DÄ internationalArchive40/2021Osteoporotic Fractures of the Thoracic and Lumbar Vertebrae

Original article

Osteoporotic Fractures of the Thoracic and Lumbar Vertebrae

A systematic review

Dtsch Arztebl Int 2021; 118: 670-7. DOI: 10.3238/arztebl.m2021.0295

Spiegl, U; Bork, H; Grüninger, S; Maus, U; Osterhoff, G; Scheyerer, M J; Pieroh, P; Schnoor, J; Heyde, C; Schnake, K J

Background: The prevalence of osteoporotic vertebral body fractures in Europe is 18–26%. Although most of these injuries can be treated conservatively, the underlying concepts have not been defined clearly or uniformly. In this article, we present the current state of the evidence on the diagnosis and conservative treatment of osteoporotic fractures of the thoracic and lumbar vertebrae.

Methods: A systematic review of the literature up to May 2020 was carried out in the PubMed and Web of Science Core Collection databases. 549 articles were identified, of which 36 were suitable for inclusion in the review. Articles were sought in the areas of diagnosis, provision of physical aids, pharmacotherapy, physiotherapy, and treatments from the realm of alternative medicine.

Results: The primary diagnostic technique was conventional x-ray in two planes (with the patient standing, if possible), which had 51.3% sensitivity and 75% specificity. If a fracture was suspected, magnetic resonance imaging (MRI) of the entire spine and regional computed tomography (CT) were carried out. The overall state of the evidence on treatment is poor; the best available evidence is for exercise therapy and physiotherapy, which are supported by three level I and four level II studies. Improvements were seen mainly in mobility and a reduced fear of falling. The use of an active orthosis can be useful as well. No evidence was found on the use of drugs or alternative medicine exclusively in the conservative treatment of osteoporotic vertebral body fractures.

Conclusion: It is reasonable to evaluate instability with imaging repeatedly, at regular intervals, over a period of six months. There is still a lack of reliable data on the optimal intensity and duration of physiotherapy, and on the use of orthoses.

LNSLNS

The conservative treatment of vertebral body fractures of the thoracic and lumbar spine is inadequately defined. This is true for both traumatic fractures of normal vertebrae (1) and osteoporotic vertebral fractures. The prevalence of osteoporotic vertebral fractures is disproportionately higher—in Europe, prevalence rates vary between 18% and 26%, depending on the region; in Germany, women account for the majority of cases (factor 2.4) (2, 3). Given the high prevalence of osteoporosis and the aging of the population, this type of fracture is expected to increase significantly (5).

The guideline of the German Osteology Society (DVO, Dachverband Osteologie) uses the Genant classification to categorize the various types of vertebral fractures; however, in recent years the osteoporotic fracture (OF) classification has widely been adopted in the field of orthopedic and trauma surgery (6, 7). The OF classification system comprises five groups and is based on x-ray, computed tomography (CT) and magnetic resonance imaging (MRI) findings (Box). The OF classification describes fracture morphology. It spans from OF 1 fracture—intravertebral edema in MRI— to OF 5 fracture which is characterized by failure of the anterior and/or posterior tension band which corresponds to distraction/rotation injuries in patients with normal bone density. A study on 146 consecutively sampled fractures as well as six analysis demonstrated substantial reliability for the OF classification system (Kappa 0.63) (6). Designed to offer guidance for selecting treatment strategies, the OF score (eTable 1) takes, in addition to the OF classification, the clinical course and risk factors into account and recommends, based on the score obtained, either conservative treatment (<6 points) or surgical treatment (>6 points). The score could be used as a basis for uniform conservative treatment decisions. However, the content of conservative treatment is insufficiently clarified.

Classification of osteoporotic fractures (OF) (<a class=6)" width="250" src="https://cfcdn.aerzteblatt.de/bilder/137713-250-0" data-bigsrc="https://cfcdn.aerzteblatt.de/bilder/137713-1400-0" data-fullurl="https://cfcdn.aerzteblatt.de/bilder/2021/12/img263390252.png" />
Box
Classification of osteoporotic fractures (OF) (6)
Score for osteoporotic fractures (OF) according to Blattert et al. (<a class=e8)" width="250" src="https://cfcdn.aerzteblatt.de/bilder/137716-250-0" data-bigsrc="https://cfcdn.aerzteblatt.de/bilder/137716-1400-0" data-fullurl="https://cfcdn.aerzteblatt.de/bilder/2021/12/img263390258.gif" />
eTable 1
Score for osteoporotic fractures (OF) according to Blattert et al. (e8)

The aim of this review was to conduct a systematic search of the literature to identify studies on the conservative treatment of osteoporotic vertebral body fractures and to describe the current state of the evidence on the conservative treatment of osteoporotic fractures of the thoracolumbar spine and create recommendations for standardized conservative treatment of these fractures. Our medium-term goal is to initiate prospective studies based on these results to expand the body of evidence in this field and to scientifically strengthen the treatment strategy.

Material and methods

The literature was searched for acute vertebral body fractures without history of adequate trauma. The inclusion and exclusion criteria are listed in eTable 2.

Criteria for the inclusion or exclusion of studies in this systematic review
eTable 2
Criteria for the inclusion or exclusion of studies in this systematic review

A systematic independent review of the literature up to 3 May 2020 was performed by two of the authors (UJS, KJS) in the PubMed and Web of Science Core Collection databases. PROSPERO registration was obtained (registration no. CRD42020168694). Using the PICO scheme (8), the following review question was defined: In patients with osteoporotic thoracolumbar fractures treated conservatively, are certain diagnostic and therapeutic measures more appropriate to recommend than others? The search terms used are listed in the eBox. Subsequently, all original articles were reviewed (level of evidence [9], conclusions). The following subject areas were defined:

  • Diagnosis
  • Provision of physical aids/orthoses
  • Pharmacotherapy
  • Physiotherapy and physical treatment strategies (physiotherapy, occupational therapy, physical therapy, exercise therapy/medical sports therapy)
  • Alternative medicine treatments.
Keywords of the database search
eBox
Keywords of the database search

Results

In total, 549 abstracts were retrieved. Of these, 452 articles were excluded based on the abstract or title. Most of the excluded articles were concerned with other pathologies or evaluated only surgical treatments. Altogether, 97 articles were read completely. Of these, further 61 articles had to be excluded after reading the entire manuscript. Based on the PRISMA flowchart, 514 articles were excluded, leaving 36 articles suitable for inclusion in the review (10) (eFigure). The 36 remaining original articles are summarized in Table 1 (11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, e1, e2, e3, e4, e5, e6). eTable 3 shows a quality assessment of the comparative studies and the cohort study. Details of the seven original articles with levels of evidence I and II from the area “Therapeutic measures“ are provided in Table 2. The Physiotherapy Evidence Database (PEDro) scale was used to assess the quality of the included randomized studies (e7). In the light of the low level of evidence of the included studies, it was decided to carry out a narrative review and discussion of the results; consequently, confounding factors were not systematically considered.

