From the Guidelines
For a patient with a compression burst fracture of L2 with loss of vertebral body height following a fall from height who is still ambulatory, I strongly recommend immediate spine specialist consultation, preferably with a neurosurgeon or orthopedic spine surgeon, to assess the need for surgical intervention given the high risk of spinal instability and potential neurological compromise. Initial management should include pain control with medications such as acetaminophen 1000mg every 6 hours and an NSAID like ibuprofen 400-600mg every 6 hours if not contraindicated, as suggested by the management of vertebral compression fractures guidelines 1. For stronger pain relief, consider tramadol 50mg every 6 hours or oxycodone 5-10mg every 4-6 hours as needed. The patient should be fitted with a thoracolumbosacral orthosis (TLSO) brace to provide spinal stability and prevent further vertebral collapse while awaiting definitive treatment, as part of a multidisciplinary approach including interventional radiology, surgery, and radiation oncology consultation for patients with pathologic fracture with spinal deformity or pulmonary dysfunction 1. Activity should be restricted with no bending, lifting, or twisting, though continued ambulation with the brace is encouraged to prevent deconditioning. Surgical intervention is likely necessary given the burst nature of the fracture with displacement, which suggests spinal instability, and typically involves posterior spinal fusion with instrumentation spanning from one level above to one level below the fracture (T12-L4). If there are no neurological deficits and the fracture is deemed stable by the specialist, conservative management with bracing for 8-12 weeks may be considered, taking into account the potential for spontaneous resolution of pain in over 6 to 8 weeks 1. This approach balances the need for spinal stability with preventing complications from immobility, as burst fractures can potentially compromise spinal canal dimensions and lead to neurological compromise if not properly managed, highlighting the importance of a thorough medical management involving appropriate osteoporosis screening and follow-up treatment 1.
From the Research
Treatment Options
- Conservative therapy is often the initial approach for managing vertebral compression fractures, including the use of analgesic medication, medication for osteoporosis, physical therapy, and bracing 2.
- For patients who are refractory to conservative management, vertebral augmentation through either vertebroplasty or kyphoplasty may be considered 2, 3.
- Medical management, including nonsteroidal anti-inflammatory drugs, calcitonin, teriparatide, and bisphosphonates, remains the first-line therapy for patients with compression fractures 3.
Vertebral Augmentation
- Vertebral augmentation, especially newer procedures like balloon-assisted kyphoplasty, has the potential to dramatically reduce pain and improve quality of life 3.
- However, there is a lack of standard of care for patients with vertebral compression fractures due to limited evidence and potential adverse effects of prolonged treatment 3.