What is the treatment for spinal fractures?

Treatment of Spinal Fractures

The treatment of spinal fractures should be tailored based on fracture stability, neurological status, and patient factors, with surgical intervention being necessary for unstable fractures or those with neurological compromise, while stable fractures can be effectively managed conservatively. 1

Initial Assessment and Classification

• Imaging evaluation:

  • Plain radiographs as initial imaging to identify vertebral body height loss and deformity 1
  • MRI to determine fracture acuity, identify bone marrow edema, and detect minimally deforming fractures 1
  • CT scans to assess fracture characteristics and determine fracture type 1

• Classification by stability:

  • Stable fractures: No risk of progressive deformity or neurological injury
  • Unstable fractures: Risk of progressive deformity or neurological compromise

Treatment Algorithm

1. Stable Fractures (without neurological deficit)

• Conservative management:

  • Pain control with analgesics
  • Early mobilization with functional treatment rather than immobilization 2
  • Calcitonin for acute symptomatic osteoporotic compression fractures (within 0-5 days of onset)
    • Recommended dosage: 200 IU nasal calcitonin for 4 weeks 3
    • Provides clinically significant pain reduction at 1-4 weeks 3
  • Consider bracing, though evidence for specific types is inconclusive 3

• Pharmacological management for osteoporotic fractures:

  • Calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 1
  • Bisphosphonates to prevent additional fractures:
    • Alendronate has shown 47% relative risk reduction in new vertebral fractures 4
    • Ibandronate is an option to prevent additional symptomatic fractures 3
  • Denosumab as an alternative in appropriate patients 5

2. Unstable Fractures or Fractures with Neurological Deficit

• Surgical intervention is indicated for:

  • Neural element compression with neurological deficit
  • Spinal fracture causing instability
  • Spinal dislocation with mechanical instability
  • Displaced fracture fragment causing neural element compromise 1

• Surgical approaches:

  • Early surgical treatment (instrumentation and fusion) is mandatory for unstable fractures 6
  • Surgical stabilization produces better results than conservative treatment for unstable fractures, with shorter periods of immobilization and rehabilitation 7

3. Specific Management for Osteoporotic Compression Fractures

• First-line treatment:

  • Conservative pain management with analgesics
  • Early mobilization as tolerated
  • Calcitonin for acute pain management (first 4 weeks) 3

• Second-line interventions:

  • Consider L2 nerve root block for fractures at L3 or L4 3
  • Vertebroplasty is NOT recommended based on level I evidence showing no statistically significant difference between vertebroplasty and sham procedure in pain reduction 3

• Prevention of future fractures:

  • Implementation of a Fracture Liaison Service for patients over 50 years 1
  • Bisphosphonate therapy (alendronate has shown 51% reduction in hip fractures and 47% reduction in vertebral fractures) 4

Rehabilitation

• Begin range-of-motion exercises as soon as medically appropriate 1
• Evidence for supervised or unsupervised exercise programs is inconclusive, though some studies suggest improvement in symptoms and emotional domains 3
• Early finger and hand motion is essential to prevent edema and stiffness 1

Special Considerations

• Children and adolescents:

  • Conservative treatment is appropriate for stable fractures without neurological lesion
  • Early surgical treatment is mandatory for unstable fractures and injuries with spinal cord lesion
  • Children with traumatic spinal cord lesions may develop deformity (scoliotic, kyphotic, or lordotic) in >90% of cases 6

• Monitoring:

  • Regular follow-up imaging to assess healing and hardware integrity (if surgical intervention was performed) 1
  • Monitor for complications such as implant failure or loosening 1

Common Pitfalls to Avoid

• Prolonged bed rest can lead to complications including muscle atrophy, deep vein thrombosis, and pressure sores
• Inadequate pain control may delay mobilization and rehabilitation
• Failing to identify unstable fractures can lead to progressive deformity and neurological compromise
• Overlooking osteoporosis as the underlying cause of vertebral fractures can lead to recurrent fractures

By following this structured approach to spinal fracture management, clinicians can optimize outcomes while minimizing complications and preventing future fractures.