Osteoporosis International

, Volume 19, Issue 7, pp 895–903

Back pain in osteoporotic vertebral fractures

  • R. M. Francis
  • T. J. Aspray
  • G. Hide
  • A. M. Sutcliffe
  • P. Wilkinson



This review article examines the epidemiology and pathogenesis of back pain and vertebral fractures in osteoporosis, reviewing the management of pain in patients with vertebral fractures and the direct and indirect effect of osteoporosis treatments on back pain.


The management of patients with vertebral fractures has largely concentrated on the prevention of further fractures by the treatment of underlying osteoporosis, with drug treatment for acute and chronic back pain and the non-pharmacological management of vertebral fractures receiving less attention.


Emerging evidence suggests that, in addition to reducing the incidence of vertebral fractures, calcitonin, intravenous bisphosphonates and teriparatide may also have a direct effect on bone pain. Targeted analgesia, tailored to individual need is often required in both the acute and chronic phases following vertebral fracture. Vertebroplasty and kyphoplasty have also been approved for use in the management of vertebral fractures and may prove useful in selected patients unresponsive to conventional pain relief. There is some evidence to support the use of individualised tailored exercise programmes aimed at strengthening back muscles to maintain bone density and reduce further fracture incidence. In addition the use of specific orthoses may help to reduce kyphosis, improve mobility and reduce pain.


Chronic back pain associated with vertebral fracture provides a great challenge to health care professionals and the patient. This demands a combination of options, including not only therapeutic interventions, but also physiotherapy, psychological support and patient education.


Back pain Exercise Osteoporosis Pain management Spinal orthoses Vertebral fractures 


