression fractures.
Grade of Recommendation: I |
Cost-Effectiveness Question | Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence |
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Cost-Effectiveness Question 1: In the treatment of osteoporotic vertebral compression fractures, what is the comparative cost-effectiveness of (a) medical therapy alone vs (b) vertebral augmentation vs (c) thermal ablation, radiofrequency ablation or cryoablation with or without augmentation vs (d) operative fusion/fixation? | There is insufficient evidence to make a recommendation for or against the cost effectiveness of medical treatment alone vs vertebral augmentation vs thermal ablation, radiofrequency ablation or cryoablation with or without augmentation vs operative fusion/fixation.
Grade of Recommendation: I |
Clinical Diagnosis Question | Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence |
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Clinical Diagnosis Question 1: Which elements (individual or in combination) of a history, symptoms, and/or physical examination are most sensitive and specific for identifying a patient with an acute osteoporotic vertebral compression fracture? | Presence of positive closed-fist percussion sign, supine sign, or back pain inducing test are suggested as findings on physical exam useful in identifying an adult patient with symptomatic acute osteoporotic vertebral compression fractures.
Grade of Recommendation: B
There is insufficient evidence to make a recommendation for or against a patient self-assessment screening tool to identify individuals at risk for acute osteoporotic vertebral compression fractures.
Grade of Recommendation: I |
Medical Treatment Questions | Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence |
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Medical Treatment Question 1: How do nonpharmacologic treatments (eg, bracing, physical therapy, acupuncture, massage, cannabis, exercise, etc.) compare in terms of reducing severity and duration of pain and disability in osteoporotic vertebral compression fractures? | A systematic review of the literature yielded no studies to adequately address this question. |
Medical Treatment Question 2: Do restrictions on patient activity alter outcomes in patients with osteoporotic vertebral compression fractures? | There is insufficient evidence to make a recommendation for or against immobilization or early activity in adults with acute osteoporotic vertebral compression fracture.
Grade of Recommendation: I |
Medical Treatment Question 3: Which pharmacologic treatments are effective in improving outcomes in acute osteoporotic vertebral compression fractures? | Calcitonin is suggested for relief of pain in adults with acute osteoporotic vertebral compression fractures. Grade of Recommendation: B Teriparatide is suggested for the relief of pain and improvement in quality of life in adults with acute osteoporotic vertebral compression fractures. Grade of Recommendation: B Bisphosphonates are suggested for relief of pain and improvement in quality of life in adults with acute osteoporotic vertebral compression fracture but are inferior to teriparatide. Grade of Recommendation: B There is insufficient evidence to make a recommendation for or against denosumab for relief of pain in adults with acute osteoporotic vertebral compression fractures. Grade of Recommendation: I There is insufficient evidence to make a recommendation for or against fentanyl for relief of pain in adults with acute osteoporotic vertebral compression fractures. Grade of Recommendation: I |
Medical Treatment Question 4. Does spinal manipulative treatment improve outcomes for patients with acute osteoporotic vertebral compression fractures? | A systematic review of the literature yielded no studies to adequately address this question. |
Medical Treatment Question 5: In patients presenting with symptomatic acute osteoporotic vertebral compression fractures, does medical treatment of the underlying bone loss improve long-term outcomes such as reduction in risk of future fragility fractures? | Teriparatide may be considered in adults with acute osteoporotic vertebral compression fractures to reduce the risk of future fragility fractures.
Grade of Recommendation: C
Bisphosphonates may be considered in adults with acute osteoporotic vertebral compression fractures to reduce the risk of future fragility fractures.
Grade of Recommendation: C |
Medical Treatment Question 6: Does the involvement of multiple specialties in clinical management change the outcomes of acute osteoporotic vertebral compression fractures? | A systematic review of the literature yielded no studies to adequately address this question. |
Imaging Diagnosis Questions | Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence |
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Imaging Diagnosis Question 1: Which imaging modalities and findings are most sensitive and specific for the accurate diagnosis of symptomatic osteoporotic vertebral compression fractures? | Flexion/extension radiographs are suggested as an option for diagnosing acute osteoporotic vertebral compression fractures when MRI cannot be obtained. Grade of Recommendation: B Scintigraphy (bone scan) is suggested as an alternative imaging modality to diagnose acute osteoporotic vertebral compression fractures when MRI cannot be obtained. Grade of Recommendation: B There is insufficient evidence to make a recommendation for or against dual-energy CT for the diagnosis of acute osteoporotic vertebral compression fractures. Grade of Recommendation: I There is insufficient evidence to make a recommendation for or against the use of radiographs for diagnosing acute osteoporotic vertebral compression fractures. Grade of Recommendation: I |
Imaging Question 2: Which imaging findings stratify the acuity of osteoporotic vertebral compression fractures? | It is suggested that the presence of a fluid sign or edema in dual energy CT scan can differentiate new or acute osteoporotic vertebral compression fractures from older fractures.
