Lumbar Compression Fracture Follow-up

Updated: Oct 12, 2018
  • Author: Andrew L Sherman, MD, MS; Chief Editor: Stephen Kishner, MD, MHA  more...
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Follow-up

Further Outpatient Care

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  • Physical therapy

    • Weight-bearing exercise is extremely important to prevent progression of osteoporosis and prevent future lumbar fractures.

    • If spinal stenosis is not a concern, extension exercises may help speed healing of the fracture and reduce morbidity.

    • Outpatient therapy also should focus on fall prevention and functional activities.

  • Medical survey

    • Throughout the year following the initial lumbar injury, the rehabilitation physician needs to monitor the patient for progression of the fracture, which can lead to worsening kyphosis. Therefore, obtain serial radiographs for 1 year after the initial injury.

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Further Inpatient Care

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  • Comprehensive inpatient rehabilitation is required when a traumatic lumbar fracture results in severe neurologic injury to the spinal cord, conus, or cauda equina region. Elderly patients may require inpatient rehabilitation when their fractures render them unable to function independently in their home environment. Typically, however, only patients with either a neurologic injury associated with the fracture or a comorbid condition will qualify for inpatient rehabilitation. Patients who do not qualify may be forced to enter a skilled nursing facility for a period of time.

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Inpatient & Outpatient Medications

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  • Pain relief

    • Pain relief is required to make the patient comfortable and enable him or her to begin rehabilitation.

    • In the acute stage, narcotic pain medications may be required; however, these medications must be titrated to avoid adverse effects. Elderly patients can frequently become confused when taking these medications and can have falls and further injuries. Constipation is also a significant concern in the elderly.

    • Calcitonin (Miacalcin), taken intranasally to prevent osteoporosis, has been found anecdotally by clinicians to reduce the severity of pain from compression fractures.

    • The use of nonsteroidal anti-inflammatory drugs (NSAIDs) had been discouraged in this setting because they may reduce radiographic healing; however, in the case of a stable wedge fracture, this reduction in healing may not be a factor, permitting use of NSAIDs for pain relief. The pain should be characterized and classified as bony or axial pain versus radicular or neuropathic pain, because the latter type of pain is treated differently.

  • Osteoporosis

    • Treatment options for osteoporosis have increased over the last few years. Estrogen replacement is still believed to be the most effective way to prevent and even reverse osteoporosis in postmenopausal women.

    • Calcium supplementation is recommended. Intranasal calcitonin can arrest the osteoporosis and can decrease pain from the vertebral fracture.

    • Alendronate (Fosamax) and raloxifene hydrochloride (Evista) are widely used for treatment of osteoporosis.

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Transfer

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  • If the need for inpatient rehabilitation has been established, transfer to an inpatient unit occurs once the patient has achieved spinal and medical stability. Surgery can be performed in certain difficult cases to speed up the patient's transfer to the rehabilitation service.

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Deterrence

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  • The key to preventing nontraumatic lumbar compression fractures is to prevent or minimize osteoporosis and to minimize potential falls. Good evidence indicates that a weight-bearing exercise program accomplishes both objectives.

  • Calcium supplementation with vitamin D is essential to prevent osteoporosis in women considered to be at high risk due to hysterectomy or genetic family history. However, the most effective calcium supplementation occurs in a woman's third and fourth decades of life, serving as a type of "bank" from which withdrawals will occur later in life.

  • A meta-analysis was performed to evaluate the efficacy of oral supplemental vitamin D in preventing nonvertebral and hip fractures among older individuals (65 y or older). The meta-analysis included 12 double-blind, randomized, controlled trials (RCTs) for nonvertebral fractures (n = 42,279) and 8 RCTs for hip fractures (n = 40,886) and compared oral vitamin D (with or without calcium) with either calcium alone or placebo. The results showed that nonvertebral fracture prevention with vitamin D is dose dependent, and a higher dose reduced fractures by at least 20% for individuals aged 65 years or older. [32]

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Complications

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  • Complications can occur, both early in the course of compression fractures and later during the follow-up phase. One study reported on 22 patients who developed late neurologic leg symptoms within a year after their injury, when no neurologic symptoms were present initially. Progressive kyphosis can also occur and occasionally restricts function, necessitating surgical correction.

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Prognosis

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  • In general, prognosis after simple compression fractures is excellent for most patients to improve with little or no residual back pain and no functional impairments. Vertebroplasty and kyphoplasty have improved the outlook in many patients who develop chronic back pain that does not improve with initial conservative treatments. These procedures have become so successful they are used earlier in the course of treatment.

  • Patients with traumatic spine injuries have a prognosis based more on neurologic level and whether their spinal cord or root injuries are complete or incomplete.

  • Patients with spinal infections have a guarded prognosis. A retrospective study of long-term functional outcome in pyogenic spinal infection found that two thirds of patients had an adverse outcome at a median followup of 61 months. [33] Similarly, another retrospective study found that two thirds of patients with spinal tuberculosis had persistent, painful disability. [34]

  • Since not all patients heal adequately with cement procedures, it would be helpful if one could predict who would or would not benefit. One study from Japan found radiographically, an intravertebral cleft larger than half the height of the fractured vertebral body (FVB) was a significant key factor in the complete pain relief group after 3 months. Further, 40% or more of the spinal canal occupied by bony fragments of the FVB was related to incomplete pain relief. [35]

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Patient Education

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