What is the recommended treatment for a 33-year-old patient with a moderate (up to 30 percent loss of height) compression fracture at the superior endplate of L2 (Lumbar Vertebra 2) with no associated retropulsion after a motor vehicle collision (MVC)?

Treatment of L2 Compression Fracture Post-MVC

For a 33-year-old patient with a moderate L2 compression fracture (up to 30% height loss) without retropulsion following motor vehicle collision, conservative medical management is the recommended initial treatment, consisting of analgesics, early mobilization, and optional bracing for 2-12 weeks. 1, 2

Initial Management (First 2-12 Weeks)

Pain Control

• NSAIDs should be used as first-line analgesic agents 1
• Narcotic medications should be used cautiously and only when absolutely necessary, as they increase risks of sedation, falls, and deconditioning 1
• Avoid prolonged use of parenteral narcotics unless pain is truly refractory 1

Mobilization Strategy

• Bed rest should be minimized to less than 2 weeks to prevent complications including bone mass loss, muscle strength loss, and increased mortality 2
• Early mobilization is critical and should begin as soon as pain allows 1, 2
• Prolonged immobilization leads to deconditioning, decreased bone mineral density, and muscle atrophy 1, 2

Bracing Considerations

• External bracing with a thoracolumbosacral orthosis (TLSO) or Jewett brace may be used to provide stability and reduce pain during initial healing 2
• Both braced and non-braced approaches show equivalent long-term outcomes, making bracing optional based on patient comfort 1

Rehabilitation Phase (2-8 Weeks)

Physical Therapy

• Physical therapy should focus on core strengthening, proper body mechanics, and gradual return to activities 2
• Progressive rehabilitation is essential to restore function and prevent deconditioning 2

Monitoring Requirements

• Monitor continuously for development of neurological symptoms, as their appearance would necessitate immediate surgical consultation 2
• Regular assessment of pain levels and functional status throughout treatment 2
• Watch for sudden increases in pain that may indicate new fractures 2

When Conservative Management Fails

Indications for Vertebral Augmentation

• Vertebroplasty or kyphoplasty should be offered if pain persists after 3 months of conservative therapy 1, 2
• Consider augmentation earlier if severe pain requires parenteral narcotics or hospitalization 1
• Vertebroplasty provides rapid, marked improvement in pain and function compared to continued conservative therapy in patients who fail initial management 1, 3

Surgical Consultation Indications

• Immediate surgical referral is required for neurological deficits, significant spinal instability, or severe vertebral collapse with canal compromise 1
• Note that this patient has no retropulsion and presumably no neurological deficits, making surgery unlikely to be needed 1

Long-Term Management (8-24 Weeks)

Fracture Prevention

• Vitamin D supplementation (800 IU/day) with adequate calcium intake (1000-1200 mg/day) is associated with 15-20% reduction in non-vertebral fractures and falls 4, 2
• Smoking cessation and alcohol limitation should be addressed 4
• Consider bone density evaluation to assess for underlying osteoporosis, though less likely in a 33-year-old trauma patient 2

Risk Factors for Treatment Failure

High-Risk Features to Monitor

• Prior vertebral compression fractures significantly increase risk of treatment failure 5
• Progressive vertebral collapse occurs in approximately 17.5% of conservatively managed traumatic VCFs 5
• Treatment failure manifests as subsequent VCF (36.3%), chronic back pain or functional disability (32.4%), or increased compression/kyphotic deformity (31.4%) 5

Critical Pitfalls to Avoid

• Never prescribe prolonged bed rest beyond 2 weeks, as it causes bone loss, deconditioning, and increased mortality 1, 2
• Avoid overreliance on narcotic medications, which lead to sedation, falls, and decreased physical conditioning 1
• Do not delay mobilization unnecessarily—early movement is protective, not harmful 1, 2
• Ensure close follow-up to identify the minority of patients who will fail conservative management and require intervention 5