What is the recommended management for an adult with lumbar L1‑L2 compression fractures, including analgesia, bracing, and osteoporosis therapy?

Treatment of L1 and L2 Compression Fractures

Begin with conservative medical management for at least 3 months unless neurological deficits, spinal instability, or severe progressive deformity are present. 1, 2

Immediate Assessment and Imaging

• Obtain MRI of the spine without IV contrast (or CT if MRI contraindicated) to characterize the fracture and exclude pathologic causes such as malignancy 1
• Rule out neurological deficits through careful examination—any deficits require immediate surgical referral 1, 2
• Assess for "red flags" including spinal instability, significant deformity, or progressive kyphosis 1

Initial Pain Management (First 4 Weeks)

Start calcitonin immediately for the first 4 weeks after fracture identification, as it provides clinically important pain reduction beyond standard analgesics. 1, 2, 3

• Use NSAIDs or opioids as needed for breakthrough pain, though exercise caution with opioids due to sedation, nausea, deconditioning, and increased fall risk in elderly patients 2
• The American Academy of Orthopaedic Surgeons found insufficient evidence to make firm recommendations for or against opioid/analgesic use, but they remain a clinical option 4

Conservative Management Strategy

Avoid prolonged bed rest or immobilization—this causes approximately 2% bone loss per week and 10-15% muscle strength loss per week, creating a dangerous cycle of deconditioning. 4, 2

• Most osteoporotic compression fractures resolve spontaneously within 6-8 weeks, with gradual pain improvement over 2-12 weeks 2, 3
• Implement early mobilization with physical therapy focusing on core strengthening, back muscle conditioning, and posture improvement 2
• Regarding bracing: evidence shows no difference in outcomes between using an external brace versus no brace for neurologically intact patients—the decision is at physician discretion 4

Essential Bone Health Interventions

Prescribe at least 1000 mg elemental calcium daily and at least 800 IU vitamin D daily immediately. 2

Initiate osteoporosis pharmacotherapy immediately—patients with compression fractures have a 20% risk of another vertebral fracture within 12 months. 2

• Ibandronate and strontium ranelate are specific options to prevent additional symptomatic fractures in patients with existing osteoporotic compression fractures 4
• Do not delay this treatment; the high recurrence risk makes this urgent 2

Follow-Up Timeline and Escalation Criteria

Reassess at 4-6 weeks to evaluate treatment response. 1, 2

• If symptoms persist beyond 8 weeks, obtain additional imaging to rule out fracture progression or new fractures 1, 2
• Natural history shows most fractures improve by 6-8 weeks; persistence beyond this warrants further evaluation 2

When to Refer for Intervention (After 3 Months of Conservative Management)

Consider vertebral augmentation (vertebroplasty or kyphoplasty) if conservative management fails after 3 months with persistent severe pain. 1, 2, 3

Additional indications for earlier intervention include:

• Spinal deformity or progressive kyphosis 1, 2, 3
• Worsening symptoms despite medications 1, 2, 3
• Pulmonary dysfunction from vertebral collapse 2, 3
• Contraindication to pain medications or requirement for parenteral narcotics 2

Vertebral augmentation provides immediate and considerable improvement in pain and mobility, with studies showing benefits in pain intensity, vertebral height, sagittal alignment, functional capacity, and quality of life. 3, 5

• Balloon kyphoplasty may provide better improvement in spinal deformity with restoration of vertebral body height compared to vertebroplasty 3
• The age of the fracture does not independently affect vertebroplasty outcomes—subacute and chronic fractures respond well 3

Immediate Surgical Referral Required For:

Refer immediately to orthopedic surgery or neurosurgery if any of the following are present:

• Neurological deficits 1, 2
• Evidence of spinal instability 1, 2
• Significant spinal deformity or progressive kyphosis 1, 2
• Spinal cord compression 3

Additional Referral Options

• Consider L2 nerve root block for fractures at L3 or L4 with acute injury and persistent pain 4
• Pain management referral is appropriate for persistent pain despite initial analgesic therapy 1
• Interventional radiology referral for vertebral augmentation consideration after 3 months of failed conservative management 1

Critical Pitfalls to Avoid

Do not assume all pain is from the known fracture—obtain new MRI if symptoms change or if imaging is more than 3 months old to identify new fractures. 2

• Always rule out pathologic fractures in patients with risk factors for malignancy; if suspected, obtain complete spine MRI with and without contrast and consider biopsy 1, 2
• Do not delay osteoporosis pharmacotherapy given the 20% risk of recurrent fracture within one year 2
• Do not prescribe prolonged bed rest—the complications of immobility (bone loss, muscle weakness, functional decline, thromboembolism) often exceed the risks of early mobilization 4, 2

Exercise Programs

• Evidence for supervised or unsupervised exercise programs is inconclusive, though one study showed improvement in symptom and emotion domains at 6 months 4
• Despite limited high-quality evidence, clinical practice supports early mobilization and progressive strengthening as part of conservative management 2