From the Guidelines
The initial management for an acute/subacute L5 compression fracture with 50% height loss and no neural compression should focus on pain control, limited bed rest, and early mobilization. Pain management typically includes acetaminophen (1000 mg every 6 hours, not exceeding 4000 mg daily) and NSAIDs such as ibuprofen (400-600 mg every 6-8 hours with food) or naproxen (500 mg twice daily) 1. For more severe pain, a short course of opioids may be prescribed, such as hydrocodone/acetaminophen 5/325 mg every 4-6 hours for 1-2 weeks.
Key Considerations
- Bed rest should be limited to 1-3 days to prevent deconditioning, followed by gradual activity increase with a soft lumbar brace for support during ambulation.
- Physical therapy should begin within 1-2 weeks, focusing on core strengthening and proper body mechanics.
- Calcium (1200 mg daily) and vitamin D (800-1000 IU daily) supplementation is recommended to support bone healing.
- Osteoporosis evaluation is essential since vertebral compression fractures often indicate underlying bone density issues. This conservative approach is appropriate because the fracture, despite significant height loss, has no neural compression that would necessitate surgical intervention, as supported by recent guidelines 1. Most compression fractures heal within 6-12 weeks with this management strategy.
From the Research
Initial Management
The initial management for an acute/subacute compression fracture of the L5 vertebra with 50% loss of height and no neural compression typically involves conservative treatment options.
- Conservative therapy consisting of analgesic medication, medication for osteoporosis, physical therapy, and bracing is often the first line of treatment 2.
- Pain management and bracing are also recommended, with two-thirds of patients experiencing spontaneous resolution of pain in 4 to 6 weeks 3.
- A focused history and exam can identify patients likely to benefit from vertebral body augmentation, such as vertebroplasty or kyphoplasty, if they have persistent back pain and bone marrow edema on magnetic resonance imaging 3.
Treatment Options
Treatment options for vertebral compression fractures include:
- Nonoperative management with pain management and bracing for patients with no neural compression 3, 4.
- Vertebral augmentation through either vertebroplasty or kyphoplasty for patients who are refractory to conservative management 2, 5.
- Open surgical management with decompression and stabilization reserved for rare patients with neural compression and progressive deformity with neurologic deficits 4.
Considerations
Considerations for treatment include:
- Understanding the risk factors, appropriate clinical evaluation, and management strategies are crucial 5.
- Analysis of the evidence shows that balloon kyphoplasty had significantly better and vertebroplasty tended to have better pain reduction compared with non-surgical management 5.
- Appropriate evaluation and medical treatment of underlying osteoporosis should be recommended or instituted 4.