Vertebral Compression Fracture

Aka: Vertebral Compression Fracture, Vertebral Crush Fracture

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II. Epidemiology

  1. Incidence
    1. U.S.: 700,000 cases/year

III. Pathophysiology

  1. Spine axial load is greater than Vertebral bone strength
  2. Only anterior column of Vertebral body collapses
    1. Contrast with Trauma which may affect any or all columns
    2. Compression Fractures are typically stable (single column)
    3. No bony retropulsion into the spinal canal (anterior column only)
  3. Anterior compression Fracture results in a wedge-like collapse
    1. Spine flexes forward, resulting in a hunched-over Posture
    2. Neural foraminal impingement does not typically occur
      1. Forward flexion opens the neural foramen

IV. Causes

  1. Osteoporosis
    1. Most common Osteoporosis complication
  2. Cancer with lytic bony metastases
  3. Follows Trauma (often minor mechanism)
    1. Occurs with minor stress in severe Osteoporosis
      1. Sneezing or coughing
      2. Transferring out of bathtub
      3. Rolling over in bed (30% of Fractures)
      4. Lifting light objects
    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. Risk Factors

  1. See Osteoporosis
  2. See Medication Causes of Osteoporosis
  3. Prior Vertebral Fracture confers 5 fold increased risk
  4. Chronic use of Systemic Corticosteroids (>5 mg daily for 3 months)
  5. Age over 50 years old (esp. age >70 years)
  6. Weight <117 lb or <53 kg (Obesity is protective)
  7. Female gender
  8. Heavy Alcohol use (>2/day in women, >3/day in men)
  9. Tobacco Abuse
  10. Vitamin D Deficiency

VI. Symptoms

  1. Often asymptomatic (found incidentally in two thirds of patients)
  2. 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)
  3. Most common sites (multiple levels often involved)
    1. Thoracic Spine: T8 to T12
    2. Lumbar Spine: L1 and L4
  4. Provocative Measures
    1. Vertebral movement (flexion, extension)
    2. Increased thoracic pressure (e.g. Valsalva Maneuver)

VII. Signs

  1. Approach
    1. Include a complete Neurologic Exam
  2. 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
  3. General findings
    1. Thoracic kyphosis (from anterior wedge Fractures)
    2. Loss of lumbar lordosis (corrects for kyphosis)
    3. Tenderness over area of acute Fracture
  4. Provocative Measures
    1. Closed Fist Percussion Test
      1. Sharp pain with clenched fist (ulnar aspect) percussion of each spinous processes
    2. Supine Sign Test
      1. Patient unable to lie supine on exam table due to pain
    3. Back Pain-Inducing Test
      1. Positive if patient unable to perform specific unassisted movements (or they induce significant pain)
      2. Sequence: Sitting upright, lying supine, rolling to lateral decubitus each side, back to sitting upright

VIII. Complications

  1. Constipation, ileus, or Bowel Obstruction
  2. Urinary Retention
  3. Impaired Activities of Daily Living
  4. Loss of Vertebral height and kyphosis
  5. Loss of mobility
    1. Deep Vein Thrombosis risk
    2. Deconditioning with Muscle Weakness and atrophy
    3. Pressure Ulcers
    4. Increased bone mineral loss and OsteoporosisFracture risk (due to deconditioning and immobility)
  6. Impaired lung function (Atelectasis and Pneumonia risk)
  7. Chronic Pain
  8. Insomnia

IX. Differential Diagnosis

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

X. Labs

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

XI. Imaging

  1. Thoracolumbar Spinal XRay (AP and lateral views)
    1. Lateral view is most diagnostic
    2. Loss of Vertebral height of 20% or 4 mm from baseline is diagnostic of Vertebral Compression Fracture
    3. 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. Differentiates acute vs chronic
    3. 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
      1. Edema is associated with recent Fracture
    4. Pathologic Fracture (malignancy) suspected
      1. No Trauma History in under age 55 years
      2. Contrast enhanced MRI is recommended if cancer is suspected
  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

