How should a lumbar compression fracture be treated in a woman under 65 years of age?

Treatment of Lumbar Compression Fracture in Women Under 65

Conservative management with early mobilization, calcitonin for 4 weeks, and immediate osteoporosis treatment is the standard first-line approach for neurologically intact women under 65 with lumbar compression fractures, with vertebral augmentation reserved only for those with persistent severe pain after 3 months of conservative therapy. 1, 2

Immediate Assessment and Red Flags

• Perform a complete neurological examination immediately to assess motor strength, sensory function, reflexes, and bowel/bladder function—any deficits mandate urgent surgical referral rather than conservative management 1, 2, 3
• Obtain MRI lumbar spine without contrast to characterize the fracture, identify bone marrow edema indicating acute injury, rule out pathologic causes (malignancy, infection), and assess spinal stability 1, 2, 3
• Transfer immediately to orthopedic surgery or neurosurgery if any of the following are present: neurological deficits, evidence of spinal instability on imaging (>50% vertebral body collapse, posterior column involvement), known or suspected malignancy, or multiple level fractures 2, 3

Conservative Management Protocol (First 3 Months)

Pain Management

• Administer calcitonin 200 IU (nasal or suppository) for 4 weeks starting immediately—this provides clinically important pain reduction at 1,2,3, and 4 weeks in acute presentations 1, 2
• Use acetaminophen as the cornerstone of pain control, with NSAIDs added for severe pain while monitoring for cardiovascular, GI, and renal complications 1
• Avoid prolonged opioid use due to risks of sedation, falls, deconditioning, and constipation—use judiciously only if other measures fail 1

Activity and Mobilization

• Prohibit prolonged bed rest beyond what is absolutely necessary—bone loss occurs at 1% per week and markers of bone resorption increase within 2 days of immobilization 4, 1
• Encourage slow, regular walking starting with 10-minute periods, gradually increasing duration as tolerated to prevent catastrophic deconditioning 1
• Allow range-of-motion exercises and light calisthenics at moderate intensity (40-70% maximum oxygen consumption) 1
• Consider bracing for activity modification, though evidence for benefit is limited 2

Osteoporosis Management (Initiate Immediately)

This is a critical step that must not be delayed—compression fractures are often the first presentation of severe osteoporosis requiring immediate treatment. 2, 3

Diagnostic Evaluation

• Obtain DEXA scan to assess bone mineral density 4
• Measure serum vitamin D level (target ≥20 ng/mL) and assess for secondary causes of osteoporosis 4
• Treatment should be initiated even before DEXA results in women with fragility fractures, as the fracture itself indicates high fracture risk 4

Pharmacologic Treatment

• First-line therapy: oral bisphosphonates (alendronate or risedronate) for women at high risk of fracture 4
• Alternative options include denosumab for women with high fracture risk or raloxifene for younger postmenopausal women 4
• Ensure adequate calcium (1,000 mg/day for women 19-50 years; 1,200 mg/day for women 51-70 years) and vitamin D (600 IU/day for women under 70 years) 4, 1
• Avoid high pulse dosages of vitamin D which increase fall risk 1

Subspecialty Referral

• Refer to endocrinology or rheumatology within 4-6 weeks for long-term osteoporosis management and to address any secondary causes 2, 3

Follow-Up Timeline and Reassessment

• Reassess at 4-6 weeks to evaluate response to initial treatment and ensure osteoporosis therapy has been initiated 2, 3
• If symptoms persist beyond 8 weeks, obtain repeat imaging to assess for fracture progression or new fractures 2, 3
• Continue conservative management for at least 3 months before considering interventional procedures 1, 3

Indications for Vertebral Augmentation

Consider referral to interventional radiology for vertebral augmentation (kyphoplasty or vertebroplasty) only if: 1, 2, 3

• Persistent severe pain after 3 months of optimal conservative management
• Pain refractory to oral medications requiring parenteral narcotics and hospital admission
• Development of significant spinal deformity or progressive kyphosis during treatment
• Pulmonary dysfunction from progressive kyphosis (restrictive lung disease)

Note: The American Academy of Orthopaedic Surgeons makes a strong recommendation against vertebroplasty for osteoporotic compression fractures, though kyphoplasty may be considered in selected cases. 2

Critical Pitfalls to Avoid

• Missing neurological deficits on initial examination can lead to permanent neurological damage—always perform thorough assessment including rectal tone if indicated 2, 3
• Failing to rule out pathologic fractures (from malignancy or infection) can delay critical diagnosis—obtain complete spine MRI with contrast if any concerning features present (unexplained weight loss, history of cancer, failure to improve) 2, 3
• Delaying osteoporosis evaluation and treatment is a critical error—the 20% risk of another vertebral fracture within 12 months makes immediate intervention essential 4, 2
• Prolonged bed rest leads to devastating complications including rapid bone loss, muscle deconditioning (15% lower extremity strength loss in 10 days), and loss of aerobic capacity equivalent to a decade of aging 4, 1
• Overuse of narcotics causing sedation, falls, and decreased physical conditioning perpetuates a vicious cycle of deconditioning and increased fracture risk 1
• Continuing ineffective conservative management indefinitely—if pain remains severe after 3 months despite optimal therapy, vertebral augmentation should be considered 1, 3