Vertebral fragility fractures in osteoporosis – A comprehensive review on its management

Introduction: Approximately 20% of individuals older than 50 years of age have been reported to present with vertebral fragility fractures (VFF) – a prevalence which is anticipated to steadily increase in future. VFF is associated with disabling pain, significant impairment of quality of life, reduced ambulatory capacity, impaired social interactions, and poor quality of sleep. Early detection, appropriate management, evaluation of osteoporosis, and prevention of future fragility fractures would form the crux of treatment. Nevertheless, there is no consensus on what constitutes the ideal management protocol for symptomatic VFF. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used to prepare this review. A detailed review of the literature was performed using PubMed, EMBASE, MEDLINE, and Cochrane Database of Systematic Reviews, which were searched for eligible studies with terms “treatment of VEF,” “osteoporotic vertebral fracture (OVF),” “management of osteoporotic compression fracture,” “imaging in OVF,” “percutaneous vertebral augmentation,” and “conservative treatment of OVF” from inception to November 2021. Duplicate studies, case reports, and letters to the editor were excluded from the study. Results: A total of 286 studies were identified using our search criteria. Of these, 142 were duplicates and 107 did not meet inclusion criteria. After removal of these articles through various stages of screening, a total of 37 studies were finally included in the review. Plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) are helpful in the diagnosis, evaluation, and management of these fractures. Radiologically, unstable VFFs need to be identified based on the following criteria (>50% vertebral height loss, kyphosis ≥25–35°, substantial retropulsion of bony fragments, significant bony, or ligamentous posterior column injuries). Conservative treatment (which includes analgesics, orthoses, and early mobilization) has remained the traditional way of treating these fractures. More recent systematic reviews have demonstrated a significant improvement in early pain control, vertebral height restoration, and ambulation with percutaneous augmentation (PKP or PVP) procedures. These studies have recommended cement augmentation in patients with intractable pain, not responding to medications. Surgical stabilization is recommended in elderly patients with pseudoarthrosis, substantial intervertebral instability, intractable pain with vertebral collapse, neurological deficit, and kyphosis. The need for long-term medical therapy to improve the bone density cannot be understated. Conclusion: A high index of suspicion is necessary to diagnose VFFs in elderly patients with back pain. Conservative treatment has remained the traditional way of treating these fractures. Recent evidence shows early pain control and better vertebral height restoration with cement augmentation procedures (PKP or PVP). Open surgical stabilization can be helpful in a subset of patients with substantial intervertebral instability, deformity, and neuro-deficit.