What is the treatment for a suspected vertebral fracture?

Treatment of Suspected Vertebral Fractures

For suspected vertebral fractures, initial management should include radiography (X-ray) of the spine as the first imaging study, followed by MRI without IV contrast if radiographs are negative or indeterminate, along with appropriate pain management and consideration of bisphosphonates for osteoporotic fractures. 1, 2

Diagnostic Approach

Initial Imaging

1. X-ray of the spine area of interest (2 views) - Rated 9/9 for appropriateness as first-line imaging 2
   • Provides initial assessment of fracture presence, location, and severity
   • Cost-effective and widely available

Secondary Imaging (if initial X-ray is negative/indeterminate)

1. MRI without IV contrast - Rated 9/9 for appropriateness as follow-up imaging 2

   • Superior for detecting occult fractures and bone marrow edema
   • Can identify complications such as spinal cord compression
   • Helps differentiate between acute and chronic fractures

2. CT without IV contrast - Rated 7/9 for appropriateness as alternative follow-up imaging 2

   • Useful when MRI is contraindicated
   • Better for assessing bony architecture and stability

Acute Management

Pain Control

• Mild pain: Acetaminophen or NSAIDs 1
• Moderate to severe pain: Short-term opioids may be considered 1
• Adjunctive therapy: Consider calcitonin for acute pain (0-5 days after onset) for 4 weeks 1

Activity Modification

• Initial brief bed rest for acute pain (1-2 days)
• Early mobilization as tolerated to prevent deconditioning
• Bracing may provide symptomatic relief in selected cases 1

Definitive Treatment

Conservative Management (First-line approach)

1. Structured physical therapy program

   • Focus on lumbar stabilization exercises 1
   • Spinal stretching exercises within pain limits
   • Balance training for long-term rehabilitation 1

2. Pharmacologic therapy for osteoporotic fractures

   • Bisphosphonates - Recommended as first-line treatment to prevent additional fractures 2, 1
   • Calcium supplementation (1000-1200 mg/day) 1
   • Vitamin D supplementation (800 IU/day) 1
   • Consider denosumab as second-line treatment if bisphosphonates are contraindicated 2
   • For very high-risk patients, consider romosozumab or teriparatide 2

Interventional Options

1. Vertebral augmentation - Consider for patients with:

   • Persistent severe pain despite conservative management
   • Significant functional limitation
   • Options include vertebroplasty or balloon kyphoplasty 1

2. Surgical intervention - Reserved for patients with:

   • Neurological deficits
   • Spinal instability
   • Significant canal stenosis 1

Special Considerations

Malignant Spinal Cord Compression

• Requires immediate high-dose dexamethasone (16-96mg/day)
• Urgent MRI and neurosurgical consultation
• Consider surgery + radiotherapy for good performance status patients 1

Monitoring and Follow-up

• Assess treatment response through pain relief and neurological function
• Monitor for development of new fractures
• Reassess bone mineral density in 1-2 years for osteoporotic fractures

Pitfalls and Caveats

• Up to 2/3 of vertebral compression fractures are not accurately diagnosed 3
• Delay in diagnosis and treatment leads to worse outcomes and increased risk of additional fractures 1, 4
• The American Academy of Orthopaedic Surgeons recommends against vertebroplasty due to evidence showing no significant difference between vertebroplasty and sham procedures 1
• Patients with vertebral fractures have a 20% risk of experiencing another vertebral fracture within one year 5

By following this evidence-based approach to suspected vertebral fractures, clinicians can effectively diagnose, treat, and prevent complications, ultimately improving patient outcomes and quality of life.