What is the recommended treatment for a subacute compression fracture at T12?

Treatment for Subacute T12 Compression Fracture

Begin with conservative medical management for 3 months, then proceed to percutaneous vertebral augmentation if pain persists or if spinal deformity or pulmonary dysfunction develops. 1

Immediate Assessment

Confirm the fracture is neurologically intact through complete neurological examination, as any deficits mandate immediate surgical referral rather than conservative care. 1 The imaging shows no malalignment, normal cord signal, and no canal compromise, which supports conservative management initially. 2

Verify this is an osteoporotic fracture without "red flags" such as known malignancy or signs of pathologic fracture—the imaging shows no suspicious lesions, supporting benign etiology. 2, 1

Conservative Medical Management (First 3 Months)

Initiate analgesics with NSAIDs as first-line agents for pain control. 1

• Limit narcotic use to avoid complications including sedation, increased fall risk, and decreased physical conditioning. 2, 1
• Avoid prolonged bed rest, which dramatically increases risk of deconditioning, bone loss, thromboembolism, and mortality. 1
• Encourage limited activity within pain tolerance to prevent immobility complications. 1
• Start bisphosphonates or other bone-protective agents immediately to prevent additional symptomatic fractures. 1

Most vertebral compression fractures show gradual improvement in pain over 2 to 12 weeks with variable return of function, and bone marrow edema (present in this case) typically resolves within 1 to 3 months. 2 However, approximately 1 in 5 patients will develop chronic back pain despite conservative treatment. 2

Indications for Vertebral Augmentation

Consider percutaneous vertebral augmentation (vertebroplasty or kyphoplasty) if severe pain persists after 3 weeks to 3 months of conservative management. 2, 1

The evidence strongly supports vertebral augmentation over continued conservative therapy when medical management fails:

• Vertebral augmentation provides immediate and substantial improvement in pain and mobility, preventing complications associated with prolonged immobility. 2, 1
• Studies show vertebral augmentation is more effective than prolonged medical treatment in achieving analgesia and improving function. 2
• The VERTOS II trial revealed that 40% of conservatively treated patients had no significant pain relief after 1 year despite higher-class prescription medications. 2

Also consider vertebral augmentation if spinal deformity (≥15% kyphosis or ≥20% vertebral body height loss) or pulmonary dysfunction develops. 2, 1

The timing of vertebral augmentation does not independently affect outcomes—patients with fractures >12 weeks have equivalent benefit to those with fractures <12 weeks. 2 Since this is a subacute fracture, the patient remains an appropriate candidate if conservative management fails. 3

Choice Between Vertebroplasty and Kyphoplasty

While both procedures are effective, the evidence comparing them is inconsistent. 2 Three level II studies showed no clinically important difference in pain outcomes between kyphoplasty and vertebroplasty at 3 to 6 months. 2 Choose based on local expertise and availability, as both provide similar pain relief. 2

When Surgical Consultation Is Mandatory

Immediate surgical referral is required for:

• Any neurological deficits (none present in this case). 1
• Frank spinal instability based on anatomic and clinical factors (none present here). 1
• Spinal cord compression from osseous retropulsion (not present in this case). 1

Critical Pitfalls to Avoid

Do not prolong bed rest beyond what is absolutely necessary—this dramatically increases risk of deconditioning, bone loss, thromboembolism, and mortality. 1

Do not overuse narcotics—they cause sedation, increase fall risk, and worsen physical conditioning. 2, 1

Do not deny vertebral augmentation to appropriate candidates after conservative therapy fails—the threshold for performing vertebral augmentation has declined given evidence of superiority over prolonged medical treatment and avoidance of narcotic complications. 2

Treatment Algorithm

1. Weeks 0-3: Conservative management with NSAIDs, limited activity within pain tolerance, avoid bed rest, initiate bone-protective therapy. 1

2. Weeks 3-12: Continue conservative management if pain is improving; consider vertebral augmentation if severe pain persists. 2, 1

3. After 3 months: Strongly consider vertebral augmentation if pain remains severe, as 40% of patients will have inadequate relief with conservative treatment alone. 2

4. Any time: Proceed immediately to surgical consultation if neurological deficits, spinal instability, or cord compression develop. 1