What is the initial approach to managing endplate vertebral body compression?

Initial Management of Endplate Vertebral Body Compression

Medical management with pain control and osteoporosis treatment is the standard initial approach for vertebral compression fractures without neurological deficits, with most patients experiencing gradual improvement over 2-12 weeks. 1

Immediate Assessment Priorities

First, assess for neurological deficits and "red flags" that require urgent intervention:

• Neurological deficits (weakness, numbness, bowel/bladder dysfunction) mandate immediate surgical referral 2, 3
• Suspected pathologic fracture (known malignancy, unexplained weight loss, age <50) requires immediate multidisciplinary evaluation 3
• Spinal instability on imaging necessitates urgent surgical consultation 3

Initial Imaging and Workup

• MRI of the spine without IV contrast is recommended for all patients to characterize the fracture and exclude pathologic causes 3
• Plain radiographs confirm the diagnosis, but MRI determines if the fracture is acute versus chronic and evaluates for underlying malignancy 2, 4

Standard Conservative Management (First 3 Months)

For neurologically intact patients, initiate the following algorithmic approach:

Pain Management

• Calcitonin should be considered specifically for the first 4 weeks after fracture identification for acute pain control 1, 3
• Analgesics as needed for pain control 5, 6

Functional Support

• Bracing may be used for symptomatic relief and functional restoration 5, 6
• Physical therapy to prevent deconditioning and maintain mobility 6

Osteoporosis Treatment

• Initiate or optimize osteoporosis screening and treatment with calcium/vitamin D supplementation plus bisphosphonates 2, 5
• Address underlying metabolic abnormalities 5

Expected Natural History

• Most healing vertebral compression fractures show gradual pain improvement over 2-12 weeks with variable return of function 1
• Reassess patients at 4-6 weeks to evaluate treatment response 3

When to Escalate to Vertebral Augmentation

Consider vertebroplasty or balloon kyphoplasty if:

• Failure of medical management with worsening symptoms after 3 months of conservative treatment 1, 3
• Earlier intervention is indicated for: progressive spinal deformity, worsening symptoms despite medications, or pulmonary dysfunction 1, 3
• Both vertebroplasty and balloon kyphoplasty provide immediate and considerable improvement in pain and mobility with similar complication rates 2, 1
• Balloon kyphoplasty may provide better improvement in spinal deformity with restoration of vertebral body height 1

Critical Pitfalls to Avoid

• Do not delay referral for patients with neurological deficits—this can lead to permanent neurological damage 3
• Do not overlook pathologic fractures in patients with risk factors for malignancy (age, history of cancer, constitutional symptoms) 1, 3
• Do not delay intervention in patients with progressive deformity or pulmonary dysfunction 1
• Failing to obtain complete spine MRI with contrast when pathologic fracture is suspected can lead to delayed diagnosis 3

Surgical Management Indications

Open surgical decompression and stabilization is reserved exclusively for:

• Vertebral compression fractures complicated by spinal instability 1, 7
• Neurological deficits or significant spinal cord compression 1, 7
• Progressive deformity with neurologic compromise 5

Surgery should be performed as soon as possible once neurological deficits are identified to prevent further deterioration 7