Vertebral compression fractures (VCFs) are the most common fracture in patients with osteoporosis. The prevalence of this condition increases as people age. People who have sustained one VCF are at five times the risk of sustaining a second VCF. Occasionally, a VCF can be present with either minor symptoms or no symptoms, but the risk still exists for additional VCFs to occur.
VCFs occur when the bony block or vertebral body in the spine collapses, which can lead to severe pain, deformity and loss of height. These fractures more commonly occur in the thoracic spine (the middle portion of the spine), especially in the lower part. While osteoporosis is the most common cause, these fractures may also be caused by trauma or metastatic tumors.
In people with severe osteoporosis, a VCF may be caused by simple daily activities such as:
- stepping out of the shower
- sneezing vigorously
- lifting a light object
In people with moderate osteoporosis, it usually takes increased force or trauma, such as:
- falling down
- attempting to lift a heavy object
People with healthy spines most commonly suffer a VCF through severe trauma. Injury severe enough to cause a vertebra to break can occur with a fall from a tall height in which the person lands on his or her feet or buttocks. It can also occur in a person involved in a car accident.
Pathologic fracture is a fracture occurring in the vertebra due to the pre-existing disease at the fracture site. Most commonly, this type of break is from cancer in the bone, which has often traveled from other sites in the body called metastasis, such as from the prostate, breast, or lungs. Metastatic tumors should be considered as the cause in patients younger than 55 with no history of trauma or only minimal trauma. The bones of the spine are commonplace for many types of cancers to spread. Cancer may cause destruction of part of the vertebra, weakening the bone until it collapses.
The pathologic fracture can also occur with other diseases, such as Paget’s disease of bone and infection of the bone (osteomyelitis).
The main clinical symptoms of VCFs may include any of the following, alone or in combination:
- Sudden onset of back pain. It tends to be in the lower back but may occur in the middle or upper back or neck. Some people may also have hip, abdominal, or thigh pain
- Numbness, tingling, and weakness which could mean compression of the nerves at the fracture site
- An increase in pain intensity while standing or walking
- A decrease in pain intensity while lying on the back
- Limited spinal mobility
- Eventual height loss
- Eventual deformity and disability
- Losing control (incontinence) of urine or stool or inability to urinate (urinary retention) which could mean the fracture may be pushing on the spinal cord itself
Complications related to VCF include:
- Segmental instability
- Neurological complications
There is a risk of segmental instability when a fracture leads to a vertebral body collapse of more than 50 percent. The spinal segments work together to enable weight-bearing, movement and support of the entire spine. When one segment deteriorates or collapses to the point of instability, it can produce pain and impair daily activities. The instability ultimately results in quicker degeneration of the spine in the affected area.
Kyphosis is a common disorder in older women who have osteoporosis and frequent VCFs. The front of the vertebrae will collapse and “wedge” due to the lack of normal vertebral space. Kyphosis leads to a more rounded thoracic spine. This deformity is sometimes referred to as hunchback or dowager’s hump.
Severe kyphosis may cause extreme and debilitating pain. The hunchback deformity may eventually compress the heart, lungs, and intestines. This, in turn, can lead to fatigue, shortness of breath and loss of appetite.
If the fracture causes part of the vertebral body to place pressure on the spinal cord, the nerves and spinal cord can be affected. The normal space between the spinal cord and the beginning of the spinal canal can be reduced if pieces of the broken vertebral body push into the spinal canal.
The narrowing of the spinal canal due to a VCF can lead to immediate injury to the spinal nerves or can cause problems later from irritation of the nerves. The lack of space can also lower the supply of blood and oxygen to the spinal cord. This can lead to numbness and pain in the nerves that are affected. The nerves may lose some of their mobility when the space around them decreases, which can lead to nerve irritation and inflammation.
X-rays: People older than 65 years, who have cancer, or who have had significant trauma may have X-rays performed. If younger than 65 years and do not have any medical problems or severe pain, then X-rays may not be necessary.
CT scan of the spine: If a fracture is discovered, it may be needed to determine the extent of the fracture.
MRI of the spine: A diagnostic test that produces 3-D images of body structures using powerful magnets and computer technology; can show the spinal cord, nerve roots and surrounding areas, as well as enlargement, degeneration, and tumors.
