What is the initial management for patients presenting with compression fractures?

Initial Management of Compression Fractures

Medical management with analgesics and early mobilization is the standard initial approach for neurologically intact patients with osteoporotic vertebral compression fractures, with most patients experiencing gradual pain improvement over 2-12 weeks. 1

Immediate Assessment

Perform a complete neurological examination immediately to identify any deficits that would mandate urgent surgical intervention rather than conservative care. 2 Look specifically for:

• Motor weakness in lower extremities
• Sensory level changes
• Bowel or bladder dysfunction
• Signs of spinal cord compression 3

Assess for "red flags" including known malignancy, progressive neurological symptoms, or signs of spinal instability that would require immediate surgical referral. 2

Obtain MRI of the spine without contrast to identify bone marrow edema indicating acute injury and to differentiate osteoporotic from pathologic fractures. 2

Conservative Medical Management (First-Line Treatment)

Use NSAIDs as first-line analgesics for pain control in neurologically intact patients. 2

Limit narcotic use to avoid complications of sedation, falls, and decreased physical conditioning. 2

Consider calcitonin for acute pain management in the first 4 weeks after fracture identification. 1

Avoid prolonged bed rest, which leads to deconditioning, bone loss, thromboembolism, and increased mortality risk. 2 Instead, encourage limited activity within pain tolerance to prevent complications of immobility. 2

Initiate bisphosphonates or other bone-protective agents to prevent additional symptomatic fractures. 2

Expected Natural History

Most healing vertebral compression fractures show gradual improvement in pain over 2 to 12 weeks with variable return of function. 1 However, approximately 1 in 5 patients will develop chronic back pain despite conservative treatment. 2

When to Consider Vertebral Augmentation

If medical management fails after 3 weeks to 3 months with persistent severe pain, consider percutaneous vertebral augmentation (vertebroplasty or kyphoplasty). 1, 2

Earlier intervention is indicated for:

• Spinal deformity development 1
• Worsening symptoms despite medications 1
• Pulmonary dysfunction 1

Both vertebroplasty and kyphoplasty provide immediate and substantial improvement in pain and mobility, preventing complications associated with prolonged immobility. 1, 2 The choice between procedures should be based on local expertise and availability, as both provide similar pain relief. 2

Immediate Surgical Indications

Immediate surgical referral is mandatory for:

• Any neurological deficits 3, 2
• Frank spinal instability 2
• Spinal cord compression 3, 2

Upon presentation with neurological deficits, initiate corticosteroid therapy immediately and perform surgery as soon as possible to prevent further neurological deterioration. 3

Critical Pitfalls to Avoid

Do not prolong bed rest beyond what is absolutely necessary, as this dramatically increases risk of deconditioning, bone loss, thromboembolism, and mortality. 2

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

Do not miss unstable fractures by performing inadequate neurological examination—complete assessment is essential. 2

Do not overlook pathologic fractures in patients with risk factors for malignancy. 1

Do not delay intervention in patients with progressive deformity or pulmonary dysfunction. 1