How should I evaluate and treat a thoracic compression fracture in an elderly patient with osteoporosis and no neurologic deficits?

Evaluation and Treatment of Thoracic Compression Fractures in Elderly Osteoporotic Patients Without Neurologic Deficits

For neurologically intact elderly patients with osteoporotic thoracic compression fractures, begin with plain radiographs for initial screening, followed by MRI thoracic spine without contrast to confirm fracture acuity and rule out pathologic causes, then initiate conservative management with calcitonin for 4 weeks plus analgesics, reserving vertebral augmentation (kyphoplasty only) for patients with persistent severe pain after 3 months of conservative therapy. 1, 2, 3

Initial Imaging Strategy

Start with plain radiographs of the thoracic spine as the initial screening study in patients without neurologic deficits who have osteoporosis risk factors. 1, 3 However, recognize that radiographs have significant limitations—they may miss up to 35% of fractures and cannot reliably determine fracture acuity without prior films for comparison. 1

Proceed immediately to MRI thoracic spine without IV contrast as the definitive imaging study for all patients. 1, 2, 3 MRI is superior because it:

• Identifies bone marrow edema that distinguishes acute fractures (typically resolving within 1-3 months) from chronic ones 1, 2
• Detects additional minimally deforming fractures that radiographs miss 2, 3
• Rules out pathologic fractures from malignancy or infection without requiring contrast in most cases 1, 2
• Guides treatment decisions for potential vertebral augmentation by identifying marrow edema 1, 2

Reserve MRI with and without IV contrast only for patients with red flags suggesting malignancy (unexplained weight loss, history of cancer, age >50 with first fracture), infection, or inflammation. 1, 3

Critical Initial Assessment Points

Perform a thorough neurologic examination including:

• Lower extremity strength, sensation, and reflexes 4, 5
• Rectal tone if any concern for cauda equina 2
• Document any radicular symptoms carefully 4

This is critical because osteoporotic compression fractures can rarely progress to cause neurologic deficits over 1-12 weeks after initial presentation, even when they appear benign initially. 4, 5 Patients may present with isolated back pain, then develop severe radicular pain and profound lower extremity weakness as the fracture progresses with posterior cortex violation and bone retropulsion into the spinal canal. 4

Conservative Management Protocol (First 3 Months)

Conservative management is the standard first-line treatment and should be continued for at least 3 months before considering interventional procedures. 1, 2, 3

Pharmacologic Pain Management

Calcitonin 200 IU (nasal or subcutaneous) for 4 weeks provides clinically important pain reduction in acute compression fractures (0-5 days after onset). 1, 2 Level II evidence demonstrates significant benefit at 1,2,3, and 4 weeks. 1 Side effects are minimal, limited to mild dizziness. 1

Analgesic ladder approach:

• Start with scheduled acetaminophen every 6 hours as first-line 2
• Add NSAIDs for severe pain, but use cautiously in elderly patients due to cardiovascular, renal, and gastrointestinal risks 2
• Reserve opioids for breakthrough pain only, at the lowest effective dose to minimize sedation, fall risk, nausea, and deconditioning 2

Activity Modification and Bracing

• Relative rest with gradual mobilization as tolerated 2
• Bracing may be considered, though evidence is insufficient to make a firm recommendation 1
• Avoid prolonged bed rest, which increases deconditioning and fall risk 1

Osteoporosis Management (Mandatory)

All patients require systematic evaluation and treatment for osteoporosis, as the compression fracture is often the first presentation of severe disease. 2, 6

Immediate steps:

• Order DXA scan to quantify bone density 2
• Assess for secondary causes of osteoporosis (vitamin D deficiency, hyperparathyroidism, hyperthyroidism, multiple myeloma, chronic steroid use) 2, 6, 7
• Initiate calcium and vitamin D supplementation 1

Pharmacologic prevention of future fractures:

• Ibandronate and strontium ranelate are evidence-based options to prevent additional symptomatic fractures 1
• Refer to endocrinology or rheumatology within 4-6 weeks for long-term osteoporosis management 2

Follow-Up Timeline and Reassessment

At 4-6 weeks: Evaluate response to conservative therapy and confirm osteoporosis treatment has been initiated. 2, 3

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

At 3 months: This is the critical decision point for considering vertebral augmentation if conservative management has failed. 2, 8

Indications for Vertebral Augmentation (Kyphoplasty Only)

Kyphoplasty is preferred over vertebroplasty—Level I evidence shows vertebroplasty provides no benefit over sham procedure, while kyphoplasty achieves superior vertebral height restoration, better deformity correction, and lower cement leakage rates. 8

Refer to interventional radiology for kyphoplasty if:

• Severe pain persists despite 3 months of optimal conservative management 2, 8
• Pain is refractory to oral medications, requiring parenteral narcotics or hospitalization 2, 8
• Progressive spinal deformity or increasing kyphosis develops during treatment 2, 8
• Restrictive pulmonary dysfunction develops secondary to progressive kyphosis 2, 8

Evidence supporting earlier intervention: Approximately 40% of patients managed conservatively experience no significant pain relief after 1 year despite prescription medications, and vertebral augmentation provides superior pain relief and functional improvement even for fractures older than 12 weeks. 8

Immediate Transfer Required (Do Not Delay)

Transfer immediately to orthopedic surgery or neurosurgery for:

• Any neurologic deficits (weakness, numbness, bowel/bladder dysfunction, radicular symptoms) 2
• Evidence of spinal instability on imaging (posterior column involvement, vertebral body collapse >50%, alignment abnormalities) 2
• Known or suspected malignancy with pathologic fracture 2, 3
• Multiple level fractures or high-energy trauma mechanism 2

Critical Pitfalls to Avoid

Missing delayed neurologic deterioration: Benign-appearing compression fractures can progress over 1-12 weeks to cause profound neurologic deficits through posterior cortex violation and bone retropulsion. 4, 5 Any new leg pain or lower extremity dysfunction warrants urgent repeat imaging. 4

Failing to rule out pathologic fractures: Always obtain complete spine MRI with contrast if there is unexplained weight loss, history of cancer, failure to improve with therapy, or atypical presentation. 2, 3, 7 Multiple myeloma can present as osteoporotic compression fractures. 7

Delaying osteoporosis evaluation: The compression fracture is often the first presentation of severe osteoporosis requiring immediate treatment to prevent additional fractures. 2, 6 Elderly patients with known osteoporosis, prior compression fractures, or chronic steroid use are at high risk for additional fractures even with minimal trauma. 1

Overlooking thoracolumbar junction fractures: The T12-L1 region is especially at risk and may be missed on limited imaging. 6 Obtain imaging of the entire thoracic and lumbar spine if there is persistent pain beyond the initially identified fracture site. 6