What is the management of acute lumbar compression fractures?

Management of Acute Lumbar Compression Fractures

Initial conservative management with pain control and activity modification is recommended for stable fractures without neurological deficits, with vertebral augmentation reserved for persistent pain after 2-12 weeks or immediate surgical consultation for neurological compromise, spinal instability, or significant deformity. 1, 2

Initial Assessment and Stability Determination

The first priority is determining fracture stability through systematic evaluation:

• Perform a thorough neurological examination to document baseline function and identify any deficits that would mandate immediate surgical consultation 1, 2
• Assess for stability indicators: absence of neurological deficits, less than 10% vertebral body height loss, no retropulsion of bone fragments into the spinal canal, less than 15% kyphosis, and less than 10% scoliosis 1, 2
• Obtain MRI of the lumbar spine without contrast to assess fracture characteristics, identify bone marrow edema indicating acute fracture, rule out pathologic causes, and evaluate for spinal canal compromise 2, 3

The American College of Radiology emphasizes that MRI with fluid-sensitive sequences is imperative for identifying acute fractures and differentiating benign from pathologic causes, particularly in patients with atypical features 4, 2

Conservative Management Protocol (First-Line for Stable Fractures)

For stable fractures without neurological deficits, implement the following approach:

• Pain control with analgesics including NSAIDs and judicious use of narcotics, avoiding prolonged narcotic use that can cause sedation, falls, and deconditioning 2, 3
• Consider calcitonin for the first 4 weeks, which has demonstrated clinically important pain reduction in acute compression fractures 3
• Limited bed rest only, as prolonged immobilization leads to bone density loss, muscle weakness, deconditioning, increased deep venous thrombosis risk, and increased mortality 2
• Activity modification and postural education to avoid flexion-based activities that increase anterior vertebral loading 5
• Reassess at 4-6 weeks to evaluate treatment response and determine if escalation is needed 3

The natural history shows gradual improvement in pain over 2-12 weeks with variable return of function, and bone marrow edema typically resolves within 1-3 months 4, 1

Indications for Vertebral Augmentation

Consider vertebral augmentation (vertebroplasty or kyphoplasty) if:

• Persistent severe pain after 3 weeks of conservative management despite appropriate analgesics 2
• Pain requiring parenteral narcotics or hospitalization 2
• Development of spinal deformity (≥15% kyphosis, ≥10% scoliosis, ≥10% dorsal wall height reduction, or ≥20% vertebral body height loss) 4
• Pulmonary dysfunction related to the compression fracture 4, 3

The ACR guidelines note that vertebral augmentation has shown superior pain relief and improved functional outcomes compared to prolonged conservative therapy, with studies demonstrating benefit even in fractures older than 12 weeks 4. However, the American Academy of Orthopaedic Surgeons makes a strong recommendation against vertebroplasty specifically, while kyphoplasty may be considered for symptomatic fractures in neurologically intact patients who fail conservative management 3

Immediate Surgical Consultation Required

Do not delay surgical referral for:

• Any neurological deficits (motor weakness, sensory changes, bowel/bladder dysfunction) indicating potential spinal cord or nerve root compromise 1, 2, 3
• Spinal instability evidenced by retropulsion of bone fragments into the spinal canal 1, 2
• Significant spinal deformity with more than 15% kyphosis at presentation 1
• Known malignancy or suspected pathologic fracture requiring multidisciplinary management including interventional radiology, surgery, and radiation oncology 4, 3

Research demonstrates that burst fractures at T12 or L1 with 50% or more decrease in mid-sagittal neural canal diameter carry significant risk of neurological involvement and progressive deficit 6. Delayed recognition of neurological deficits can lead to permanent neurological damage 3

Special Considerations for Pathologic Fractures

In patients with known malignancy presenting with new lumbar compression fractures:

• MRI with and without contrast is imperative to assess epidural extension, paraspinal involvement, and degree of spinal cord compression 4
• Use the Spinal Instability Neoplastic Score (SINS) to classify stability: stable (0-6), potentially unstable (7-12), or unstable (13-18) 4
• Biopsy can be performed during vertebral augmentation to verify etiology and detect unsuspected malignancy 4
• Coordinate with radiation oncology for metastatic disease causing pain or neurologic compromise 4

Critical Pitfalls to Avoid

• Missing unstable fractures by failing to perform adequate neurological examination at initial presentation 1, 2
• Prolonged bed rest leading to deconditioning, bone loss, cardiovascular/respiratory muscle weakness, and increased mortality 2
• Overuse of narcotics causing sedation, increased fall risk, and decreased physical conditioning 2
• Failing to rule out pathologic fractures in patients with known malignancy, atypical pain patterns, or fractures from minimal trauma 3
• Delayed recognition in minor trauma cases, particularly at the thoracolumbar junction (T12-L1), where osteoporotic fractures are frequently overlooked initially 7
• Attributing all pain to the lumbar spine without percussion examination at the thoracolumbar junction where compression fractures commonly occur 7

Approximately 1 in 5 patients with osteoporotic vertebral compression fractures will develop chronic back pain, and the VERTOS II trial showed that 40% of conservatively treated patients had no significant pain relief after 1 year despite higher-class prescription medications 4. This underscores the importance of systematic reassessment and appropriate escalation of care when conservative management fails.