Dual-energy x-ray absorptiometry (DXA or DEXA) or bone densitometry: This test is the established standard for measuring bone mineral density and can determine if osteoporosis exists. The scanner painlessly and rapidly directs x-ray energy from two different sources towards the bone being examined in an alternating fashion at a set frequency. A DEXA scan can detect small changes in bone mass and is also more flexible since it can be used to examine both the spine and the extremities. A scan of the spine, hip or the entire body requires less than four minutes.
Non-surgical treatment for Vertebral Compression Fractures
Traditionally, people with severe pain from VCFs have been treated with bed rest, medications, bracing or invasive spinal surgery, often with limited effectiveness. Pain secondary to acute vertebral fracture appears to be caused in part by vertebral instability (non-union or slow-forming union) at the fracture site. VCF-related pain that is allowed to heal naturally can last as long as three months. However, the pain usually decreases significantly in a matter of days or weeks.
- Pain medications: Over-the-counter pain medications are often effective in relieving pain. Both acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) are commonly recommended. Narcotic pain medications and muscle relaxants are often prescribed but only for short periods of time, due to the risk of addiction.
- Activity modification: Bed rest may be advised for a short period of time, followed by a limitation on some activities. However, prolonged inactivity should be avoided.
- Back bracing: A back brace can provide external support to limit the motion of fractured vertebrae, similar to the support a cast provides on a leg fracture. The rigid style of back brace limits spine-related motion greatly, which may help reduce pain. However, braces should be used cautiously and only under a doctor’s supervision. Weakening and loss of muscle can occur with excessive use of braces for lumbar conditions.
Surgical Treatment for Vertebral Compression Fractures:
When conservative treatment options have proven ineffective, the following surgical procedures may be used to treat VCFs:
Vertebroplasty and Kyphoplasty
These procedures for spinal compression fractures involve small, minimally invasive incisions, so they require very little healing time. They also use acrylic bone cement that hardens quickly, stabilizing the spinal bone fragments and therefore stabilizing the spine immediately. Most patients go home the same day or after one night’s hospital stay.
Patients with the following criteria may be considered candidates for vertebroplasty or kyphoplasty:
- Osteoporotic VCFs in any area of the spine that has been present for more than two weeks, causing moderate to severe pain and unresponsive to conservative therapy
- Painful metastases and multiple myelomas
- Painful vertebral hemangiomas (benign, malformed vascular tumors composed of newly formed blood vessels)
- Vertebral osteonecrosis (a condition resulting from poor blood supply to an area of bone, which causes bone death)
- Reinforcement of a pathologically weak vertebral body before a surgical stabilization procedure
Vertebroplasty: This procedure is effective for relieving pain from vertebral compression fractures and helping to stabilize the fracture. During this procedure:
- A needle is inserted into the damaged vertebrae.
- X-rays help ensure that it’s done with accuracy.
- The doctor injects a bone cement mixture into the fractured vertebrae.
- The cement mixture hardens in about 10 minutes.
- The patient typically goes home the same day or after a one-night hospital stay.
Kyphoplasty: This procedure helps correct the bone deformity and relieves the pain associated with vertebral compression fractures. The procedure involves:
- A tube is inserted through a half-inch cut in the back into the damaged vertebrae. X-rays help ensure the accuracy of the procedure.
- A thin catheter tube — with a balloon at the tip — is guided into the vertebra.
- The balloon is inflated to create a cavity in which liquid bone cement is injected.
- The balloon is then deflated and removed, and bone cement is injected into the cavity.
- The cement mixture hardens in about 10 minutes.
Patients with any of the following criteria should not undergo these procedures:
- A VCF that is completely healed or is responding effectively to conservative therapy
- A VCF that has been present for more than one year
- Greater than 80-90 percent collapse of the vertebral body
- Spinal curvature, such as scoliosis or kyphosis, that is due to causes other than osteoporosis
- Spinal stenosis or herniated discs with nerve or spinal cord compression and loss of neurological function not associated with a VCF
- Untreated coagulopathy (a disease or condition affecting the blood’s ability to coagulate)
- Osteomyelitis (an inflammation of the bone and bone marrow, usually caused by bacterial infection)
- Discitis (nonbacterial inflammation of an intervertebral disc or disc space)
- Significant compromise of the spinal canal caused by impeding bone fragment or tumor