Lumbar Compression Fracture Treatment & Management

Physical Therapy

The indications for surgical management of lumbar compression fractures are discussed in Surgical Intervention. Nonoperative treatment consists of pain relief, bracing, and rehabilitation.

Traumatic injuries with neurologic compromise usually require comprehensive inpatient rehabilitation. Mobility and strength rehabilitation programs are individualized to each patient's capabilities. All therapy disciplines comprising the multidisciplinary team participate in the comprehensive program. In most cases, rehabilitation begins with the patient in a thoracic-lumbar-sacral orthosis (TLSO). More information on comprehensive spinal cord rehabilitation is available in Spinal Cord Injury and Aging.

Elderly patients with osteoporotic compression fractures are often treated with TLSO bracing and rehabilitation. To facilitate progress in the rehabilitation program, some patients can be treated in a less restrictive corset or abdominal binder if their pain is well controlled. Early mobilization is important to prevent secondary complications of immobility. The therapy occasionally begins in an inpatient setting and then moves to an outpatient setting. Weight-bearing exercises are usually part of the program and are believed to be the main type of therapy required to prevent progression of the osteoporosis in the future. Extension exercises are also considered beneficial. Radiographic monitoring of the fracture over the ensuing months is important, because some fractures can worsen to the point at which they require surgical stabilization.

Occupational Therapy

Used primarily when a patient requires inpatient rehabilitation, occupational therapy is essential to restore the patient's maximal level of function.

Recreational Therapy

Recreational therapy is an essential component of the inpatient rehabilitation program. For many patients, recreational therapists bridge the gap between the hospital and the community.

Early mobilization is extremely important to decrease the frequency of secondary medical complications. Complications can occur in young adults and in elderly patients.

• Osteoporotic lumbar fractures

  • Many of these patients have comorbid medical illnesses such as heart disease, lung disease, or diabetes. Often, a period of bed rest can worsen these and other conditions.
  • Other common complications that can occur during bed rest include pneumonia, deep vein thrombosis, pulmonary embolism, skin breakdown, and gastric ulceration.
  • Prolonged bed rest in an elderly individual can worsen underlying osteoporosis and increase the risk of additional fractures.
• Pathologic fractures

  • All patients with compression fractures require a thorough examination to make certain the fracture is not a secondary manifestation of a systemic illness.
  • If a systemic disease is identified (eg, malignancy, infection, renal disease), proper medical treatment is needed.
• Traumatic injuries

  • As in nontraumatic injuries, early mobilization is important in patients with traumatic injuries, to prevent secondary complications.
  • These patients can also have neurologic injury affecting the bowel and bladder, in addition to the complications listed above. Therefore, programs for catheterization and bowel evacuation are required.

Surgical intervention is required when neurologic dysfunction and/or instability occurs as a result of the lumbar fracture.

• Neurologic impairment

  • Neurologic problems may manifest in many ways. Reduced leg strength (paresis) or complete weakness (paralysis) is an obvious problem. Loss of sensation in the lower extremities and in the perianal area (saddle anesthesia) can be just as important. Urinary retention and urinary and fecal incontinence are very important signs that indicate the need for emergency surgery.
  • The extent of neurologic problems also depends on whether there is compression of the lower portion of the spinal cord (conus medullaris) or lumbar nerve roots (cauda equina).
  • Clinical instability is manifested primarily by severe pain that does not improve or that worsens with time. Patients with clinical instability may require surgery. This information is corroborated radiographically by visualizing kyphotic deformity on plain radiographs and disruption of the interspinous ligaments on MRIs.
  • Radiographic instability refers to cases in which the ligamentous disruption is severe, canal compromise occurs to a degree that neurologic symptoms are present, and movement of the fracture fragments is seen on dynamic or motion radiographs. These fractures almost always need surgical fixation, although on rare occasions a rigid brace will suffice. Some patients who initially are braced may show gradual worsening of symptoms on radiographs, with findings of progressive kyphosis with loss of vertebral body height. These patients also require surgical intervention.
• Types of surgery

  • The surgical procedure used for correction of a lumbar fracture depends on certain factors. These critical factors include the degree of bony canal compromise seen on axial images, the angulation on sagittal views, the level of fracture, neurologic examination findings, and the patient's premorbid health status.
  • The choice of an anterior or a posterior approach for decompression is dictated by the location and severity of bony canal compromise. The fractured segment also must be stabilized, a procedure that is often performed with instrumentation using various plating and rod techniques. Anterior procedures involving the upper lumbar vertebrae (ie, L1, L2) may require the diaphragm to be mobilized because the crura attach at these levels. Fractures in the lower lumbar levels (eg, L5) are difficult to decompress anteriorly and are often stabilized surgically using a posterior method. Minimally invasive techniques are becoming more pervasive and popular and soon should impact the ability to perform surgery in these complex cases.^{[8, 9, 10]}
• Postoperative bracing

  • Once a patient has undergone surgery, a brace is prescribed in the postoperative period, depending on the etiology of the fracture.
  • The time period is variable for individual patients, depending on their health status.