  1. 1.
    NIH Conference Development Panel (2001) Osteoporosis prevention, diagnosis and therapy. JAMA 285:785–795CrossRefGoogle Scholar
  2. 2.
    Cooper C (1993) Epidemiology and public health impact of osteoporosis. Baillere Clin Rheumatol: Osteoporosis 7:459–477CrossRefGoogle Scholar
  3. 3.
    McNally EG, Wilson DJ, Ostlere SJ (2001) Limited magnetic resonance imaging in low back pain instead of plain radiographs: experience with first 1000 cases. Clin Radiol 56:922–925PubMedCrossRefGoogle Scholar
  4. 4.
    Bingefors K, Isacson D (2004) Epidemiology, co-morbidity, and impact on health-related quality of life of self-reported headache and musculoskeletal pain - a gender perspective. Eur J Pain 8:435–450PubMedCrossRefGoogle Scholar
  5. 5.
    Roy DK, O’Neill DW, Finn JD et al (2003) Determinants of incident vertebral fracture in men and women: results from the European Prospective Osteoporosis Study (EPOS). Osteoporos Int 14:19–26PubMedCrossRefGoogle Scholar
  6. 6.
    O’Neill TW, Felsenberg D, Varlow J et al (1996) The prevalence of vertebral deformity in European men and women: the European Vertebral Osteoporosis Study. J Bone Miner Res 11:1010–1018PubMedCrossRefGoogle Scholar
  7. 7.
    van Staa TP, Dennison EM, Leufkens HG et al (2001) Epidemiology of fractures in England and Wales. Bone 29:517–522PubMedCrossRefGoogle Scholar
  8. 8.
    Silverman SL, Piziak VK, Chen P et al (2005) Relationship of health related quality of life to prevalent and new or worsening back pain in postmenopausal women with osteoporosis. J Rheumatol 32:2405–2409PubMedGoogle Scholar
  9. 9.
    Scane AC, Francis RM, Sutcliffe AM et al (1999) Case-control study of the pathogenesis and sequelae of symptomatic vertebral fractures in men. Osteoporos Int 9:91–97PubMedCrossRefGoogle Scholar
  10. 10.
    Dolan P, Torgerson D (1998) The cost of treating osteoporotic fractures in the UK female population. Osteoporos Int 8:611–617PubMedCrossRefGoogle Scholar
  11. 11.
    Nevitt MC, Ettinger B, Black DM et al (1998) The association of radiographically detected vertebral fractures with back pain and function: a prospective study. Ann Intern Med 128:793–800PubMedGoogle Scholar
  12. 12.
    Jalava T, Sarna S, Pylkkanen L et al (2003) Association between vertebral fracture and increased mortality in osteoporotic patients. J Bone Miner Res 18:1254–1260PubMedCrossRefGoogle Scholar
  13. 13.
    Kado DM, Browner WS, Palermo L et al (1999) Vertebral fractures and mortality in older women: a prospective study. Study of Osteoporotic Fractures Research Group. Arch Intern Med 159:1215–1220PubMedCrossRefGoogle Scholar
  14. 14.
    Black D, Arden NK, Palermo L et al (1999) Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist factures. J Bone Miner Res 14:821–828PubMedCrossRefGoogle Scholar
  15. 15.
    Lindsay R, Silverman SL, Cooper C et al (2001) Risk of new vertebral fracture in the year following a fracture. JAMA 285:320–323PubMedCrossRefGoogle Scholar
  16. 16.
    Lee YL, Yip KM (1996) The osteoporotic spine. Clin Orthop Relat Res 323:91–97PubMedCrossRefGoogle Scholar
  17. 17.
    Lyritis GP, Mayasis B, Tsakalakos N et al (1989) The natural history of the osteoporotic vertebral fracture. Clin Rheumatol 8(Suppl 2):66–69PubMedCrossRefGoogle Scholar
  18. 18.
    Hordon LD, Francis RM, Marshall DH et al (1986) Are scintigrams of the spine useful in vertebral osteoporosis? Clin Radiol 37:487–489PubMedCrossRefGoogle Scholar
  19. 19.
    Royal College of General Practitioners (1996) Clinical guidelines for the management of acute low back painGoogle Scholar
  20. 20.
    WHO guidelines: cancer pain relief, 2nd edn (1996) World Health Organization, GenevaGoogle Scholar
  21. 21.
    Pincus T, Burton AK, Vogel S et al (2002) A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine 27:109–120CrossRefGoogle Scholar
  22. 22.
    Linton SJ (2002) A prospective study of the effects of sexual or physical abuse on back pain. Pain 96:347–351PubMedCrossRefGoogle Scholar
  23. 23.
    Mercado AC, Carroll LJ, Cassidy JD et al (2005) Passive coping is a risk factor for disabling neck or low back pain. Pain 117:51–57PubMedCrossRefGoogle Scholar
  24. 24.
    Thomas E, Silman AJ, Croft PR et al (1999) Predicting who develops chronic low back pain in primary care: a prospective study. Br Med J 318:1662–1667Google Scholar
  25. 25.
    Main CJ, Spanswick, CC, Watson P (2000) The nature of disability. In: Main C, Spanswick C (eds) Pain management. Churchill Livingstone, London, pp 337–356Google Scholar
  26. 26.
