Management of L2 Compression Fractures

Initial Assessment and Management

The American College of Radiology recommends medical management as the first-line approach for patients with new symptomatic compression fractures without neurological deficits 1
MRI of the spine without IV contrast (or CT spine without contrast if MRI is contraindicated) should be obtained to assess the fracture characteristics and rule out pathologic causes 1
Pain management should include calcitonin for the first 4 weeks, which has shown clinically important pain reduction in acute compression fractures 3, 4

Patients with osteoporotic compression fractures without neurological deficits, spinal deformity, or "red flags" can be managed conservatively 1
Patients in the first 3 months post-fracture with improving symptoms can be managed conservatively 1, 2

Patients with neurological deficits require immediate referral to orthopedic surgery or neurosurgery 1, 2
Patients with evidence of spinal instability should be referred to orthopedic surgery or neurosurgery 1
Patients with severe and worsening pain despite 3 months of conservative management should be referred to orthopedic surgery or neurosurgery 1, 2
Patients with significant spinal deformity or progressive kyphosis should be referred to orthopedic surgery or neurosurgery 1

Consider referral to interventional radiology for patients with persistent pain after 3 months of conservative management 1
Referral to interventional radiology is appropriate for patients with spinal deformity, worsening symptoms, or pulmonary dysfunction who are candidates for percutaneous vertebral augmentation 1, 2

Consider referral to pain management for patients with persistent pain despite initial analgesic therapy 4
Referral to pain management may be appropriate for consideration of L2 nerve root blocks if pain persists 3

Always rule out pathologic fractures - if there is suspicion of malignancy, a complete spine MRI without and with contrast is indicated, along with potential biopsy 1

Patients should be reassessed at 4-6 weeks to evaluate response to initial treatment 4
If symptoms persist beyond 8 weeks, consider additional imaging to rule out fracture progression or new fractures 1