What is the best initial approach for a 64-year-old woman with an anterior wedge compression fracture of L1 on CT?

Initial Management of L1 Anterior Wedge Compression Fracture in a 64-Year-Old Woman

Begin with conservative medical management for the first 3 weeks to 3 months, including analgesics, early mobilization, and osteoporosis treatment, while reserving vertebral augmentation for persistent severe pain, significant spinal deformity (>20% height loss), or pulmonary dysfunction after this period. 1, 2

Immediate Assessment at Initial Visit

Neurological Examination

• Perform a complete neurological examination immediately to identify any motor weakness, sensory deficits, or bowel/bladder dysfunction that would mandate urgent surgical consultation rather than conservative care. 2, 3
• Check specifically for lower limb motor strength, sensory distribution in legs and perineal region, and rectal tone. 2
• Any neurological deficit requires immediate surgical referral with corticosteroid initiation and surgery performed as soon as possible. 2, 3

Spinal Stability Assessment

• Assess for focal tenderness, step-off deformity on palpation, and ability to bear weight. 2
• Measure vertebral body height loss—greater than 20% height loss indicates significant spinal deformity and may warrant earlier intervention. 1, 2
• Inability to ambulate despite adequate analgesia signals spinal instability requiring surgical stabilization. 2

MRI Without Contrast

• Obtain MRI of the lumbar spine without contrast to identify bone marrow edema (confirming acute fracture), assess for spinal cord compression, and exclude pathologic causes such as malignancy. 2, 3
• MRI is essential to differentiate acute from chronic fractures and to detect retropulsed bone fragments. 2

Screen for Pathologic Fracture

• Take detailed history for red flags: known malignancy, unexplained weight loss, night pain (worse at rest rather than with activity), fever, or constitutional symptoms. 2, 3
• If red flags present or known cancer history, obtain MRI with and without IV contrast to assess epidural tumor extension. 2
• When imaging is ambiguous, image-guided biopsy is necessary to establish diagnosis. 2

Conservative Medical Management (First 3 Weeks to 3 Months)

Pain Control

• Start with acetaminophen or NSAIDs as first-line analgesics for mild to moderate pain. 1, 3, 4
• 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. 3
• Use short-term opioids only if necessary for severe pain, but limit duration to avoid sedation, falls, and deconditioning. 1, 2, 3

Activity Modification

• Avoid prolonged bed rest beyond acute pain control—this leads to rapid deconditioning with muscle weakness, bone loss of approximately 1% per week, and increased fall risk. 2, 3
• Encourage limited activity within pain tolerance to prevent complications of immobility including deep venous thrombosis and cardiovascular/respiratory deconditioning. 1, 3

Osteoporosis Treatment

• Initiate bisphosphonates (alendronate or risedronate) immediately as first-line agents to prevent additional symptomatic fractures. 1, 4, 5
• For patients with oral intolerance, dementia, malabsorption, or non-compliance, use zoledronic acid (intravenous) or denosumab (subcutaneous) as alternatives. 1
• Ensure adequate calcium intake (1000-1200 mg/day) and vitamin D supplementation (800 IU/day). 1

Re-evaluation Timeline

• Re-evaluate pain and functional status between 3 weeks and 3 months after initiating therapy to decide whether escalation to vertebral augmentation is warranted. 2, 3
• The VERTOS II trial demonstrated that 40% of conservatively treated patients had no significant pain relief after 1 year despite higher-class prescription medications, supporting intervention if conservative management fails. 1, 3

Indications for Vertebral Augmentation (Vertebroplasty or Kyphoplasty)

Consider vertebral augmentation if any of the following develop:

• Persistent severe pain after 3 weeks to 3 months of appropriate conservative management with analgesics. 1, 2, 3
• Vertebral body height loss >20% (significant spinal deformity). 1, 2
• Development of pulmonary dysfunction attributable to kyphotic deformity. 1, 2
• Requirement for parenteral narcotics or intolerable oral-analgesic side effects (confusion, sedation, severe constipation). 2

Evidence for Vertebral Augmentation

• Vertebral augmentation provides superior pain relief and functional outcomes compared with prolonged conservative therapy, with immediate and substantial improvement in pain and mobility. 1, 2, 3
• Benefits are evident even for fractures older than 12 weeks, so fracture age does not independently affect outcomes. 1, 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. 2

Absolute Indications for Immediate Surgical Consultation

Any of the following require urgent surgical referral:

• Any neurologic deficit (motor weakness, sensory loss, bowel/bladder dysfunction) indicating spinal cord or nerve-root compromise—requires urgent decompression and stabilization after initiating corticosteroid therapy. 1, 2, 3
• Frank spinal instability with retropulsion of bone fragments into the spinal canal. 1, 2
• Imaging evidence of spinal cord compression, especially from osseous retropulsion. 1, 2
• Progressive deformity (junctional kyphosis) despite conservative management. 1

Critical Pitfalls to Avoid

• Do not prolong bed rest beyond what is absolutely necessary—this dramatically increases risk of deconditioning, bone loss (1% per week), thromboembolism, and mortality. 2, 3
• Do not overuse opioids—they cause sedation, increase fall risk, worsen physical conditioning, and do not prevent the 40% failure rate of conservative management. 1, 2, 3
• Do not delay osteoporosis treatment—approximately 1 in 5 patients develop chronic back pain, and the risk of subsequent fractures is high without treatment. 1, 6
• Do not miss pathologic fractures—night pain that worsens at rest (rather than with activity) is atypical for benign osteoporotic fractures and requires investigation. 2
• Do not perform inadequate neurological examination—complete assessment is essential to avoid missing deficits that mandate urgent surgical intervention. 2, 3

Follow-Up and Long-Term Management

• Systematic follow-up is essential as part of a five-step plan: identifying the fracture, inviting for fracture risk evaluation, differential diagnosis, therapy, and follow-up. 1
• Implement a multidisciplinary approach including physical therapy for balance training and fall prevention to reduce subsequent fracture risk. 1
• Continue bisphosphonates for 3-5 years, and longer in patients who remain at high risk. 1
• Monitor adherence to osteoporosis medications, as long-term adherence is typically poor outside structured fracture liaison services. 1