From the Guidelines
I strongly recommend obtaining a clinical assessment for point tenderness at the L2 vertebral level to determine if the observed superior endplate concavity represents an acute compression fracture requiring treatment. The radiological finding shows a concavity in the upper surface of the L2 vertebra, which could be due to a compression fracture, though its age cannot be determined from imaging alone 1. If point tenderness is present at this level, it suggests the fracture may be recent and potentially symptomatic. According to the American College of Radiology, most vertebral compression fractures show gradual improvement in pain over 2 to 12 weeks, with variable return of function 1.
Treatment options would depend on the clinical correlation - if acute, management might include pain control, possibly with NSAIDs or other analgesics, limited activity modification, and potentially bracing for comfort 1. Physical therapy may be beneficial once acute pain subsides. It is essential to note that approximately 1 in 5 patients with osteoporotic VCFs will develop chronic back pain as a result of the fracture 1.
Key considerations in management include:
- Correlation between imaging and clinical findings to determine the age and symptomatology of the fracture
- Pain control and management of symptoms
- Potential for bracing and limited activity modification
- Role of physical therapy in rehabilitation
- Risk of chronic back pain and spinal deformity associated with vertebral compression fractures 1.
From the Research
Vertebral Compression Fractures
- Vertebral compression fractures (VCFs) are a common complication of osteoporosis, affecting more than 700,000 Americans annually 2.
- The risk of fracture increases with age, with four in 10 white women older than 50 years experiencing a hip, spine, or vertebral fracture in their lifetime 2.
- Patients with an acute VCF may report abrupt onset of back pain with position changes, coughing, sneezing, or lifting, and physical examination findings can demonstrate kyphosis and midline spine tenderness 2.
Diagnosis and Treatment
- Diagnosis of VCFs can be made through plain radiography, and more than two-thirds of patients are asymptomatic and diagnosed incidentally 2.
- Treatment options for VCFs include analgesics, limited bed rest, bracing, physical therapy, nerve root blocks, and epidural injections 2, 3.
- Percutaneous vertebral augmentation, including vertebroplasty and kyphoplasty, can be considered in patients with inadequate pain relief with nonsurgical care or when persistent pain substantially affects quality of life 2, 4.
Correlation with Point Tenderness
- Point tenderness is a common physical examination finding in patients with VCFs, and correlation with point tenderness is recommended to confirm the diagnosis 2.
- A study on changes in lumbar endplate area and concavity associated with disc degeneration found that endplates become more convex over time in both sagittal and coronal planes with advancing intervertebral disc degeneration 5.
Management of Osteoporosis and Spinal Fractures
- Contemporary guidelines and evolving paradigms for the management of osteoporosis and spinal fractures recommend the use of modern scoring systems such as Fracture Risk Assessment Tool (FRAX®) for evaluating fracture risk in osteoporosis 6.
- The role of primary surgical intervention for vertebral compression fracture and secondary fracture prevention with pharmacological therapy is described, with randomized clinical trial-based wisdom on its timing and dosage, drug holiday, adverse effects, and relevant evidence-based literature 6.