What is the treatment for an L2 compression fracture?

Treatment for L2 Compression Fracture

For an L2 compression fracture, initial treatment should include calcitonin for 4 weeks in acute cases (within 0-5 days of onset), along with appropriate analgesics, followed by consideration of bisphosphonates to prevent additional fractures. 1, 2

Initial Management Algorithm

1. Pain Management

   • For mild pain: Acetaminophen or NSAIDs 2
   • For moderate to severe pain: Short-term opioids may be considered 2
   • Calcitonin therapy (200 IU daily) for 4 weeks if within 0-5 days of fracture onset 1, 2
     • Available as nasal spray or suppositories
     • Provides clinically important pain reduction at 1,2,3, and 4 weeks
     • Side effects may include mild dizziness

2. Bracing and Activity

   • External bracing to limit motion and provide support
   • Early mobilization with appropriate pain control
   • Avoid prolonged bed rest which can worsen osteoporosis

3. Medical Management

   • Calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 2
   • Consider bisphosphonates to prevent additional fractures 1, 2
   • Antiresorptive agents have high-strength evidence for pain palliation 2

Rehabilitation

• Structured physical therapy program targeting lumbar stabilization 2
• Early introduction of physical training and muscle strengthening 2
• Long-term continuation of balance training 2

Interventional Options

Consider these options if conservative treatment fails after 4-6 weeks:

1. Vertebral Augmentation

   • Kyphoplasty has a weak recommendation for treating symptomatic fractures in neurologically intact patients 1, 2
   • Provides rapid pain relief and structural reinforcement 2
   • Vertebroplasty is NOT recommended (strong recommendation against) 1

2. Nerve Blocks

   • L2 nerve root blocks can be considered for pain management, especially for L3 or L4 compression fractures 1, 2

Surgical Indications

Surgery is generally NOT indicated for stable anterior wedge compression fractures without neurological compromise 2. Consider surgery only if:

• Spinal instability is present
• Neurological compromise occurs
• Significant canal stenosis develops

Important Caveats and Considerations

• Timing matters: Calcitonin is most effective when started within 0-5 days of fracture onset 1
• Watch for concomitant fractures: If pain persists after treatment, consider the possibility of additional undiagnosed fractures, including sacral insufficiency fractures 3
• Osteoporosis evaluation: All patients with vertebral compression fractures should be evaluated for underlying osteoporosis 4
• Spontaneous height restoration: Some cases may experience spontaneous height restoration, particularly when treated with kyphoplasty 5
• Differential diagnosis: Always consider other causes of vertebral fractures beyond osteoporosis, including malignancy, before attributing to osteoporosis alone 4

The American Academy of Orthopaedic Surgeons guidelines emphasize conservative management with calcitonin for acute fractures, with consideration of minimally invasive procedures only when conservative management fails 1, 2.