Overview of the studies included in the review
Table 1
Overview of the studies included in the review
Studies with levels of evidence I and II from the area “Therapeutic Measures“
Table 2
Studies with levels of evidence I and II from the area “Therapeutic Measures“
Flowchart of the procedure for the systematic literature search, based on the PRISMA principles (<a class=10)" width="250" src="https://cfcdn.aerzteblatt.de/bilder/137715-250-0" data-bigsrc="https://cfcdn.aerzteblatt.de/bilder/137715-1400-0" data-fullurl="https://cfcdn.aerzteblatt.de/bilder/2021/12/img263390256.gif" />
eFigure
Flowchart of the procedure for the systematic literature search, based on the PRISMA principles (10)
Quality assessment of all comparative studies and cohort studies using the Newcastle-Ottawa scale (<a class=e18)" width="250" src="https://cfcdn.aerzteblatt.de/bilder/137718-250-0" data-bigsrc="https://cfcdn.aerzteblatt.de/bilder/137718-1400-0" data-fullurl="https://cfcdn.aerzteblatt.de/bilder/2021/12/img263390262.gif" />
eTable 3
Quality assessment of all comparative studies and cohort studies using the Newcastle-Ottawa scale (e18)

Diagnosis

Primary diagnostic assessment

The primary diagnostic technique is conventional x-ray in two planes (with the patient standing, if possible). This approach achieved 51.3% sensitivity and 75.0% specificity; fractures were correctly diagnosed with a rate of 24.8% (11, 12). Thus, if a fracture was suspected, magnetic resonance imaging (MRI) was recommended to avoid under-treatment (11, 13, 14, 15, 16). In the conclusion of their registry study, Lenski et al. (14) recommended an MRI scan of the entire thoracic and lumbar spine with short-tau inversion recovery (STIR) sequences. Several studies used MRI-based prognostic estimates to establish the indication for conservative treatment (17, 18, 19, 20). Dual-energy x-ray absorptiometry (DXA) appears to be an alternative to MRI. However, a retrospective case series showed that the level of diagnostic quality came with a diagnostic accuracy of 95% only close to that of MRI if the images were interpreted by experienced radiologists (21). If MRI is contraindicated, skeletal scintigraphy can be performed; a retrospective case series found that acute osteoporotic vertebral body fractures were correctly diagnosed using this diagnostic technique in 96% of cases (22).

Follow-up examinations

With regard to the timing and frequency of clinical and radiographic follow-up examinations, Abe et al. (23) showed in a prospective longitudinal study that at the 3-week, 6–8 week and 24-week follow-up assessments persistent instabilities of 4.9°, 2.9 and 1.8°, respectively, were identified in the comparative x-rays obtained in supine and standing positions.

The diagnosis of osteoporosis

In addition to DXA, volumetric bone density assessment with quantitative computed tomography (QCT) as well as abdominal CT allows to categorize bone density and to determine the risk of fracture (24, 25, 26, 27, 28, 29, 30). Large studies clearly showed that low T-score values in DXA were associated with osteoporotic singular or multiple vertebral body fractures and the extent of subsequent sintering (24). In a retrospective study, Yu et al. compared DXA values (lateral and anteroposterior views) and QCT values of 240 postmenopausal patients with regard to fracture manifestation (25). The results of each of the three methods were statistically significantly associated with the occurrence of osteoporotic fractures (25).

In addition, two studies evaluated whether lumbar CT scans obtained during fracture diagnosis were suitable as a method of detecting osteoporosis (29, 30). Here, a study on a cohort demonstrated a specificity of >90% in case of low Hounsfield units (HU) of <110 (29).

Physical aids/orthoses

In a study comparing the efficacy of a dynamic orthosis versus a soft lumbar orthosis, Li et al. (31) demonstrated a comparable, statistically significant pain reduction and improvement in function without increase in kyphosis; however, the study did not include a patient group without orthosis. In a prospective case-control study, Meccariello et al. (32) compared conservative treatment with a dynamic orthosis versus a three-point brace. At the 3– and 6-month follow-ups, patients treated with a dynamic orthosis showed a statistically significant improvement in pain (mean pain at 6-month follow-up measured using a visual analog scale [VAS] was by 1.7 lower in the dynamic orthosis group; p<0.05) and in quality of life (difference in OLBPDQ score [OLBPDQ, Oswestry Low Back Pain Disability Questionnaire] of 6.1 at six-month follow-up) without statistically significant differences in radiographic outcome.

Pharmacotherapy

Analgesia

Only one study with a prospective longitudinal design was concerned with a precise analgesic treatment algorithm, based on the WHO analgesic ladder, in patients receiving conservative treatment (33).

Anti-osteoporotic treatment

In a large, prospective case-control study, Spechbach et al. (34) demonstrated advantages of initiating anti-osteoporotic diagnosis and treatment already in the hospital. One of these benefits was a significantly higher percentage of drug prescriptions after six months (69% versus 27%).

Physiotherapy and physical treatment strategies

Seven level I/II studies evaluated physiotherapy and physical treatment strategies (Table 2; 35–40, e1). Moderate quality evidence supported that physical exercise can improve physical performance (balance, strength and endurance of the extensor muscles of the spine) and can reduce pain and fear of falling; however, these studies had limitations (35, 36, 37, 38, 39).

In a randomized, controlled level II trial, Stanghelle et al. (36) found positive effects of a strength and balance exercise program on secondary endpoints, such as balance, but not on gait speed, the primary endpoint of the study. In a randomized, controlled level II trial, Evstigneeva et al. (37) reported statistically significant improvements in quality of life, mobility and balance (at 12-month follow-up: QUALLEFO-41 score: 44.6  ± 7.8 in the exercise group versus 56.6  ± 9.4 in the control group; p<0.0001 [QUALEFFO, Quality-of-Life Questionnaire]); the study included patients with fractures sustained within the past 6 months and did not document details of the activities of daily living in the control group.

In a randomized, controlled level II trial of 12 months of daily home exercise, Giangregorio et al. (40) found no statistically significant differences with regard to the number of falls and further fractures between the intervention group and the control group; the study population consisted primarily of high-risk patients and with 66% the adherence level was low. In a level I trial of a 12-week home exercise program, Barker et al. (e1) observed improvements in endurance and mobility at four months, especially among patients ≤= 70 years. These benefits were no longer detectable at twelve months; in addition, most participants did not reach the exercise intensity target and treatment adherence was poor.

In a prospective study on 106 patients, Weerink et al. (e2) evaluated the initial treatment after osteoporotic vertebral body fractures. Especially patients under 80 years of age were found to predominantly have good functional results after conservative treatment. A retrospective analysis did not find a functional difference between early mobilization and primary immobilization. However, an increased complication rate was observed after immobilization.

