What is the treatment for thoracic compression fractures?

Treatment of Thoracic Compression Fractures

The treatment of thoracic compression fractures should follow a stepwise approach, with initial conservative management for most patients, reserving vertebral augmentation procedures for those with persistent pain after 4-6 weeks of conservative therapy. 1

Initial Assessment and Imaging

• Initial imaging:

  • Radiography of the thoracic spine as first-line screening for patients with thoracic back pain and risk factors for osteoporotic fractures 1
  • MRI thoracic spine without IV contrast is recommended to:
    • Identify compression fractures even when radiographs are negative
    • Assess fracture acuity (presence of marrow edema)
    • Evaluate for soft tissue or neurologic compression 1
  • CT thoracic spine without IV contrast may be useful in emergency settings or for presurgical planning 1

• Risk factors to identify:

  • Age >65 years
  • Known osteoporosis
  • Prior compression fractures
  • Chronic steroid use 1

Treatment Algorithm

1. Conservative Management (First-Line)

• Pain control:

  • NSAIDs and other analgesics for pain management
  • Consider calcitonin for 4 weeks following fracture onset (moderate recommendation) 1
  • Consider L2 nerve root blocks for pain from L3 or L4 fractures (weak recommendation) 1
  • Facet joint injections may provide relief for secondary facet pain 2

• Activity modification:

  • Limited bed rest (excessive immobilization can worsen bone loss)
  • Gradual return to activities as tolerated

• Bracing:

  • May be considered for pain control and to limit kyphosis
  • Evidence for effectiveness is limited 1

2. Vertebral Augmentation (For Persistent Pain)

• Consider for patients with:

  • Persistent pain after 4-6 weeks of conservative management
  • Pain significantly affecting mobility and quality of life
  • Fractures showing edema on MRI (indicating acuity) 1

• Procedures:

  • Kyphoplasty: Weak recommendation for use in neurologically intact patients 1

    • May provide better restoration of vertebral height and kyphosis correction compared to vertebroplasty
    • Shows clinically important pain relief at 24 hours, with diminishing effect over time 1

  • Vertebroplasty: Strong recommendation AGAINST its use 1

    • Multiple studies show no significant benefit over conservative management

3. Surgical Intervention

• Reserved for cases with:

  • Neurological deficits
  • Spinal instability
  • Progressive deformity 3

• Surgical options:

  • Decompression and internal fixation with transpedicular screw-rod systems
  • Better neurological outcomes when surgery performed within 24 hours of injury for traumatic fractures 3

Special Considerations

• Pathologic fractures:

  • If malignancy is suspected, biopsy is needed to confirm diagnosis
  • MRI can help differentiate benign from malignant fractures 1

• Osteoporosis management:

  • Initiate or optimize osteoporosis treatment to prevent future fractures
  • Consider ibandronate and strontium ranelate (weak recommendation) 1

• Fracture age:

  • Both acute and chronic fractures may benefit from intervention
  • Bone scan or MRI can help identify fracture acuity when timing is unclear 1

Pitfalls and Caveats

• Radiographic fracture assessment alone is not a reliable surrogate for symptomatic fracture; clinical correlation is essential 1
• The presence of a fracture on imaging, even if chronic, may not be the source of current back pain 1
• Multiple compression fractures significantly increase morbidity, mortality, and decrease quality of life 1
• Early intervention (within 24 hours) for traumatic fractures with neurological deficits shows better outcomes 3
• Vertebroplasty, despite widespread use, has strong recommendations against its use based on high-quality evidence 1

By following this structured approach, most patients with thoracic compression fractures can achieve pain control and functional improvement while minimizing complications and preventing future fractures.