    Smith LA, Oldman AD, McQuay HJ, Moore RA et al (2000) Teasing apart quality and validity in systematic reviews: an example from acupuncture trials in chronic neck and back pain. Pain 86:119–132PubMedCrossRefGoogle Scholar
  27. 27.
    Ernst E, White AR (1998) Acupuncture for back pain: a meta-analysis of randomised controlled trials. Arch Int Med 158:2235–2241CrossRefGoogle Scholar
  28. 28.
    Koes BK, Scholten RJPM, Mens JMA et al (1997) Efficacy of non-steroidal anti-inflammatory drugs for low back pain: a systematic review of randomised clinical trials. Ann Rheum Dis 56:214–223PubMedCrossRefGoogle Scholar
  29. 29.
    Mason KL, Moore RA, Derry S et al (2004) Systematic review of topical capsaicin for the treatment of chronic pain. Br Med J 328:991–994CrossRefGoogle Scholar
  30. 30.
    Staiger TO, Gaster B, Sullivan MD et al (2003) Systematic review of antidepressants in the treatment of chronic low back pain. Spine 28:2540–2545PubMedCrossRefGoogle Scholar
  31. 31.
    Reeve J, Menon D, Corabian P (1996) Transcutaneous electrical nerve stimulation (TENS): a technology assessment. Int J Technol Assess Health Care 12:299–324PubMedGoogle Scholar
  32. 32.
    Maier C, Hildebrandt J, Klinger R et al; MONTAS Study Group (2002) Morphine responsiveness, efficacy and tolerability in patients with chronic non-tumor associated pain - results of a double-blind placebo-controlled trial (MONTAS). Pain 97:223–233PubMedCrossRefGoogle Scholar
  33. 33.
    Watts RW, Silagy CA (1995) A meta-analysis on the efficacy of epidural corticosteroids in the treatment of sciatica. Anaesth Intensive Care 23:564–569PubMedGoogle Scholar
  34. 34.
    Turner JA, Loeser JD, Bell KG (1995) Spinal cord stimulation for chronic low back pain; a systematic literature synthesis. Neurosurgery 37:1088–1096PubMedCrossRefGoogle Scholar
  35. 35.
    Morley S, Eccleston C, Williams A (1999) Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 80:1–13PubMedCrossRefGoogle Scholar
  36. 36.
    Koes BW, Bouter LM, Beckerman H et al (1991) Physiotherapy exercises and back pain: a blinded review. Br Med J 302:1572–1576Google Scholar
  37. 37.
    van Tulder M, Malmivaara A, Esmail R et al (2000) Exercise therapy for low back pain: a systematic review within the framework of the cochrane collaboration back review group. Spine 25:2784–2796PubMedCrossRefGoogle Scholar
  38. 38.
    Haldorsen EM, Grasdal AL, Skouen JS et al (2002) Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain. Pain 95:49–63PubMedCrossRefGoogle Scholar
  39. 39.
    Watson PJ, Booker CK, Moores L et al (2004) Returning the chronically unemployed with low back pain to employment. Eur J Pain 8:359–369PubMedCrossRefGoogle Scholar
  40. 40.
    Paier GS (1996) Specter of the crone; the experience of vertebral fracture. Adv Nurs Sci 18:27–36Google Scholar
  41. 41.
    Begerow B, Pfeifer M, Pospeschill M et al (1999) Time since vertebral fracture: an important variable concerning quality of life in patients with postmenopausal osteoporosis. Osteoporos Int 10:26–33PubMedCrossRefGoogle Scholar
  42. 42.
    Wright A (1998) Nursing interventions with advanced osteoporosis. Home Healthcare Nurse 16:144–151PubMedCrossRefGoogle Scholar
  43. 43.
    Jensen AL, Harder I (2004) The osteoporotic pain experience. Osteoporos Int 15:204–208PubMedCrossRefGoogle Scholar
  44. 44.
    Lyritis GP, Tsakalakos N, Magiasis B et al (1991) Analgesic effect of salmon calcitonin in osteoporotic vertebral fractures: a double-blind placebo-controlled clinical study. Calcif Tissue Int 49:369–372PubMedCrossRefGoogle Scholar
  45. 45.
    Lyritis GP, Paspati I, Karachalios T et al (1997) Pain relief from nasal salmon calcitonin in osteoporotic vertebral crush fractures. A double blind, placebo-controlled clinical study. Acta Orthop Scand Suppl 275:112–114PubMedGoogle Scholar
  46. 46.
    Knopp JA, Diner BM, Blitz M et al (2005) Calcitonin for treating acute pain of osteoporotic vertebral compression fractures: a systematic review of randomized, controlled trials. Osteoporos Int 16:1281–1290PubMedCrossRefGoogle Scholar
  47. 47.
    Gennari C (2002) Analgesic effect of calcitonin in osteoporosis. Bone 30(Suppl 5):67S–70SPubMedCrossRefGoogle Scholar
  48. 48.
    Rovetta G, Monteforte P, Balestra V (2000) Intravenous clodronate for acute pain induced by osteoporotic vertebral fracture. Drugs Exp Clin Res 26:25–30PubMedGoogle Scholar
  49. 49.
    Abdulla AJ (2000) Use of pamidronate for acute pain relief following osteoporotic vertebral fractures. Rheumatology 39:567–568PubMedCrossRefGoogle Scholar
  50. 50.
