What is the initial management for a patient with a compression fracture of the lumbar spine?

Initial Management of Lumbar Compression Fractures

Medical management with pain control is the first-line treatment for lumbar compression fractures in neurologically intact patients for the initial 3 months, with NSAIDs and calcitonin providing the strongest evidence for pain relief. 1, 2

Immediate Assessment Priorities

Rule out neurological compromise and pathologic fracture first:

• Perform neurological examination checking for motor weakness, sensory deficits, bowel/bladder dysfunction, or radicular symptoms 1, 2
• If neurological deficits are present, initiate corticosteroid therapy immediately and obtain urgent surgical consultation 1, 2
• Obtain MRI to differentiate benign osteoporotic fractures from malignant pathologic fractures, especially if patient has history of malignancy or "red flag" features 1

First-Line Pain Management (0-3 Months)

Pharmacologic therapy:

• NSAIDs are effective for pain relief over 2-12 weeks and should be the initial analgesic choice 2
• Calcitonin 200 IU nasal spray for 4 weeks provides clinically important pain reduction in acute fractures (0-5 days post-injury) 1, 2
• Opioids may be used but evidence is inconclusive; monitor closely for dependence, constipation, and other side effects 1, 2

Activity modification:

• Avoid prolonged bed rest as it leads to deconditioning, bone mineral density loss, and increased deep venous thrombosis risk 2
• Encourage early mobilization with activity modification 3, 4
• Bracing may be considered though evidence is inconclusive 1, 2

Indications for Vertebral Augmentation

Consider vertebroplasty or balloon kyphoplasty if:

• Pain persists despite 3 months of medical management 1, 2
• Spinal deformity develops 1, 2
• Worsening symptoms occur 1, 2
• Pulmonary dysfunction develops 1, 2

Both vertebroplasty and kyphoplasty are equally effective in reducing pain and disability, with kyphoplasty providing superior vertebral height restoration and less cement leakage 1

Osteoporosis Treatment to Prevent Future Fractures

Initiate bone-protective therapy:

• Ibandronate and strontium ranelate are options to prevent additional symptomatic fractures 1, 2
• Bisphosphonates should be considered for long-term fracture prevention 1, 2

Special Populations

Pathologic fractures from malignancy require different management:

• Obtain MRI of complete spine with and without IV contrast 1
• Multidisciplinary consultation including interventional radiology, surgery, and radiation oncology 1, 2
• External beam radiation therapy is standard for painful osseous metastases 1
• Surgery is indicated for spinal instability or neurologic deficits 1

Common Pitfalls to Avoid

• Do not prescribe prolonged bed rest - this worsens outcomes through deconditioning and bone loss 2
• Monitor for neurological deterioration - any new weakness, numbness, or bowel/bladder changes requires immediate surgical evaluation 1, 2
• Screen for underlying malignancy - obtain MRI if patient has cancer history, unexplained weight loss, or atypical presentation 1, 2
• Watch for NSAID complications - monitor for gastrointestinal bleeding, renal dysfunction, and cardiovascular events with prolonged use 2
• Address underlying osteoporosis - failure to treat bone density increases risk of subsequent fractures 1, 2