Vertebral Compression Fractures (VCF) are defined as a loss of height of a vertebral body resulting from a failure of the structural osseous components of the vertebrae.1
VCFs may result from osteoporosis, malignancy, infection, or trauma. Among these, osteoporosis is the most common cause of VCFs.2 Benign insufficiency 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%-20%. 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 and high dose oral cortisone use. Primary prevention includes avoiding first and secondhand smoke, participation in regular weight-bearing exercise as well as calcium and vitamin D intake. Premenopausal calcium intake may be just as important as that amount taken postmenopausally.3
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. As high as 30 percent of patients with skeletal metastases may experience pathologic vertebral fractures.6
Regardless of the etiology, compression fractures occur when the load on the bone exceeds the vertebral body’s strength to withstand it. 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 or infection. 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 are asymptomatic and never cause a patient to seek medical attention. Over 50% of benign VCFs will go undiagnosed in their acute phase. A small number of VCFs are initially diagnosed during a work-up for unrelated complaints.7 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
Pre-terminal – Some vertebral fractures are caused by 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.7-9
The risk of future fractures is elevated after an initial vertebral compression fracture. 19% of individuals will develop another compression fracture within a year.7-9
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.10 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.
2. 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.
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 ADL function. However, considerable caution needs to be exercised as these may exacerbate pain or worsen the fracture.
Judicious early use of pain medications must be balanced against potential side effects such as severe constipation or sedation.
Once it is clear that the above treatments have been unsuccessful or the pain is too severe to manage, then VBA procedures should be considered.
At different disease stages
Bracing in the form of TLSO, if tolerated, should be considered for stable fractures. For stable sacral fractures, a sacral corset can be helpful. Urgent surgical consultation should be initiated if any potentially unstable fracture is identified, (especially with a present neurological deficit on physical exam) of if any second column fracture with neurological involvement (burst fracture) occurs.
Medications – A multimodal approach to medication management should be instituted. While acetaminophen can be used safely for most patients devoid of severe hepatic dysfunction, long term use of non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution given their potential adverse gastrointestinal, renal and cardiovascular effects. Another helpful adjunct is calcitonin, which may improve back pain in the acute phase.11 Opioids such as hydrocodone, oxycodone and tramadol can be considered for severe pain. Care should be taken with their use, especially in the elderly, which happens to be the most common subset of patients to sustain VCFs. Constipation that causes the Valsalva phenomenon, thus increasing intraspinal pressure and therefore pain, in many cases, is a common side effect of these drugs.
Postural taping, relative rest, heat, ice and transcutaneous nerve stimulation (TENS) may all provide some benefit during the acute stages.
The timing and efficacy of vertebral augmentation procedures are controversial since the current literatures show mixed results. However, these procedures can provide an important therapeutic option for those who continue to experience severe ongoing pain 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.
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.
Once the pain from VCF has subsided either via a conservative approach or the percutaneous procedure approach:
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 malignancy is 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.
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 at all.
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 y guidance and instruction for spinal stabilization, osteoporosis (weight-bearing exercises) 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, radiology or anesthesiology.
Coordinated: Often, the VCF is a presentation or complication of another disease entity such as osteoporosis, or malignancy. Thus, the treatment must be coordinated between multiple specialists to address the primary disease as well as functional impairments secondary to the VCF itself.
Interdisciplinary: The patient needs to be involved in the decision-making process.
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
Explanation that vertebral fractures will heal on their own, if allowed to do so and that pain is often manageable with the use of conservative measures and with minimal risk in most cases must be explained in detail. Any potential procedure discussed should involve a preliminary complete and detailed discussion regarding informed consent.
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 an important measurement tool. Visual analog scores, the Oswestry Disability Index, or the SF-36 survey can also be used.
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,12,13 myofascial pain syndrome, or intervertebral discs. Furthermore, a detailed history can aid in recognizing malignancy as a potential etiology. Vertebral compression fractures 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
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge 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.
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
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.14
- Silver SL. The clinical Consequence of vertebral compression fracture. 992;13 Suppl 2:S27-31.
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- Wasnich U. Vertebral fracture epidemiology. Bone. 1996;18:1791-1796.
- 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.
- Buggay D, Jaffe K. Metastatic bone tumors of the pelvis and lower extremity. J Surg Orthop Adv. 2003; 12:192.
- Steven Waldman. Pain Management, 2nd Ed. Philadelphia, PA, 2011:1375-1377.
- 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.
- Rapado A. General management of vertebral fractures. Bone. 1996;18 (3 suppl):191S.
- Lindsay R, Silverman SL, Cooper C, et al. Risk of new vertebral fracture in the year following a fracture. JAMA. 2001;285:320-323.
- 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.
- 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
- Mitra R, Huy D, Alamin T, Cheng I. Facet pain in thoracic compression fractures. Pain Med. 2010;11:1674-1677.
- Bogduk N, MacVicar J, Borowczyk J. The pain of verterbral compression fractures can arise in the posterior elements. Pain Med. 2010;11:1666-1673.
- 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.
Soo Y Kim, MD
Nothing to Disclose
Jung Hwan Kim, MD
Nothing to Disclose
Andrew I. Gitkind, MD
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