Management Protocol for L2 Vertebral Compression Fracture
For L2 vertebral compression fractures, initial conservative management for 2-12 weeks is recommended for stable fractures without neurological deficits, followed by vertebral augmentation if pain persists or complications develop. 1
Initial Assessment
- Determine fracture stability based on absence of neurological deficits, minimal height loss (<10%), absence of retropulsion, and minimal deformity (<15% kyphosis, <10% scoliosis) 2
- MRI with fluid-sensitive sequences helps identify acute fractures, fracture clefts, and differentiate synchronous fractures 1
- Bone scan or SPECT/CT may help determine fracture age when clinical history is unclear 1
Conservative Management (First-Line for Stable Fractures)
- Pain control with analgesics including NSAIDs and limited use of narcotics (caution with sedation and fall risk) 1
- Limited bed rest to avoid complications of immobility (bone density decreases ~2% per week, muscle strength decreases 1-3% per day) 1
- Bracing for comfort and stabilization 3
- Physical therapy to maintain strength and mobility 4
- Osteoporosis management:
Indications for Vertebral Augmentation
- Failure of conservative management with persistent pain after 3 weeks 1
- Severe pain requiring parenteral narcotics or hospitalization 1
- Spinal deformity or pulmonary dysfunction 1
- Risk factors for failure of conservative treatment: age >78.5 years, severe osteoporosis (T-score <-2.95), BMI >25.5, vertebral collapse >28.5% 7
Vertebral Augmentation Techniques
- Vertebroplasty (VP): Injection of bone cement into fractured vertebra 1
- Balloon kyphoplasty (BK): Creation of cavity with balloon before cement injection 1
- Both techniques provide comparable pain relief, though kyphoplasty may offer better height restoration and less cement leakage 8
- Timing: While traditionally performed after 3 weeks of failed conservative treatment, evidence supports benefits for both acute (<6 weeks) and chronic fractures 1
Surgical Consultation
- Reserved for patients with:
Follow-up and Monitoring
- Regular assessment of pain control and functional status 9
- Monitoring for subsequent fractures, which occur in approximately 5-8% of patients within one year 7
- Continued management of underlying osteoporosis 9
Common Pitfalls to Avoid
- Prolonged bed rest leading to deconditioning, bone loss, and increased mortality 1
- Overuse of narcotics causing sedation, falls, and decreased physical conditioning 1
- Delaying vertebral augmentation in patients with risk factors for failed conservative management 7
- Missing unstable fractures by not performing adequate neurological examination 2
- Neglecting treatment of underlying osteoporosis, leading to subsequent fractures 9