What is the initial treatment for lumbar compression fractures?

Initial Treatment for Lumbar Compression Fractures

For neurologically intact patients with lumbar compression fractures, initiate conservative management for 3 months consisting of analgesics (NSAIDs preferred over opioids), early mobilization to prevent deconditioning, and osteoporosis treatment with bisphosphonates plus calcium/vitamin D supplementation, reserving vertebral augmentation only for those with persistent severe pain after this conservative trial. 1, 2

Immediate Assessment Requirements

Perform a complete neurological examination immediately to identify any deficits that would mandate urgent surgical referral, as missing unstable fractures is a critical pitfall. 1

• Obtain MRI of the lumbar spine without contrast or CT to characterize the fracture and identify bone marrow edema indicating acute injury. 1
• Assess for significant vertebral collapse, angulation, or canal compromise which may indicate instability requiring surgery. 2
• Determine if the fracture is osteoporotic versus traumatic or pathologic, as management approaches differ. 2

Conservative Management Protocol (First 3 Months)

Pain Control

• Use NSAIDs as first-line analgesics, with carefully monitored narcotics only if necessary, as evidence for opioids is inconclusive. 1, 2
• Avoid overuse of narcotics which causes sedation, falls, and decreased physical conditioning—a major pitfall in management. 1
• For acute presentations, calcitonin 200 IU (nasal or suppository) for 4 weeks provides clinically important pain reduction at 1,2,3, and 4 weeks. 1

Mobilization Strategy

• Avoid prolonged bed rest, which leads to deconditioning, bone loss, and increased mortality risk. 1
• Permit slow, regular walking starting with 10-minute periods, gradually increasing duration. 1
• Allow range-of-motion exercises and light calisthenics that generate 40-70% of maximum oxygen consumption. 1
• Activities should remain moderate intensity to prevent fracture progression while allowing initial healing. 1

Bracing Considerations

• Both external bracing and no-brace approaches show equivalent improvement in pain and disability outcomes for neurologically intact patients, so bracing is optional rather than mandatory. 2

Osteoporosis Treatment (Initiate Immediately)

Start bisphosphonate therapy immediately to prevent additional symptomatic fractures, as this addresses the underlying disease process. 1

• Ibandronate or other bisphosphonates should be initiated for fracture prevention. 1
• Ensure adequate calcium intake (1000-1200 mg/day) and vitamin D supplementation (800 IU/day) to maintain serum 25(OH)D levels ≥30-50 ng/mL. 3, 1
• Avoid high pulse dosages of vitamin D which increase fall risk. 1
• For patients on chronic glucocorticoids (≥2.5 mg/day prednisone for >3 months), oral bisphosphonates are strongly recommended as they reduce total and vertebral fractures at 24 months. 3

Vertebral Augmentation Indications

Consider vertebroplasty or kyphoplasty only after 3 weeks to 3 months of failed conservative management with persistent severe pain and MRI-confirmed bone marrow edema. 1, 2

• Vertebroplasty provides immediate and considerable improvement in pain and mobility within 24 hours, with 24% of patients able to cease all analgesia after the procedure. 3
• The benefit of vertebroplasty over conservative therapy is most pronounced in early mobilization, even though clinical outcomes at 6 weeks, 6 months, and 12 months may be equivalent. 3
• Additional indications include spinal deformity or pulmonary dysfunction development, or contraindication to surgery in patients with ongoing pain. 1

Surgical Referral (Immediate)

Refer immediately for surgical consultation if any of the following are present:

• Any neurological deficits or frank spinal instability. 1, 2
• Burst fractures with significant vertebral collapse, angulation, or severe spinal stenosis. 2, 4
• Pathologic fractures with spinal cord compression. 1
• Initiate corticosteroid therapy immediately and perform surgery as soon as possible to prevent further deterioration in patients with neurological deficits. 1

Special Considerations for Pathologic Fractures

• For compression fractures due to metastatic disease, asymptomatic pathologic fractures may be managed with radiation oncology consultation or medical management. 1
• Severe worsening pain requires a multidisciplinary approach with interventional radiology, surgery, and radiation oncology. 1
• Neurological involvement mandates both surgical and radiation oncology consultation. 1

Critical Pitfalls to Avoid

• Do not prescribe prolonged bed rest—this is the single most harmful intervention, leading to deconditioning, bone loss, and increased mortality. 1
• Do not over-rely on narcotics—this causes sedation, falls, and decreased physical conditioning. 1
• Do not perform inadequate neurological examination—missing unstable fractures can lead to catastrophic outcomes. 1
• Do not rush to vertebral augmentation—most compression fractures are stable and respond to conservative management within 3 months. 4