A limitation was that all of the discussed studies with a high level of evidence included patients with unknown fracture age or subacute fractures (>3 months) and thus did not reflect the primary phase of conservative treatment. Overall, effects shown for early initiated exercise therapy/physiotherapy were mainly positive; however, the strength of evidence with regard to optimum treatment density, length of treatment and specific treatment units is insufficient.

Alternative medicine interventions

No pertinent studies were found in the current literature.

Discussion

From the perspective of orthopedic and trauma surgery, the OF classification has generally been shown to be an easier to apply and more surgically relevant system to classify osteoporotic fractures (5). On the basis of the OF classification, the Spine Section of the German Society for Orthopedics and Trauma Surgery (DGOU) also developed a score for the therapeutic indication and the subsequent surgical interventions (e8). This score provides clear indications for the surgical treatment of patients with relevant fracture instability or neurological deficits. A CT scan should be obtained to assess fracture morphology and fracture stability (6).

If conservative treatment is initiated, regular follow-up examinations are required. The authors of this study recommend to obtain standing follow-up radiographs after mobilization and at weeks one, three and six as well as later in the course, if symptoms persist.

At the time an osteoporotic fracture is diagnosed, neither a bone density scan nor a specific treatment of osteoporosis has been undertaken in up to 80% of the affected patients (e9). For the diagnosis of osteoporosis, the German Osteology Society (DVO) recommends a basic assessment after multiple minor fractures or after singular moderate or severe fractures (e10). The DVO uses the Genant classification to classify these fractures (7). The probability to have osteoporosis is increased 2 to >10 times after two or more grade 1 vertebral fractures (20%–25% vertebral height loss) or after one or more grade 2 or 3 vertebral body fractures (vertebral height loss >25 or 40%). For example, the odds ratio for the presence of osteoporosis in patients with a history of three vertebral body fractures is 21.2 (95% confidence interval: [7.1; 63.6]; 47.6% of those affected) and with a history of one grade 4 vertebral body fracture the odds ratio is 22.2 [8.3; 58.8] (24). The relative risk for occurrence of a fracture is shown in eTable 4.

Relative risk of fracture (RR) per standard deviation in the DXA bone density measurement (<a class=e20)" width="250" src="https://cfcdn.aerzteblatt.de/bilder/137719-250-0" data-bigsrc="https://cfcdn.aerzteblatt.de/bilder/137719-1400-0" data-fullurl="https://cfcdn.aerzteblatt.de/bilder/2021/12/img263390264.gif" />
eTable 4
Relative risk of fracture (RR) per standard deviation in the DXA bone density measurement (e20)

The overall risk is determined based on a special medical history, taking into account risk factors, clinical examination, laboratory tests to rule out secondary osteoporosis, x-rays, and DXA bone density measurement. Since the risk of subsequent fractures is greatly increased in patients with a history of grade 2 or higher fractures, it is sufficient in these cases to rule out secondary osteoporosis and contraindication to pharmacotherapy to be able to start the initial therapy.

There is a lack of uniform strategies for the treatment of osteoporotic vertebral fractures due to the inadequacy of the available data. A systematic Cochrane review by Gibbs et al. (e11) showed that the effects of physical exercise after osteoporotic vertebral fracture have not been adequately studied.

Similarly, the optimum daily period of use of a dynamic orthosis has not been conclusively established. However, wearing a dynamic orthosis daily for 2–4 hours over a period of 3–6 months appears to be the most effective regimen (e12). Overall, there is evidence that chronification of pain after osteoporotic vertebral body fracture may occur in every second patient (e13). Specific analgesia as part of the conservative treatment of osteoporotic vertebral body fractures is in general inadequately defined; however, the DVO guideline mentions basic measures of pain therapy in patients with osteoporosis (e10).

The majority of studies on drug treatments for osteoporosis included not only patients with osteoporotic vertebral body fractures but other fractures as well; consequently, these studies were not suitable for inclusion in the review, but they will still be discussed here selectively. The indications for anti-osteoporotic therapy in the absence of risk factors are listed in eTable 5. For detailed information about individual anti-osteoporotic treatment planning, please refer to the current guideline of the DVO (e10). As a general rule, the specific active agent to be used should be selected based on the individual risk of the patient. Basic therapy with calcium and vitamin D is generally recommended. The DVO guideline should be used to estimate the individual risk (e14).

Indications for anti-osteoporotic therapy in the absence of risk factors
eTable 5
Indications for anti-osteoporotic therapy in the absence of risk factors

Based on current high (level I) evidence showing statistically significant reduction in the risk of new vertebral fractures compared to bisphosphonate treatment, osteoanabolic therapy with teriparatide and romosozumab was incorporated in the management of postmenopausal women at very high risk of fracture (e10, e15, e16). In addition, the use of romosozumab was found to be associated with a statistically significant reduction in non-vertebral fractures compared to treatment with teriparatide (e16). However, due its side effects, romosozumab is only approved for use in women without history of cardiovascular disease, such as myocardial infarction and stroke.

A longitudinal study of 1.2 million patients, evaluating anti-osteoporotic agents, showed a statistically significant reduction in the risk of clinical vertebral fractures within a 12-month period (e17). The relative reductions in fracture risk achieved with the osteoanabolic drug teriparatide, antiresorptive bisphosphonate therapy and denosumab were 64%, 23% and 51%, respectively (e17).

In summary, swift diagnostic evaluation and initiation of pharmacotherapy are essential elements of the conservative treatment of osteoporotic vertebral body fractures and should ideally be initiated already in the acute phase. Drugs should be selected on an individual basis, considering the patient’s risks (e.g. the risk of medication-related osteonecrosis of the jaw, among others) and the various contraindications of the agents.

Conclusion

Conventional radiography should be used for the initial assessment. If a fracture is suspected, magnetic resonance imaging (MRI) and computed tomography (CT) are indicated. Follow-up radiography at regular intervals (weeks 1, 3, 6, 12, and 26) is advisable. Anti-osteoporotic diagnosis and treatment should be initiated. Physiotherapy should be started early. The use of dynamic orthoses may be of advantage.

Conflict of interest statement
Prof. Heyde received royalties and consulting fees from Medacta International.

Prof. Maus received consulting fees and lecture fees from UCB, Amgen, Theramex, Lilly, Alexion, und Kyowa Kirin.

PD Osterhoff received consulting fees from Medtronic.

Dr. Schnake received consultant and author fees from Ottobock.

The remaining authors declare that no conflict of interest exists.

Manuscript received on 12 February 2021, revised version accepted on 13 July 2021

Translated from the original German by Ralf Thoene, MD.

