Management of Traumatic Vertebral Fracture

Immediate Transfer Required (Do Not Delay)

The American College of Radiology recommends immediate transfer to orthopedic surgery or neurosurgery for patients with neurological deficits, spinal instability, or high-energy trauma 2, 1
Patients with multiple level fractures or fractures from high-energy trauma require immediate transfer to orthopedic surgery or neurosurgery 1
The American College of Radiology also recommends immediate transfer for patients with known or suspected malignancy with pathologic fracture 2, 1

The American College of Radiology recommends obtaining MRI of the spine without contrast as the most appropriate initial imaging study for neurologically intact patients 1, 3
MRI provides essential information, including distinguishing acute from chronic fractures, ruling out pathologic causes, and identifying additional fractures 1, 3

The American College of Radiology recommends conservative management as the standard first-line approach for neurologically intact patients with stable fractures 4, 1, 5
Calcitonin provides clinically important pain reduction beyond standard analgesics for the first 4 weeks 1, 5
Acetaminophen and NSAIDs are recommended as first-line analgesics 1, 5
Opioids should be used judiciously with caution given risks of sedation, nausea, deconditioning, and falls in elderly patients 1, 5

All patients with vertebral fractures require systematic evaluation for osteoporosis, according to the Annals of the Rheumatic Diseases 8, 9, 1
DXA scan of spine and hip is recommended to measure bone mineral density 8, 9
Laboratory evaluation, including erythrocyte sedimentation rate, serum calcium, albumin, creatinine, thyroid-stimulating hormone, and vitamin D, is also recommended 8, 9

The Annals of the Rheumatic Diseases recommend initiating osteoporosis pharmacotherapy immediately, as patients have a 20% risk of another vertebral fracture within 12 months 8, 5
Alendronate or risedronate are recommended as first-choice agents 7
Zoledronic acid or denosumab may be used for patients with oral intolerance, dementia, malabsorption, or non-compliance 7

The Journal of Neurointerventional Surgery recommends referring patients to interventional radiology or orthopedic surgery after 3 months of failed conservative management for severe and worsening pain, significant spinal deformity, or pulmonary dysfunction 4, 1, 5
Vertebroplasty and kyphoplasty are reasonable therapeutic options showing superior pain reduction compared to conservative management in selected patients, with major complications occurring in <1% of patients with osteoporotic fractures 4, 2, 1

Palliative radiotherapy reduces back pain in approximately 60% of patients with pathologic fractures, with pain relief beginning 7-10 days after treatment and reaching maximum between 4-8 weeks 6
Vertebral augmentation provides rapid pain relief, reduced disability, and improved performance status for cancer patients without significant mechanical instability or cord compression 6
The Spinal Instability Neoplastic Score (SINS) should be used to evaluate spinal stability in patients with pathologic fractures 2

The Annals of the Rheumatic Diseases recommend implementing systematic secondary fracture prevention through a Fracture Liaison Service (FLS) with a dedicated coordinator 8, 9
FLS significantly improves osteoporosis treatment implementation, with 45% of patients receiving appropriate management within 6 months versus only 26% in control groups 8, 9