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

Initial Management of Compression Fractures

Conservative medical management with analgesics and early mobilization is the recommended initial treatment for neurologically intact patients with compression fractures, with or without external bracing showing equivalent outcomes. 1, 2, 3

Immediate Assessment (Days 0-5)

Neurological Examination

• Assess for any neurological deficits immediately, as their presence mandates surgical consultation rather than conservative management 1, 2
• Evaluate for spinal cord compression, cauda equina syndrome, or progressive neurological symptoms 1

Fracture Characterization

• Determine if the fracture is osteoporotic versus traumatic/pathologic, as this affects treatment approach 1
• Look for "red flags" including fever, weight loss, history of malignancy, or severe trauma suggesting non-osteoporotic etiology 1
• Assess for spinal instability markers: significant vertebral collapse (>50%), severe angulation, canal compromise, or retropulsion 1, 2

Initial Conservative Treatment (Weeks 0-12)

Pain Management

• Start with NSAIDs as first-line analgesics for pain control 1, 3
• Use opioid/narcotic medications cautiously and only when necessary, as they increase risks of sedation, falls, deconditioning, and prolonged immobility 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 Strategy

• Minimize bed rest to less than 2 weeks to prevent complications including decreased bone mineral density, muscle strength loss, deconditioning, and increased mortality 3, 4
• Initiate early mobilization as soon as pain allows, typically within days to weeks 1, 3, 4

Bracing Decision

• External bracing (TLSO or Jewett brace) is optional, as both braced and non-braced approaches demonstrate equivalent improvement in pain and disability outcomes 2, 3, 4
• Bracing may be used for patient comfort and to provide psychological reassurance during initial healing 4

Osteoporosis Treatment

Fracture Prevention

• Initiate ibandronate or strontium ranelate to prevent additional symptomatic fractures in patients presenting with osteoporotic compression fractures 1
• Alendronate has demonstrated 47-48% relative risk reduction in new vertebral fractures and 51-54% reduction in clinical symptomatic vertebral fractures in osteoporotic patients 5
• Ensure adequate calcium and vitamin D supplementation 4

Expected Natural History

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

Indications for Escalation Beyond Conservative Management

Vertebral Augmentation Consideration (After 3 Months)

• If pain persists after 3 months of conservative therapy, consider vertebral augmentation (vertebroplasty or kyphoplasty) 1, 3, 4
• Earlier intervention may be warranted if severe pain requires parenteral narcotics or hospitalization 3
• Vertebral augmentation provides rapid, marked improvement in pain and function compared to continued conservative therapy 1, 3

Surgical Consultation Indications

• Immediate surgical consultation is required for: neurological deficits, spinal instability, significant vertebral collapse with canal compromise, or severe spinal deformity (≥15% kyphosis, ≥10% scoliosis, ≥20% vertebral body height loss) 1, 2

Risk Factors for Conservative Treatment Failure

Patients at higher risk of failing 3 weeks of conservative treatment include those with 6:

• Advanced age (>78.5 years)
• Severe osteoporosis (T-score <-2.95)
• Overweight status (BMI >25.5)
• Larger collapse rates (>28.5%)

Critical Pitfalls to Avoid

• Do not prescribe prolonged bed rest, as it accelerates bone loss, muscle atrophy, deconditioning, and increases mortality risk 3, 4
• Avoid overreliance on narcotic medications, which cause sedation, increase fall risk, and impair physical conditioning 3
• Do not delay osteoporosis treatment, as approximately 1 in 5 patients develop chronic back pain and 13-40% experience inadequate pain relief with conservative management alone 1