Compression Fractures of the Spine

Disease/Disorder

Definition

Vertebral Compression Fractures (VCF) are defined as a height loss of 4 mm or 20% loss from baseline resulting from a failure of the trabecular meshwork within the vertebrae.^1,2

Etiology

VCFs may result from osteoporosis, malignancy, infection, or trauma. Among these, osteoporosis is the most common cause of VCFs.² Osteoporotic VCFs occur as a result of a natural decrease in bone density related to osteoporosis and aging. By definition, there is no infiltration into bone by any extra-osseous process. On the other hand, pathologic insufficiency VCFs are due to weakening of bone density as a result of a bony destructive factor such as primary or metastatic bone cancer or osteomyelitis.

Traumatic VCFs may result from high-energy trauma such as a motor vehicle accident, fall from height, violent act, or gunshot wound.

Epidemiology including risk factors and primary prevention

Prevalence of osteoporotic VCFs in people between the ages of 50-79 is anywhere between 12%-40%.  Over 750,000 new osteoporotic VCFs occur each year in the United States, over a third of which become chronically painful. Those at increased risk include post-menopausal woman, smokers, thin or frail individuals with low body fat or those with chronic steroid useage.  Primary prevention includes avoiding first and secondhand smoke, participation in regular weight-bearing exercise, lowering alcohol consumption as well as increasing calcium and vitamin D intake. Premenopausal calcium intake may be just as important as that amount taken postmenopausally.^2,4

Traumatic fractures affecting the thoracolumbar spine most commonly occurs after blunt trauma, and the incidence ranges from 2-6 percent of those who sustain such an injury.⁴   The age distribution is bimodal.  Peaks are seen in age groups between 15 to 29 and greater than 65.⁵

Metastases arising from breast, lung, prostate, and thyroid carcinomas are well known to cause pathologic fractures of the spine.  Primary tumors such as multiple myeloma and lymphoma may result in this condition as well.  Up to 30% of patients with skeletal metastases may experience pathologic vertebral fractures.⁶ Breast and prostate cancer patients that receive adjuvant hormone therapy with aromatase inhibitors, and androgen deprivation therapy, respectively, suffer bone loss, increasing their risk of fracture.⁷

Patho-anatomy/physiology

Regardless of the etiology, compression fractures occur when the load on the bone exceeds the vertebral body’s strength to withstand excessive stress. Strength of the vertebral body is largely dependent upon the strength of its trabecular bone.  The majority of axial force absorbed by the vertebral body is transmitted through the trabecular bone.

Loss of trabecular bone strength can be due to multiple factors including a decrease in bone density.  This can occur because of aging, osteoporosis, infection, or renal dysfunction.  In cases of pathologic fractures, lytic lesions indicating osteoclastic activation with osteoblastic inhibition, rather than osteoblastic lesions accelerate this deleterious process.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

New onset/acute – The majority of VCFs never cause a patient to seek medical attention.  Two-thirds of benign VCFs will go undiagnosed in their acute phase.²   A small number of VCFs are initially diagnosed during a work-up for unrelated complaints.⁸ Symptomatic VCFs can be excruciatingly painful requiring medical intervention, ranging from conservative measures to invasive interventional procedures.

Subacute – Pain typically improves substantially and as it does, the patient’s mobility likewise increases.

Chronic/stable – Pain typically resolves. Function returns to pre-fracture levels in many instances. Portends a 5-fold increase of adjacent level fraction.²

Pre-terminal – Some vertebral fractures are caused by primary or metastatic malignancy, and may be associated with kyphosis, deconditioning, respiratory difficulty, or antalgic gait. 75% of people with painful compression fractures complain of chronic axial pain.^8-10

The risk of future fractures is elevated after an initial vertebral compression fracture. 19% of individuals will develop another compression fracture within a year.^2,8-10

Specific secondary or associated conditions and complications

After an initial VCF, future fractures are likely, regardless of treatment. The incidence of a secondary fracture is slightly higher if vertebral body augmentation procedure (VBA) was performed as part of the treatment of the initial fracture.¹¹ If the fracture fails to heal quickly and pain persists, the individual may quickly become deconditioned. Symptoms of this can include persistent back pain, increased bone loss, and decreased lung capacity.

Rehabilitation Management and Treatments

Available or current treatment guidelines

To date, there are no clear treatment guidelines outlining management protocols for VCFs which have been established.  However, certain principles of treatment typically apply.

