In an adult patient with very mild compression of T6‑T8 (thoracic vertebrae 6 to 8), no prior spinal surgery, no significant comorbidities, and no progressive neurological deficits, what is the appropriate initial management?

Management of Very Mild Thoracic Compression Fractures (T6-T8)

Conservative management with pain control and osteoporosis evaluation is the appropriate initial approach for an adult with very mild compression of T6-T8 vertebrae who has no neurological deficits, no red flags, and no prior spinal surgery. 1, 2

Initial Clinical Assessment

Perform a focused neurological examination specifically assessing:

• Motor strength in bilateral lower extremities (hip flexion, knee extension, ankle dorsiflexion/plantarflexion) 1, 3
• Sensory testing to dermatomal levels below T8 1
• Rectal tone if any concern for cauda equina (though less relevant at thoracic levels) 2
• Presence of myelopathic signs: spasticity, hyperreflexia, positive Babinski sign 1
• Bowel/bladder dysfunction 1, 2

Screen for red flags that would change management:

• History of malignancy 1, 2
• Unexplained weight loss 2
• Age >50 with first fracture 2
• Fever or constitutional symptoms suggesting infection 1
• High-energy trauma mechanism 2, 4

Imaging Strategy

MRI thoracic spine without IV contrast is the most appropriate imaging study if not already obtained. 1, 2 This modality serves multiple critical purposes:

• Distinguishes acute from chronic compression by detecting bone marrow edema (resolves within 1-3 months) 2
• Rules out pathologic causes (malignancy, infection) without requiring contrast in most cases 1, 2
• Identifies additional occult fractures that may be missed on plain radiographs 2
• Guides treatment decisions regarding candidacy for vertebral augmentation if conservative management fails 2

Contrast-enhanced MRI is not indicated for straightforward osteoporotic compression fractures unless there is clinical suspicion for malignancy or infection. 1, 2

Conservative Management Protocol (First 3 Months)

Pain Management Algorithm:

• First-line: Scheduled acetaminophen 650-1000 mg every 6 hours (not as-needed) 2
• Second-line: Add NSAIDs (ibuprofen 400-600 mg TID or naproxen 500 mg BID) for severe pain, but use cautiously in elderly patients due to cardiovascular, renal, and gastrointestinal risks 2
• Third-line: Short-acting opioids at lowest effective dose for breakthrough pain only, minimizing sedation, fall risk, nausea, and deconditioning 2
• Consider: Calcitonin for the first 4 weeks may provide clinically important pain reduction in acute compression fractures, though evidence is limited 2

Activity Modification:

• Avoid heavy lifting, bending, and twisting movements 1, 2
• Bracing may be considered for comfort and to limit flexion, though evidence for efficacy is limited 2
• Gradual mobilization as tolerated to prevent deconditioning 4

Osteoporosis Evaluation (Mandatory)

All patients with compression fractures require systematic osteoporosis assessment: 1, 2

• DXA scan if not recently performed 2
• Laboratory evaluation for secondary causes: serum calcium, phosphate, alkaline phosphatase, 25-OH vitamin D, TSH, complete blood count, comprehensive metabolic panel 2
• Initiate appropriate pharmacologic therapy (bisphosphonates, denosumab, or anabolic agents depending on fracture risk) 2
• Referral to endocrinology or rheumatology within 4-6 weeks for long-term osteoporosis management 2

Follow-Up Timeline

4-6 weeks: Reassess response to conservative therapy and confirm osteoporosis treatment has been initiated 2

8 weeks: If pain persists, consider repeat imaging to assess for fracture progression or new fractures 2

3 months: If severe pain continues despite optimal conservative management, refer to interventional radiology for consideration of vertebral augmentation (kyphoplasty preferred over vertebroplasty) 1, 2

Indications for Earlier Intervention or Referral

Immediate surgical consultation is required if: 1, 3, 5, 2

• Any new neurological deficits develop (weakness, numbness, bowel/bladder dysfunction) 1, 3, 5
• Evidence of spinal cord compression on imaging 1, 5
• Spinal instability (posterior column involvement, >50% vertebral body collapse, alignment abnormalities) 3, 2

Earlier referral to interventional radiology (before 3 months) is appropriate for: 2

• Pain refractory to oral medications requiring parenteral narcotics or hospitalization 2
• Progressive spinal deformity or increasing kyphosis during treatment 1, 2
• Development of restrictive pulmonary dysfunction secondary to worsening kyphosis 1, 2

Multidisciplinary consultation (interventional radiology, surgery, radiation oncology) if: 1, 2

• Known or suspected malignancy with pathologic fracture 1, 2
• Imaging findings ambiguous for benign versus pathologic etiology 1

Critical Pitfalls to Avoid

• Missing neurological deficits on initial examination can lead to delayed surgical intervention and worse outcomes; always perform thorough neurological assessment including rectal tone if indicated 3, 2
• Failing to rule out pathologic fractures in patients with red flags (history of malignancy, unexplained weight loss, age >50 with first fracture); obtain complete spine imaging with contrast if malignancy suspected 1, 2
• Delaying osteoporosis evaluation and treatment is a critical error, as compression fractures are often the first presentation of severe osteoporosis requiring immediate pharmacologic intervention 2
• Premature surgical or interventional referral before completing a 3-month trial of conservative management in neurologically intact patients, as most achieve significant pain relief with conservative care 1, 2
• Overlooking progressive deformity or pulmonary dysfunction during follow-up, which are indications for earlier intervention beyond standard conservative management 1, 3, 2

Expected Outcomes

Most neurologically intact patients with osteoporotic compression fractures achieve significant pain relief with conservative management by 3 months, making this the appropriate trial period before considering vertebral augmentation. 1, 2 Studies show no difference in long-term disability scores between patients treated surgically versus conservatively when neurological status is intact. 4