Corresponding author
Prof. Dr. med. Ulrich Spiegl
Universitätsklinik Leipzig
Klinik und Poliklinik für Unfall-, Wiederherstellungs-
und Plastische Chirurgie
Liebigstr. 20, 04103 Leipzig, Germany
uli.spiegl@gmx.de

Cite this as:
Spiegl U, Bork H, Grüninger S, Maus U, Osterhoff G, Scheyerer MJ, Pieroh P, Schnoor J, Heyde CE, Schnake KJ: Osteoporotic fractures of the thoracic and lumbar vertebrae: diagnosis and conservative treatment—
a systematic review. Dtsch Arztebl Int 2021; 118: 670–7.
DOI: 10.3238/arztebl.m2021.0295

Supplementary material

eReferences, eBox, eTables, eFigure:
www.aerzteblatt-international.de/m2021.0295

1.
Spiegl UJ, Fischer K, Schmidt J, et al.: The conservative treatment of traumatic thoracolumbar vertebral fractures. Dtsch Arztebl Int 2018; 115: 697–704 VOLLTEXT
2.
Ballane G, Cauley JA, Luckey MM, El-Hajj Fuleihan G: Worldwide prevalence and incidence of osteoporotic vertebral fractures. Osteoporos Int 2017; 28: 1531–42 CrossRef MEDLINE
3.
Bassgen K, Westphal T, Haar P, et al.: Population-based prospective study on the incidence of osteoporosis-associated fractures in a German population of 200,413 inhabitants. J Public Health 2013; 35: 255–61 CrossRef MEDLINE
4.
Schultz A, Andersson G, Ortengren R, Haderspeck K, Nachemson A: Loads on the lumbar spine. Validation of a biomechanical analysis by measurements of intradiscal pressures and myoelectric signals. J Bone Joint Surg Am 1982; 64: 713–20 MEDLINE
5.
Kim TY, Jang S, Park CM, et al.: Trends of incidence, mortality, and future projection of spinal fractures in Korea using nationwide claims data. J Korean Med Sci 2016; 31: 801–5 CrossRef MEDLINE PubMed Central
6.
Schnake KJ, Blattert TR, Hahn P, et al.: Classification of osteoporotic thoracolumbar spine fractures: Recommendations of the spine section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J 2018; 8: 46S-9S CrossRef MEDLINE PubMed Central
7.
Genant HK, Jergas M: Assessment of prevalent and incident vertebral fractures in osteoporosis research. Osteoporos Int 2003; 14 Suppl 3: S43–55 CrossRef MEDLINE
8.
Farrugia P, Petrisor BA, Farrokhyar F, Bhandari M: Practical tips for surgical research: Research questions, hypotheses and objectives. Can J Surg 2010; 53: 278–81.
9.
Bassler D, Antes G: Wie erhalte ich Antworten auf meine Fragen? Lehrbuch Evidenzbasierte Medizin in Klinik und Praxis. Köln: Deutscher Ärzte-Verlag; 2000.
10.
Page MJ, McKenzie JE, Bossuyt PM, et al.: The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71 CrossRef MEDLINE PubMed Central
11.
Terakado A, Orita S, Inage K, et al.: A clinical prospective observational cohort study on the prevalence and primary diagnostic accuracy of occult vertebral fractures in aged women with acute lower back pain using magnetic resonance iImaging. Pain Res Manag 2017; 2017: 9265259 CrossRef MEDLINE PubMed Central
12.
Ito Z, Harada A, Matsui Y, et al.: Can you diagnose for vertebral fracture correctly by plain X-ray? Osteoporos Int 2006; 17: 1584–91 CrossRef MEDLINE
13.
Marongiu G, Congia S, Verona M, Lombardo M, Podda D, Capone A: The impact of magnetic resonance imaging in the diagnostic and classification process of osteoporotic vertebral fractures. Injury 2018; 49 Suppl 3: S26-31 CrossRef MEDLINE
14.
Lenski M, Buser N, Scherer M: Concomitant and previous osteoporotic vertebral fractures. Acta Orthop 2017; 88: 192–7 CrossRef MEDLINE PubMed Central
15.
Lin HH, Chou PH, Wang ST, Yu JK, Chang MC, Liu CL: Determination of the painful level in osteoporotic vertebral fractures—retrospective comparison between plain film, bone scan, and magnetic resonance imaging. J Chin Med Assoc 2015; 78: 714–8 CrossRef MEDLINE
16.
Qasem KM, Suzuki A, Yamada K, et al.: Discriminating imaging findings of acute osteoporotic vertebral fracture: a prospective multicenter cohort study. J Orthop Surg Res 2014; 9: 96 CrossRef MEDLINE PubMed Central
17.
Ahmadi SA, Takahashi S, Hoshino M, et al.: Association between MRI findings and back pain after osteoporotic vertebral fractures: a multicenter prospective cohort study. Spine J 2019; 19: 1186–93 CrossRef MEDLINE
18.
Lee JM, Lee YS, Kim YB, Park SW, Kang DH, Lee SH: What effects does necrotic area of contrast-enhanced MRI in osteoporotic vertebral fracture have on further compression and clinical outcome? J Korean Neurosurg Soc 2017; 60: 181–8 CrossRef MEDLINE PubMed Central
19.
Seo JY, Kwon YS, Kim KJ, Shin JY, Kim YH, Ha KY: Clinical importance of posterior vertebral height loss on plain radiography when conservatively treating osteoporotic vertebral fractures. Injury 2017; 48: 1503–9 CrossRef MEDLINE
20.
Omi H, Yokoyama T, Ono A, Numasawa T, Wada K, Fujisawa Y: Can MRI predict subsequent pseudarthrosis resulting from osteoporotic thoracolumbar vertebral fractures? Eur Spine J 2014; 23: 2705–10 CrossRef MEDLINE
21.
Kaup M, Wichmann JL, Scholtz JE, et al.: Dual-Energy CT-based display of bone marrow edema in osteoporotic vertebral compression fractures: Impact on diagnostic accuracy of radiologists with varying levels of experience in correlation to MR imaging. Radiology 2016; 280: 510–9 CrossRef MEDLINE
22.
Kim JH, Kim JI, Jang BH, Seo JG, Kim JH: The comparison of bone scan and MRI in osteoporotic compression fractures. Asian Spine J 2010; 4: 89–95 CrossRef MEDLINE PubMed Central
23.
Abe T, Shibao Y, Takeuchi Y, et al.: Initial hospitalization with rigorous bed rest followed by bracing and rehabilitation as an option of conservative treatment for osteoporotic vertebral fractures in elderly patients: a pilot one arm safety and feasibility study. Arch Osteoporos 2018; 13: 134 CrossRef MEDLINE PubMed Central
24.
Kherad M, Mellstrom D, Rosengren BE, et al.: The number and characteristics of prevalent vertebral fractures in elderly men are associated with low bone mass and osteoporosis. Bone Joint J 2015; 97-B: 1106–10 CrossRef MEDLINE
25.
Yu W, Gluer CC, Grampp S, et al.: Spinal bone mineral assessment in postmenopausal women: a comparison between dual X-ray absorptiometry and quantitative computed tomography. Osteoporos Int 1995; 5: 433–9 CrossRef MEDLINE
