What is the appropriate management for a patient with a traumatic vertebral fracture?

Management of Traumatic Vertebral Fracture

For traumatic vertebral fractures, immediate transfer to orthopedic surgery or neurosurgery is required for any neurological deficits, spinal instability, or high-energy trauma; otherwise, neurologically intact patients with stable fractures should receive conservative outpatient management for 3 months before considering vertebral augmentation. 1

Immediate Transfer Required (Do Not Delay)

Transfer immediately to orthopedic surgery or neurosurgery for:

• Neurological deficits including weakness, numbness, bowel/bladder dysfunction, or radicular symptoms due to high risk of permanent spinal cord damage 2, 1
• Spinal instability on imaging including posterior column involvement, vertebral body collapse >50%, or alignment abnormalities 2, 1
• Multiple level fractures or fractures from high-energy trauma (motor vehicle collision, fall from height) 1
• Known or suspected malignancy with pathologic fracture requiring multidisciplinary management with interventional radiology, surgery, and radiation oncology 2, 1

Critical pitfall: Missing neurological deficits on initial examination—always perform thorough neurological assessment including rectal tone if indicated 1

Initial Imaging for Stable Patients

Obtain MRI of the spine without contrast as the most appropriate initial imaging study for neurologically intact patients 1, 3

MRI provides essential information:

• Distinguishes acute from chronic fractures by detecting bone marrow edema (resolves within 1-3 months) 1
• Rules out pathologic causes by differentiating benign osteoporotic fractures from malignancy or infection 1, 3
• Identifies additional fractures that may be overlooked on plain radiographs 1
• Guides treatment decisions for potential vertebral augmentation 1

Critical pitfall: Failing to rule out pathologic fractures—obtain complete spine imaging with contrast if malignancy suspected based on unexplained weight loss, history of cancer, age >50 with first fracture, or failure to improve with therapy 2, 1

Conservative Management Protocol (First 3 Months)

Conservative management is the standard first-line approach for neurologically intact patients with stable fractures 2, 1, 4

Pain Management

• Calcitonin for the first 4 weeks provides clinically important pain reduction beyond standard analgesics 1, 4
• Acetaminophen and NSAIDs as first-line analgesics 1, 4
• Opioids used judiciously with caution given risks of sedation, nausea, deconditioning, and falls in elderly patients 1, 4

Activity and Rehabilitation

• Avoid prolonged bed rest—bed rest causes bone loss at 1% per week (50 times faster than normal age-related loss) and 15% muscle strength loss after just 10 days 2, 3, 4
• Early mobilization with physical therapy focusing on maintaining mobility, strengthening core and back muscles, and improving posture 2, 4
• Bracing may be used for comfort but should not promote prolonged immobilization 5

Essential Supplementation

• Calcium 1000-1200 mg daily 2, 4
• Vitamin D 800 IU daily 2, 4

Critical pitfall: Delaying osteoporosis evaluation—this is often the first presentation of severe osteoporosis requiring immediate treatment 1

Osteoporosis Management

All patients with vertebral fractures require systematic evaluation for osteoporosis 2, 1

Immediate Assessment

• DXA scan of spine and hip to measure bone mineral density 2
• Laboratory evaluation including erythrocyte sedimentation rate, serum calcium, albumin, creatinine, thyroid-stimulating hormone, and vitamin D 2
• Additional testing when clinically indicated (protein electrophoresis, testosterone in men) to identify secondary osteoporosis present in up to 30% of women and 55% of men 6

Pharmacological Treatment

Initiate osteoporosis pharmacotherapy immediately—patients have a 20% risk of another vertebral fracture within 12 months 2, 4

• Alendronate or risedronate as first-choice agents (well tolerated, low cost, demonstrated reduction in vertebral, non-vertebral, and hip fractures) 2
• Zoledronic acid (intravenous) or denosumab (subcutaneous) for patients with oral intolerance, dementia, malabsorption, or non-compliance 2
• Teriparatide for patients with very high fracture risk 2

Subspecialty Referral

Refer to endocrinology or rheumatology within 4-6 weeks for long-term osteoporosis management 1

Follow-Up Timeline

• 4-6 weeks: Reassess response to initial treatment 1, 4
• 8 weeks: If symptoms persist, consider repeat imaging to assess for fracture progression or new fractures 1, 4
• 3 months: If severe pain persists despite conservative management, refer for vertebral augmentation consideration 2, 1, 4

Vertebral Augmentation Indications

Refer to interventional radiology or orthopedic surgery after 3 months of failed conservative management for 2, 1, 4:

• Severe and worsening pain preventing ambulation or physical therapy
• Significant spinal deformity or progressive kyphosis
• Pulmonary dysfunction from progressive kyphosis
• Contraindication to pain medications or requirement for parenteral narcotics

Evidence note: Vertebroplasty and kyphoplasty are reasonable therapeutic options showing superior pain reduction compared to conservative management in selected patients, with major complications occurring in <1% of patients with osteoporotic fractures 2, 1

Earlier Referral Considerations

Consider referral before 3 months for:

• Pain refractory to oral medications requiring parenteral narcotics and hospital admission 1
• Acute fractures <6 weeks duration with severe pain (vertebral augmentation shows superior outcomes in this timeframe) 1

Special Considerations for Pathologic Fractures

For fractures secondary to malignancy 2:

• Palliative radiotherapy reduces back pain in approximately 60% of patients, with pain relief beginning 7-10 days after treatment and reaching maximum between 4-8 weeks 2
• Vertebral augmentation provides rapid pain relief, reduced disability, and improved performance status for cancer patients without significant mechanical instability or cord compression 2
• Spinal Instability Neoplastic Score (SINS) should be used to evaluate spinal stability: stable (0-6), potentially unstable (7-12), unstable (13-18) 2

Fracture Liaison Service

Implement systematic secondary fracture prevention through a Fracture Liaison Service (FLS) with a dedicated coordinator (often a well-educated nurse) who identifies all elderly patients with recent fractures, organizes diagnostic investigations, and initiates interventions 2

RCTs demonstrate that FLS significantly improves osteoporosis treatment implementation—45% of patients received appropriate management within 6 months versus only 26% in control groups 2