What is the recommended management for a T8-T9 superior endplate compression fracture?

From the Guidelines

The recommended management for a T8-T9 superior endplate compression fracture typically involves conservative treatment with pain control, limited activity, and bracing. Initial pain management should include acetaminophen (1000 mg every 6 hours) and/or NSAIDs like ibuprofen (400-600 mg every 6-8 hours) if not contraindicated, as suggested by the American College of Radiology 1. For more severe pain, a short course of opioids such as hydrocodone/acetaminophen 5/325 mg every 4-6 hours for 1-2 weeks may be necessary. Activity modification is crucial, with bed rest for the first few days followed by gradual mobilization as tolerated. A thoracolumbosacral orthosis (TLSO) brace is often prescribed for 6-12 weeks to provide spinal stability and reduce pain during healing. Physical therapy should be initiated after acute pain subsides, typically 2-4 weeks post-injury, focusing on core strengthening and proper body mechanics. Regular follow-up imaging at 6-12 weeks is important to assess healing. This conservative approach is appropriate because most stable thoracic compression fractures heal well without surgery, as noted in the management of vertebral compression fractures guidelines 1. However, surgical intervention may be considered if there is significant neurological compromise, spinal instability (>50% height loss or kyphotic angulation >30 degrees), or if pain persists despite conservative measures, as outlined in the guidelines for pathologic fractures with neurologic effects 1 and spinal deformity or pulmonary dysfunction 1. Vertebroplasty or kyphoplasty might be options for persistent pain in select patients. It's also important to consider the prevention and treatment of glucocorticoid-induced osteoporosis, as recommended by the American College of Rheumatology 1, and to assess for any underlying conditions that may have contributed to the compression fracture, such as osteoporosis or neoplasms, as discussed in the introduction to the management of vertebral compression fractures 1.

Some key points to consider in the management of T8-T9 superior endplate compression fractures include:

• The use of a multidisciplinary approach, including interventional radiology, surgery, and radiation oncology consultation, for patients with pathologic fracture with spinal deformity or pulmonary dysfunction 1
• The importance of thorough medical management, including appropriate osteoporosis screening and follow-up treatment, as outlined in the ACR Appropriateness Criteria topic on “Osteoporosis and Bone Mineral Density” 1
• The need for regular follow-up imaging to assess healing and to monitor for any potential complications, such as spinal instability or neurological compromise.

Overall, the goal of management for a T8-T9 superior endplate compression fracture is to provide adequate pain control, promote healing, and prevent any potential complications, while also considering the individual patient's underlying conditions and overall health status.

From the Research

Management Options for T8-T9 Superior Endplate Compression Fractures

• The management of vertebral compression fractures, including T8-T9 superior endplate compression fractures, is multimodal in nature and starts with conservative therapy consisting of analgesic medication, medication for osteoporosis, physical therapy, and bracing 2.
• Patients who are refractory to conservative management may be candidates for vertebral augmentation through either vertebroplasty or kyphoplasty 2, 3.
• Evidence suggests that vertebral augmentation, especially some of the newer procedures, have the potential to dramatically reduce pain and improve quality of life 3.
• For patients with osteoporotic vertebral compression fractures complicated with spinal deformity and neurologic deficit, surgical options such as indirect reduction, kyphoplasty, and short posterior instrumentation may be considered 4.
• In cases where there is a neurological deficit associated with fractures or progressive pseudarthrotic kyphosis, indirect postural reduction, kyphoplasty, and posterior percutaneous short segment transpedicle instrumentation may be effective 4.
• Posterior stabilization without neural decompression may also be a viable option for patients with osteoporotic thoracolumbar fractures with dynamic cord compression causing incomplete neurological deficits 5.

Diagnostic Considerations

• Diagnosis of vertebral compression fractures is typically confirmed using plain radiographs, while computed tomography and magnetic resonance imaging may be required to evaluate for a malignant cause or if there are neurological deficits on examination 6.
• Magnetic resonance imaging is also the modality of choice to determine if the fracture is acute vs chronic in nature 6.

Treatment Goals

• The goal of treatment for vertebral compression fractures is to provide symptom relief and improve quality of life 3, 6.
• Treatment should be individualized based on the patient's specific needs and circumstances, taking into account factors such as the severity of the fracture, the presence of neurological deficits, and the patient's overall health status 3, 4, 6.