Usually, conservative pain management using nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are sufficient for mild symptoms. For more severe pain, calcitonin, and/or opioids may be added.

Although the benefits of bracing in VCFs without severe deformity or neurological deficit are controversial, early bracing to limit forward flexion has been shown to reduce pain.

Physical therapy incorporating weight bearing exercises can prevent further deconditioning and help restore activities of daily living (ADL) function.  However, considerable caution needs to be exercised as these may exacerbate pain or worsen the fracture.

Once conservative measurements have been exhausted or pain is severe, VBA should be considered, although evidence is still controversial.

At different disease stages

New onset/acute

Medications: A multimodal approach to medication should be instituted. Acetaminophen can be safely used for most patients devoid of severe hepatic dysfunction. NSAIDs and opioids can be used for more severe pain. However, caution should be exercised are both carry potential adverse effects. NSAIDs carry risks that affect the gastrointestinal, renal and cardiovascular systems. Opioids should be used judiciously in elderly individuals, due to risk of sedation, and falls. Otherwise, opioids carry other potential adverse effects such as opioid induced constipation, dependency, and opioid induced hyperalgesia (OIH).¹² Constipation can increase intraspinal pressure by the Valsalva phenomenon and there increase pain in the spine. Calcitonin may also be useful in management of VCF as an adjunctive treatment for patients not receiving adequate relief with acetaminophen or NSAIDs. Bisphosphonates may be considered for future VCF risk reduction if osteoporosis is the underlying etiology of VCF.^13,14

Bracing: Despite lack of strong evidence, bracing is a common practice in the management of stable VCF. Randomized controlled trials (RTCs) have demonstrated no significant difference in clinical outcome between management with no brace, soft brace, or rigid brace.¹⁵ However, bracing such as thoracic lumbar sacral orthosis (TLSO), hard or soft cervical collars, and sacral corsets may be utilized for patient comfort depending on the level of injury.  Some studies reveal that thoracolumbar bracing may increase comfort, improve gait and pain but have little effect on spinal stability.¹⁶ Patient education should be provided to prevent muscular weakness with chronic wear, or skin abrasions or sores that may arise from improperly donned orthoses.

Postural taping, relative rest, heat, ice and transcutaneous nerve stimulation (TENS) may all provide some benefit during the acute stages.

Surgery: Urgent surgical consultation should be sought for unstable fracture, second column fracture, or evidence of neurological deficits or neurological involvement on physical exam.

If malignancy is suspected or detected, immediate oncological evaluation is warranted, and this need not be delayed until after pain control is obtained.  This should be initiated immediately upon diagnosis.

Subacute phase

Conservative management:

• If osteoporosis is present, vigorous treatment with bisphosphonates, teriparatide, and/or other osteoporosis medications should be considered. Endocrinology or rheumatology consult may be helpful in some instances.
• If bracing was the primary treatment, then after bracing for 8-12 weeks, dependent on pain improvement, weaning of the brace by an hour a day is most often suggested, until the orthosis is no longer used.

The timing and efficacy of vertebral augmentation procedures remain controversial. However, these procedures can provide an important therapeutic option for those who continue to experience severe ongoing pain or demonstrate neurological decline despite medications or other non-invasive early intervention.  Thorough physical exam and review of imaging must be undertaken to determine if the fractured segment is likely the main source of pain.

Percutaneous procedures:

• Vertebroplasty – Injection of cement into the vertebral body for fixation of the fracture and improvement in pain.
• Kyphoplasty – Vertebroplasty with use of a balloon or curette to create a cavity within the vertebral body and in balloon kyphoplasty to potentially restore the height of the vertebral body prior to fixation with cement.

Numerous adverse outcomes have been reported with vertebroplasty and kyphoplasty procedures. A 2018 Cochrane review did not show role for vertebroplasty for treating acute or subacute osteoporotic vertebral fractures. ¹⁷

Chronic/stable phase

Occurs when pain has dissipated completely or has stabilized, and no other treatments are being offered. Typically, it will take 12 weeks to reach this stage, barring re-injury or adjacent level fractures.  Management of the underlying causes should be continued.

Previous ADL activities, sports or other activities may be gradually resumed, preferably with the guidance of a physical therapist.  In this setting, a physical therapist can provide guidance and instruction for spinal stabilization, osteoporosis (weight-bearing exercises), spinal proprioception training, and home exercises. The physical therapy protocol should be focused on postural training (ex. back extension exercises) and balance training to reduce risks of fall. Physical therapy can reduce secondary lower back pain and potentially prevent future fractures by promoting improved posture and core strength.

