What is the treatment for acute compression fractures?

Treatment of Acute Compression Fractures

Conservative medical management is the initial treatment for acute compression fractures, consisting of analgesics (NSAIDs first-line, cautious opioid use), early mobilization, and optional bracing for 2-12 weeks, with vertebral augmentation (vertebroplasty or kyphoplasty) reserved for patients who fail conservative therapy after 3 months or require parenteral narcotics. 1, 2

Initial Conservative Management (First 3 Months)

Pain Control

• NSAIDs are first-line analgesics for pain management in acute compression fractures 1
• Opioids should be used cautiously due to risks of sedation, falls, decreased physical conditioning, and nausea—particularly problematic in elderly patients 1
• Calcitonin 200 IU (nasal or suppository) for 4 weeks provides clinically important pain reduction at 1,2,3, and 4 weeks in acute presentations 3, 4
• Most patients achieve spontaneous pain resolution within 6-8 weeks without intervention 1, 5

Mobilization Strategy

• Early mobilization is critical to prevent complications including decreased bone mineral density, muscle strength loss, deep venous thrombosis, cardiovascular/respiratory deconditioning, and increased mortality 1, 2
• Avoid prolonged bed rest—it causes rapid bone loss, muscle weakness, glucose intolerance, urinary complications, anxiety, depression, and creates a vicious cycle of deconditioning 1, 2, 5
• Bracing may be used but shows equivalent outcomes to non-braced approaches 2

Vertebral Augmentation Indications (After 3 Months)

Vertebral augmentation should be offered when conservative therapy fails, defined as: 1

• Pain refractory to oral medications after 3 months of conservative treatment 1
• Contraindication to pain medications 1
• Requirement for parenteral narcotics or hospital admission 1
• Development of spinal deformity or pulmonary dysfunction 1

Evidence for Vertebral Augmentation

• Vertebroplasty and kyphoplasty provide immediate and considerable improvement in pain and mobility compared to continued conservative therapy 1, 6
• In the VERTOS II trial, vertebroplasty resulted in mean VAS score reduction of -5.2 at 1 month versus -2.7 with conservative treatment (difference 2.6, p<0.0001), with benefits sustained at 1 year 6
• 70% of vertebroplasty patients showed statistically significant pain reduction and improved physical functioning at 24 hours, with 24% able to cease all analgesia after 24 hours (versus 0% in conservative treatment group) 1
• Meta-analyses demonstrate improvements in pain intensity, vertebral height, sagittal alignment, functional capacity, and quality of life with vertebral augmentation 1

Timing Considerations

• Studies show vertebral augmentation is superior to placebo for pain reduction in fractures <6 weeks duration 1
• However, fractures >12 weeks show equivalent benefit to those <12 weeks, suggesting fracture age does not independently affect outcomes 1
• In VERTOS II, 40% of conservatively treated patients had no significant pain relief after 1 year despite higher-class prescription medications 1

Vertebroplasty vs. Kyphoplasty

• Both procedures are equally effective in substantially reducing pain and disability 1
• Kyphoplasty shows superior improvement in vertebral height restoration and kyphotic angle correction with less cement leakage 1
• Kyphoplasty costs approximately 2.5 times more than vertebroplasty with no clear superiority in pain outcomes 5

Surgical Consultation Indications

Immediate surgical referral is required for: 1, 2, 3, 5

• Any neurological deficits 1, 2, 3
• Frank spinal instability 1, 3
• Significant spinal deformity (junctional kyphosis, retropulsion) 1
• Spinal cord compression 3

Concurrent Osteoporosis Management

Initiate osteoporosis pharmacotherapy immediately to prevent additional fractures: 3, 5

• Ibandronate or strontium ranelate specifically recommended for preventing additional symptomatic fractures 3, 5
• 20% risk of another vertebral fracture within 12 months after the first fracture 5
• Ensure adequate calcium intake (1000-1200 mg/day) and vitamin D supplementation (800 IU/day) 3

Critical Pitfalls to Avoid

• Do not prescribe prolonged bed rest—causes deconditioning, bone loss, and increased mortality 1, 2, 3, 5
• Avoid overuse of narcotics—leads to sedation, falls, decreased physical conditioning, and adverse drug reactions in >70% of patients (>10% severe reactions in elderly) 1, 2, 3
• Do not delay osteoporosis pharmacotherapy—high risk of subsequent fractures 5
• Obtain MRI if symptoms change or imaging is >3 months old to identify new fractures that may be overlooked on plain radiographs 1, 5
• Perform adequate neurological examination to avoid missing unstable fractures requiring urgent surgical intervention 3