Referrals Needed for L2 Compression Fracture
For a compression fracture at L2, medical management is the primary approach for the first 3 months, with referrals to orthopedic surgery or neurosurgery indicated only if there are neurological deficits, spinal instability, or failure to respond to conservative treatment. 1
Initial Assessment and Management
- Medical management is the first-line approach for patients with new symptomatic compression fractures without neurological deficits 1
- MRI of the spine without IV contrast (or CT spine without contrast if MRI is contraindicated) should be obtained to assess the fracture characteristics and rule out pathologic causes 1
- Pain management should include calcitonin for the first 4 weeks, which has shown clinically important pain reduction in acute compression fractures 1
Referral Algorithm Based on Clinical Presentation
No Referral Needed (Manage Conservatively):
- Patients with osteoporotic compression fractures without neurological deficits, spinal deformity, or "red flags" 1
- Patients in the first 3 months post-fracture with improving symptoms 1
Orthopedic Surgery or Neurosurgery Referral:
- Patients with neurological deficits (immediate referral) 1
- Patients with evidence of spinal instability 1
- Patients with severe and worsening pain despite 3 months of conservative management 1
- Patients with significant spinal deformity or progressive kyphosis 1
Interventional Radiology Referral:
- Consider for patients with persistent pain after 3 months of conservative management 1
- Appropriate for patients with spinal deformity, worsening symptoms, or pulmonary dysfunction who are candidates for percutaneous vertebral augmentation 1
Pain Management Referral:
- Consider for patients with persistent pain despite initial analgesic therapy 1
- May be appropriate for consideration of L2 nerve root blocks if pain persists 1
Special Considerations
- Always rule out pathologic fractures - if there is suspicion of malignancy, a complete spine MRI without and with contrast is indicated, along with potential biopsy 1
- Be aware that patients with L2 compression fractures may have concomitant fractures at other levels that could be contributing to pain, including sacral insufficiency fractures 2
- Closed-fist percussion of the spine (sensitivity 87.5%, specificity 90%) and assessment of pain while lying supine (sensitivity 81.25%, specificity 93.33%) can help differentiate acute from chronic fractures when MRI is not immediately available 3
Follow-up Recommendations
- Patients should be reassessed at 4-6 weeks to evaluate response to initial treatment 1
- If symptoms persist beyond 8 weeks, consider additional imaging to rule out fracture progression or new fractures 1
- Physical therapy referral should be considered after acute pain subsides to focus on maintaining mobility, strengthening core and back muscles, and improving posture 4