26.
Loffler MT, Jacob A, Valentinitsch A, et al.: Improved prediction of incident vertebral fractures using opportunistic QCT compared to DXA. Eur Radiol 2019; 29: 4980–9 CrossRef MEDLINE PubMed Central
27.
Rehman Q, Lang T, Modin G, Lane NE: Quantitative computed tomography of the lumbar spine, not dual x-ray absorptiometry, is an independent predictor of prevalent vertebral fractures in postmenopausal women with osteopenia receiving long-term glucocorticoid and hormone-replacement therapy. Semin Arthritis Rheum 2002; 46: 1292–7 CrossRef MEDLINE
28.
Lang TF, Li J, Harris ST, Genant HK: Assessment of vertebral bone mineral density using volumetric quantitative CT. J Comput Assist Tomogr 1999; 23: 130–7 CrossRef MEDLINE
29.
Lee SJ, Binkley N, Lubner MG, Bruce RJ, Ziemlewicz TJ, Pickhardt PJ: Opportunistic screening for osteoporosis using the sagittal reconstruction from routine abdominal CT for combined assessment of vertebral fractures and density. Osteoporos Int 2016; 27: 1131–6 CrossRef MEDLINE
30.
Zou D, Ye K, Tian Y, et al.: Characteristics of vertebral CT Hounsfield units in elderly patients with acute vertebral fragility fractures. Eur Spine J 2020; 29: 1092–7 CrossRef MEDLINE
31.
Li M, Law SW, Cheng J, Kee HM, Wong MS: A comparison study on the efficacy of SpinoMed(R) and soft lumbar orthosis for osteoporotic vertebral fracture. Prosthet Orthot Int 2015; 39: 270–6 CrossRef MEDLINE
32.
Meccariello L, Muzii VF, Falzarano G, et al.: Dynamic corset versus three-point brace in the treatment of osteoporotic compression fractures of the thoracic and lumbar spine: a prospective, comparative study. Aging Clin Exp Res 2017; 29: 443–9 CrossRef MEDLINE
33.
Shah S, Goregaonkar AB: Conservative management of osteoporotic vertebral fractures: A prospective study of thirty patients. Cureus 2016; 8: e542 CrossRef
34.
Spechbach H, Fabreguet I, Saule E, et al.: Higher rates of osteoporosis treatment initiation and persistence in patients with newly diagnosed vertebral fracture when introduced in inpatients than later in outpatients. Osteoporos Int 2019; 30: 1353–62 CrossRef MEDLINE
35.
Bennell KL, Matthews B, Greig A, et al.: Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Musculoskelet Disord 2010; 11: 36 CrossRef MEDLINE PubMed Central
36.
Stanghelle B, Bentzen H, Giangregorio et al.: Effects of a resistance and balance exercise programme on physical fitness, health-related quality of life and fear of falling in older women with osteoporosis and vertebral fracture: a randomized controlled trial. Osteoporos Int 2020; 31: 1069–78 CrossRef CrossRef
37.
Evstigneeva L, Lesnyak O, Bultink IE, et al.: Effect of twelve-month physical exercise program on patients with osteoporotic vertebral fractures: a randomized, controlled trial. Osteoporos Int 2016; 27: 2515–24 CrossRef MEDLINE
38.
Bergland A, Thorsen H, Karesen R: Effect of exercise on mobility, balance, and health-related quality of life in osteoporotic women with a history of vertebral fracture: a randomized, controlled trial. Osteoporos Int 2011; 22: 1863–71 CrossRef MEDLINE
39.
Olsen CF, Bergland A: The effect of exercise and education on fear of falling in elderly women with osteoporosis and a history of vertebral fracture: results of a randomized controlled trial. Osteoporos Int 2014; 25: 2017–25 CrossRef MEDLINE
40.
Giangregorio LM, Gibbs JC, Templeton JA, et al.: Build better bones with exercise (B3E pilot trial): results of a feasibility study of a multicenter randomized controlled trial of 12 months of home exercise in older women with vertebral fracture. Osteoporos Int 2018; 29: 2545–56 CrossRef MEDLINE
e1.
Barker KL, Newman M, Stallard N, et al.: Physiotherapy rehabilitation for osteoporotic vertebral fracture—a randomised controlled trial and economic evaluation (PROVE trial). Osteoporos Int 2020; 31: 277–89 CrossRef MEDLINE
e2.
Weerink LB, Folbert EC, Kraai M, Smit RS, Hegeman JH, van der Velde D: Thoracolumbar spine fractures in the geriatric fracture center: early ambulation leads to good results on short term and is a successful and safe alternative compared to immobilization in elderly patients with two-column vertebral fractures. Geriatr Orthop Surg Rehabil 2014; 5: 43–9 CrossRef MEDLINE PubMed Central
e3.
Briot K, Fechtenbaum J, Etcheto A, Kolta S, Feydy A, Roux C: Diagnosis of vertebral fractures using a low-dose biplanar imaging system. Osteoporos Int 2015; 26: 2649–55 CrossRef MEDLINE
e4.
Williams AL, Al-Busaidi A, Sparrow PJ, Adams JE, Whitehouse RW: Under-reporting of osteoporotic vertebral fractures on computed tomography. Eur J Radiol 2009; 69: 179–83 CrossRef MEDLINE
e5.
Ljunghall S, Gardsell P, Johnell O, et al.: Synthetic human calcitonin in postmenopausal osteoporosis: a placebo-controlled, double-blind study. Calcif Tissue Int 1991; 49: 17–9 CrossRef MEDLINE
e6.
Takahashi S, Hoshino M, Takayama K, et al.: The natural course of the paravertebral muscles after the onset of osteoporotic vertebral fracture. Osteoporos Int 2020; 31: 1089–95 CrossRef MEDLINE
e7.
Maher CG, Sherrington C, Herbert RD, et al. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 2003; 83: 713–21 CrossRef MEDLINE
e8.
Blattert TR, Schnake KJ, Gonschorek O, et al.: Nonsurgical and surgical management of osteoporotic vertebral body fractures: Recommendations of the spine section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J 2018; 8: 50S-55S CrossRef MEDLINE PubMed Central
e9.
Leslie WD, Giangregorio LM, Yogendran M, et al.: A population-based analysis of the post-fracture care gap 1996–2008: the situation is not improving. Osteoporos Int 2012; 23: 1623–9 CrossRef MEDLINE
e10.
DVO-Leitlinie Osteoporose. 2017. www.dv-osteologie.org/uploads/Leitlinie%202017/Finale%20Version%20Leitlinie%20Osteoporose%202017_end.pdf (last accessed on 10 August 2021).
e11.
Gibbs JC, MacIntyre NJ, Ponzano M, et al.: Exercise for improving outcomes after osteoporotic vertebral fracture. Cochrane Database Syst Rev 2019; 7: CD008618 CrossRef MEDLINE PubMed Central
