What is the recommended initial management for a new lumbar vertebral compression fracture?

Treatment for New Lumbar Compression Fracture

For a new lumbar vertebral compression fracture without known malignancy, initiate medical management immediately while obtaining MRI of the lumbar spine without contrast to assess fracture acuity and rule out pathologic causes. 1

Immediate Assessment Requirements

Perform a complete neurological examination to identify motor weakness, sensory deficits, or bowel/bladder dysfunction—any of these findings mandate immediate surgical consultation and corticosteroid therapy. 2, 3

Assess for spinal instability by examining for focal tenderness, step-off deformity, inability to bear weight, or vertebral body height loss >20%. 1, 2

Obtain MRI lumbar spine without IV contrast to identify bone marrow edema (indicating acute fracture), assess for spinal cord compression, exclude malignancy, and evaluate for retropulsed bone fragments. 1, 2, 3

Conservative Medical Management (First 3 Months)

Start acetaminophen as first-line analgesia, avoiding NSAIDs if cardiovascular or renal comorbidities exist. 2

Add calcitonin 200 IU (nasal or suppository) for 4 weeks if presenting acutely, as this provides clinically important pain reduction at 1,2,3, and 4 weeks. 2, 4

Use short-term narcotic medications only if necessary for severe pain—prolonged opioid use causes sedation, falls, decreased physical conditioning, and does not prevent the 40% failure rate of conservative management at 1 year. 2, 3

Avoid prolonged bed rest beyond acute pain control, as it leads to bone density loss, muscle weakness, deconditioning, increased deep venous thrombosis risk, cardiovascular/respiratory muscle weakness, and increased mortality. 2, 3, 5

Reassess at 3 weeks to 3 months to evaluate treatment response and determine if escalation to vertebral augmentation is needed. 1, 2, 3

Indications for Vertebral Augmentation

Consider vertebral augmentation (vertebroplasty or kyphoplasty) if:

• Persistent severe pain after 3 weeks to 3 months of conservative management despite appropriate analgesics 1, 2, 3
• Significant spinal deformity with >20% vertebral body height loss 1, 2
• Development of pulmonary dysfunction related to kyphotic deformity 1, 2

Vertebral augmentation provides superior pain relief and improved functional outcomes compared to prolonged conservative therapy, with immediate and considerable improvement in pain and patient mobility. Studies demonstrate benefit even in fractures older than 12 weeks. 1, 3

Both vertebroplasty and kyphoplasty are equally effective in substantially reducing pain and disability, though kyphoplasty provides superior improvement in spinal deformity with increased vertebral body height restoration and less cement leakage. 1

Immediate Surgical Consultation Required

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

• Any neurologic deficits (motor weakness, sensory loss, bowel/bladder dysfunction) indicating spinal cord or nerve root compromise—requires decompression and stabilization as soon as possible after initiating corticosteroid therapy 1, 2, 3, 6
• Frank spinal instability with retropulsion of bone fragments into the spinal canal 1, 3, 6
• Spinal cord compression on imaging, particularly from osseous retropulsion 1, 6
• Progressive deformity with inability to bear weight 6

Special Considerations for Pathologic Fractures

If known malignancy or "red flags" present (unexplained weight loss, night pain, constitutional symptoms, cancer history):

• Obtain MRI of the complete spine without and with IV contrast to assess epidural extension and degree of spinal cord compression 1, 3
• Image-guided biopsy is appropriate when imaging findings are ambiguous 1
• Coordinate multidisciplinary approach including interventional radiology, surgery, and radiation oncology consultation 1

Critical Pitfalls to Avoid

Missing unstable fractures by failing to perform adequate neurological examination at initial presentation can lead to catastrophic outcomes. 2, 3

Delaying osteoporosis treatment in patients with confirmed vertebral fractures should be avoided, as approximately 1 in 5 patients develop chronic back pain and the risk of subsequent fractures is high. 2, 7

Overuse of narcotics causes sedation, increased fall risk, and decreased physical conditioning without preventing treatment failure. 2, 3

Failing to rule out pathologic fractures in patients with known malignancy, atypical pain patterns, or fractures from minimal trauma can delay appropriate multidisciplinary management. 3