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 the 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

The 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 usage. 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 occur 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. The 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 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 fracture.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.

Evidence-based Clinical Guidelines for Management and Treatment

North American Spine Society (NASS) developed a clinical practice guideline for the diagnosis and treatment of osteoporotic vertebral fractures in adults based on a systematic review of evidence that reflects the most current treatment concepts that are reflected in the highest quality clinical literature available on this topic since September 30, 2020.¹² The following management and treatment portions included in this section have been updated based on information from the NASS guideline.

The inclusion/exclusion criteria for the patient population that this guideline pertains to are listed below.

Inclusion criteria

• Age ≥ 18 years
• Spinal or sacral fractures
• Single or multiple-level fractures
• Simple or complex fractures
• With or without pain (pain may include axial, radicular, generalized, or a combination)

Exclusion criteria

• Cervical spine
• Acute or chronic spine infection i.e. epidural abscess, discitis, and/or osteomyelitis
• Major trauma
• Isolated intradural tumor
• Primary or metastatic tumor involvement to the spine

Table 1. Goals of Treatment of VCF

Medical Treatment

Non-pharmacologic treatment

Bracing/Taping

Bracing may be an option for adults with osteoporotic VCFs but there is insufficient evidence to recommend a specific type of bracing. Kato et al. compared the preventive effect of rigid brace and soft brace treatments and determined that the treatment with bracing showed no significant difference in quality of life, improving back pain, or preventing spinal deformity.¹³

Looking specifically at the three-point orthosis brace versus a dynamic corset brace while treating osteoporotic VCFs, the patients treated with dynamic orthosis had better outcomes in reduction of pain, improvement in quality of life, and increased respiratory function. However, they still had equal effectiveness in stabilizing the fracture with fewer complications compared to non-braced patients.¹⁴

In another prospective comparative study that compared soft lumbar orthoses to metal-made orthoses with soft padding during the subacute stage, Li et al. concluded that there were no significant differences in clinical outcomes.¹⁵

Regarding taping, there is insufficient evidence however in one prospective randomized control trial study where the authors examined the effects of postural taping on various factors including pain, quality of life, and functionality after an osteoporotic VCF. In conclusion, Palmer et al. determined that the use of taping in the recovery period has the potential to improve pain and functionality compared to those who do not use taping.¹⁶

Timeline for Physical Therapy and Mobilization

There is insufficient evidence regarding the exact timeline for strict immobilization vs early mobilization in geriatric patients with VCF. However, one retrospective case series study provided level IV evidence that suggested that early mobilization of older adults with acute osteoporotic VCF resulted in functional outcomes that were comparable to those who remained in strict immobilization until 3 months follow up with less risk of complications.¹⁷

Spinal Manipulative Treatments

Spinal manipulation has been increasingly popular and common in recent years. However, a systematic review of the literature cited in the North American Spine Society (NASS) guidelines¹² for osteoporotic VCF reveals that there are no studies yet that adequately address manipulative treatment in this particular patient population.

Pharmacological Treatments

NSAIDS

Non-steroidal anti-inflammatories (NSAIDs) are a common first line medication of choice for short term relief in the treatment of acute or chronic back pain secondary to vertebral compression fractures. Conventional or nonselective NSAIDs are those that inhibit both the COX-1 and COX-2 isoenzyme, whereas selective variants target the COX-2 alone. NSAIDs are found to generally offer effective analgesic effect, however risks with use include including upper gastrointestinal bleeding, gastric ulceration, renal toxicity, and platelet dysfunction. As such, decision for use should be made on a case-by-case basis with consideration for patients with comorbidities that may contribute to higher risk of adverse side effects.

It should be additionally note that NSAIDs (as a result of their anti-inflammatory effect) inhibit production of prostaglandin E2 which is known to have a role in bone healing. However, despite their widespread and storied use, there lacks a definitive conclusion on their actual contribution to bone health when considering patients with healing fractures.³⁰

Calcitonin

Calcitonin is a hormone produced primarily by the thyroid gland in humans. It plays an important role in calcium homeostasis. It is also used as a medication in some cases to help treat conditions like osteoporosis. There are two common forms of administration: intranasal and subcutaneous. While intranasal is often the preferred method, for ease of use and patient comfort, it is shown that subcutaneous and intranasal calcitonin produce similar effects in pain reduction in patients with acute osteoporotic VCF.¹⁸ Calcitonin is seen to not only provide significant pain relief but also promote earlier mobilization.^19,20

Teriparatide

Teriparatide is a recombinant form of parathyroid hormone that is a medication that can be used in the setting of osteoporosis treatment, especially in patient populations that are at high risk for fractures. It has been considered in adults with acute osteoporotic VCF to help reduce the risk of future fragility fractures. In some occasions, specifically in patients who have a history of multiple and repeating new-onset osteoporotic VCFs, teriparatide can potentially reduce the risk for future fractures and the need for percutaneous vertebroplasty.²¹

Bisphosphonates

Bisphosphonates are a common class of medications that are used in the treatment of osteoporosis and other bone disorders by inhibiting bone resorption. In the setting of VCF, specifically in osteoporotic VCFs, bisphosphonates may help prevent further bone loss and potentially reduce the risk of additional fractures. The combination of bisphosphonates, specifically zoledronic acid, with percutaneous kyphoplasty can improve the therapeutic efficacy of osteoporotic VCF after surgery and significantly reduce recurring fractures.²²

Denosumab

Denosumab is a medication that is also often used in the treatment of osteoporosis and other bone-related conditions. It is a monoclonal antibody that targets and inhibits RANK ligand, which is a protein that is essential for the formation, function, and survival of osteoclasts. In the OVCF patient population, it was seen that denosumab helped pain relief quicker than some other medications, specifically alendronate.²³