e12.
Pfeifer M, Begerow B, Minne HW: Effects of a new spinal orthosis on posture, trunk strength, and quality of life in women with postmenopausal osteoporosis: a randomized trial. Am J Phys Med Rehabil 2004; 83: 177–86 CrossRef MEDLINE
e13.
Clark EM, Gooberman-Hill R, Peters TJ: Using self-reports of pain and other variables to distinguish between older women with back pain due to vertebral fractures and those with back pain due to degenerative changes. Osteoporos Int 2016; 27: 1459–67 CrossRef MEDLINE PubMed Central
e14.
Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E: FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int 2008; 19: 385–97 CrossRef MEDLINE PubMed Central
e15.
Kendler DL, Marin F, Zerbini CAF, et al.: Effects of teriparatide and risedronate on new fractures in post-menopausal women with severe osteoporosis (VERO): a multicentre, double-blind, double-dummy, randomised controlled trial. Lancet 2018; 391: 230–40 CrossRef
e16.
Saag KG, Petersen J, Brandi ML, et al.: Romosozumab or Alendronate for Fracture Prevention in Women with Osteoporosis. N Engl J Med 2017; 377: 1417–27 CrossRef MEDLINE
e17.
Yusuf AA, Cummings SR, Watts NB, et al.: Real-world effectiveness of osteoporosis therapies for fracture reduction in post-menopausal women. Arch Osteoporos 2018; 13: 33 CrossRef MEDLINE PubMed Central
e18.
Wells GA, Shea B, O’Connell D, et al.: The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [webpage on the Internet]. Ottawa, ON: Ottawa Hospital Research Institute; 2011. www.ohri.ca/programs/clinical_epidemiology/oxford.asp. (last accessed on 10 August 2021).
e19.
Schuit SC, van der Klift M, Weel AE, et al.: Fracture incidence and association with bone mineral density in elderly men and women: the Rotterdam Study. Bone 2004; 34: 195–202 CrossRef MEDLINE
e20.
Marshall D, Johnell O, Wedel H. Meta-Analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 1996; 312: 1254–59 CrossRef MEDLINE PubMed Central
Department of Orthopedic, Trauma and Plastic Surgery, University Hospital of Leipzig, Leipzig, Germany: Prof. Dr. med. Ulrich Spiegl, PD Dr. med. Georg Osterhoff, Dr. med. Philipp Pieroh, Prof. Dr. med. habil. Christoph-Eckhard Heyde
Rehabilitation Center, St. Josef-Stift Sendenhorst, Sendenhorst, Germany:
Dr. Hartmut Bork
Department of Orthopedic and Trauma Surgery, University Hospital of the Paracelsus Medical University (PMU), Nuremberg site, Nürnberg, Germany:
Dr. med. Sebastian Grüninger
Department of Orthopedic and Trauma Surgery, Special Orthopedic Surgery, Osteology (DVO, German Osteology Society), University Hospital of Düsseldorf, Düsseldorf, Germany: Prof. Dr. med.
Uwe Maus
Department of Orthopedics and Trauma Surgery, University Hospital Cologne, Cologne, Germany: PD Dr. Max J. Scheyerer
Department of Anesthesiology and Intensive Care Medicine, Paul Gerhardt Stift Hospital, Lutherstadt Wittenberg, Germany: PD Dr. med. habil. Jörg Schnoor MBA
Interdisciplinary Center for Spine and Scoliosis therapy. Malteser Waldkrankenhaus St. Marien, Erlangen, Germany:
Dr. med. Klaus J. Schnake
Classification of osteoporotic fractures (OF) (6)
Box
Classification of osteoporotic fractures (OF) (6)
Overview of the studies included in the review
Table 1
Overview of the studies included in the review
Studies with levels of evidence I and II from the area “Therapeutic Measures“
Table 2
Studies with levels of evidence I and II from the area “Therapeutic Measures“
Keywords of the database search
eBox
Keywords of the database search
Flowchart of the procedure for the systematic literature search, based on the PRISMA principles (10)
eFigure
Flowchart of the procedure for the systematic literature search, based on the PRISMA principles (10)
Score for osteoporotic fractures (OF) according to Blattert et al. (e8)
eTable 1
Score for osteoporotic fractures (OF) according to Blattert et al. (e8)
Criteria for the inclusion or exclusion of studies in this systematic review
eTable 2
Criteria for the inclusion or exclusion of studies in this systematic review
Quality assessment of all comparative studies and cohort studies using the Newcastle-Ottawa scale (e18)
eTable 3
Quality assessment of all comparative studies and cohort studies using the Newcastle-Ottawa scale (e18)
Relative risk of fracture (RR) per standard deviation in the DXA bone density measurement (e20)
eTable 4
Relative risk of fracture (RR) per standard deviation in the DXA bone density measurement (e20)
Indications for anti-osteoporotic therapy in the absence of risk factors
eTable 5
Indications for anti-osteoporotic therapy in the absence of risk factors
1.Spiegl UJ, Fischer K, Schmidt J, et al.: The conservative treatment of traumatic thoracolumbar vertebral fractures. Dtsch Arztebl Int 2018; 115: 697–704 VOLLTEXT
2.Ballane G, Cauley JA, Luckey MM, El-Hajj Fuleihan G: Worldwide prevalence and incidence of osteoporotic vertebral fractures. Osteoporos Int 2017; 28: 1531–42 CrossRef MEDLINE
3.Bassgen K, Westphal T, Haar P, et al.: Population-based prospective study on the incidence of osteoporosis-associated fractures in a German population of 200,413 inhabitants. J Public Health 2013; 35: 255–61 CrossRef MEDLINE
4.Schultz A, Andersson G, Ortengren R, Haderspeck K, Nachemson A: Loads on the lumbar spine. Validation of a biomechanical analysis by measurements of intradiscal pressures and myoelectric signals. J Bone Joint Surg Am 1982; 64: 713–20 MEDLINE
5.Kim TY, Jang S, Park CM, et al.: Trends of incidence, mortality, and future projection of spinal fractures in Korea using nationwide claims data. J Korean Med Sci 2016; 31: 801–5 CrossRef MEDLINE PubMed Central
6.Schnake KJ, Blattert TR, Hahn P, et al.: Classification of osteoporotic thoracolumbar spine fractures: Recommendations of the spine section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J 2018; 8: 46S-9S CrossRef MEDLINE PubMed Central
