From the Guidelines
For a patient with a compression burst fracture of the L3 vertebral body with 2% loss of height who is ambulatory following a fall from height, immediate management should include spinal stabilization with a thoracolumbosacral orthosis (TLSO) brace for 8-12 weeks. Pain management should consist of acetaminophen 1000mg every 6 hours and NSAIDs such as ibuprofen 600mg every 6 hours, alternating between the two medications, as nonoperative or conservative management is often the traditional first-line treatment of painful VCFs 1. For breakthrough pain, tramadol 50mg every 6 hours as needed can be prescribed, with caution given the associated effects of sedation, nausea, further decrease in physical conditioning, and fall risks 1. The patient should be referred urgently to a spine specialist (neurosurgeon or orthopedic spine surgeon) for evaluation within 24-48 hours, as some burst fractures require surgical intervention, especially if there is spinal canal compromise or neurological symptoms. Key considerations in management include:
- Minimizing bed rest and encouraging early mobilization while wearing the brace to prevent complications of prolonged immobilization such as muscle atrophy, deep vein thrombosis, and pulmonary complications.
- Initiating physical therapy once cleared by the specialist, focusing on core strengthening and proper body mechanics.
- Recommending calcium supplementation (1200mg daily) and vitamin D (800-1000 IU daily) to support bone healing, as these are crucial for patients with osteoporotic fractures 1.
- Scheduling regular follow-up imaging at 6 weeks and 3 months to monitor fracture healing. This approach is guided by the most recent and highest quality evidence, prioritizing morbidity, mortality, and quality of life outcomes, and considering the potential benefits and risks of different management strategies 1.
From the Research
Treatment Options
- For patients with vertebral compression fractures, including those with compression burst fractures, management is multimodal in nature and starts with conservative therapy consisting of analgesic medication, medication for osteoporosis, physical therapy, and bracing 2.
- Patients who are refractory to conservative management may be candidates for vertebral augmentation through either vertebroplasty or kyphoplasty 2.
- In cases of burst fractures, surgical treatment may be necessary, with important considerations including coronal and sagittal alignment of the spine, patency of the neural canal, the two-column concept of spinal stability, and bony vertebral body reconstitution 3.
Surgical Considerations
- Distraction and the creation of spinal lordosis are necessary for reduction in burst fracture treatment 3.
- The forces required to reduce the intracanal fragment in burst fractures were found to be predominantly distraction, with the application of uniform distraction forces being most effective in posterior reduction 4.
- The posterior longitudinal ligament provides only a minor contribution in the reduction of the fracture, with the attachments of the posterior portion of the anulus fibrosus playing a more significant role 4.
Diagnosis and Imaging
- Diagnosis of vertebral compression fractures involves a clinical history and various imaging studies, including lumbar x-ray and computerized axial tomography (CT) scans 2, 3, 5.
- Medical imaging plays a crucial role in the diagnosis and treatment of vertebral compression fractures, particularly in assessing the extent of the fracture and guiding treatment decisions 5.