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. 2024 Sep 3;7(9):e2432041.
doi: 10.1001/jamanetworkopen.2024.32041.

Conservative Treatments in the Management of Acute Painful Vertebral Compression Fractures: A Systematic Review and Network Meta-Analysis

Assil-Ramin Alimy  1 , Athanasios D Anastasilakis  2   3 , John J Carey  2   4 , Stella D'Oronzo  2   5 , Anda M Naciu  2   6 , Julien Paccou  2   7 , Maria P Yavropoulou  2   8 , Willem F Lems  2   9 , Tim Rolvien  1   2
Affiliations

Conservative Treatments in the Management of Acute Painful Vertebral Compression Fractures: A Systematic Review and Network Meta-Analysis

Assil-Ramin Alimy et al. JAMA Netw Open. .

Abstract

Importance: Osteoporotic vertebral compression fractures (VCFs) frequently cause substantial pain and reduced mobility, posing a major health problem. Despite the critical need for effective pain management to restore functionality and improve patient outcomes, the value of various conservative treatments for acute VCF has not been systematically investigated.

Objective: To assess and compare different conservative treatment options in managing acute pain related to VCF.

Data sources: On May 16, 2023, 4 databases-PubMed, Embase, Scopus, and CINAHL-were searched. In addition, a gray literature search within Scopus and Embase was also conducted.

Study selection: Included studies were prospective comparative and randomized clinical trials that assessed conservative treatments for acute VCF.

Data extraction and synthesis: Data extraction and synthesis were performed by 2 authors according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Network Meta-Analyses recommendations. A frequentist graph-theoretical model and a random-effects model were applied for the meta-analysis.

Main outcomes and measures: Primary outcomes were short-term (4 weeks) pain during activity and long-term (latest available follow-up) nonspecified pain in patients with acute VCF.

Results: The study included 20 trials, encompassing 2102 patients, and evaluated various interventions for managing VCF. Calcitonin (standardized mean difference [SMD], -4.86; 95% CI, -6.87 to -2.86) and nonsteroidal anti-inflammatory drugs (NSAIDs; SMD, -3.94; 95% CI, -7.30 to -0.58) were beneficial regarding short-term pain during activity compared with placebo. For long-term nonspecific pain management, bisphosphonates were associated with inferior pain outcomes compared with daily (SMD, 1.21; 95% CI, 0.11 to 2.31) or weekly (SMD, 1.13; 95% CI, 0.05 to 2.21) administration of teriparatide, with no treatment being superior to NSAIDs. The qualitative analysis of adverse events highlighted that typical adverse events associated with these medications were observed.

Conclusions and relevance: NSAIDs and teriparatide may be the preferred treatment options for pain management in acute osteoporotic VCF. Although calcitonin also proved to be beneficial, its safety profile and potential adverse effects restrict its widespread application. The limited evidence on braces and analgesics underscores the urgent need for future research.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Carey reported receiving grants from UCB, grants and personal fees from Amgen, and personal fees from Consilient outside the submitted work; serving as president of the International Society for Clinical Densitometry (ISCD); being a member of the faculty for all ISCD densitometry courses; and being a member of Position Development Conference task forces and expert review panel and a speaker at the ISCD annual meetings from 2008 to 2024. Dr Lems reported receiving personal fees from UCB, Amgen, Pfizer, and Galapagos outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flowchart of Included Studies
BP indicates bisphosphonate; NSAID, nonsteroidal anti-inflammatory drug; and WJ-MSC, Wharton jelly–derived mesenchymal stem cell. aRefers to the 4 prospective comparative studies.
Figure 2.
Figure 2.. Short-Term Pain During Activity
A, Network plot of studies included in network meta-analysis on short-term pain management during activity. Circle size is proportional to the number of trials for each intervention, and the line thickness is proportional to the number of trials comparing the interventions. B, Network meta-analysis for short-term pain management during activity comparing pharmacological interventions with placebo. Data are presented as the standardized mean difference (SMD) and 95% CI for pain during activity. Values below 0 indicate that the treatment mentioned first (before the vs) is favored, whereas values above 0 indicate that the treatment mentioned last (after the vs) is favored. NSAID indicates nonsteroidal anti-inflammatory drug.
Figure 3.
Figure 3.. Pharmacological Interventions for Long-Term Pain Management (Nonspecified Pain)
A, Network plot of studies included in network meta-analysis of pharmacological interventions regarding long-term pain management. Circle size is proportional to the number of trials for each intervention, and the line thickness is proportional to the number of trials comparing the interventions. B, Network meta-analysis for long-term pain management (nonspecified) comparing pharmacological interventions with nonsteroidal anti-inflammatory drug (NSAID). Data are presented as the standardized mean difference (SMD) and 95% CI for long-term pain outcomes. Values below 0 indicate that the treatment mentioned first (before the vs) is favored, whereas values above 0 indicate that the treatment mentioned last (after the vs) is favored.
Figure 4.
Figure 4.. Braces for Long-Term Pain Management (Nonspecified Pain)
A, Network plot of studies included in network meta-analysis of brace treatment regarding long-term pain management. Circle size is proportional to the number of trials for each intervention, and the line thickness is proportional to the number of trials comparing the interventions. B, Network meta-analysis for long-term pain management (nonspecified) comparing the treatment with various braces with no brace treatment. Data are presented as the standardized mean difference (SMD) and 95% CI for long-term pain. Values below 0 indicate that the treatment mentioned first (before the vs) is favored, whereas values above 0 indicate that the treatment mentioned last (after the vs) is favored regarding pain outcomes.
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