to the editor: I appreciated the excellent review of vertebral compression fractures (VCFs) by Drs. McCarthy and Davis. The text of the article and Table 1 stated that lidocaine patches are an option for pain relief. However, the best evidence does not show any benefit from lidocaine 5% patches compared with placebo for somatic back pain.

There are no published randomized controlled trials (RCTs) of lidocaine patches for pain from VCFs. However, two unpublished RCTs showed no significant difference between placebo patches and lidocaine 5% patches for low back pain.^1,2 Another RCT showed no significant difference between placebo and lidocaine patches for chronic low back pain.³ A final RCT showed no improvement in pain control with lidocaine patches vs. placebo for traumatic rib fractures.⁴

At a cost of $220 per month and with an over-the-counter lidocaine 4% patch now available, the lidocaine 5% patch is an expensive placebo for our patients.

in reply: Thank you for the insightful commentary on our article. We agree that the evidence for lidocaine patches is not strong for somatic back pain, and we found no studies evaluating topical lidocaine for the management of VCFs. As we mentioned in our article, the American Academy of Orthopaedic Surgeons found inconclusive evidence to support specific analgesics for acute VCF pain.¹ Our literature search failed to find many RCTs of medications other than calcitonin to treat pain from VCFs. Nonetheless, this pain can be substantial, and although data examining the effectiveness of analgesics are lacking, we felt it worthwhile to mention the more common medications used in practice.

Many patients with VCFs are older, and medications commonly used to treat pain from VCFs are on the Beers list of medications to avoid in older patients. In current clinical practice, there may be a role for acetaminophen or topical lidocaine, even though the effectiveness of acetaminophen has been questioned.² Narcotics also lack sound evidence and are associated with more serious adverse effects.³ In an effort to do no harm, selecting medications such as acetaminophen and lidocaine may be warranted in older patients, even if the evidence for pain relief is less than robust. In addition to trying to recommend evidence-based treatments, we should remain cost conscious, and we appreciate the mention of the newer over-the-counter lidocaine patch as a less expensive option.