What is the recommended treatment for an elderly female with a compression fracture of T11 (thoracic vertebra 11) and back pain, including the role of physical therapy?

Treatment for T11 Compression Fracture in an Elderly Female

Medical management is the appropriate first-line treatment for the first 3 months, and physical therapy should be initiated as part of this conservative approach to maintain mobility and prevent deconditioning. 1

Initial Conservative Management (First 3 Months)

For elderly patients with osteoporotic compression fractures without neurologic deficits or "red flags," the American College of Radiology recommends medical management as the standard initial approach. 1 This includes:

Pain Control Strategy

• Intravenous acetaminophen every 6 hours as first-line treatment in a multimodal analgesic approach 1
• NSAIDs may be added for severe pain, though carefully consider adverse events and drug interactions in elderly patients 1
• Minimize opioid use to avoid confusion, sedation, and severe constipation that commonly occur in this population 1
• Reserve opioids only for breakthrough pain at the lowest effective dose for the shortest duration 1

Physical Therapy Role

Physical therapy should be initiated early and is a critical component of treatment. 2 The goals include:

• Maintaining mobility to prevent the devastating effects of bed rest 1
• Strengthening core and back muscles to support the spine 2
• Improving posture to reduce mechanical stress 2

Avoid prolonged bed rest, as it causes bone loss at 1% per week (50 times faster than normal age-related loss), 15% loss of lower extremity strength in just 10 days, and 10-15% loss of aerobic capacity. 1 This creates a vicious cycle of deconditioning and increased fracture risk. 1

Common Pitfall to Avoid

The most critical error is excessive immobilization. While some initial rest may be needed for severe pain, prolonged bed rest leads to decubitus ulcers, deep venous thrombosis, muscle atrophy, and further bone loss—particularly devastating in elderly osteoporotic patients. 1

When to Consider Advanced Interventions

Percutaneous vertebral augmentation (vertebroplasty or kyphoplasty) becomes appropriate if:

• Medical management fails after 3 months 1
• Spinal deformity develops 1
• Worsening symptoms occur 1
• Pulmonary dysfunction develops 1

Research demonstrates that vertebroplasty provides 81% pain improvement within 24 hours and 94% improvement at 6 months in elderly patients, with 69% improvement in physical functioning. 3 However, this should not replace the initial conservative trial. 1

Red Flags Requiring Urgent Evaluation

Immediate MRI and specialist consultation are needed if:

• Neurologic deficits develop (myelopathy or radiculopathy) 1, 4
• Spinal cord compression occurs 4
• Suspected malignancy (known cancer history, unexplained weight loss) 1

Surgery becomes the standard of care only when spinal instability or neurologic deficits are present. 1, 4

Practical Implementation

1. Start multimodal analgesia immediately with scheduled acetaminophen 1
2. Refer to physical therapy within the first week to begin gentle mobilization 2
3. Limit bed rest to 24-48 hours maximum for severe pain only 1
4. Initiate osteoporosis treatment (calcium, vitamin D, bisphosphonates) to prevent future fractures 1
5. Reassess at 6-8 weeks as most fractures heal and pain subsides during this timeframe 1
6. Consider vertebral augmentation only after 3 months if conservative management fails 1

The evidence strongly supports that physical therapy is not only safe but essential in elderly patients with T11 compression fractures, provided there are no neurologic deficits or spinal instability. 2, 5