What is the diagnosis and treatment approach for a patient with suspected compression fracture, possibly due to osteoporosis or recent trauma?

Compression Fracture: Diagnosis and Treatment

Diagnostic Approach

Start with plain radiography (anteroposterior and lateral views) in patients with suspected osteoporotic compression fracture, particularly those with a history of osteoporosis or steroid use. 1

Initial Imaging Strategy

• Plain radiographs are the appropriate first-line imaging for patients with low suspicion of trauma or minor trauma and suspected vertebral compression fracture 1
• Upright radiographs provide functional information about axial loading and can assess spinal stability with flexion-extension views 1
• MRI lumbar spine without IV contrast is the preferred advanced imaging when radiographs are positive or clinical suspicion remains high, as it determines fracture acuity via bone marrow edema and distinguishes benign from pathologic fractures 1

Key Diagnostic Features on MRI

• Bone marrow edema indicates acute injury requiring treatment 1
• Convex posterior vertebral body border, extension into posterior elements, and abnormal marrow signal suggest pathologic (malignant) fracture 1
• MRI with and without IV contrast should be obtained when malignancy, infection, or inflammation is suspected 1

When to Use CT

• CT without IV contrast provides detailed fracture analysis for posterior column involvement, pedicle integrity, and posterior cortex evaluation 1
• CT is useful for assessing osseous integrity in pathologic fractures but poorly depicts intradural and spinal cord pathology 1
• CT myelography can assess spinal canal patency in osteoporotic fractures with neurologic deficit, though it requires lumbar puncture 1

Acute Management (0-5 Days)

For neurologically intact patients with acute compression fractures, initiate calcitonin 200 IU (nasal or suppository) for 4 weeks, which provides clinically important pain reduction. 1, 2

Conservative Treatment Protocol

• Calcitonin demonstrates clinically important pain relief at 1,2,3, and 4 weeks in acute presentations 1, 2
• Analgesics including NSAIDs are appropriate, though evidence for opioids remains inconclusive 1, 2
• Avoid prolonged bed rest, which leads to deconditioning, bone loss, and increased mortality 1, 2
• Permit slow, regular walking starting with 10-minute periods, gradually increasing duration 2

Osteoporosis Treatment to Prevent Future Fractures

• Initiate ibandronate or strontium ranelate to prevent additional symptomatic fractures 1, 2
• Ensure adequate calcium intake (1000-1200 mg/day) and vitamin D supplementation (800 IU/day) 2
• Avoid high pulse dosages of vitamin D which increase fall risk 2

Indications for Vertebral Augmentation

Consider vertebral augmentation (kyphoplasty or vertebroplasty) only if persistent severe pain after 3 weeks of conservative management, or if spinal deformity or pulmonary dysfunction develops. 2

Evidence Limitations

• Vertebroplasty shows no benefit over sham procedure based on Level I evidence, with pain relief at 24 hours but no clinically important benefit after 6 weeks 1, 3
• Kyphoplasty versus vertebroplasty studies show inconsistent results, with no clear difference in pain outcomes at 3 days and 6 months 1
• The American Academy of Orthopaedic Surgeons cannot recommend for or against specific treatments due to limited quality evidence 1

Appropriate Candidates for Augmentation

• Persistent severe pain after 3 weeks of conservative treatment with bone marrow edema on MRI 2
• Contraindication to surgery in patients with ongoing pain 2
• Spinal deformity or pulmonary dysfunction development 2

Immediate Surgical Referral Required

Any neurological deficit, frank spinal instability, or pathologic fracture with spinal cord compression mandates immediate surgical consultation. 2, 3

Red Flags Requiring Urgent Intervention

• Any neurological deficits require immediate orthopedic or neurosurgical consultation 2, 3
• Spinal instability on imaging requires immediate surgical evaluation 3
• Spinal cord compression requires urgent surgical decompression 3
• Progressive kyphosis or significant spinal deformity warrants surgical referral 3
• Initiate corticosteroid therapy immediately and perform surgery as soon as possible in patients with neurological deficits 2

Special Considerations for Pathologic Fractures

For compression fractures due to metastatic disease, asymptomatic pathologic fractures may be managed with radiation oncology consultation, while severe worsening pain requires a multidisciplinary approach. 2

• Neurological involvement mandates both surgical and radiation oncology consultation 2
• FDG-PET/CT can distinguish benign versus pathologic compression fractures when other imaging modalities are indeterminate 1
• History of cancer is the only red flag shown to increase probability of finding spinal malignancy 1

Clinical Examination Pearls

• Closed-fist percussion of the spine has 87.5% sensitivity and 90% specificity for acute fractures 4
• Inability to lie supine on examination couch has 81.25% sensitivity and 93.33% specificity for acute fractures 4
• These clinical signs help predict which patients have acute fractures requiring MRI 4

Critical Pitfalls to Avoid

• Overuse of narcotics causes sedation, falls, and decreased physical conditioning 2
• Missing unstable fractures by performing inadequate neurological examination 2
• Approximately two-thirds of vertebral compression fractures are not accurately diagnosed and therefore not treated 5
• Radiographic fracture assessment is not a reliable surrogate for symptomatic fracture—many chronic fractures on imaging may not be the pain source 1

Follow-Up Timeline

• Reassess at 4-6 weeks to evaluate response to conservative treatment 3
• Consider vertebral augmentation if worsening at 3 months 3
• Most patients improve over 2-12 weeks regardless of specific interventions 3