What is the management of a superior endplate fracture of the L2 vertebral body with minimal height loss in a 64-year-old female (YOF) with generalized ligamentous laxity (GLF) already taking Tramacet (tramadol and acetaminophen)?

From the Guidelines

For a 64-year-old female with a superior endplate fracture of the L2 vertebral body with minimal height loss following a ground-level fall, who is already taking Tramacet, I recommend continuing Tramacet as prescribed for pain control and considering a multimodal pain management approach to optimize pain relief and functional recovery. The patient's current medication regimen can be supplemented with a scheduled acetaminophen regimen (1000 mg every 6 hours, not exceeding 4000 mg daily) to provide baseline pain relief, as most patients with osteoporotic VCFs experience spontaneous resolution of pain in over 6 to 8 weeks 1.

A short course of an NSAID like naproxen (500 mg twice daily with food) for 1-2 weeks may help reduce inflammation if there are no contraindications such as kidney disease, heart disease, or gastrointestinal issues. It is essential to use narcotics with caution due to their associated effects of sedation, nausea, further decrease in physical conditioning, and fall risks 1.

The patient should maintain relative rest for 1-2 weeks but avoid prolonged bed rest, gradually increasing activity as tolerated. A properly fitted back brace may provide support and pain relief during the healing process. Immobilization with bed rest and bracing are also part of conservative treatment, which is often complementary to other treatment strategies 1.

Physical therapy should be initiated after the acute pain phase (typically 2-3 weeks) to restore function and prevent deconditioning. This approach addresses both the pain and functional aspects of recovery, as vertebral fractures typically heal within 6-12 weeks. Regular follow-up is essential to monitor healing and adjust the treatment plan as needed.

Key considerations in the management of this patient include:

• Monitoring for potential side effects of medications
• Gradually increasing activity to prevent deconditioning
• Providing adequate support and pain relief during the healing process
• Initiating physical therapy to restore function and prevent long-term disability
• Regular follow-up to adjust the treatment plan as needed, considering the patient's response to treatment and potential complications.

From the Research

Management of Superior Endplate Fracture of the L2 Vertebral Body

• The management of superior endplate fracture of the L2 vertebral body with minimal height loss in a 64-year-old female (YOF) already taking tramacet is a complex issue that requires careful consideration of various treatment options.
• According to 2, the major treatment strategies for patients with compression fractures are conservative pain management and vertebral augmentation.
• Conservative pain management includes medical management with nonsteroidal anti-inflammatory drugs, calcitonin, teriparatide, and bisphosphonates, which remains the first-line therapy for patients with vertebral compression fractures.
• However, the use of epidural steroid injections (ESIs) should be approached with caution, as they may lead to increased bone fragility and risk of vertebral fracture, as suggested by 3 and 4.
• In terms of pharmacotherapy for spine-related pain in older adults, 5 recommends rational therapeutic choices based on geriatric spine pain diagnosis, such as NSAIDs and acetaminophen for arthritic and myofascial-based pain, gabapentinoids or duloxetine for neuropathic and radicular pain, and combination therapy for mixed etiologies.
• Additionally, 6 provides an overview of the evidence for the use of various medications, including paracetamol, opioids, NSAIDs, muscle relaxants, antibiotics, and antidepressants, for treating low back pain in adults, highlighting the importance of careful consideration of the risks and benefits of each medication.

Treatment Options

• Conservative pain management with medical management, such as NSAIDs, calcitonin, teriparatide, and bisphosphonates, may be a suitable option for this patient.
• Vertebral augmentation, such as balloon-assisted kyphoplasty, may also be considered, as it has been shown to dramatically reduce pain and improve quality of life in patients with vertebral compression fractures, as suggested by 2.
• However, the use of ESIs should be approached with caution, and alternative treatment options should be considered, as suggested by 3 and 4.
• Pharmacotherapy for spine-related pain in older adults should be tailored to the individual patient's needs and diagnosis, taking into account the potential risks and benefits of each medication, as recommended by 5 and 6.