    Kawabata A, Kawao N, Hironaka Y et al (2006) Antiallodynic effect of etidronate, a bisphosphonate, in rats with adjuvant-induced arthritis: involvement of ATP-sensitive K+ channels. Neuropharmacology 51:182–190PubMedCrossRefGoogle Scholar
  51. 51.
    Genant HK, Halse J, Briney WG et al (2005) The effects of teriparatide on the incidence of back pain in postmenopausal women with osteoporosis. Curr Med Res Opin 21:1027–1034PubMedCrossRefGoogle Scholar
  52. 52.
    Nevitt MC, Chen P, Dore RK et al (2006) Reduced risk of back pain following teriparatide treatment: a meta-analysis. Osteoporos Int 17:273–280PubMedCrossRefGoogle Scholar
  53. 53.
    Ringe JD, Dorst A, Faber H et al (2004) Superiority of alfacalcidol over plain vitamin D in the treatment of glucocorticoid-induced osteoporosis. Rheumatol Int 24:63–70PubMedCrossRefGoogle Scholar
  54. 54.
    National Institute for Clinical Excellence (2003) Percutaneous vertebroplasty. Interventional Procedure Guidance 12Google Scholar
  55. 55.
    National Institute for Clinical Excellence (2006) Balloon kyphoplasty for vertebral compression fractures. Interventional Procedure Guidance 166Google Scholar
  56. 56.
    Grados F, Depriester C, Cayrolle G et al (2000) Long-term observations of vertebral osteoporotic fractures treated by percutaneous vertebroplasty. Rheumatology (Oxford) 39:1410–1414CrossRefGoogle Scholar
  57. 57.
    Álvarez L, Alcaraz M, Pérez-Higueras A et al (2006) Percutaneous vertebroplasty: functional improvement in patients with osteoporotic compression fractures. Spine 31:1113–1118PubMedCrossRefGoogle Scholar
  58. 58.
    Diamond TH, Bryant C, Browne L et al (2006) Clinical outcomes after acute osteoporotic vertebral fractures: a 2-year non-randomised trial comparing percutaneous vertebroplasty with conservative therapy. Med J Aust 184:113–117PubMedGoogle Scholar
  59. 59.
    Voormolen MH, Mali WP, Lohle PN et al (2007) Percutaneous vertebroplasty compared with optimal pain medication treatment: short-term clinical outcome of patients with subacute or chronic painful osteoporotic vertebral compression fractures. The VERTOS study. Am J Neuroradiol 28:555–560PubMedGoogle Scholar
  60. 60.
    Crandall D, Slaughter D, Hankins PJ et al (2004) Acute versus chronic vertebral compression fractures treated with kyphoplasty: early results. Spine J 4:418–424PubMedCrossRefGoogle Scholar
  61. 61.
    Grafe IA, Da Fonseca K, Hilleier J et al (2005) Reduction of pain and fracture incidence after kyphoplasty: 1-year outcomes of a prospective controlled trial of patients with primary osteoporosis. Osteoporos Int 16:2005–2012PubMedCrossRefGoogle Scholar
  62. 62.
    Shindle MK, Gardner MJ, Koob J et al (2006) Vertebral height restoration in osteoporotic compression fractures: kyphoplasty balloon tamp is superior to postural correction alone. Osteoporos Int 17:1815–1819PubMedCrossRefGoogle Scholar
  63. 63.
    Dublin AB, Hartman J, Latchaw RE et al (2005) The vertebral body fracture in osteoporosis: restoration of height using percutaneous vertebroplasty. Am J Neuroradiol 26:489–492PubMedGoogle Scholar
  64. 64.
    Trout AT, Kallmes DF, Layton KF et al (2006) Vertebral endplate fractures: an indicator of the abnormal forces generated in the spine after vertebroplasty. J Bone Miner Res 21:1797–1802PubMedCrossRefGoogle Scholar
  65. 65.
    Donovan MA, Khandji AG, Siris E (2004) Multiple adjacent vertebral fractures after kyphoplasty in a patient with steroid-induced osteoporosis. J Bone Miner Res 19:712–723PubMedCrossRefGoogle Scholar
  66. 66.
    Pfeifer M, Begerow B, Minne HW (2004) Effects of a new spinal orthosis on posture, trunk strength and quality of life in women with postmenopausal osteoporosis. A Randomised Controlled Trial. Am J Phy Med Rehabil 83:177–186CrossRefGoogle Scholar
  67. 67.
    Sinaki M, Mikkelsen BA (1984) Postmenopausal spinal osteoporosis flexion v extension exercises. Arch Phys Med Rehabil 65:593–596PubMedGoogle Scholar
  68. 68.
    Sinaki M, Itoi E, Wahner HW et al (2002) Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow up of postmenopausal women. Bone 30:836–841PubMedCrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2007

Authors and Affiliations

  • R. M. Francis
    • 1
    • 4
  • T. J. Aspray
    • 2
  • G. Hide
    • 3
  • A. M. Sutcliffe
    • 4
  • P. Wilkinson
    • 5
  1. 1.School of Clinical Medical SciencesUniversity of NewcastleNewcastle upon TyneUK
  2. 2.Sunderland Royal HospitalSunderlandUK
  3. 3.Department of RadiologyFreeman HospitalNewcastle upon TyneUK
  4. 4.Musculoskeletal UnitFreeman HospitalNewcastle upon TyneUK
  5. 5.Pain Management UnitRoyal Victoria InfirmaryNewcastle upon TyneUK

Personalised recommendations