What is the appropriate initial management for a moderate wedge compression fracture of T11?

Management of Moderate Wedge Compression Fracture of T11

Begin with conservative medical management including analgesics, limited bed rest, and early mobilization, reserving vertebral augmentation for persistent severe pain after 3 weeks to 3 months of conservative therapy. 1, 2

Immediate Assessment

Perform a complete neurological examination immediately to document baseline motor strength, sensory function, and bowel/bladder control—any deficits mandate urgent surgical consultation rather than conservative care. 1, 2, 3

Obtain MRI of the thoracic spine without contrast to identify bone marrow edema confirming acute injury, assess for spinal canal compromise or retropulsed bone fragments, and exclude pathologic causes (malignancy). 1, 2, 3

Assess for stability indicators:

• Vertebral body height loss (moderate wedge typically <20-30% loss) 3
• Absence of retropulsion into spinal canal 1
• Kyphotic angle <15 degrees 1
• No pedicle or facet joint fractures 4
• Ability to bear weight without step-off deformity 3

Conservative Management Protocol (First-Line Treatment)

Pain control with acetaminophen or NSAIDs as first-line agents, avoiding NSAIDs if cardiovascular or renal comorbidities exist. 3

Consider calcitonin 200 IU (nasal or suppository) for the first 4 weeks, which provides clinically important pain reduction in acute compression fractures. 1, 3

Use narcotics judiciously and short-term only for severe pain, as prolonged opioid use causes sedation, increased fall risk, deconditioning, and does not prevent the 40% failure rate of conservative management. 1, 2, 3

Limit bed rest to what is absolutely necessary—prolonged immobilization leads to bone density loss, muscle weakness, deconditioning, deep venous thrombosis, and increased mortality. 1, 2, 3

Encourage limited activity within pain tolerance to prevent complications of immobility while allowing fracture healing. 2, 5

Initiate bisphosphonates or denosumab as first-line treatment for underlying osteoporosis to prevent additional symptomatic fractures. 2, 5

Re-evaluate at 3 weeks to 3 months to assess treatment response and determine if escalation to vertebral augmentation is needed. 1, 3

Indications for Vertebral Augmentation

Consider vertebroplasty or kyphoplasty if:

• Persistent severe pain after 3 weeks to 3 months of appropriate conservative management 1, 2, 3
• Development of significant spinal deformity (>20% vertebral body height loss) 3
• Development of pulmonary dysfunction attributable to kyphotic deformity 2, 3

The American College of Radiology guidelines demonstrate that vertebral augmentation provides superior pain relief and functional outcomes compared to prolonged conservative therapy, with benefits evident even for fractures older than 12 weeks. 1, 2 The VERTOS II trial revealed that 40% of conservatively treated patients had no significant pain relief after 1 year despite higher-class prescription medications. 2

Kyphoplasty achieves greater restoration of vertebral body height, better correction of spinal deformity, and lower cement leakage rates compared to vertebroplasty, though both provide substantial pain and disability reduction. 3

Immediate Surgical Consultation Required

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

• Any neurological deficits (motor weakness, sensory changes, bowel/bladder dysfunction)—initiate corticosteroid therapy immediately and perform surgery as soon as possible 1, 2, 3
• Retropulsion of bone fragments into the spinal canal causing spinal cord compression 1, 2, 3
• Frank spinal instability with inability to bear weight or progressive deformity 2, 3
• Kyphotic angle >15 degrees at presentation 1

Special Considerations for Pathologic Fractures

If red flags are present (known malignancy, unexplained weight loss, night pain, constitutional symptoms), obtain MRI of the entire spine with and without contrast to assess epidural tumor extension and degree of spinal cord compression. 3

Coordinate multidisciplinary management including interventional radiology, spine surgery, and radiation oncology for confirmed pathologic fractures. 6, 3

Consider image-guided biopsy when imaging findings are ambiguous or to verify etiology during vertebral augmentation. 1, 3

Critical Pitfalls to Avoid

Do not prolong bed rest beyond acute pain control, as this dramatically increases risk of deconditioning, bone loss, thromboembolism, and mortality. 1, 2, 3

Do not overuse narcotics, which cause sedation, increase fall risk, worsen physical conditioning, and do not improve long-term outcomes. 1, 2, 3

Do not miss unstable fractures by performing inadequate neurological examination—complete assessment at initial presentation is essential. 1, 2, 3

Do not deny vertebral augmentation to appropriate candidates after conservative therapy fails, as this increases adverse outcomes associated with prolonged immobility and chronic pain. 1, 2

Do not fail to rule out pathologic fractures in patients with known malignancy, atypical pain patterns, or fractures from minimal trauma. 1, 3