Management of Acute Lumbar Compression Fractures

Initial Assessment and Stability Determination

The American College of Radiology emphasizes that MRI with fluid-sensitive sequences is imperative for identifying acute fractures and differentiating benign from pathologic causes, particularly in patients with atypical features 4, 2
Perform a thorough neurological examination to document baseline function and identify any deficits that would mandate immediate surgical consultation 1, 2
Assess for stability indicators: absence of neurological deficits, less than 10% vertebral body height loss, no retropulsion of bone fragments into the spinal canal, less than 15% kyphosis, and less than 10% scoliosis 1, 2
Obtain MRI of the lumbar spine without contrast to assess fracture characteristics, identify bone marrow edema indicating acute fracture, rule out pathologic causes, and evaluate for spinal canal compromise 2, 3

Pain control with analgesics including NSAIDs and judicious use of narcotics, avoiding prolonged narcotic use that can cause sedation, falls, and deconditioning 2, 3
Consider calcitonin for the first 4 weeks, which has demonstrated clinically important pain reduction in acute compression fractures 3
Limited bed rest only, as prolonged immobilization leads to bone density loss, muscle weakness, deconditioning, increased deep venous thrombosis risk, and increased mortality 2
Reassess at 4-6 weeks to evaluate treatment response and determine if escalation is needed 3

Consider vertebral augmentation (vertebroplasty or kyphoplasty) if persistent severe pain after 3 weeks of conservative management despite appropriate analgesics 2
The ACR guidelines note that vertebral augmentation has shown superior pain relief and improved functional outcomes compared to prolonged conservative therapy, with studies demonstrating benefit even in fractures older than 12 weeks 5
The American Academy of Orthopaedic Surgeons makes a strong recommendation against vertebroplasty specifically, while kyphoplasty may be considered for symptomatic fractures in neurologically intact patients who fail conservative management 3

Do not delay surgical referral for any neurological deficits (motor weakness, sensory changes, bowel/bladder dysfunction) indicating potential spinal cord or nerve root compromise 1, 2, 3
Spinal instability evidenced by retropulsion of bone fragments into the spinal canal requires immediate surgical consultation 1, 2
Significant spinal deformity with more than 15% kyphosis at presentation requires immediate surgical consultation 1
Known malignancy or suspected pathologic fracture requiring multidisciplinary management including interventional radiology, surgery, and radiation oncology 4, 3

MRI with and without contrast is imperative to assess epidural extension, paraspinal involvement, and degree of spinal cord compression in patients with known malignancy presenting with new lumbar compression fractures 4
Use the Spinal Instability Neoplastic Score (SINS) to classify stability: stable (0-6), potentially unstable (7-12), or unstable (13-18) 4
Biopsy can be performed during vertebral augmentation to verify etiology and detect unsuspected malignancy 5
Coordinate with radiation oncology for metastatic disease causing pain or neurologic compromise 4

Missing unstable fractures by failing to perform adequate neurological examination at initial presentation 1, 2
Prolonged bed rest leading to deconditioning, bone loss, cardiovascular/respiratory muscle weakness, and increased mortality 2
Overuse of narcotics causing sedation, increased fall risk, and decreased physical conditioning 2
Failing to rule out pathologic fractures in patients with known malignancy, atypical pain patterns, or fractures from minimal trauma 3