Management of T11 Anterior Wedge Compression Fracture
For an isolated T11 anterior wedge compression fracture without neurological deficits or known malignancy, initiate medical management for the first 3 months, and consider vertebral augmentation (vertebroplasty or kyphoplasty) if pain persists, spinal deformity exceeds 20% vertebral body height loss, or pulmonary dysfunction develops. 1, 2
Immediate Assessment
Perform a focused neurological examination to identify motor weakness, sensory deficits, or bowel/bladder dysfunction that would mandate immediate surgical referral. 3
Obtain MRI of the thoracic spine without IV contrast to:
- Identify bone marrow edema confirming fracture acuity 1, 3
- Exclude pathologic fracture from malignancy 1, 3
- Assess for spinal cord compression or retropulsed bone fragments 3
- Evaluate spinal stability 1
Screen for red flags including unexplained weight loss, night pain, constitutional symptoms, or history of malignancy that would require complete spine MRI with and without contrast and possible image-guided biopsy. 1, 3
Conservative Medical Management (First 3 Months)
Start acetaminophen as first-line analgesia, avoiding NSAIDs if cardiovascular or renal comorbidities exist. 3
Consider 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, 3
Use short-term opioids only if necessary for severe pain, as prolonged use causes sedation, falls, decreased conditioning, and does not prevent the 40% failure rate of conservative management at 1 year. 3
Avoid prolonged bed rest beyond acute pain control, as it leads to deconditioning, bone loss, and increased mortality risk. 3
Re-evaluate pain and functional status between 3 weeks and 3 months to determine if escalation to vertebral augmentation is warranted. 3
Indications for Vertebral Augmentation
The ACR guidelines clearly delineate when to escalate from conservative management. 1
Consider vertebroplasty or kyphoplasty if:
- Persistent severe pain after 3 weeks to 3 months of appropriate conservative treatment 1, 2, 3
- Vertebral body height loss >20% (significant spinal deformity) 3
- Development of pulmonary dysfunction attributable to kyphotic deformity 1, 3
- Progressive worsening symptoms despite medical management 1, 2
Vertebral augmentation provides superior pain relief and functional outcomes compared with prolonged conservative therapy, with benefits evident even for fractures older than 12 weeks. 3
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
Refer immediately for surgical decompression and stabilization if:
- Any neurologic deficit present (motor weakness, sensory loss, bowel/bladder dysfunction) 1, 3, 4, 5
- Frank spinal instability with inability to bear weight or progressive deformity 3, 4
- Spinal cord compression on imaging, particularly from osseous retropulsion 1, 3, 4
- Retropulsed bone fragments into the spinal canal 3, 5
Neurologic recovery occurred in 60% of patients with osteoporotic burst fractures and neurologic compromise who underwent surgical decompression, though significant disability secondary to pain remained common. 5
Critical Pitfalls to Avoid
Do not delay intervention in patients with progressive deformity >20% height loss or pulmonary dysfunction, as these warrant earlier vertebral augmentation rather than waiting the full 3 months. 1, 3
Do not overlook pathologic fractures in patients with risk factors for malignancy; obtain complete spine MRI with contrast if red flags present. 1, 3
Do not delay osteoporosis treatment in patients with confirmed vertebral fractures, as approximately 1 in 5 develop chronic back pain and subsequent fracture risk is high. 3
Do not miss neurologic deficits, as delayed surgical decompression leads to worse neurological outcomes. 4, 5