Grade of Recommendation: B
There is insufficient evidence to make recommendation for or against the use of the vacuum sign cleft on radiographs or bone scan to confirm a nonunion painful fracture.
Grade of Recommendation: I |
Interventional Treatment Questions | Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence |
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Interventional Treatment Question 1: Do steroid and/or anesthetic injections improve outcomes in patients with acute osteoporotic vertebral compression fractures? | There is insufficient evidence to make a recommendation for or against facet blocks in addition to percutaneous vertebroplasty compared to percutaneous vertebroplasty alone in adults with osteoporotic vertebral compression fractures. Grade of Recommendation: I There is insufficient evidence to make a recommendation for or against facet blocks with local anesthetics and corticosteroids in adults with osteoporotic vertebral compression fractures. Grade of Recommendation: I |
Interventional Treatment Question 2: What is the risk of treating multiple vertebral levels at one time, for patients with multilevel osteoporotic vertebral compression fractures? | Vertebral augmentation may be considered as a safe and effective option to treat multiple vertebral fractures during one procedure time with a low risk in adults with osteoporotic vertebral compression fractures. Grade of Recommendation: C |
Interventional Treatment Question 3: Does vertebral augmentation improve outcomes in patients with acute osteoporotic vertebral compression fractures compared to medical therapy? | Vertebral augmentation is recommended as it provides rapid and sustained clinically and statistically significant improvement in pain and function in adults with acute osteoporotic vertebral compression fractures. Grade of Recommendation: A Vertebral augmentation is suggested to improve the segmental alignment compared to medical treatment in adults with osteoporotic vertebral compression fractures. Grade of Recommendation: B There is conflicting evidence to make a recommendation for or against vertebral augmentation compared to medical treatment in terms of new, adjacent-level, or distant fractures in adults with osteoporotic vertebral compression fractures. Grade of Recommendation: I |
Interventional Treatment Question 4: Does mechanical device (an implant that includes more than a bone filler) improve outcomes in patients with symptomatic osteoporotic vertebral compression fractures compared to medical care? | A systematic review of the literature yielded no studies to adequately address this question. |
Interventional Treatment Question 5: Does the correction of vertebral height loss or segmental kyphosis during vertebral augmentation for symptomatic osteoporotic vertebral compression fractures result in improved clinical outcomes? | For adults with osteoporotic vertebral compression fractures containing vertebral cleft, it is suggested that vertebral augmentation can improve height and wedge angle, but this restoration has no significant difference in pain relief. Grade of Recommendation: B It is suggested that kyphoplasty shows improved height restoration and kyphotic angle, but degree of height restoration and kyphotic angle did not provide further improvement in pain relief or function in adults with osteoporotic vertebral compression fractures. Grade of Recommendation: B It is suggested that vertebroplasty and kyphoplasty, regardless of height restoration or kyphotic angle improvement, are equivalent in providing pain relief and improved function in adults with osteoporotic vertebral compression fractures. Grade of Recommendation: B |
Interventional Treatment Question 6: For patients with symptomatic acute osteoporotic vertebral compression fractures, what is the optimal timing for vertebral augmentation? | In adults with osteoporotic vertebral compression fractures, it is suggested that there is optimal timing for treatment with vertebral augmentation and delayed treatment is associated with worse clinical outcomes. Grade of Recommendation: B |
Interventional Treatment Question 7: Does vertebral augmentation improve clinical outcomes in patients with back pain and an intravertebral cleft on imaging of chronic osteoporotic vertebral compression fractures?
| There is insufficient evidence to make a recommendation for or against the use of vertebral augmentation to improve back pain in adults with osteoporotic vertebral compression fractures with or without intravertebral clefts in nonacute osteoporotic vertebral compression fractures.
Grade of Recommendation: I |
Interventional Treatment Question 8: Are there specific characteristics of the fracture or the patient that influence outcomes in patients with osteoporotic compression fractures undergoing vertebral augmentation | Patient Factors
It is suggested that decreased bone mineral density is associated with an increased risk of further fractures (new or recollapse) after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: B
It is suggested that increasing age and female sex are associated with increased risk of further fractures (new or recollapse) after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: B
It is suggested that multiple preexisting vertebral fractures are associated with increased risk of further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: B
It is suggested that lower serum 25(OH)D levels are associated with increased risk of further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: B
It is suggested that lower BMI is associated with increased risk of further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: B
Comorbidities may be considered as a factor in increased risk of further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: C
There is insufficient evidence to make a recommendation for or against the use of various biomedical markers as risk factors for further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: I
There is insufficient evidence to make a recommendation for or against the effect of long-term steroid use on the outcome of vertebral augmentation for osteoporotic vertebral compression fractures.
