Vertebral Compression Fractures
(See also Overview of Fractures.)
Vertebral compression fractures due to osteoporosis are common in the thoracic spine (usually below T6) and lumbar spine, particularly near the T12-L1 junction. There may be no preceding trauma or only minimal trauma (eg, a minor fall, sudden bending, lifting, coughing). Patients who have had an osteoporotic vertebral fracture are at higher risk of other vertebral and nonvertebral fractures.
Occasionally, compression or other vertebral fractures result from significant force (eg, a motor vehicle crash, a fall from a height, a gunshot wound). In such cases, a spinal cord injury is often also present, and the spine may be fractured in > 1 place. If the cause was a fall or jump from a height, one or both heels may also be fractured; 10% of all patients with a calcaneal fracture also have a thoracolumbar fracture (because of the axial load to the skeleton when landing on the heels).
Osteoporotic vertebral fractures are asymptomatic or cause only loss of height or kyphosis in about two thirds of patients. In other patients, pain may develop immediately or later. The pain may radiate into the abdomen. Radicular pain, weakness, and reflex or sphincter abnormalities are uncommon. The pain typically decreases after about 4 weeks and resolves after about 12 weeks.
Nonosteoporotic vertebral compression fractures cause acute pain, bone tenderness at the fracture site, and usually muscle spasm.
Osteoporotic fractures are usually diagnosed by x-ray. Findings are usually
Vertebral osteoporotic fractures are commonly diagnosed as incidental findings. If patients do not have risk factors for osteoporosis (eg, older age), these fractures are unlikely.
Solitary fractures above T4 suggest cancer rather than osteoporosis. If patients are not known to have osteoporosis, dual-energy x-ray absorptiometry (DXA) should be done. If osteoporosis is newly diagnosed, patients should be evaluated for causes of secondary osteoporosis.
If significant trauma has occurred, CT is done to evaluate the entire spinal column, and if neurologic deficits or symptoms are present, MRI of the appropriate section of the spinal cord is done.
If the cause was a fall or jump from a height, clinicians should check for calcaneus fractures and for additional vertebral fractures. If suicidal ideation is suspected or expressed, a psychiatrist should be consulted.
Treatment of vertebral fractures focuses on pain relief and early mobilization. Analgesics are given. Early resumption of normal activity helps limit further bone loss and disability.
Physical therapists can help by teaching correct lifting techniques and prescribing exercises to strengthen paravertebral muscles, but therapy may need to be delayed until pain is controlled.
Osteoporosis, if present, should be treated (eg, with a bisphosphonate). Calcitonin may also be used and can help relieve pain and increase bone density.
Bracing is commonly prescribed, but its efficacy is unclear.
In some cases, vertebroplasty, sometimes preceded by kyphoplasty, can relieve severe pain. In vertebroplasty, methyl methacrylate is injected into the vertebral body. In kyphoplasty, the vertebral body is expanded with a balloon.
These procedures may reduce deformity in the injected vertebrae but do not reduce and may even increase the risk of fractures in adjacent vertebrae. Other risks may include rib fractures, cement leakage, and pulmonary edema or myocardial infarction (MI).
If fractures result from significant trauma, the spine is immobilized immediately, and CT or MRI is done to evaluate the stability of the fractures. Spinal cord injuries, if present, are treated promptly, and supportive care (eg, analgesics, early mobilization) is provided.
Most vertebral fractures result from osteoporosis.
About two thirds of vertebral osteoporotic fractures are asymptomatic or cause only loss of height or kyphosis.
Suspect cancer if patients have a solitary fracture above T4.
If patients are not known to have osteoporosis, schedule dual-energy x-ray absorptiometry.
Encourage early mobilization.
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