Treatment Options for Lumbar Compression Fractures

Q: Treatment Options for Lumbar Compression Fractures

Hello： A. <br>When performing an MRI, in addition to assessing the degree of vertebral collapse, it is also important to evaluate whether there is nerve compression. <br>B. <br>Generally, if the vertebral height is collapsed by 1/2 and there are symptoms of buttock and leg pain d

Compression fracture of the second lumbar vertebra due to a fall?

Hello, my mother, born in 1944, had an accident on June 4th when she accidentally stepped into a gap and fell to the ground, resulting in a crush fracture of her second lumbar vertebra due to gravitational impact, leaving only half of the vertebra intact.
She was urgently taken to the nearest National Taiwan University Hospital, where X-rays and a CT scan were performed.
On June 5th, we were instructed to order a back brace, and on June 6th, she began wearing the brace for rehabilitation.
Due to severe pain, she has been taking painkillers four times a day, which has caused her stomach discomfort.
After informing the doctor, he suggested switching to over-the-counter pain medication that is less harsh on the stomach.
The attending physician, Dr.
Yang Shih-Hung from the neurosurgery department, has only visited twice and then went on vacation.
The doctor who came for consultation advised that she should not stop taking pain medication, as discontinuing it would result in significant pain in the injured spine, hindering rehabilitation.
Therefore, my mother has to endure the pain daily while taking painkillers, especially when transitioning from sitting to standing, which requires her to rest due to severe thigh pain before she can slowly walk step by step.

On June 10th, my mother informed me that she realized the pain primarily originates from her buttocks rather than her thighs.
The doctors have not provided information about available treatment options or the subsequent steps we should take.
Finally, on the morning of June 12th, the attending physician appeared and only asked if my mother was in pain.
After confirming she was, he ordered an X-ray.
I was almost fainting; she has a crush fracture, and there has been no treatment.
A week later, he only asked if she was in pain again before hurriedly leaving.
The therapist later explained that rehabilitation is necessary to determine if there is nerve compression and to stimulate the lumbar vertebra for bone regeneration.
This treatment must continue until the buttock pain subsides before she can be discharged, and she will still need to wear the brace for about six months.

To be honest, the treatment approach at National Taiwan University differs significantly from my understanding.
Later, my aunt informed me that a friend recommended Dr.
Ma Yi-Hsin at Tri-Service General Hospital for minimally invasive surgery (vertebroplasty).
Therefore, I began searching for information regarding this type of surgery.
This afternoon, I requested my mother's X-ray disc from National Taiwan University and took it to see Dr.
Jiang Yong-Hsiao at Taipei Medical University.
After reviewing it, he explained three options: first, bed rest until the lumbar vertebra heals (since half of it is missing, it cannot provide support, and prolonged rehabilitation may damage the lower vertebrae); second, using screws, but this requires anchoring to the adjacent healthy bone, which he does not recommend; finally, he mentioned that it would have been possible to perform vertebroplasty immediately after the injury.

I would like to ask:
1.
Is the treatment process at National Taiwan University Hospital correct?
2.
Can a back brace alone support the lumbar spine with half of the vertebra missing?
3.
Is taking so many painkillers daily for rehabilitation not placing a greater burden on the body?
4.
Given my mother's condition, as Dr.
Jiang mentioned, could she have undergone minimally invasive surgery immediately after the injury and been able to get out of bed the next day until discharge?
I sincerely hope to know which option would be better for my mother, as I do not want her to endure these pains at her age.
Thank you very much.

Qiao Niu, 40~49 year old female. Ask Date: 2017/06/13

Dr. Lai Zhaokang reply Neurosurgery

Hello: A.
When performing an MRI, in addition to assessing the degree of vertebral collapse, it is also important to evaluate whether there is nerve compression.
B.
Generally, if the vertebral height is collapsed by 1/2 and there are symptoms of buttock and leg pain due to nerve compression, consideration should be given to nerve decompression followed by internal fixation with screws and bone cement (there are also minimally invasive options).
C.
If you would like to first try using a jack to elevate the spine and then supplement with bone cement, this is also a good minimally invasive method and can even be done as an outpatient procedure.
However, if you are not satisfied postoperatively, you will have to proceed with nerve decompression and internal fixation surgery.
D.
Wearing a brace is the most basic treatment, regardless of whether you have other treatments.
Wishing you well, Dr.
Lai Chao-Kang, Chief of the Spine Neurosurgery Department, Changhua Hospital.

Reply Date: 2017/06/13

More Info

Hello,
Thank you for sharing your mother's situation regarding her lumbar compression fracture. It sounds like a challenging time for both of you, and I appreciate your desire to understand the best treatment options available. Let’s address your questions one by one.

1. Is the treatment process at National Taiwan University Hospital correct?
The treatment process for lumbar compression fractures can vary based on the severity of the fracture, the patient's overall health, and the presence of any neurological deficits. In cases of stable compression fractures without neurological involvement, conservative management, including pain control and physical therapy, is often the first line of treatment. However, if the fracture is unstable or if there are significant symptoms, more aggressive interventions may be warranted. It is essential for the treating physician to monitor the patient's progress and adjust the treatment plan accordingly. If you feel that your mother's needs are not being adequately addressed, seeking a second opinion, as you have done, is a reasonable approach.

2. Can a back brace support the lumbar spine if half of the vertebra is missing?
A back brace can provide some support and stability to the lumbar spine, but it may not be sufficient if a significant portion of the vertebra is missing. The spine relies on the integrity of its vertebrae for stability, and a compromised structure can lead to further complications, including pain and potential deformity. In cases where there is a substantial loss of vertebral height or structure, surgical intervention may be necessary to restore stability and prevent further injury.

3. Is taking a lot of pain medication for rehabilitation a burden on the body?
Chronic use of pain medications, especially non-steroidal anti-inflammatory drugs (NSAIDs), can indeed have side effects, including gastrointestinal issues, kidney problems, and potential cardiovascular risks. It is crucial to balance pain management with the need for rehabilitation. If your mother is experiencing significant side effects from her pain medication, discussing alternative pain management strategies with her healthcare provider is essential. These may include physical therapy modalities, such as heat or electrical stimulation, which can help manage pain without relying solely on medications.

4. Could minimally invasive surgery have been an option right after the injury?
Minimally invasive procedures, such as vertebroplasty or kyphoplasty (commonly referred to as "bone cement" procedures), can be effective for certain types of compression fractures, particularly in cases where there is significant pain and instability. These procedures involve injecting a special cement into the fractured vertebra to stabilize it and alleviate pain. If your mother’s fracture was assessed as suitable for such a procedure at the time of injury, it could have potentially allowed her to mobilize sooner and reduce her reliance on pain medications. However, the decision for surgery often depends on the specific characteristics of the fracture and the patient's overall health.

In conclusion, it is vital to have open communication with your mother's healthcare team. If you feel that her current treatment plan is not meeting her needs, advocating for a second opinion or exploring other treatment options, such as minimally invasive surgery, may be beneficial. Additionally, ensuring that her pain is managed effectively while allowing for rehabilitation is crucial for her recovery.
I hope this information helps you navigate your mother's treatment options and leads to a better quality of life for her. Please feel free to reach out with any further questions or concerns.

Best wishes for your mother's recovery.

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