What is the initial treatment for lumbar compression fractures?

Initial Treatment for Lumbar Compression Fractures

For neurologically intact patients with lumbar compression fractures, initiate conservative medical management as the primary treatment for the first 3 months, including pain control with NSAIDs and carefully monitored narcotics, early mobilization to prevent complications of bed rest, and consideration of external bracing (though bracing shows equivalent outcomes to no bracing). 1, 2

Immediate Management (First 2 Weeks)

Pain Control

• Start with NSAIDs as first-line analgesics for pain management 2, 3
• Add carefully monitored narcotic medications for breakthrough pain when NSAIDs are insufficient 2, 3
• The evidence for specific analgesic regimens is limited, but pain control is essential to enable early mobilization 1

Activity Modification

• Prescribe limited bed rest initially but keep it to an absolute minimum (less than 2 weeks) to avoid complications including bone mass loss, muscle strength loss, and deconditioning 3
• Begin early mobilization as soon as pain allows, as prolonged immobilization leads to muscle atrophy and decreased bone mineral density 1, 3

Bracing Decision

• External bracing with a thoracolumbosacral orthosis (TLSO) or Jewett brace is optional, as both braced and non-braced approaches show equivalent improvement in pain and disability outcomes 2
• If bracing is chosen, use it to provide stability and reduce pain during initial healing 3
• The evidence for bracing is inconclusive with only one level II study showing no clear superiority 1

Rehabilitation Phase (2-8 Weeks)

Physical Therapy

• Initiate physical therapy focusing on core strengthening, proper body mechanics, and gradual return to activities 3
• The evidence for supervised versus unsupervised exercise programs is inconclusive, but some benefit exists for symptom improvement at 6-12 months 1

Monitoring

• Assess for any new neurological symptoms at each visit, as their development necessitates immediate surgical consultation 2, 3
• Monitor pain levels and functional status regularly 3

Long-Term Management (8 Weeks to 3 Months)

Osteoporosis Treatment

• Optimize calcium (1000-1200 mg daily) and vitamin D supplementation (600-800 IU daily or more to maintain serum 25(OH)D levels ≥30-50 ng/mL) 1
• Recommend lifestyle modifications including smoking cessation, limiting alcohol to ≤2 servings daily, balanced diet, weight maintenance, and regular weight-bearing exercises 1
• For patients ≥40 years with high or very high fracture risk, strongly recommend osteoporosis pharmacotherapy (oral bisphosphonates as first-line) in addition to calcium and vitamin D 1

Reassessment at 3 Months

• If pain persists after 3 months of conservative management, consider vertebral augmentation procedures (vertebroplasty or kyphoplasty) 1, 2, 3
• Note that vertebroplasty is controversial, with the American Academy of Orthopaedic Surgeons recommending against it based on two level I studies showing no difference versus sham procedure 1
• However, other guidelines support vertebral augmentation for persistent pain affecting mobility and quality of life 1, 2

Critical Red Flags Requiring Surgical Consultation

Immediate Surgical Referral Indicated For:

• Neurological deficits or spinal cord compression 1, 2
• Significant vertebral collapse, severe angulation, or canal compromise indicating instability 2
• Burst fractures with severe spinal stenosis or kyphotic deformity 4
• Fracture-dislocation patterns 4

Special Considerations

Pathologic Fractures

• If malignancy is suspected, obtain MRI of the complete spine without and with IV contrast to differentiate benign from malignant fractures 1
• Pathologic fractures require a multidisciplinary approach including radiation oncology, interventional radiology, and surgical consultation 1

Common Pitfalls to Avoid

• Do not prescribe prolonged bed rest beyond 2 weeks, as this significantly increases complications including DVT, pneumonia, muscle atrophy, and bone loss 1, 3
• Do not delay osteoporosis treatment, as adjacent level fractures are common in untreated patients 3
• Do not assume all compression fractures are osteoporotic—always evaluate for malignancy in patients with known cancer history or atypical features 1

Evidence Conflicts

While the American Academy of Orthopaedic Surgeons strongly recommends against vertebroplasty based on sham-controlled trials 1, other specialty societies (American College of Radiology, Society of Interventional Radiology) support vertebral augmentation for persistent pain after conservative management failure 1, 2. The key distinction is timing: reserve vertebral augmentation only for patients who fail 3 months of appropriate conservative management rather than as initial treatment 1, 2.