XII. Management: Stable Compression Fractures

  1. Confirm that Fracture site is stable (typical)
  2. Symptomatic back pain management
    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. Acetaminophen
    4. NSAIDs
    5. Lidocaine Patches
    6. Opioids may be needed for breakthrough pain (other measures are preferred)
    7. Avoid Muscle relaxants (ineffective and Fall Risk)
  3. Physical therapy
    1. Initiate early in course (>2 weeks) for best outcomes
      1. However, starting too early (first 2 weeks) may worsen Vertebral collapse and kyphosis
    2. Multi-session and multi-modal physical therapy program
      1. Flexibility
      2. Balance
      3. Return to performing Activities of Daily Living
      4. Core and antigravity Muscle Strengthening
    3. 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
    4. Encourage upper body Exercises and walking
      1. Back extensor strengthening
    5. 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
      1. Avoid chronic use due to secondary core Muscle Weakness
    2. Dynamic corset orthoses are preferred over 3 point orthoses
      1. Greater reduction in pain and improved quality of life
      2. Meccariello (2017) Aging Clin Exp Res 29(3): 443-9 [PubMed]
    3. 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. Nerve Blocks
    1. L2 Nerve root blocks
      1. Consider in symptomatic L3-4 osteoporotic compression Fractures
      2. May reduce pain for 2-4 weeks
    2. Facet Joint Injections
      1. Limited but promising evidence from small study
      2. Im (2016) Cardiovasc Intervent Radiol 39(5): 740-45 [PubMed]
  6. Procedures
    1. See surgical management below
    2. Consider for refractory severe pain or >4 to 10 weeks of persistent pain

XIII. Management: Osteoporosis Specific

  1. Maintain Vitamin D 800 IU daily
  2. Maintain Calcium 1200 mg daily
  3. 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]
  4. 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)

XIV. 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. Vertebral Augmentation for Refractory severe pain or >4 to 6 weeks (up to 10 weeks) of pain
    1. Percutaneous Vertebroplasty
      1. Liquid cement injected percutaneously into affected, compressed Vertebra
      2. Similar efficacy to (and less expensive than) Kyphoplasty in most outcomes (except Vertebral height)
    2. Balloon Kyphoplasty (Restores Vertebral height)
      1. Balloon inserted percutaneously into collapsed Vertebral body to expand it to original height
      2. Cement injected into expanded Vertebral body
      3. Restores Vertebral height, but otherwise similar efficacy to Vertebroplasty

XV. Prevention

  1. See Osteoporosis Prevention
  2. Osteoporosis Screening and management
  3. Bone loading Exercise program (e.g. walking)
  4. Muscle Strengthening
  5. Tobacco Cessation
  6. Avoid excessive Alcohol
  7. Vitamin D 800 IU daily
  8. Calcium 1200 mg daily

XVI. Course

  1. Pain typically improves over a 6 to 12 week period (resolution within 3 to 12 months in most cases)
  2. More than 50% of patients will have adequate pain reduction by 3 months of conservative therapy

XVII. Prognosis

  1. Vertebral Compression Fractures in older women
    1. Nursing Home Admission high rates
    2. Annual mortality rates approach 15% in some studies
  2. Additional future Fracture risk
    1. Additional Vertebral Fracture risk: 5 fold increased risk
    2. Other additional Fracture risk: 2-3 fold fold increased risk

XVIII. References

  1. Orman and Swaminathan in Herbert (2015) EM:Rap 15(8): 1-2
  2. Raisz in Wilson (1998) Endocrinology, p. 1223-4
  3. Creech-Organ (2026) Am Fam Physician 113(1): 51-6 [PubMed]
  4. McCarthy (2016) Am Fam Physician 94(1): 44-50 [PubMed]
  5. Old (2004) Am Fam Physician 69:111-6 [PubMed]
  6. Predey (2002) Am Fam Physician 66(4):611-17 [PubMed]

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