A 71-year-old woman comes to the physician because of increasing mid-back pain for the last 2 weeks. The pain has not improved with ibuprofen and acetaminophen combined with oxycodone. The pain limits her ambulation, dressing, and housekeeping.
Her temperature is 36.5 C (97.7 F), blood pressure is 130/70 mm Hg, pulse is 86/min, and respirations are 14/min. Her back examination shows moderate tenderness in the mid-back along the vertebral column. She has an otherwise unremarkable examination.
A lateral spine film reveals diffuse osteopenia with a vertebral compression fracture of T10. Blood for a complete blood count, metabolic panel, alkaline phosphatase, and 25-hydroxy vitamin D has been obtained.
Which of the following is most likely to provide early pain relief in this patient?

Question

A 71-year-old woman comes to the physician because of increasing mid-back pain for the last 2 weeks.  The pain has not improved with ibuprofen and acetaminophen combined with oxycodone.  The pain limits her ambulation, dressing, and housekeeping.
Her temperature is 36.5 C (97.7 F), blood pressure is 130/70 mm Hg, pulse is 86/min, and respirations are 14/min.  Her back examination shows moderate tenderness in the mid-back along the vertebral column.  She has an otherwise unremarkable examination.
A lateral spine film reveals diffuse osteopenia with a vertebral compression fracture of T10.  Blood for a complete blood count, metabolic panel, alkaline phosphatase, and 25-hydroxy vitamin D has been obtained.
Which of the following is most likely to provide early pain relief in this patient?

Quizplus · Accepted Answer

This patient presents with a vertebral compression fracture, which is the most common type of osteoporotic fracture. Over 60% of osteoporotic vertebral compression fractures are clinically silent, but symptomatic patients can experience pain for 2-6 weeks or longer. The pain can radiate to the anterior abdomen and create a "girdle of pain." Many patients are successfully treated with an NSAID and acetaminophen, sometimes with an opioid. When pain persists, intranasal calcitonin is often effective. Although calcitonin is not a first-line agent to treat osteoporosis, intranasal calcitonin has been shown to significantly reduce pain from vertebral compression fractures. (Choice A) A variety of back braces are used for vertebral compression fractures, but clear-cut data demonstrating efficacy is lacking. Moreover, back braces can limit mobilization and promote disuse osteoporosis. (Choice B) Both intravenous and oral bisphosphonates are used for long-term treatment of osteoporosis and may provide pain relief over time. However, they are not effective for acute pain relief from vertebral compression fractures. (Choice C) Muscle relaxants are somewhat beneficial for nonspecific acute low back pain, but have not been demonstrated to be helpful in the management of vertebral compression fractures. (Choice E) While uncontrolled studies suggested that vertebroplasty is beneficial for symptomatic compression fractures, prospective controlled trials have failed to demonstrate efficacy. Vertebroplasty is invasive and associated with some risk due to cement leakage, including nerve injury and pulmonary embolization. Educational objective: Symptomatic vertebral compression fractures are managed acutely by NSAIDS, acetaminophen, and sometimes opioids. When this therapy fails, intranasal calcitonin for 2-4 weeks can provide symptomatic improvement. __________ References: Calcitonin for treating acute pain of osteoporotic vertebral compression fracture: A systematic review of randomized, controlled trials. (http://www.ncbi.nlm.nih.gov/pubmed/15614441) Osteoporotic compression fractures of the spine; current options and considerations for treatment. (http://www.ncbi.nlm.nih.gov/pubmed/16934715)

A 71-Year-Old Woman Comes to the Physician Because of Increasing