How should isolated thoracic vertebrae T6 and T11 compression fractures be managed in a patient without neurologic deficit?

Management of T6 and T11 Compression Fractures

Begin with conservative medical management for 3 weeks to 3 months, then proceed to vertebral augmentation if pain persists or if significant deformity (>20% height loss), pulmonary dysfunction, or progressive symptoms develop; reserve surgery exclusively for neurologic deficits, spinal instability, or cord compression. 1

Immediate Assessment and Red-Flag Screening

• Perform a focused neurological examination to detect motor weakness, sensory deficits, or bowel/bladder dysfunction—any of these findings mandate urgent surgical referral rather than conservative care 1, 2
• Screen for red-flag symptoms including unexplained weight loss, nocturnal pain unrelieved by rest, constitutional symptoms, or history of malignancy; if present, obtain contrast-enhanced thoracic spine MRI and consider image-guided biopsy to exclude pathologic fracture 1, 3
• Obtain non-contrast thoracic spine MRI to confirm fracture acuity by identifying bone-marrow edema and to exclude spinal cord compression or retropulsed bone fragments 1

Conservative Medical Management (First 3 Weeks to 3 Months)

• Initiate acetaminophen as first-line analgesia; avoid NSAIDs in patients with cardiovascular or renal comorbidities 1
• Consider short-term calcitonin (200 IU nasally) for up to 4 weeks to achieve clinically important pain reduction during the acute phase 1, 3
• Reserve short-term opioids for severe pain only; prolonged opioid use does not prevent the approximately 40% failure rate of conservative therapy at 1 year 1, 3
• Prevent prolonged bed rest beyond the acute pain phase to avoid deconditioning, bone loss, and increased mortality 1
• Most vertebral compression fractures show gradual improvement in pain over 2 to 12 weeks with variable return of function 4

Indications for Vertebral Augmentation

Consider vertebral augmentation (vertebroplasty or kyphoplasty) when any of the following criteria are met:

• Persistent severe pain despite appropriate conservative treatment for 3 weeks to 3 months 1, 3
• Vertebral body height loss greater than 20% (significant kyphotic deformity) 1, 3
• Development of pulmonary dysfunction attributable to kyphotic deformity 1, 3
• Progressive worsening of symptoms despite optimal medical management 1, 3

Vertebral augmentation provides superior pain relief and functional improvement compared with prolonged conservative therapy, with benefits evident even for fractures older than 12 weeks 4, 1. Kyphoplasty achieves greater restoration of vertebral body height, better correction of spinal deformity, and lower cement-leakage rates than vertebroplasty 1, 3. The age of the fracture does not independently affect outcomes of vertebroplasty 4, 3.

Absolute Indications for Immediate Surgical Consultation

Surgery is reserved exclusively for the following scenarios:

• Any neurologic deficit (motor weakness, sensory loss, or bowel/bladder dysfunction) mandates urgent decompression and stabilization 1, 2
• Frank spinal instability (inability to bear weight or rapidly progressive deformity) requires prompt surgical intervention 1, 2
• Imaging evidence of spinal cord compression, especially from osseous retropulsion, necessitates immediate surgical referral 1, 2
• Spinal deformity with junctional kyphosis or retropulsion in the setting of neurologic compromise 4

Critical Pitfalls to Avoid

• Do not postpone vertebral augmentation in patients with progressive deformity >20% height loss or pulmonary compromise; earlier intervention improves outcomes 1, 3
• Do not miss pathologic fractures in individuals with malignancy risk factors; obtain contrast-enhanced spine MRI when red-flag symptoms are present 1, 3
• Initiate osteoporosis treatment promptly after a confirmed vertebral fracture; approximately 20% of patients develop chronic back pain and have high risk of subsequent fractures 1, 3
• Recognize neurologic deficits early; delayed decompression is associated with poorer neurological recovery 1, 2
• Do not perform surgery when vertebral augmentation would suffice, as this leads to unnecessary risks and complications 2
• Re-evaluate pain intensity and functional status between 3 weeks and 3 months to decide whether vertebral augmentation is indicated 1