In patients thought to have a pathologic cause for lumbar fractures, appropriate consultations with medical specialists are required to assist with either the diagnostic workup or medical management of these conditions.

• Orthopedic and neurosurgical specialists are consulted in traumatic injuries to assist with surgical management and to help decide if the fracture can be managed nonoperatively via kyphoplasty.^[11] Consultation with a surgeon also may be required in nontraumatic lumbar fractures if radiographic progression occurs or if the pain does not improve.
• A rheumatologist is often helpful in the treatment of generalized osteoporosis.
• A physiatrist should almost always be consulted in these cases to assist with rehabilitation, brace management, pain management, and functional restoration of the fracture patient.
• A specialist who performs vertebroplasty (eg, physiatrist, radiologist, surgeon, pain management specialist) should be consulted if kyphoplasty cannot be performed and the pain is not improving with bracing over the first 2-6 weeks.

Two related procedures, vertebroplasty and kyphoplasty, are available for the patient with a lumbar wedge fracture who continues to experience pain despite aggressive conservative treatment.

• Vertebroplasty has been available for many years. This procedure involves injecting a form of cement polymer into the fractured vertebral body. The vertebral body then has better resistance to physiologic loads when the patient is upright, thus decreasing the amount of pain associated with the fracture. The procedure may be performed with the patient under local or general anesthesia. A percutaneous trocar or large needle is introduced into the fractured body through the pedicle, and the cement is injected. Fluoroscopy is used to guide the surgeon for correct localization.

  • A Mayo Clinic review of the first 1000 compression fractures treated by vertebroplasty at that institution found a high rate of success and a low rate of complications, the most common being rib fractures. Most patients reported significant pain relief at the 2-hour postprocedure evaluation.^[12] A prospective study from the Netherlands with 36-month followup found an immediate, significant, and lasting reduction in the average and worst back pain with vertebroplasty.^[13]
  • The main risk of vertebroplasty, other than spread of the cement to neural structures, is subsequent vertebral body fracture, often of an adjacent vertebra.^[14] This occurs with increased frequency in patients who have recently undergone vertebroplasty. Trout and colleagues found the risk for subsequent fracture to be 4 1/2 times greater in patients who underwent the procedure versus those who did not.^[15]
• Kyphoplasty (seen in the image below) is similar to vertebroplasty, except a balloon is used to expand the volume of the fractured segment prior to introducing the cement polymer.^{[11, 16]}

  • Kyphoplasty may be the treatment of choice in patients with secondary posture kyphosis, because the procedure appears to be able to partly restore vertebral height and thereby reduce kyphotic deformity.^[17] Extrusion of cement into the spinal canal is less likely with kyphoplasty than with vertebroplasty, because the cement is delivered into a closed balloon.
  • Unfortunately, kyphoplasty cannot be performed for every fracture. Canal compromise usually contraindicates kyphoplasty (and sometimes vertebroplasty). An extremely severe fracture may not allow the balloon to enter. Fluoroscopic view of a kyphoplasty procedure.
• The main risk for vertebroplasty and kyphoplasty is migration of bone or cement fragments into the spinal canal. Leakage of cement into the venous circulation, with subsequent pulmonary embolism, has also been reported.^{[12, 17]} Adjacent-level fractures are often reported with kyphoplasty, but research is ongoing to try to reduce the frequency of this complication.
• Despite the risks, vertebroplasty and kyphoplasty have proved so successful that they are now being advocated earlier in the course of treatment. At first, they were used after brace failure, 10-12 weeks after the fracture occurred; however, many authorities now advocate the use of these procedures 2-6 weeks after the fracture in selected patients.
• Malignant fractures are more often treated surgically with cement, but vertebroplasty and kyphoplasty are also used to provide palliation of pain and symptom relief.^[3] Fluoroscopy is used in a manner similar to that used in vertebroplasty.