From the Guidelines
Management of an L2 compression fracture with neurological manifestations requires immediate comprehensive care, including surgical intervention, as it is typically necessary when neurological deficits are present. The initial management includes hospital admission for neurological monitoring, pain control with medications like morphine (2-5mg IV every 4 hours as needed) or hydromorphone (0.5-1mg IV every 4 hours as needed), and methylprednisolone (30mg/kg IV bolus followed by 5.4mg/kg/hr for 23 hours) if spinal cord injury is suspected and treatment can begin within 8 hours of injury 1.
Key Considerations
- Surgical intervention is reserved for patients with neurologic deficits, spinal deformity, or spinal instability, as stated in the ACR Appropriateness Criteria for management of vertebral compression fractures 1.
- Options for surgical intervention include decompression laminectomy to relieve pressure on neural elements and spinal fusion with instrumentation to stabilize the vertebral column.
- Timing of surgery is crucial, with earlier intervention (within 24-48 hours) generally producing better outcomes for patients with progressive neurological deficits.
Post-Operative Care
- Post-operative care includes physical therapy, occupational therapy, bracing (TLSO brace worn for 6-12 weeks), and rehabilitation to maximize functional recovery.
- Regular follow-up with neurosurgery or orthopedic spine specialists is essential to monitor neurological status and healing progress, with imaging studies at 6 weeks, 3 months, and 6 months post-treatment to assess fracture healing and spinal alignment.
Additional Considerations
- The use of vertebroplasty is not recommended for the treatment of symptomatic osteoporotic spinal compression fractures, as stated in the clinical practice guideline by the Journal of the American Academy of Orthopaedic Surgeons 1.
- The use of calcitonin for 4 weeks following the onset of fracture may be considered, as it has a moderate recommendation for the treatment of symptomatic osteoporotic spinal compression fractures 1.
From the Research
Management Plan for L2 Compression Fracture with Neurological Manifestations
The management plan for a patient with an L2 compression fracture presenting with neurological manifestations involves several key considerations:
- Surgical intervention: In cases where neurological deterioration occurs due to cement extravasation into the spinal canal, immediate surgical removal of the cement and decompression can lead to significant improvement in neurological deficits 2.
- Decompressive surgery: For patients with osteoporotic vertebral fractures and late collapse, decompressive surgery and stabilization can be effective in improving neurological function and allowing patients to regain mobility 3.
- Posterior approach: A posterior approach with bilateral posterior transpedicular decompression and instrumented arthrodesis with cemented pedicle screws can be used to manage osteoporotic fractures with neurological impairment 3.
- Emergency open decompression: In cases where cauda equina syndrome is suspected, emergency open decompression combined with multilevel screw fixation may be necessary to relieve pressure on the spinal cord and improve neurological function 4.
- Non-surgical management: For patients with less severe fractures and no neurological deficits, non-surgical management options such as electromagnetotherapy and kinezitherapy may be considered 5.
Key Considerations
- Risk factors: Identifying risk factors associated with poor recovery, such as osteoporosis and late collapse, is crucial for developing an effective treatment plan 3.
- Neurological assessment: A thorough neurological assessment is essential to determine the extent of neurological impairment and guide treatment decisions 2, 3, 6, 4.
- Imaging studies: Imaging studies such as MRI and CT scans can help diagnose the extent of the fracture and any associated neurological complications 2, 5, 4.