What is the treatment for a compression fracture of the L2 vertebra with 25% height loss?

Treatment of L2 Vertebral Compression Fracture with 25% Height Loss

For a vertebral compression fracture of L2 with 25% height loss, initial conservative medical management is recommended for 2-3 months, followed by vertebral augmentation procedures if pain persists despite medical therapy. 1

Initial Management (First 0-12 weeks)

Medical Management

1. Pain Control

   • NSAIDs and acetaminophen as first-line agents
   • Limited use of opioids for severe pain
   • Calcitonin therapy for 4 weeks - shown to provide clinically important pain reduction 1
     • Options include nasal calcitonin or suppositories (200 IU)
     • Side effects may include mild dizziness

2. Activity Modification

   • Limited bed rest (avoid prolonged immobilization)
   • Early mobilization as tolerated
   • Gradual return to activities

3. Bracing

   • Consider thoracolumbar bracing for comfort and stability
   • Note: Evidence for bracing is inconclusive but may provide symptomatic relief 1

4. Osteoporosis Management

   • Calcium and vitamin D supplementation
   • Bisphosphonates (ibandronate) to prevent additional fractures 1
   • Bone density evaluation

If Pain Persists After 3 Months of Conservative Management

Vertebral Augmentation Procedures

• Vertebroplasty (VP) or Balloon Kyphoplasty (BK) should be considered if:

  • Pain persists despite medical management
  • Spinal deformity is present
  • Pulmonary dysfunction occurs 1

• Both procedures provide:

  • Immediate and substantial pain relief
  • Improved patient mobility
  • Prevention of secondary sequelae (decreased bone mineral density, muscle weakness)
  • Improved pulmonary function 1

• Balloon Kyphoplasty may offer:

  • Superior improvement in spinal deformity
  • Extension of kyphotic angle
  • Increased vertebral body height
  • Less cement leakage
  • Better functional recovery compared to vertebroplasty 1

Special Considerations

Nerve Block Option

• L2 nerve root block may be considered for acute pain relief
• Particularly effective for L3 or L4 fractures, but may also help with L2 fracture pain 2
• Provides short-term relief (up to 2 weeks) but lacks long-term efficacy 2

Physical Therapy

• Initiate once acute pain subsides
• Focus on core strengthening and posture improvement
• Evidence for supervised exercise programs is inconclusive but may improve symptoms and emotional domains 1, 3

Monitoring and Follow-up

• Regular radiographic assessment to monitor fracture healing and vertebral height
• Evaluate for progressive deformity
• Screen for additional vertebral fractures

Important Clinical Pitfalls

1. Ruling out pathologic fracture - Ensure fracture is osteoporotic rather than pathologic (due to malignancy or infection)

   • MRI is most useful for differentiating between osteoporotic and pathologic fractures 3

2. Timing of intervention - The VERTOS II trial suggests that patients who haven't achieved sufficient pain relief by 3 months with conservative treatment should be considered for vertebral augmentation 1

3. Avoiding prolonged immobilization - Extended bed rest can lead to deconditioning, increased bone loss, and higher risk of deep vein thrombosis

4. Monitoring for adjacent level fractures - Patients with one vertebral compression fracture are at higher risk for subsequent fractures