Interventional Treatment

Steroid and/or Anesthetic Injections

A facet block is often used in interventional treatment for facet joint-related pain that is often a significant contributor to chronic back pain. In the setting of osteoporotic VCF it has been seen as an alternative interventional treatment for pain. In one particular instance, it was seen that facet blocks when compared to percutaneous vertebroplasty were less successful in providing pain relief in the short term (1-2 weeks). However, in the long term, the difference in pain relief was negligible between the two interventions.²⁴

Vertebral Augmentation (percutaneous vertebroplasty and/or kyphoplasty)

Vertebroplasty and kyphoplasty are two percutaneous interventional procedures in which under fluoroscopic guidance, medical-grade cement is injected into vertebral bodies providing structural support. The techniques themselves are similar, with the key difference being that in kyphoplasty, balloon expansion is used to create a cavity in the vertebral body.

In the recently published NASS Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Adults with Osteoporotic Vertebral Fractures, the authors recommended vertebral augmentation for providing rapid and sustained clinically and statistically significant improvement in pain and function in adults with acute osteoporotic vertebral compression fractures. Criteria for this recommendation are based on two or more consistent Level 1 studies, defined as high-quality randomized trials with statistically significant differences, high-quality prospective studies, testing of previously developed diagnostic criteria on consecutive patients, and systematic review of Level 1 studies.¹² In one such study, a prospective randomized control study showed that in aged patients with acute osteoporotic vertebral fractures and severe pain, early vertebroplasty resulted in improved functional outcomes, fewer medical complications, and better pain relief over a year.²⁵

Alternatively, a 2018 Cochrane Review of high to moderate-quality evidence did not support the role of vertebroplasty for the treatment of acute or subacute osteoporotic vertebral fractures in routine clinical care. The findings of the review did not demonstrate an increased risk of serious adverse events associated with vertebroplasty, although it highlights the reporting of serious adverse events in several trials reviewed.²⁶

Vertebral augmentation can provide an important therapeutic option for patients experiencing symptoms attributable to VCF. When discussing vertebral augmentation with a patient, it is important to provide high quality evidenced-based information about the risks and benefits associated with the procedure.

Coordination of care

Parallel practice: Vertebral augmentation 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 to make further adjustments or changes to the plan.

Cutting Edge/Emerging and Unique Concepts and Practice

New needles and devices are being developed on a seemingly monthly basis to improve vertebral augmentation 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 unipedicular 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

The role of percutaneous vertebral augmentation (VBA), including vertebroplasty and kyphoplasty, in managing osteoporotic vertebral compression fractures (VCFs) remains controversial. Early randomized, placebo-controlled trials found no significant benefit of vertebroplasty over sham procedures in terms of pain relief or functional outcomes.^28,29 These findings raised concerns regarding the widespread use of VBA, leading to changes in clinical guidelines.

Subsequent studies have produced mixed results. Some non-blinded trials suggested benefits from kyphoplasty, but the lack of blinding limits the strength of these conclusions. A 2018 Cochrane review further reinforced skepticism, concluding that vertebroplasty does not provide a clinically significant benefit for patients with osteoporotic VCFs.²⁷

Despite these findings, some analysis suggest that early VBA may be cost-effective compared to prolonged conservative management in select patients with painful VCFs, particularly those experiencing severe immobility-related complications. However, these conclusions are based on limited evidence and require further validation.

The persistent controversy is due to variations in study methodologies, patient selection criteria, and outcome measures. High-quality, randomized controlled trials with standardized protocols are needed to clarify the long-term role of VBA in VCF management and to identify which patients may benefit most from these interventions.

References

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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.
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13. Kato T, Inose H, Ichimura S, et al. Comparison of Rigid and Soft-Brace Treatments for Acute Osteoporotic Vertebral Compression Fracture: A Prospective, Randomized, Multicenter Study. J Clin Med. 2019;8(2):198. Published 2019 Feb 6. doi:10.3390/jcm8020198
14. Meccariello L, Muzii VF, Falzarano G, et al. Dynamic corset versus three-point brace in the treatment of osteoporotic compression fractures of the thoracic and lumbar spine: a prospective, comparative study. Aging Clin Exp Res. 2017;29(3):443-449. doi:10.1007/s40520-016-0602-x
15. Li M, Law SW, Cheng J, Kee HM, Wong MS. A comparison study on the efficacy of SpinoMed® and soft lumbar orthosis for osteoporotic vertebral fracture. Prosthet Orthot Int. 2015;39(4):270-276. doi:10.1177/0309364614528204
16. Palmer S, Barnett S, Cramp M, Berry A, Thomas A, Clark EM. Effects of postural taping on pain, function and quality of life following osteoporotic vertebral fractures-A feasibility trial. Musculoskeletal Care. 2018;16(3):345-352. doi:10.1002/msc.1350
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30. Piche JD, Muscatelli S, Ahmady A, Patel R, Aleem I. The effect of non-steroidal anti-inflammatory medications on spinal fracture healing: a systematic review. J Spine Surg. 2021 Dec;7(4):516-523. doi: 10.21037/jss-21-77. PMID: 35128126; PMCID: PMC8743295.

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.

Laura Y. Huang, MD, Lizeth Caldera, BS, MS, Reed Yaras, DO, Natalia Miranda-Cantellops, MD. Compression Fractures of the Spine. 10/28/2021

Author Disclosure

Thiru M. Annaswamy, MD, MA
Nothing to Disclose

Melissa Sun, DO
Nothing to Disclose

Zach Oberdoerster, DO
Nothing to Disclose