What is the recommended management for a patient with an S1 vertebral body fracture with mild impaction?

Management of S1 Vertebral Body Fracture with Mild Impaction

For an S1 vertebral body fracture with mild impaction, initiate conservative medical management as the first-line treatment, including pain control with analgesics (consider calcitonin for the first 4 weeks), activity modification with early mobilization as tolerated, and osteoporosis treatment if applicable. 1, 2

Initial Assessment

Obtain MRI of the spine without IV contrast to fully characterize the fracture, assess for spinal canal compromise, and rule out pathologic causes such as malignancy or infection. 1, 3 If MRI is contraindicated, CT spine without contrast is an acceptable alternative. 3

Perform a focused neurological examination specifically assessing for:

• Saddle anesthesia or perineal sensory changes 1
• Bowel or bladder dysfunction 1
• Lower extremity motor weakness or sensory deficits 1, 3
• Gait disturbances 4

Conservative Management Protocol

Pain Management:

• Prescribe calcitonin for the first 4 weeks, which provides clinically important pain reduction in acute compression fractures 1, 2, 3
• Use titrated analgesics as needed, avoiding prolonged narcotic use due to side effects including constipation and deconditioning 4
• Consider local pain management techniques 5

Activity Modification:

• Avoid prolonged bed rest beyond 2-3 days, as bed rest leads to 1% bone loss per week (50 times faster than age-related loss) and 15% loss of lower extremity strength after just 10 days 4
• Encourage early mobilization within pain tolerance 5, 6
• Consider bracing for comfort during the acute phase, though evidence for efficacy is limited 5, 7

Physical Therapy:

• Initiate supervised physical therapy with spinal stretching exercises once acute pain subsides 5, 6
• Focus on core strengthening and postural training 6, 7

Osteoporosis Treatment:

• Start calcium and vitamin D supplementation 4, 6
• Initiate antiresorptive therapy (bisphosphonates or other agents) if osteoporosis is confirmed 4, 6

Immediate Referral Criteria (Do Not Delay)

Refer immediately to orthopedic surgery or neurosurgery if:

• Any neurological deficits are present, including saddle anesthesia, bowel/bladder dysfunction, or lower extremity weakness 1, 3
• Evidence of spinal instability on imaging 1
• Suspected pathologic fracture (known malignancy, unexplained weight loss, age <50 without trauma) 1, 3

For suspected pathologic fractures, obtain MRI with and without contrast and consider biopsy. 1, 3 Coordinate multidisciplinary management including interventional radiology, surgery, and radiation oncology as appropriate. 4

Delayed Referral Criteria (After 3 Months of Conservative Management)

Refer to orthopedic surgery, neurosurgery, or interventional radiology if:

• Severe and worsening pain persists despite 3 months of conservative management 1, 2, 3
• Significant spinal deformity or progressive kyphosis develops 1, 2, 3
• Pulmonary dysfunction occurs due to spinal deformity 2, 3

Vertebral augmentation (vertebroplasty or kyphoplasty) may be considered for patients who fail conservative management after 3 months, though note that the American Academy of Orthopaedic Surgeons makes a strong recommendation against vertebroplasty for osteoporotic compression fractures. 1 Kyphoplasty may be an option for symptomatic fractures in neurologically intact patients. 1, 2

Follow-Up Schedule

Reassess at 4-6 weeks to evaluate response to initial treatment. 1, 3 Most vertebral compression fractures show gradual improvement in pain over 2-12 weeks with conservative management. 2

If symptoms persist beyond 8 weeks, consider repeat imaging to rule out fracture progression or new fractures. 3

Common Pitfalls to Avoid

Do not miss pathologic fractures: S1 fractures are relatively uncommon for osteoporotic compression fractures, which typically occur at thoracolumbar levels. 4 Maintain high suspicion for malignancy, infection, or other pathologic causes. 1, 3

Do not prescribe prolonged bed rest: This leads to rapid bone loss, muscle deconditioning, deep venous thrombosis, and decubitus ulcers, creating a vicious cycle that increases risk of additional fractures. 4

Do not delay referral for neurological deficits: Permanent neurological damage can occur with delayed treatment. 1, 3

Do not overlook the need for osteoporosis treatment: Once a vertebral fracture occurs, there is a 20% risk of another vertebral fracture within 12 months. 4 Aggressive osteoporosis management is essential for secondary prevention.