Vertebral Compression Fracture

Aka: Vertebral Compression Fracture, Vertebral Crush Fracture

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II. Causes

  1. Osteoporosis
    1. Most common Osteoporosis complication (700,000 related U.S. Vertebral Fractures per year)
  2. Cancer with lytic bony metastases

III. Risk Factors

  1. See Osteoporosis
  2. Prior Vertebral Fracture confers 5 fold increased risk
  3. Chronic use of Systemic Corticosteroids (>5 mg daily for 3 months)
  4. Increasing age over 50 years old
  5. Weihgt <117 lb (<53 kg)
  6. Female gender
  7. Heavy Alcohol use (>2/day in women, >3/day in men)
  8. Tobacco Abuse
  9. Vitamin D Deficiency

IV. Symptoms

  1. Sudden onset of severe back pain
    1. Radiation of pain across back and into trunk
      1. Rarely radiates into legs
    2. Paraspinous muscle Fatigue related pain (prolonged)
  2. Most common sites (multiple levels often involved)
    1. Thoracic Spine: T8 to T12
    2. Lumbar Spine: L1 and L4
  3. Follows Trauma (often minor mechanism)
    1. Occurs with minor stress in severe Osteoporosis
      1. Sneezing
      2. Transferring out of bathtub
      3. Rolling over in bed (30% of Fractures)
    2. Occurs with greater stress in moderate Osteoporosis
      1. Fall out of a chair
    3. Higher energy injury can cause compression in anyone
      1. Motor Vehicle Accident
      2. Fall from height

V. Signs

  1. Loss of total height measurement
    1. Women: >4 cm height loss since age 25 years
    2. Men: >6 cm height loss since age 25 years
  2. Thoracic kyphosis (from anterior wedge Fractures)
  3. Lumbar lordosis (corrects for kyphosis)
  4. Tenderness over area of acute Fracture

VI. Complications

  1. Constipation, ileus, or Bowel Obstruction
  2. Urinary Retention
  3. Loss of mobility
    1. Deep Vein Thrombosis risk
    2. Deconditioning with Muscle Weakness
    3. Pressure Ulcers
  4. Impaired lung function (Atelectasis and Pneumonia risk)
  5. Chronic Pain

VII. Differential Diagnosis

  1. Musculoskeletal Low Back Pain
  2. Osteoarthritis
  3. Spinal stenosis
  4. Multiple Myeloma
  5. Metastatic Vertebral involvement
  6. Spinal Osteomyelitis
  7. Hyperparathyroidism

VIII. Labs

  1. Consider secondary Osteoporosis Evaluation (e.g. younger patients, Hypercalcemia)
  2. See Osteoporosis Evaluation for labs related to secondary cause

IX. Imaging

  1. Spinal XRay (esp. lateral xray)
    1. Loss of Vertebral height of 20% or 4 mm from baseline
    2. Grading of changes
      1. End-plate deformity
      2. Anterior wedge Fracture
      3. Complete collapse of Vertebrae (burst Fracture)
  2. CT Spine Indications
    1. Characterize suspected Fracture site
    2. Suspected Lumbar Spinal Stenosis
  3. MRI Spine Indications
    1. Suspected Lumbar Spinal Stenosis
    2. Significant secondary neurologic sequelae
      1. Vertebral bone retropulsed into spinal canal with neurologic symptoms
      2. Cauda Equina Syndrome suspected
    3. Differentiate acute versus old compression Fracture (edema associated with recent Fracture)
    4. Pathologic Fracture (malignancy) suspected
      1. No Trauma History in under age 55 years
  4. Bone scan indications
    1. Atypical presentation with several levels involved
    2. Sacral insufficiency Fracture (H-pattern at Sacrum)
  5. DEXA Scan
    1. Obtain after Vertebral Compression Fracture diagnosis to grade severity of Osteoporosis

