What is the treatment for vertebral compression fractures?

Treatment of Vertebral Compression Fractures

For neurologically intact patients with vertebral compression fractures, initiate conservative medical management for the first 3 months, reserving percutaneous vertebral augmentation (vertebroplasty or kyphoplasty) for those with persistent severe pain, spinal deformity, or pulmonary dysfunction after this period. 1

Initial Assessment

• Obtain MRI of the spine without contrast to identify bone marrow edema indicating acute injury and to differentiate osteoporotic from pathologic fractures 1, 2
• Perform complete neurological examination immediately to identify any deficits that would mandate urgent surgical intervention rather than conservative care 2, 3
• Assess for "red flags" including known malignancy, neurological symptoms, or signs of spinal instability 2
• If malignancy is suspected, obtain MRI of the complete spine without and with IV contrast, and consider image-guided biopsy if imaging findings are ambiguous 1

Conservative Medical Management (First-Line for 3 Months)

Pain Control:

• Use NSAIDs as first-line analgesics for pain control 2, 3
• Limit narcotic use to avoid complications of sedation, falls, and decreased physical conditioning 2, 3
• Consider calcitonin 200 IU (nasal or suppository) for 4 weeks if presenting acutely, as it provides clinically important pain reduction at 1,2,3, and 4 weeks 3

Activity Modification:

• Avoid prolonged bed rest, which leads to deconditioning, bone loss, thromboembolism, and increased mortality risk 2, 3
• Encourage limited activity within pain tolerance to prevent complications of immobility 2
• Permit slow, regular walking starting with 10-minute periods, gradually increasing duration, with range-of-motion exercises and light calisthenics at 40-70% of maximum oxygen consumption 3

Bone Protection:

• Initiate bisphosphonates (such as alendronate) or other bone-protective agents to prevent additional symptomatic fractures 2, 3
• Alendronate reduces the incidence of new vertebral fractures by 47-48% (from 15.0% to 7.9% in patients with prior fracture, and from 4.8% to 2.5% in those without) 4
• Ensure adequate calcium intake (1000-1200 mg/day) and vitamin D supplementation (800 IU/day), but avoid high pulse dosages of vitamin D which increase fall risk 3

Indications for Percutaneous Vertebral Augmentation

Consider vertebral augmentation (vertebroplasty or kyphoplasty) if:

• Persistent severe pain after 3 weeks to 3 months of conservative management 1, 2
• Development of spinal deformity or pulmonary dysfunction 1, 2
• Contraindication to surgery in patients with ongoing pain and edema on MRI 1, 3

Evidence supporting vertebral augmentation:

• Vertebroplasty and kyphoplasty are equally effective in substantially reducing pain and disability, with comparable effectiveness persisting from 2 to 5 years after the procedure 1
• Kyphoplasty provides superior functional recovery compared with vertebroplasty due to improvement in spinal deformity with extension of the kyphotic angle and increased vertebral body height 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 1, 2
• Meta-analysis shows vertebroplasty provides better pain relief at 1 week and 1 month compared to conservative treatment, with improved quality of life 5
• Vertebroplasty results in 53% reduction in pain scores at 24 hours (from 19 to 9 on a 0-25 scale) and 29% improvement in physical functioning, with 24% of patients able to cease all analgesia after 24 hours 6

Surgical Consultation (Urgent/Emergent Indications)

Immediate surgical referral is mandatory for:

• Any neurological deficits, with initiation of corticosteroid therapy immediately and performance of surgery as soon as possible to prevent further deterioration 1, 2, 7
• Frank spinal instability based on anatomic and clinical factors 2, 3
• Spinal cord compression, particularly from osseous compression, where surgery is more likely to allow neurological recovery than radiation alone 1, 7

Surgical approach:

• Combined anterior and posterior approach is appropriate for complete decompression of the spinal cord and stabilization of both anterior and posterior columns in complex spinal injuries 7
• Delays in surgical decompression lead to worse neurological outcomes 7

Management of Pathologic Fractures (Malignancy-Related)

For asymptomatic pathologic fractures:

• Radiation oncology consultation or medical management is usually appropriate 1

For pathologic fractures with severe and worsening pain:

• Multidisciplinary approach including interventional radiology, surgery, and radiation oncology consultation is recommended 1
• Percutaneous thermal ablation or percutaneous vertebral augmentation is usually appropriate 1

For pathologic fractures with spinal deformity or pulmonary dysfunction:

• Multidisciplinary approach with percutaneous vertebral augmentation is usually appropriate 1

For pathologic fractures with neurologic effects:

• Surgical consultation and radiation oncology consultation are usually appropriate 1
• Decompressive surgery followed by radiation therapy may benefit symptomatic spinal cord compression in patients <65 years of age, with single level compression, neurologic deficits for <48 hours, and predicted survival of at least 3 months 1

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, 3
• Do not overuse narcotics, which cause sedation, increase fall risk, and worsen physical conditioning 2, 3
• Do not miss unstable fractures by performing inadequate neurological examination—complete assessment is essential 2, 3
• Do not deny vertebral augmentation to appropriate candidates after conservative therapy fails, as this increases adverse outcomes associated with immobility 2
• Do not assume core decompression of the vertebral body is effective—a 2023 randomized controlled trial showed no significant improvement in pain and disability compared to conservative treatment 8