From the Guidelines
Management of an L2 compression fracture should prioritize conservative measures, including pain control, activity modification, and supportive care, with surgery reserved for cases with neurological deficits, significant instability, or intractable pain. The initial treatment focuses on pain management with acetaminophen (500-1000mg every 6 hours), NSAIDs like ibuprofen (400-800mg three times daily), or if needed, short-term opioids such as hydrocodone/acetaminophen (5/325mg every 4-6 hours as needed) 1. Muscle relaxants like cyclobenzaprine (5-10mg three times daily) may help with associated muscle spasms. Patients should limit bed rest to 1-3 days to prevent deconditioning, followed by gradual return to activities as tolerated. A thoracolumbar orthosis (back brace) may provide stability and pain relief for 6-12 weeks. Physical therapy should begin within 1-2 weeks to improve strength, posture, and mobility. For osteoporotic fractures, bisphosphonates like alendronate (70mg weekly) or zoledronic acid (5mg IV annually) may be prescribed to prevent future fractures, as they can improve vertebral bone mineral density and resolve bone pain 1. Some studies suggest vertebroplasty/kyphoplasty for refractory pain associated with vertebral compression fractures in selected patients 1, but the use of vertebroplasty is not recommended according to other guidelines 1. Most L2 compression fractures heal within 6-12 weeks with conservative management. Key considerations in management include:
- Pain control
- Activity modification
- Supportive care
- Prevention of future fractures with bisphosphonates if osteoporotic
- Reserved use of surgery for specific indications. Given the most recent and highest quality evidence, conservative management should be the primary approach for L2 compression fractures, with a focus on pain control, mobility, and prevention of further bone loss 1.
From the Research
Management for L2 Compression Fracture
The management for an L2 compression fracture typically involves a combination of non-surgical and surgical options.
- Non-surgical management includes pain management and bracing, with two-thirds of patients experiencing spontaneous resolution of pain in 4 to 6 weeks 2.
- Patients with persistent back pain and bone marrow edema on magnetic resonance imaging may benefit from injection of cement into the fractured vertebral body with either vertebroplasty or kyphoplasty 2.
- Vertebral augmentation procedures, including vertebroplasty, kyphoplasty, and vertebral augmentation with implants, can provide immediate pain relief and improve quality of life 3.
- The ideal candidate for vertebral augmentation is a patient with a symptomatic fracture seen on cross-sectional imaging in which nonsurgical management has failed and has positive signs on physical examination with no absolute contraindication 3.
Treatment Options
- Percutaneous vertebral augmentation is a minimally invasive procedure that stabilizes osseous fractures and provides immediate pain relief 3.
- Kyphoplasty and vertebroplasty are effective methods for treating vertebral compression fractures, with most patients reporting immediate, durable pain relief 2.
- Open surgical management with decompression and stabilization should be reserved for patients with neural compression and progressive deformity with neurologic deficits 4.
- Medical management, including nonsteroidal anti-inflammatory drugs, calcitonin, teriparatide, and bisphosphonates, remains the first-line therapy for patients with vertebral compression fractures 5.
Evaluation and Follow-up
- Diagnosis is 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.
- Patients should undergo the appropriate follow-up to ensure optimal recovery, and receive appropriate therapy for the underlying disorder that predisposed them to the vertebral fracture 3.