Grade of Recommendation: I
There is insufficient evidence to make a recommendation for or against the impact of high preop sacral inclination and high spinal deformity index in evaluating risk of further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: I
There is insufficient evidence to make a recommendation for or against the impact of activity level in evaluating risk of further fractures after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: I
There is insufficient evidence to make a recommendation for or against the impact of ASA score in predicting VAS scores after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: I
There is insufficient evidence to make a recommendation for or against the impact of ASA score in predicting risk of mortality after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: I
Fracture Factors
It is suggested that intravertebral cleft (IVC) is associated with poor outcomes after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: B
It is suggested that higher preoperative kyphotic angle is associated with inferior/poor outcomes, such as new vertebral compression fractures and VAS/RMDQ scores, after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: B
It is suggested that vertebral compression fractures located in the thoracolumbar junction are associated with a higher risk of new vertebral compression fractures, and also have progressive kyphosis and neurological complications after vertebral augmentation of osteoporotic vertebral compression fractures.
Grade of Recommendation: B
It is suggested that a greater degree of vertebral body edema on preoperative MRI is associated with better outcomes in patients treated with vertebral augmentation for osteoporotic vertebral compression fractures.
Grade of Recommendation: B
There is insufficient evidence to make a recommendation for or against type of fracture or shape as a risk factor for progressive kyphosis and secondary AVF in patients with osteoporotic vertebral compression fractures underdoing vertebral augmentation.
Grade of Recommendation: I
There is insufficient evidence to make a recommendation for or against the presence of osteonecrosis being predisposing factors for recollapse in adults undergoing vertebroplasty for osteoporotic vertebral compression fractures.
Grade of Recommendation: I
cThere is insufficient evidence for or against the occurrence of intradiscal cement leakage in the presence of high signal T2 intensity in the adjacent disc in the absence of endplate cortical disruption.
Grade of Recommendation: I
There is insufficient evidence for or against IVC and posterior fascia edema being associated with residual back pain after vertebral augmentation in adults with osteoporotic vertebral compression fractures.
Grade of Recommendation: I
There is insufficient evidence for or against adjacent segment alignment and thoracolumbar alignment being associated with adjacent level fractures after vertebral augmentation in adults with osteoporotic vertebral compression fractures.
Grade of Recommendation: I
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Surgical Treatment Questions | Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence |
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Surgical Question 1: Does instrumented fusion improve outcomes in patients with acute osteoporotic vertebral compression fractures compared to nonoperative care or interventional procedures? | In adults with osteoporotic vertebral compression fractures with burst morphology, both vertebral augmentation and instrumented fusion may be considered as treatment options as they appear to provide similar clinical outcomes. Grade of Recommendation: C There is conflicting evidence to make a recommendation for or against instrumented fusion in adults with acute osteoporotic vertebral compression fractures compared to interventional procedures with respect to radiological outcomes. Grade of Recommendation: I |
Surgical Question 2: What are the clinical or radiological indications for recommending open surgical procedures in patients with acute osteoporotic vertebral compression fractures? | A systematic review of the literature yielded no studies to adequately address this question. |
Surgical Question 3: Does the use of minimally invasive surgical approaches (eg, percutaneous pedicle screws, muscle-sparing decompression/arthrodesis techniques) improve outcomes compared to open surgical approaches in patients undergoing surgery for acute osteoporotic vertebral compression fractures? | There is insufficient evidence to make a recommendation for or against minimally invasive surgical approaches compared to open surgical approaches in adults undergoing surgery for acute osteoporotic vertebral compression fractures. Grade of Recommendation: I |
Surgical Question 4: What are the risk factors for adjacent vertebral body fractures after surgical intervention in patients with osteoporotic vertebral compression fractures? | There is insufficient evidence to identify risk factors for adjacent vertebral body fractures after surgical intervention in adults with osteoporotic vertebral compression fractures. Grade of Recommendation: I |
Surgical Question 5: Are there specific characteristics of the fracture or the patient that influence outcomes in patients with osteoporotic vertebral compression fractures undergoing surgical treatment? | Spine care providers may consider preoperative hypoalbuminemia* as associated with an increased risk of postoperative mortality in adults undergoing surgical treatment for osteoporotic vertebral compression fractures.
Grade of Recommendation: C
There is insufficient evidence to make a recommendation regarding other patient or fracture characteristics affecting outcomes after surgical intervention for osteoporotic vertebral compression fractures.
Grade of Recommendation: I |
Surgical Question 6: In patients undergoing surgery for symptomatic osteoporotic vertebral compression fractures, are clinical and radiological outcomes affected by the types of implants used? | PMMA screw augmentation may be considered as an option to reduce the risk of postoperative screw loosening in adults undergoing surgery for osteoporotic vertebral compression fractures.
Grade of Recommendation: C
There is insufficient evidence to make a recommendation for or against the use of anterior vs posterior vs anterior plus posterior techniques in adults with neurological deficits undergoing surgery for osteoporotic vertebral compression fractures.
Grade of Recommendation: I |
*See work group narrative in full text for cautionary statement regarding the interpretation of hypoalbuminemia.