What is the treatment for a patient with a wedge compression fracture?

Treatment of Wedge Compression Fractures

Initial conservative management with pain control is the first-line treatment for most osteoporotic wedge compression fractures, with vertebral augmentation (kyphoplasty preferred over vertebroplasty) reserved for patients who fail conservative therapy after 3 months or have persistent severe pain. 1

Initial Assessment and Triage

Determine fracture etiology and stability first:

• Assess for neurologic deficits (motor, sensory, bowel/bladder function) - their presence mandates immediate surgical consultation 1, 2
• Evaluate for malignancy if patient has known cancer history or atypical features - MRI is imperative in these cases 1
• Check for spinal instability indicators: >10% dorsal wall height reduction, >20% vertebral body height loss, or retropulsion of bone fragments 1, 2
• Document baseline neurological examination carefully to avoid missing instability 2

Conservative Management (First-Line)

For neurologically intact patients with stable fractures:

Pharmacologic Management

• Calcitonin 200 IU (nasal or subcutaneous) for 4 weeks - this is a moderate-strength recommendation showing clinically important pain reduction at 1,2,3, and 4 weeks 1
• Analgesics as needed for pain control (though evidence for opioids is inconclusive) 1
• Ibandronate or strontium ranelate to prevent additional symptomatic fractures (weak recommendation) 1

Physical Measures

• Pain control with appropriate analgesics 2
• Cervical collar may be considered for comfort if cervical involvement 2
• Evidence for bracing is inconclusive - neither age nor level of fracture clearly predicts benefit 1
• Evidence for supervised exercise programs is inconclusive 1

Natural History

• Most healing compression fractures show gradual improvement in pain over 2-12 weeks with variable return of function 1, 2
• Discharge with outpatient follow-up is appropriate for stable fractures 2

Vertebral Augmentation - When Conservative Management Fails

Critical timing consideration: Patients who have not achieved sufficient pain relief by 3 months with conservative treatment are candidates for vertebral augmentation 1

Kyphoplasty vs Vertebroplasty Decision

Kyphoplasty is preferred over vertebroplasty for the following reasons:

• Both procedures are equally effective for pain reduction and disability improvement 1
• Kyphoplasty provides superior functional recovery due to better correction of spinal deformity (improved kyphotic angle and increased vertebral body height) 1
• Kyphoplasty has less cement leakage compared to vertebroplasty 1
• The American Academy of Orthopaedic Surgeons has a strong recommendation AGAINST vertebroplasty 1
• Kyphoplasty is a weak recommendation FOR use in neurologically intact patients 1

Benefits of Vertebral Augmentation

• Immediate and considerable improvement in pain and patient mobility 1
• Prevents secondary sequelae: decreased bone mineral density, muscle strength loss with immobility, increased DVT risk, cardiovascular/respiratory deconditioning 1
• Improves pulmonary function through better alignment and decreased pain 1
• Fracture age does not independently affect outcomes - both acute (<6 weeks) and chronic (>12 weeks) fractures benefit equally 1

Special Population: Malignancy-Related Fractures

For patients with known malignancy and vertebral compression fractures:

• Kyphoplasty shows superior outcomes - in the Cancer Patient Fracture Evaluation RCT, kyphoplasty improved Roland-Morris disability scores by 8.3 points at 1 month vs 0.1 points with conservative management (p<0.0001) 1
• Advantages include immediate pain relief, avoiding delays in chemoradiation, outpatient care, tissue biopsy capability, and potential antitumor effect of bone cement 1
• Use SINS (Spinal Instability Neoplastic Score) to evaluate stability: stable (0-6), potentially unstable (7-12), unstable (13-18) 1
• Radiation therapy should be performed 2-4 weeks following orthopedic procedures (30 Gy in 10 fractions or 20 Gy in 5 fractions) 1

Surgical Consultation - Immediate Indications

Refer immediately for surgical evaluation if:

• Neurologic deficits present 1, 2
• Significant spinal deformity (>15% kyphosis or >10% scoliosis) 2
• Spinal instability or retropulsion of bone fragments into spinal canal 1, 2
• Worsening symptoms despite medical management 1

Additional Surgical Consultation Uses

• Prescribing and supervising immobilization devices 1

Common Pitfalls to Avoid

• Do not use vertebroplasty as first-line vertebral augmentation - kyphoplasty is superior for functional outcomes 1
• Do not delay vertebral augmentation indefinitely - if no improvement by 3 months with conservative care, proceed with intervention 1
• Do not miss malignancy - obtain MRI in patients with cancer history or atypical features 1
• Do not overlook neurologic examination - careful baseline documentation is essential to detect instability 2
• Do not use radiation therapy for non-pathologic fractures - RT is reserved only for confirmed metastatic disease 1

Special Considerations for L3/L4 Fractures

• L2 nerve root block is an option for treating pain associated with L3 or L4 compression fractures in neurologically intact patients (weak recommendation) 1