Guidelines for Treating Acute Vertebral Compression Fractures
The management of acute vertebral compression fractures should follow a multimodal approach including acetaminophen as first-line treatment, with consideration of nerve blocks for hip region fractures, and limited use of opioids only for breakthrough pain at the lowest effective dose for the shortest period. 1, 2
Initial Pain Management
First-Line Medications
- Intravenous acetaminophen every 6 hours is recommended as first-line treatment for acute pain management in elderly patients with vertebral compression fractures 1
- For mild pain: oral acetaminophen or NSAIDs 2
- For moderate to severe pain: consider short-term opioids with caution 2
- Important: Opioid administration requires progressive dose reduction due to high risk of morphine accumulation, over-sedation, respiratory depression, and delirium in elderly patients 1
Regional Anesthesia
- For hip region fractures: Peripheral nerve blocks are strongly recommended at the time of presentation to reduce opioid use 1
- L2 nerve root blocks are specifically recommended for L3 or L4 compression fractures 2
- Epidural and paravertebral blocks are strongly recommended for patients with rib fractures 1
Comprehensive Management Approach
Medical Management
- Calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 2
- Bisphosphonates to prevent additional fractures and help with pain palliation 2
- Calcitonin for 4 weeks in acute cases (0-5 days after onset) 2
Non-Pharmacological Interventions
- Immobilization of affected areas 1
- Application of ice packs 1
- Structured physical therapy program targeting lumbar stabilization 2
- Bracing may offer symptomatic relief in selected cases 2
Rehabilitation Protocol
Acute stage (first 3 weeks):
- Initial bed rest for 4-8 days until patient can turn easily from side to side
- Back support provision
- Gradual mobilization with frequent but brief intervals 3
Healing stage (next 10 weeks):
Long-term management:
Interventional Procedures
Vertebral Augmentation
- The American Academy of Orthopaedic Surgeons recommends against vertebroplasty due to strong evidence showing no significant difference between vertebroplasty and sham procedures 2
- However, more recent research suggests vertebroplasty may provide prompt pain relief and rapid rehabilitation compared to conservative therapy 4
- Consider vertebral augmentation (vertebroplasty or balloon kyphoplasty) only in patients with:
- Inadequate pain relief with conservative care
- Persistent pain substantially affecting quality of life 5
Special Considerations
Malignant Spinal Cord Compression
- Immediate high-dose dexamethasone (16-96mg/day)
- Urgent MRI and neurosurgical consultation
- Surgery + Radiotherapy for good performance status patients
- Radiotherapy alone for non-surgical candidates 2
Surgical Indications
- Immediate surgical decompression and stabilization for patients with:
- Neurological deficits
- Spinal instability 2
Clinical Assessment Tips
- Closed-fist percussion sign: Tapping over the spinous process with a closed fist can help identify acute fractures (sensitivity 87.5%, specificity 90%) 6
- Supine sign: Pain when lying supine suggests acute fracture (sensitivity 81.25%, specificity 93.33%) 6
- MRI is the definitive investigation to distinguish between acute and chronic healed fractures 6
Common Pitfalls to Avoid
- Delaying diagnosis and treatment, which leads to worse outcomes 2
- Overuse of opioids in elderly patients 1
- Failing to consider underlying causes (osteoporosis, malignancy) 5
- Not assessing for spinal instability in patients with pathologic fractures 2
- Neglecting to monitor neurological status closely during treatment 2