7.Genant HK, Jergas M: Assessment of prevalent and incident vertebral fractures in osteoporosis research. Osteoporos Int 2003; 14 Suppl 3: S43–55 CrossRef MEDLINE
8.Farrugia P, Petrisor BA, Farrokhyar F, Bhandari M: Practical tips for surgical research: Research questions, hypotheses and objectives. Can J Surg 2010; 53: 278–81.
9.Bassler D, Antes G: Wie erhalte ich Antworten auf meine Fragen? Lehrbuch Evidenzbasierte Medizin in Klinik und Praxis. Köln: Deutscher Ärzte-Verlag; 2000.
10.Page MJ, McKenzie JE, Bossuyt PM, et al.: The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71 CrossRef MEDLINE PubMed Central
11.Terakado A, Orita S, Inage K, et al.: A clinical prospective observational cohort study on the prevalence and primary diagnostic accuracy of occult vertebral fractures in aged women with acute lower back pain using magnetic resonance iImaging. Pain Res Manag 2017; 2017: 9265259 CrossRef MEDLINE PubMed Central
12.Ito Z, Harada A, Matsui Y, et al.: Can you diagnose for vertebral fracture correctly by plain X-ray? Osteoporos Int 2006; 17: 1584–91 CrossRef MEDLINE
13.Marongiu G, Congia S, Verona M, Lombardo M, Podda D, Capone A: The impact of magnetic resonance imaging in the diagnostic and classification process of osteoporotic vertebral fractures. Injury 2018; 49 Suppl 3: S26-31 CrossRef MEDLINE
14.Lenski M, Buser N, Scherer M: Concomitant and previous osteoporotic vertebral fractures. Acta Orthop 2017; 88: 192–7 CrossRef MEDLINE PubMed Central
15.Lin HH, Chou PH, Wang ST, Yu JK, Chang MC, Liu CL: Determination of the painful level in osteoporotic vertebral fractures—retrospective comparison between plain film, bone scan, and magnetic resonance imaging. J Chin Med Assoc 2015; 78: 714–8 CrossRef MEDLINE
16.Qasem KM, Suzuki A, Yamada K, et al.: Discriminating imaging findings of acute osteoporotic vertebral fracture: a prospective multicenter cohort study. J Orthop Surg Res 2014; 9: 96 CrossRef MEDLINE PubMed Central
17.Ahmadi SA, Takahashi S, Hoshino M, et al.: Association between MRI findings and back pain after osteoporotic vertebral fractures: a multicenter prospective cohort study. Spine J 2019; 19: 1186–93 CrossRef MEDLINE
18.Lee JM, Lee YS, Kim YB, Park SW, Kang DH, Lee SH: What effects does necrotic area of contrast-enhanced MRI in osteoporotic vertebral fracture have on further compression and clinical outcome? J Korean Neurosurg Soc 2017; 60: 181–8 CrossRef MEDLINE PubMed Central
19.Seo JY, Kwon YS, Kim KJ, Shin JY, Kim YH, Ha KY: Clinical importance of posterior vertebral height loss on plain radiography when conservatively treating osteoporotic vertebral fractures. Injury 2017; 48: 1503–9 CrossRef MEDLINE
20.Omi H, Yokoyama T, Ono A, Numasawa T, Wada K, Fujisawa Y: Can MRI predict subsequent pseudarthrosis resulting from osteoporotic thoracolumbar vertebral fractures? Eur Spine J 2014; 23: 2705–10 CrossRef MEDLINE
21.Kaup M, Wichmann JL, Scholtz JE, et al.: Dual-Energy CT-based display of bone marrow edema in osteoporotic vertebral compression fractures: Impact on diagnostic accuracy of radiologists with varying levels of experience in correlation to MR imaging. Radiology 2016; 280: 510–9 CrossRef MEDLINE
22.Kim JH, Kim JI, Jang BH, Seo JG, Kim JH: The comparison of bone scan and MRI in osteoporotic compression fractures. Asian Spine J 2010; 4: 89–95 CrossRef MEDLINE PubMed Central
23.Abe T, Shibao Y, Takeuchi Y, et al.: Initial hospitalization with rigorous bed rest followed by bracing and rehabilitation as an option of conservative treatment for osteoporotic vertebral fractures in elderly patients: a pilot one arm safety and feasibility study. Arch Osteoporos 2018; 13: 134 CrossRef MEDLINE PubMed Central
24.Kherad M, Mellstrom D, Rosengren BE, et al.: The number and characteristics of prevalent vertebral fractures in elderly men are associated with low bone mass and osteoporosis. Bone Joint J 2015; 97-B: 1106–10 CrossRef MEDLINE
25.Yu W, Gluer CC, Grampp S, et al.: Spinal bone mineral assessment in postmenopausal women: a comparison between dual X-ray absorptiometry and quantitative computed tomography. Osteoporos Int 1995; 5: 433–9 CrossRef MEDLINE
26.Loffler MT, Jacob A, Valentinitsch A, et al.: Improved prediction of incident vertebral fractures using opportunistic QCT compared to DXA. Eur Radiol 2019; 29: 4980–9 CrossRef MEDLINE PubMed Central
27.Rehman Q, Lang T, Modin G, Lane NE: Quantitative computed tomography of the lumbar spine, not dual x-ray absorptiometry, is an independent predictor of prevalent vertebral fractures in postmenopausal women with osteopenia receiving long-term glucocorticoid and hormone-replacement therapy. Semin Arthritis Rheum 2002; 46: 1292–7 CrossRef MEDLINE
28.Lang TF, Li J, Harris ST, Genant HK: Assessment of vertebral bone mineral density using volumetric quantitative CT. J Comput Assist Tomogr 1999; 23: 130–7 CrossRef MEDLINE
29.Lee SJ, Binkley N, Lubner MG, Bruce RJ, Ziemlewicz TJ, Pickhardt PJ: Opportunistic screening for osteoporosis using the sagittal reconstruction from routine abdominal CT for combined assessment of vertebral fractures and density. Osteoporos Int 2016; 27: 1131–6 CrossRef MEDLINE
30.Zou D, Ye K, Tian Y, et al.: Characteristics of vertebral CT Hounsfield units in elderly patients with acute vertebral fragility fractures. Eur Spine J 2020; 29: 1092–7 CrossRef MEDLINE
31.Li M, Law SW, Cheng J, Kee HM, Wong MS: A comparison study on the efficacy of SpinoMed(R) and soft lumbar orthosis for osteoporotic vertebral fracture. Prosthet Orthot Int 2015; 39: 270–6 CrossRef MEDLINE
32.Meccariello L, Muzii VF, Falzarano G, et al.: Dynamic corset versus three-point brace in the treatment of osteoporotic compression fractures of the thoracic and lumbar spine: a prospective, comparative study. Aging Clin Exp Res 2017; 29: 443–9 CrossRef MEDLINE
33.Shah S, Goregaonkar AB: Conservative management of osteoporotic vertebral fractures: A prospective study of thirty patients. Cureus 2016; 8: e542 CrossRef
