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

Initial Management of Compression Fractures

For neurologically intact patients with acute compression fractures, initiate conservative medical management consisting of pain control with NSAIDs (avoiding prolonged narcotics), early mobilization within days, and optional bracing—both braced and non-braced approaches show equivalent outcomes. 1, 2, 3

Immediate Assessment (Days 0-5)

Neurological Examination

• Perform a thorough neurological examination to identify any deficits, as their presence mandates surgical consultation rather than conservative management 1, 2
• Assess for signs of spinal cord compression including motor weakness, sensory changes, or bowel/bladder dysfunction 1

Imaging and Stability Assessment

• Evaluate for significant vertebral collapse (>20% height loss), severe angulation (>15% kyphosis), or canal compromise that indicates instability requiring surgical intervention 1, 2
• Determine fracture etiology (osteoporotic versus traumatic versus malignant) as this fundamentally alters management approach 1
• MRI can identify bone marrow edema indicating acute fracture, which typically resolves within 1-3 months 1

Conservative Management Protocol (First 2-12 Weeks)

Pain Control Strategy

• Use NSAIDs as first-line analgesics for pain management 1, 3
• Reserve narcotics only for severe breakthrough pain, using them cautiously and for the shortest duration possible due to risks of sedation, falls, deconditioning, and increased mortality 1, 3
• For acute osteoporotic fractures (0-5 days from onset), administer calcitonin 200 IU for 4 weeks, which provides clinically important pain reduction at 1,2,3, and 4 weeks 1

Mobilization and Activity

• Minimize bed rest to less than 2 weeks—prolonged immobilization causes bone mass loss, muscle strength loss, deconditioning, and increased mortality 3, 4
• Initiate early mobilization as soon as pain tolerates to prevent complications of immobility 1, 3, 4
• Physical therapy should focus on core strengthening, proper body mechanics, and gradual return to activities 4

Bracing Decision

• External bracing with a thoracolumbosacral orthosis (TLSO) or Jewett brace is optional—both braced and non-braced approaches demonstrate equivalent improvement in pain and disability outcomes 2, 3
• If bracing is used, it provides stability and may reduce pain during initial healing 4
• The American Academy of Orthopaedic Surgeons found insufficient evidence to recommend for or against bracing 1

Osteoporosis Treatment

Fracture Prevention

• Initiate bisphosphonate therapy (such as alendronate) or strontium ranelate to prevent additional symptomatic fractures in patients presenting with osteoporotic compression fractures 1, 5
• Alendronate has demonstrated a 48% relative risk reduction in new vertebral fractures and 51% reduction in hip fractures in patients with existing vertebral fractures 5
• Ensure adequate calcium and vitamin D supplementation 4

When Conservative Management Fails (After 3 Months)

Vertebral Augmentation Indications

• Consider vertebroplasty or kyphoplasty if pain persists after 3 months of conservative therapy, as vertebral augmentation provides rapid, marked improvement in pain and function compared to continued conservative treatment 1, 3
• Earlier intervention may be appropriate if severe pain requires parenteral narcotics or hospitalization 3
• Approximately 40% of conservatively treated patients have no significant pain relief after 1 year, and 1 in 5 develop chronic back pain 1
• Vertebral augmentation has shown superior outcomes to prolonged medical treatment in achieving analgesia and improving function 1

Surgical Consultation Criteria

• Reserve surgical intervention for patients with neurological deficits, significant spinal instability, severe vertebral collapse with canal compromise, or spinal deformity 1, 2, 3

Critical Pitfalls to Avoid

• Do not prescribe prolonged bed rest—it accelerates bone loss, muscle atrophy, and increases mortality risk 3, 4
• Avoid overreliance on narcotic medications—they cause sedation, increase fall risk, and promote deconditioning without addressing the underlying problem 1, 3
• Do not delay osteoporosis treatment, as patients with one compression fracture are at high risk for subsequent fractures 1, 5
• Monitor for new or worsening pain that may indicate adjacent level fractures, which occur in approximately 13% of patients during the first year 6

Expected Natural History

• Most vertebral compression fractures show gradual improvement in pain over 2-12 weeks with variable return of function 1, 3
• Approximately 65% of patients respond successfully to conservative treatment within 3 weeks 6
• Bone marrow edema on MRI typically resolves within 1-3 months 1