What is the appropriate management plan for a patient with acute and chronic compression fractures of the lumbar spine, degenerative disc disease, and spondylosis?

Management of Acute L3 Compression Fracture with Chronic Multilevel Fractures and Degenerative Disease

For the acute L3 compression fracture, proceed with vertebroplasty or kyphoplasty after a minimum 6-week trial of conservative management if pain remains intractable, as these procedures provide rapid analgesia and structural reinforcement with effective pain relief lasting 6-12 months. 1, 2

Immediate Assessment and Conservative Management (First 6 Weeks)

Pain Control Strategy

• Initiate NSAIDs as first-line therapy for the acute compression fracture pain, as they provide effective pain relief for back pain over 2-12 weeks compared to placebo 1, 3
• Cardiovascular, gastrointestinal, and renal risks must be assessed before prescribing NSAIDs 1
• Add alpha-2-delta calcium-channel antagonists (pregabalin or gabapentin) for neuropathic pain component from neural foraminal stenosis, which provide Category A1 evidence for effective pain relief over 5-12 weeks 1, 2
• Common side effects include dizziness, somnolence, and peripheral edema 1

Opioid Considerations

• Reserve opioids only for severe refractory pain at the lowest dose for the shortest duration 2
• Extended-release opioid formulations (morphine, oxycodone) provide effective pain relief for 1-9 weeks but cause nausea, vomiting, and constipation 1
• No formal recommendation exists for routine opioid use in osteoporotic compression fractures due to insufficient evidence 1

Adjunctive Medical Therapy

• Calcitonin (nasal 200 IU or subcutaneous 100 IU) is an option for acute fracture pain, providing clinically important pain reduction at 1-4 weeks 1
• Mild dizziness is the primary side effect 1
• Initiate ibandronate or strontium ranelate to prevent additional symptomatic fractures in patients with existing osteoporotic compression fractures 1

Interventional Management for Acute L3 Fracture

Vertebral Augmentation Indications

Vertebroplasty or kyphoplasty should be performed after 6 weeks of failed conservative management when the following criteria are met: 1

• Intractable pain despite adequate analgesic therapy
• Significant side effects from analgesics (confusion, sedation, severe constipation)
• Point tenderness at the L3 spinous process on physical examination 1

Specific Consideration for L3/L4 Levels

• An L2 nerve root block is an option for treating the acute L3 compression fracture with correlating clinical symptoms 1

Contraindications to Vertebral Augmentation

Absolute contraindications include: 1

• Active systemic or spinal infection
• Uncorrectable bleeding diathesis
• Insufficient cardiopulmonary health for sedation
• Known polymer allergy

Relative contraindications include: 1

• Significant spinal canal stenosis with compressive myelopathy from retropulsed fragments
• Radiculopathy exceeding local vertebral pain

Management of Neural Foraminal Stenosis and Radicular Symptoms

Image-Guided Epidural Steroid Injections

• Fluoroscopically-guided epidural steroid injections are essential for persistent radicular symptoms from neural foraminal stenosis 2
• Blind injections have no place in this clinical scenario; image guidance is integral to best practice 2

Urgent Referral Criteria

Refer urgently within 2 weeks if: 2

• Severe radicular pain that is disabling and prevents normal everyday tasks
• Any progressive neurological deficits (sensory or motor changes)
• Progressive neurological deficits mandate surgical evaluation 1, 2

Monitoring for Complications

Adjacent Segment Disease Risk

• The chronic T11, L1, and L2 fractures combined with degenerative disc disease increase risk for adjacent segment complications including listhesis, instability, herniated disc, stenosis, and new compression fractures 4
• Reevaluate within 1 month if severe pain or functional deficits persist 2
• Monitor for recurrent symptoms, which occur in up to 30% of patients after interventions 2

Red Flags Requiring Immediate Evaluation

If significant change in disease course occurs, consider causes beyond the known fractures: 1

• New acute fracture at different level
• Spinal cord compression
• Progressive neurological deterioration
• Perform appropriate imaging (MRI preferred) to evaluate 1

Surgical Consultation Indications

Consult spine surgery for: 1

• Frank spinal instability
• Neurological deficits from spinal cord compression
• Severe disabling deformity from multilevel compression fractures
• Refractory pain or disability with radiographic structural damage
• Significant functional limitations persisting after vertebral augmentation 2

Critical Pitfalls to Avoid

• Do not delay treatment for progressive neurological deficits, as this is associated with significantly poorer outcomes 2
• Correlate MRI findings with clinical symptoms, as imaging abnormalities are often nonspecific and common in asymptomatic individuals 2
• Do not perform vertebral augmentation if clear disparity exists between physical examination and imaging, or if alternative pain source is evident 1
• Avoid bracing as routine treatment; evidence is inconclusive with only single studies of limited generalizability 1

Advanced Options for Refractory Cases

• Spinal cord stimulation should be considered for persistent radicular pain after surgery or failed interventional procedures 2
• Percutaneous disc decompression provides effective pain relief for back and radicular pain over 2 weeks to 12 months based on observational evidence 1