X. Management: Stable Compression Fractures

  1. Confirm that Fracture site is stable (typical)
  2. Symptomatic back pain management (includes Opioids)
    1. Should allow for adequate lung excursion with prevention of Atelectasis and secondary Pneumonia
    2. Initial excessive Opioid requirements may warrant hospital observation or admission
    3. NSAIDs or Acetaminophen
    4. Opioids
    5. Lidocaine Patches
  3. Physical therapy
    1. Early mobility is key
      1. Decreases risk of deconditioning, Pressure Ulcers, and Venous Thromboembolism
      2. Initial bed rest may be needed for severe intractable pain
    2. Encourage upper body Exercises and walking
      1. Back extensor strengthening
    3. Avoid flexion Exercises (e.g. crunches)
      1. Increases risk of additional compression Fractures
  4. External back-bracing (for 4 weeks, up to 6-8 weeks maximum)
    1. Use for comfort and pain control
    2. Consider Thoracolumbosacral Orthosis Brace (TLSO Brace)
      1. May improve pain control and overall function and mobility
      2. May provoke localized Muscle spasm and cause local skin breakdown
      3. Pfeifer (2004) Am J Phys Med Rehabil 83(3): 177-86 +PMID:15043351 [PubMed]
  5. Procedures (see Consultations below)
    1. L2 Nerve root blocks
      1. May reduce pain for 2-4 weeks
    2. Vertebroplasty
      1. Liquid cement injected percutaneously into affected, compressed Vertebra
    3. Kyphoplasty
      1. Balloon inserted percutaneously into collapsed Vertebral body to expand it to original height
      2. Cement injected into expanded Vertebral body
  6. Osteoporosis agents for acute pain
    1. Calcitonin (Miacalcin) nasal spray
      1. Dosing: 200 IU intranasally daily
      2. Increases bone density 1-2% per year
      3. Effective in painful Vertebral Fractures if started within 10 days of acute Fracture
      4. Possible increased risk of cancer
      5. Silverman (2002) Osteoporos Int 13:858-67 [PubMed]
      6. Knopp-Sihota (2012) Osteoporos Int 23:17-38 [PubMed]
  7. Osteoporosis agents for prevention of further Vertebral Compression Fractures
    1. Teriparatide (Forteo)
      1. Dosing: 20 mcg daily subcutaneously
      2. Recombinant Parathyroid Hormone
      3. Limits: Do not use with bisphosphonate and do not use longer than 2 years
      4. Very expensive
      5. Efficacy: Reduced risk for osteoporotic Vertebral Fractures
        1. Neer (2001) N Engl J Med 344:1434-41 [PubMed]
    2. Denosumab (Prolia) Injection
      1. Effective for Vertebral spine Fractures
      2. Dose: 60 mg SQ
      3. Increased risk of infection
      4. Consider in men with high Fracture risk secondary to androgen deprivation therapy (for Prostate Cancer)

XI. Management: Neurosurgery or Spine SurgeryConsultation Indications

  1. Serious acute imaging findings
    1. Vertebral bone retropulsed into spinal canal with neurologic symptoms
    2. Cauda Equina Syndrome suspected
  2. Refractory severe pain or >6 weeks of pain
    1. Percutaneous Vertebroplasty
    2. Kyphoplasty (Restores Vertebral height)

XII. Prevention

  1. See Osteoporosis Management
  2. Bone loading Exercise program (e.g. walking)
  3. Muscle Strengthening

XIII. Course

  1. Improvement usually occurs over 6 to 12 week period
  2. More than 50% of patients will have adequate pain reduction by 3 months of conservative therapy

XIV. References

  1. Orman and Swaminathan in Herbert (2015) EM:Rap 15(8): 1-2
  2. Raisz in Wilson (1998) Endocrinology, p. 1223-4
  3. McCarthy (2016) Am Fam Physician 94(1): 44-50 [PubMed]
  4. Old (2004) Am Fam Physician 69:111-6 [PubMed]
  5. Predey (2002) Am Fam Physician 66(4):611-17 [PubMed]

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