What is the best management approach for a female patient with a recent compression fracture at T9, who is experiencing pain and has a history of caregiving, with an MRI confirming the compression fracture?

Management of T9 Compression Fracture

For this patient with an acute T9 compression fracture, initiate conservative management with immediate pain control, limited bed rest (not prolonged), and calcitonin for 4 weeks, then reassess at 3 weeks for consideration of vertebral augmentation if pain remains severe despite optimal medical therapy. 1

Immediate Management (First 4 Weeks)

Pain Control

• Provide immediate analgesics before completing diagnostic workup, including NSAIDs and judicious short-term narcotics 1, 2
• Avoid prolonged narcotic use due to risks of sedation, falls, deconditioning, and complications from immobility 1, 2
• Administer calcitonin (intranasal 200 IU or subcutaneous) for 4 weeks, which provides clinically important pain reduction in acute compression fractures (0-5 days from onset) 1, 2

Activity Modification

• Limit bed rest to the minimum necessary - prolonged immobilization causes bone density loss, muscle weakness, deep venous thrombosis risk, cardiovascular/respiratory deconditioning, and increased mortality 1, 2
• Encourage early mobilization within pain tolerance to prevent secondary complications 1
• Consider bracing for comfort, though evidence is limited to a single study 1

Reassessment at 3 Weeks

Decision Point for Vertebral Augmentation

If severe pain persists at 3 weeks despite appropriate conservative management, vertebral augmentation (vertebroplasty or balloon kyphoplasty) becomes the appropriate next step. 1, 2

The ACR guidelines demonstrate that:

• 40% of conservatively treated patients have no significant pain relief after 1 year despite higher-class prescription medications 1
• Vertebral augmentation provides superior pain relief and improved functional outcomes compared to prolonged conservative therapy 1, 2
• Studies show benefit in fractures **<6 weeks duration**, though fractures >12 weeks also respond equivalently 1
• Approximately 1 in 5 patients develop chronic back pain without intervention 1

Vertebroplasty vs. Kyphoplasty

• Both procedures are equally effective for pain reduction and disability improvement at long-term follow-up 1
• Balloon kyphoplasty may provide superior vertebral height restoration and less cement leakage compared to vertebroplasty 1
• The procedure can include biopsy to verify etiology and detect unsuspected malignancy 1

Red Flags Requiring Immediate Surgical Consultation

Do not delay surgical referral if any of the following are present:

• Neurological deficits (motor weakness, sensory changes, bowel/bladder dysfunction) indicating spinal cord or nerve root compromise 1, 3, 2
• Spinal instability with retropulsion of bone fragments into the spinal canal 1, 2
• Significant spinal deformity (>15% kyphosis, >10% scoliosis, >20% vertebral body height loss) 1, 2
• Suspected pathologic fracture from malignancy requiring multidisciplinary management 1

Osteoporosis Evaluation and Secondary Prevention

All patients ≥50 years with compression fractures require osteoporosis assessment:

• Obtain DXA scanning and clinical risk factor assessment 1, 4
• Initiate pharmacological treatment with bisphosphonates (ibandronate) or strontium ranelate to prevent additional symptomatic fractures 1
• Begin early physical therapy with spinal stretching exercises, muscle strengthening, balance training, and fall prevention strategies 4, 5

Critical Pitfalls to Avoid

• Prolonged bed rest - leads to deconditioning, bone loss, and increased mortality 1, 2
• Excessive narcotic use - causes sedation, increased fall risk, and decreased physical conditioning 1, 2
• Delaying vertebral augmentation beyond 3 months in patients with persistent severe pain - 40% will have inadequate pain relief with conservative management alone 1
• Missing neurological deficits at initial presentation that mandate immediate surgical consultation 1, 3, 2
• Failing to evaluate for underlying malignancy in atypical presentations or patients with known cancer 1, 2

Long-Term Management

• Continue ordinary activities within pain limits 5
• Maintain physical therapy with back school programs, which are more effective than physiotherapy alone 5
• Monitor for subsequent compression fractures, which occur in approximately 5-10% of patients during the first year 6