Coordination of care

Parallel practice: VBA procedures can be performed by specialists in physiatry, surgery, interventional radiology or anesthesiology.

Coordinated: Often, VCF is a presentation or complication of another disease entity such as osteoporosis, infection, or malignancy. The treatment must be coordinated between multiple specialists such as physicians, rehabilitation psychologists, orthotists, and physical therapists to address the primary disease and any functional impairments.

Interdisciplinary: For successful treatment, patients need education on their disease, role of different health care providers, and treatment plan, as well as involvement in the decision-making processes.

Integrated: All the specialists involved in the treatment plan must re-evaluate the success/failure of the initial treatment choice in order to make further adjustments or changes to the plan

Patient & family education

Patients should receive detailed explanation that in most cases, vertebral fractures will heal on their own, if allowed to do so, and that pain is often manageable with the use of conservative measures (such as rest, activity modification, medications, orthotics, and physical therapy) . Any potential procedure discussed should involve a detailed discussion regarding informed consent.

Emerging/unique interventions

Impairment-Based Measurement

The American Medical Association Guides to Permanent Impairment can be used once maximum medical improvement has been reached and a permanent impairment needs to be quantified. In some cases, a role for functional capacity evaluation may also exist.

Other measures of function such as the Short Form (36) Health Survey (SF-36) can be used in research of treatment outcomes or even clinically if needed.

Measurement of Patient Outcomes

Resumption of pre-fracture activities is the often the most reliable measurement tool. Visual analog scores, the Oswestry Disability Index, or the SF-36 survey can assist with tracking pain and quality of life.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Individualized and multimodal approach is paramount in successful treatment of VCF’s.  Judicious medication management and careful introduction of physical therapy must be maintained while monitoring for adverse effects. Since the fractures frequently heal on their own, any persistent pain that patients may experience might be from other pain generators, such as the facet joints, discogenic back pain,^18,19 sacroiliac joint dysfunction, and or myofascial pain syndrome.  Furthermore, a detailed history can aid in recognizing malignancy as a potential etiology.  VCF’s can cause anterior displacement of the center of gravity due to increased kyphosis. Kyphoplasty or vertebroplasty can potentially reduce kyphosis and associated disability. If MRI demonstrates edema in the bone, and the patient has tenderness to palpation over the region in question, VBA can be considered, regardless of the age of the fracture.

Table 1. Goals of Treatment of VCF

Goals of Treatment of VCF

• Alleviate pain and promote early mobilization • Promote healing of injured tissue • Relieve muscle spasm • Restore normal range of motion (ROM) and decrease kyphosis and proprioceptive afferents for the spine and lower limbs • Increase strength and balance and improve aerobic capacity • Educate patient about healthy lifestyle and risk factors of falls to prevent further episodes • Return patient to activities of daily living and prior level of activity

Cutting Edge/Emerging and Unique Concepts and Practice

New needles and devices are being developed on a seemingly monthly basis to improve VBA procedures. These devices include curettes to create a cavity in the vertebral body, similar to that which a balloon creates, and curved needles to allow uni-pedicular approaches and better position of the balloon and or cement in the center of the vertebral body.  In addition, hand drills are often used to create a channel for the trochar, therefore minimizing the chance that the trochar would be accidentally advanced through the anterior wall of the vertebral body.

Gaps in the Evidence-Based Knowledge

Controversy exists among recent published studies concerning the percutaneous procedures. Two randomized, placebo-controlled studies claimed no long-term benefit to VBA, whereas a more recent study published in The Lancet found otherwise. In contrast, other recent studies suggest the cost effectiveness of early VBA when compared to conservative managements in painful VCF cases.²⁰

