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 or carefully monitored narcotics, early mobilization (avoiding prolonged bed rest beyond 2 weeks), and optional external bracing—with or without bracing showing equivalent outcomes—while reserving vertebral augmentation for those with persistent severe pain after 3 months of conservative therapy. 1, 2, 3

Immediate Assessment and Risk Stratification

Neurological Examination

• Perform thorough neurological assessment to identify any deficits, as their presence necessitates immediate surgical consultation rather than conservative management 1, 2
• Evaluate for spinal cord compression, cauda equina syndrome, or progressive neurological deterioration 1

Fracture Characterization

• Determine fracture stability by assessing for significant vertebral collapse (>20% height loss), severe angulation (>15% kyphosis), or canal compromise, which may indicate surgical intervention 1, 2
• Distinguish between osteoporotic and traumatic etiologies, as this influences treatment approach 1
• Rule out pathologic fractures from malignancy through clinical history and imaging, as these require multidisciplinary oncologic management 1

Identify "Red Flags"

• Screen for infection, malignancy, or other secondary causes that would alter management 1
• Assess timing of fracture (acute vs chronic) to guide intervention decisions 1

Conservative Medical Management (First-Line for 2-12 Weeks)

Pain Control Strategy

• Use NSAIDs as first-line analgesics for pain management in neurologically intact patients 1, 3
• Reserve narcotic medications for breakthrough pain only, with careful monitoring due to risks of sedation, falls, deconditioning, and increased mortality 1, 3
• For acute 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 compared to placebo 1

Mobilization Protocol

• Initiate early mobilization as soon as pain tolerates to prevent complications of immobility including decreased bone mineral density, muscle strength loss, and increased mortality 2, 3, 4
• Limit bed rest to less than 2 weeks maximum, as prolonged immobilization causes bone mass loss, muscle atrophy, and deconditioning 3, 4
• Implement physical therapy focusing on core strengthening and proper body mechanics once acute pain subsides 4

External Bracing Decision

• Bracing is optional, as both braced and non-braced approaches demonstrate equivalent improvement in pain and disability outcomes for neurologically intact patients 2, 3
• If bracing is chosen for patient comfort, use thoracolumbosacral orthosis (TLSO) or Jewett brace during the initial healing phase 4
• The decision to brace should be based on patient preference and comfort rather than expectation of superior outcomes 2

Risk Factors for Conservative Treatment Failure

Identify patients at higher risk for failing 3 weeks of conservative therapy, who may benefit from earlier consideration of vertebral augmentation 5:

• Age >78.5 years 5
• Severe osteoporosis (T-score <-2.95) 5
• BMI >25.5 5
• Vertebral collapse rate >28.5% 5

Vertebral Augmentation Timing

Indications for Vertebroplasty or Kyphoplasty

• Offer vertebral augmentation if pain persists after 3 months of conservative therapy, as it provides rapid and marked improvement in pain and function compared to continued medical management 1, 3
• Consider earlier intervention (before 3 months) if severe pain requires parenteral narcotics or hospitalization 3
• Vertebral augmentation shows superior pain relief and improved functional outcomes compared to prolonged conservative therapy in patients who fail initial management 1, 5

Evidence Considerations

• Approximately 65% of patients respond successfully to conservative treatment, while 35% require vertebral augmentation 5
• Vertebral augmentation demonstrates immediate and considerable improvement in pain and mobility, supporting its use when conservative measures fail 1
• While kyphoplasty shows better outcomes than conservative treatment in the first month, by 3 months outcomes are equivalent, supporting the initial 3-month conservative trial 5

Surgical Consultation Indications

Reserve surgical intervention for 1, 2, 3:

• Neurological deficits or progressive neurological compromise 1, 2
• Significant spinal instability or severe vertebral collapse with canal compromise 2, 3
• Spinal deformity requiring correction (junctional kyphosis, retropulsion) 1

Critical Pitfalls to Avoid

• Do not prescribe prolonged bed rest beyond 2 weeks, as it accelerates bone loss, causes muscle deconditioning, and increases mortality risk 3, 4
• Avoid overreliance on narcotic medications, which lead to sedation, increased fall risk, and decreased physical conditioning 1, 3
• Do not delay vertebral augmentation beyond 3 months in patients with persistent severe pain, as approximately 1 in 5 patients with osteoporotic compression fractures develop chronic back pain without intervention 1
• Do not perform vertebral augmentation prematurely in patients without risk factors for conservative treatment failure, as 65% improve with conservative management alone 5

Osteoporosis Management

Fracture Prevention

• Initiate ibandronate or strontium ranelate to prevent additional symptomatic fractures in patients presenting with osteoporotic compression fractures 1
• Ensure adequate vitamin D supplementation and calcium intake for long-term bone health 4
• Consider antiresorptive agents if appropriate for the patient's osteoporosis severity 4