34.Spechbach H, Fabreguet I, Saule E, et al.: Higher rates of osteoporosis treatment initiation and persistence in patients with newly diagnosed vertebral fracture when introduced in inpatients than later in outpatients. Osteoporos Int 2019; 30: 1353–62 CrossRef MEDLINE
35.Bennell KL, Matthews B, Greig A, et al.: Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Musculoskelet Disord 2010; 11: 36 CrossRef MEDLINE PubMed Central
36.Stanghelle B, Bentzen H, Giangregorio et al.: Effects of a resistance and balance exercise programme on physical fitness, health-related quality of life and fear of falling in older women with osteoporosis and vertebral fracture: a randomized controlled trial. Osteoporos Int 2020; 31: 1069–78 CrossRef CrossRef
37.Evstigneeva L, Lesnyak O, Bultink IE, et al.: Effect of twelve-month physical exercise program on patients with osteoporotic vertebral fractures: a randomized, controlled trial. Osteoporos Int 2016; 27: 2515–24 CrossRef MEDLINE
38.Bergland A, Thorsen H, Karesen R: Effect of exercise on mobility, balance, and health-related quality of life in osteoporotic women with a history of vertebral fracture: a randomized, controlled trial. Osteoporos Int 2011; 22: 1863–71 CrossRef MEDLINE
39.Olsen CF, Bergland A: The effect of exercise and education on fear of falling in elderly women with osteoporosis and a history of vertebral fracture: results of a randomized controlled trial. Osteoporos Int 2014; 25: 2017–25 CrossRef MEDLINE
40.Giangregorio LM, Gibbs JC, Templeton JA, et al.: Build better bones with exercise (B3E pilot trial): results of a feasibility study of a multicenter randomized controlled trial of 12 months of home exercise in older women with vertebral fracture. Osteoporos Int 2018; 29: 2545–56 CrossRef MEDLINE
e1.Barker KL, Newman M, Stallard N, et al.: Physiotherapy rehabilitation for osteoporotic vertebral fracture—a randomised controlled trial and economic evaluation (PROVE trial). Osteoporos Int 2020; 31: 277–89 CrossRef MEDLINE
e2.Weerink LB, Folbert EC, Kraai M, Smit RS, Hegeman JH, van der Velde D: Thoracolumbar spine fractures in the geriatric fracture center: early ambulation leads to good results on short term and is a successful and safe alternative compared to immobilization in elderly patients with two-column vertebral fractures. Geriatr Orthop Surg Rehabil 2014; 5: 43–9 CrossRef MEDLINE PubMed Central
e3.Briot K, Fechtenbaum J, Etcheto A, Kolta S, Feydy A, Roux C: Diagnosis of vertebral fractures using a low-dose biplanar imaging system. Osteoporos Int 2015; 26: 2649–55 CrossRef MEDLINE
e4.Williams AL, Al-Busaidi A, Sparrow PJ, Adams JE, Whitehouse RW: Under-reporting of osteoporotic vertebral fractures on computed tomography. Eur J Radiol 2009; 69: 179–83 CrossRef MEDLINE
e5.Ljunghall S, Gardsell P, Johnell O, et al.: Synthetic human calcitonin in postmenopausal osteoporosis: a placebo-controlled, double-blind study. Calcif Tissue Int 1991; 49: 17–9 CrossRef MEDLINE
e6.Takahashi S, Hoshino M, Takayama K, et al.: The natural course of the paravertebral muscles after the onset of osteoporotic vertebral fracture. Osteoporos Int 2020; 31: 1089–95 CrossRef MEDLINE
e7.Maher CG, Sherrington C, Herbert RD, et al. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 2003; 83: 713–21 CrossRef MEDLINE
e8.Blattert TR, Schnake KJ, Gonschorek O, et al.: Nonsurgical and surgical management of osteoporotic vertebral body fractures: Recommendations of the spine section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J 2018; 8: 50S-55S CrossRef MEDLINE PubMed Central
e9.Leslie WD, Giangregorio LM, Yogendran M, et al.: A population-based analysis of the post-fracture care gap 1996–2008: the situation is not improving. Osteoporos Int 2012; 23: 1623–9 CrossRef MEDLINE
e10.DVO-Leitlinie Osteoporose. 2017. www.dv-osteologie.org/uploads/Leitlinie%202017/Finale%20Version%20Leitlinie%20Osteoporose%202017_end.pdf (last accessed on 10 August 2021).
e11.Gibbs JC, MacIntyre NJ, Ponzano M, et al.: Exercise for improving outcomes after osteoporotic vertebral fracture. Cochrane Database Syst Rev 2019; 7: CD008618 CrossRef MEDLINE PubMed Central
e12.Pfeifer M, Begerow B, Minne HW: Effects of a new spinal orthosis on posture, trunk strength, and quality of life in women with postmenopausal osteoporosis: a randomized trial. Am J Phys Med Rehabil 2004; 83: 177–86 CrossRef MEDLINE
e13.Clark EM, Gooberman-Hill R, Peters TJ: Using self-reports of pain and other variables to distinguish between older women with back pain due to vertebral fractures and those with back pain due to degenerative changes. Osteoporos Int 2016; 27: 1459–67 CrossRef MEDLINE PubMed Central
e14.Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E: FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int 2008; 19: 385–97 CrossRef MEDLINE PubMed Central
e15.Kendler DL, Marin F, Zerbini CAF, et al.: Effects of teriparatide and risedronate on new fractures in post-menopausal women with severe osteoporosis (VERO): a multicentre, double-blind, double-dummy, randomised controlled trial. Lancet 2018; 391: 230–40 CrossRef
e16.Saag KG, Petersen J, Brandi ML, et al.: Romosozumab or Alendronate for Fracture Prevention in Women with Osteoporosis. N Engl J Med 2017; 377: 1417–27 CrossRef MEDLINE
e17.Yusuf AA, Cummings SR, Watts NB, et al.: Real-world effectiveness of osteoporosis therapies for fracture reduction in post-menopausal women. Arch Osteoporos 2018; 13: 33 CrossRef MEDLINE PubMed Central
e18.Wells GA, Shea B, O’Connell D, et al.: The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [webpage on the Internet]. Ottawa, ON: Ottawa Hospital Research Institute; 2011. www.ohri.ca/programs/clinical_epidemiology/oxford.asp. (last accessed on 10 August 2021).
e19.Schuit SC, van der Klift M, Weel AE, et al.: Fracture incidence and association with bone mineral density in elderly men and women: the Rotterdam Study. Bone 2004; 34: 195–202 CrossRef MEDLINE
e20.Marshall D, Johnell O, Wedel H. Meta-Analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 1996; 312: 1254–59 CrossRef MEDLINE PubMed Central