References

1. Silver SL. The clinical Consequence of vertebral compression fracture. 992;13 Suppl 2:S27-31.
2. McCarthy J, Davis A. Diagnosis and Management of Vertebral Compression Fractures. Am Fam Physician. 2016 Jul 1;94(1):44-50. PMID: 27386723.
3. Alexandru D, So W. Evaluation and management of vertebral compression fractures. Perm J. 2012 Fall;16(4):46-51.
4. AU Greenbaum J, Walters N, Levy PD. An evidenced-based approach to radiographic assessment of cervical spine injuries in the emergency department. J Emerg Med. 2009;36(1):64-71.
5. Buggay D, Jaffe K. Metastatic bone tumors of the pelvis and lower extremity. J Surg Orthop Adv. 2003; 12:192.
6. Steven Waldman. Pain Management, 2nd Ed.   Philadelphia, PA, 2011:1375-1377.
7. Taxel P, Faircloth E, Idrees S, Van Poznak C. Cancer Treatment-Induced Bone Loss in Women With Breast Cancer and Men With Prostate Cancer. J Endocr Soc. 2018 May 21;2(7):574-588. doi: 10.1210/js.2018-00052. PMID: 29942922; PMCID: PMC6007245.
8. Huang C, Ross PD, Wasnich RD. Vertebral fracture and other predictors of physical impairment and health care utilization. Arch Intern Med. 1996;156(21):2469-2475.
9. Rapado A. General management of vertebral fractures. Bone. 1996;18 (3 suppl):191S.
10. Lindsay R, Silverman SL, Cooper C, et al. Risk of new vertebral fracture in the year following a fracture. JAMA. 2001;285:320-323.
11. Mudano AS, Bian J, Cope JU, et al. Vertebroplasty and kyphoplasty are associated with an increased risk of secondary vertebral compression fractures: a population-based cohort study. Osteoporos Int. 2009; 20:819.
12. Tompkins DA, Campbell CM. Opioid-induced hyperalgesia: clinically relevant or extraneous research phenomenon?. Curr Pain Headache Rep. 2011;15(2):129-136. doi:10.1007/s11916-010-0171-1
13. Genev IK, Tobin MK, Zaidi SP, Khan SR, Amirouche FML, Mehta AI. Spinal Compression Fracture Management: A Review of Current Treatment Strategies and Possible Future Avenues. Global Spine J. 2017;7(1):71-82. doi:10.1055/s-0036-1583288
14. Knopp-Sihota JA, Newburn-Cook CV, et al. Calcitonin for treating acute and chronic pain of recent and remote osteoporotic vertebral compression fractures. Osteoposis Int. 2012;23:17-38
15. Hofler RC, Jones GA. Bracing for Acute and Subacute Osteoporotic Compression Fractures: A Systematic Review of the Literature. World Neurosurg. 2020 Sep;141:e453-e460. doi: 10.1016/j.wneu.2020.05.199. Epub 2020 May 28. PMID: 32474094.
16. Pfeifer M, Gehlen M, Hinz C. Rückenorthesen in der Behandlung von Wirbelkörperfrakturen bei Osteoporose : Eine systematische Übersichtsarbeit [Spinal orthoses in the treatment of vertebral fractures with osteoporosis : A systematic review article]. Z Rheumatol. 2017 Dec;76(10):860-868. German. doi: 10.1007/s00393-017-0404-3. PMID: 29143126.
17. Buchbinder R, Johnston RV, Rischin KJ, Homik J, Jones CA, Golmohammadi K, Kallmes DF. Percutaneous vertebroplasty for osteoporotic vertebral compression fracture. Cochrane Database Syst Rev. 2018 Apr 4;4(4):CD006349. doi: 10.1002/14651858.CD006349.pub3. Update in: Cochrane Database Syst Rev. 2018 Nov 06;11:CD006349. PMID: 29618171; PMCID: PMC6494647.
18. Mitra R, Huy D, Alamin T, Cheng I. Facet pain in thoracic compression fractures. Pain Med. 2010;11:1674-1677.
19. Bogduk N, MacVicar J, Borowczyk J. The pain of verterbral compression fractures can arise in the posterior elements. Pain Med. 2010;11:1666-1673.
20. Takura T, Yoshimatsu M,et al. Cost-Effectiveness Analysis of Percutaneous Vertebroplasty for Osteoporotic Compression Fractures. Clin Spine Surg. 2017;30(3):E205-E210.

Original Version of the Topic

Faisel Zaman, MD. Compression Fractures of the Spine. 11/10/2011.

Previous Revision(s) of the Topic

Soo Y Kim, MD, Jung Hwan Kim, MD, Andrew I. Gitkind, MD. Compression Fractures of the Spine. 9/1/2017.

Author Disclosure

Laura Y. Huang, MD
Nothing to Disclose

Lizeth Caldera, BS, MS
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Reed Yaras, DO
Nothing to Disclose

Natalia Miranda-Cantellops, MD
Nothing to Disclose