Do I refer a patient with 2 compression fractures and tolerable pain to an orthopedic (ortho) specialist?

Referral Decision for Compression Fractures with Tolerable Pain

For a patient with 2 compression fractures and tolerable pain who is neurologically intact, orthopedic referral is not immediately necessary—initiate conservative management with outpatient follow-up and refer only if specific red flags develop or conservative treatment fails after 3 months. 1, 2, 3

Initial Assessment Requirements

Before making the referral decision, you must document:

• Complete neurological examination including motor strength, sensory function, and bowel/bladder function to establish baseline and rule out deficits 1, 2, 3
• Fracture stability indicators: less than 10% vertebral body height loss, no bone fragment retropulsion into spinal canal, less than 15% kyphosis, and less than 10% scoliosis 1, 3
• MRI of the spine without contrast to assess fracture acuity (bone marrow edema), rule out pathologic causes (malignancy), and evaluate spinal canal compromise 2, 3

Conservative Management Protocol (First-Line Treatment)

For neurologically intact patients with stable fractures and tolerable pain:

• Calcitonin for 4 weeks provides clinically important pain reduction in acute compression fractures 4, 2, 3
• Analgesics including NSAIDs with judicious short-term narcotic use, avoiding prolonged opioid therapy that increases fall risk and deconditioning 3
• Avoid prolonged bed rest—immobilization causes bone density loss, muscle weakness, DVT risk, and increased mortality 3
• Reassess at 4-6 weeks to evaluate treatment response 2, 3

Immediate Orthopedic/Surgical Referral Required (Do Not Delay)

Refer immediately if any of the following are present:

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

Delayed Referral Criteria (After Conservative Management Fails)

Refer to orthopedic surgery or interventional pain specialist if:

• Severe persistent pain after 3 months of appropriate conservative management despite adequate analgesics 2, 3
• Progressive kyphosis or significant spinal deformity developing during follow-up 2
• Pulmonary dysfunction related to compression fractures 2
• Persistent severe pain after 3 weeks for consideration of vertebral augmentation (kyphoplasty), though note the American Academy of Orthopaedic Surgeons strongly recommends against vertebroplasty specifically 2, 3

Evidence Considerations

The American College of Radiology and multiple guidelines emphasize that medical management is first-line for symptomatic compression fractures without neurological deficits 2, 3. The natural history shows gradual pain improvement over 2-12 weeks with conservative treatment 1. Minimally invasive procedures like kyphoplasty demonstrate superior pain relief when conservative therapy fails after 3 weeks, with 95% clinical improvement rates 3, 5.

Critical Pitfalls to Avoid

• Missing unstable fractures by failing to perform adequate neurological examination at initial presentation 1, 3
• Delaying referral for neurological deficits can result in permanent neurological damage 2
• Failing to rule out pathologic fractures in patients with known malignancy, atypical pain patterns, or minimal trauma mechanisms—obtain MRI with and without contrast if malignancy suspected 2, 3
• Prescribing prolonged bed rest which increases mortality and morbidity 3