AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Osteoporosis and osteoporotic vertebral compression fractures are commonly encountered clinical problems. The definition of osteoporosis is diminished bone density measuring 2.5 standard deviations below the average bone density of healthy, 25-year-old, same-sex members of the population. In the United States, approximately 35% of women older than 65 years have osteoporosis. Vertebral compression fracture is the most common complication of osteoporosis. More than 700,000 new vertebral compression fractures occur every year in the United States alone, accounting for more than 100,000 hospital admissions and resulting in close to $1.5 billion in annual costs.

Most of patients experiencing an osteoporotic vertebral compression fracture remain asymptomatic or minimally symptomatic; however, a large number of these patients do experience significant pain, resulting in decreased quality of life and disability. Conventional medical treatment for these patients includes pain medication, activity limitation, physical therapy, and (possibly) bracing.^{1, 2} Vertebroplasty and kyphoplasty are 2 minimally invasive spinal procedures that have emerged as viable treatments for patients who do not respond to more conservative measures.^{3, 4, 5, 6} Surgery for this population of patients is not well tolerated and is typically performed only as a last resort in severe cases.

See also the following related eMedicine topics:
Osteoporosis [Orthopedic Surgery]
Osteoporosis [Pediatrics: General Medicine]
Osteoporosis (Primary)
Osteoporosis (Secondary)
Percutaneous Vertebroplasty
Vertebroplasty and Kyphoplasty, Percutaneous

See also the following related Medscape topics:
CME/CE National Osteoporosis Foundation Issues Guidelines for Osteoporosis Management
Resource Center Osteoporosis

Pathophysiology

Vertebral compression fractures characteristically demonstrate a wedge-shaped pattern with gross collapse of the anterior portion of the vertebral body and relative preservation of the posterior body height. A second common form of fracture is a central crush fracture that may frequently occur in the lower lumbar spine. Cortical and trabecular bone loss, as well as disruption of the micro-architecture of bone, are all typical of osteoporosis. Spinal flexion and axial compression have been shown to place maximal stress on the superior endplate of the vertebral body. The asymmetry of the vertebral body produces maximal stress at the anterior aspect of the cortical shell. A combination of these factors, that is, decreased, asymmetric, and irregular bone density, is a hallmark of osteoporotic bone loss. Coupled with even minimal flexion and/or axial loading, these factors predispose the osteoporotic vertebrae to wedge-shaped compression fractures, acquired kyphosis, and general height loss.

Once 1 vertebral compression fracture has occurred, a biomechanical environment is created that favors additional fractures. This occurs as a result of the vertebral compression fracture causing an additional kyphosis, shifting the patient's center of gravity anteriorly and producing a longer moment arm. This longer moment arm increases kyphotic angulation and places additional stress on the vertebrae, particularly the vertebrae adjacent to the primary fracture.

Frequency

United States

More than 24 million people have osteoporosis, placing them at risk for compression fractures. Vertebral compression fractures occur in 153 per 100,000 females and in 81 per 100,000 males. Of the 700,000 people with vertebral fractures in the United States, one third are symptomatic and require treatment.

Mortality/Morbidity

Osteoporotic vertebral compression fractures have been shown to adversely affect physical function, quality of life, and mental health and to increase mortality.

Women with vertebral fractures have been shown to have a 23% increase in age-adjusted mortality rate within 5 years of a normal compression fracture. Women with multiple or severe vertebral fractures have a 34% increase in mortality risk compared with age-adjusted controls. This is in contradistinction to hip fractures, in which a 20% increase in mortality rate occurs only within the first 6 months following the fracture.

Elderly patients prescribed pain medications and/or bed rest may experience multiple medical complications, including confusion, increased fall risk, gastrointestinal adverse effects, skin breakdown, thrombo-embolic events, and lung dysfunction.

Race

Osteoporosis occurs in all racial groups but is most common in white and Asian populations.

Sex

Vertebral compression fractures occur more commonly in females. Men also develop osteoporosis, but it tends to appear 5-10 years later than it does in women and to occur at one third the rate that it does in the female population.¹

See also the following related Medscape topic:
CME MORES May Help Identify Men at Risk for Osteoporosis 

Age

Osteoporotic vertebral compression fractures are most common in postmenopausal women. In the United States, 25% of women older than 70 years and 50% of women older than 80 years have radiographic evidence of vertebral compression fractures. Men older than 75 years typically begin to develop osteoporosis and are at increased risk of vertebral compression fracture.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Most osteoporotic vertebral compression fractures are asymptomatic and are incidentally diagnosed on radiographic examination. Patients with nonpainful vertebral compression fractures may report height loss. Any patient with measurable height loss of more than 5 cm (2 in) should be evaluated for vertebral compression fracture, because even a single vertebral compression fracture is associated with height loss. The other common causes of height loss are kyphosis, scoliosis, and spondylolisthesis.

A patient with a painful vertebral compression fracture typically describes abrupt onset of pain during an atraumatic, low-exertion activity, such as bending forward, standing from a seated position, opening a window, coughing, or sneezing. Fifty percent of patients with painful vertebral fractures give a history of a recent fall. At the time of the physician visit, the patient may have difficulty localizing the precise level of back pain. The pain is often improved with lying down and resting and is worse with standing and exertion. Occasionally, the patient may report back pain radiating around his/her trunk in a dermatomal pattern. Symptoms related to bowel or bladder changes or neurologic deficits are not characteristic of a vertebral compression fracture and warrant further evaluation for alternate diagnoses.

Physical

Patients often present with increased thoracic kyphosis or flattening of the lumbar lordosis. A normally proportioned individual usually stands with fingertips hanging down at midthigh. Direct measure of height demonstrates a loss. Spinal shortening should be suspected in any patient whose fingertips reach the lower thigh or knee. Flexion tends to aggravate the pain more than extension. On palpation, localized spinal tenderness is often present. A detailed neurologic assessment is essential in any patient presenting with back pain.

Causes

The leading risk factor for developing an osteoporotic vertebral compression fracture is a previous vertebral compression or hip fracture. Nineteen percent of women who have had 2 prior vertebral fractures and who are taking only calcium/vitamin D experience a new fracture within a year. In females, the next leading risk factor for osteoporotic vertebral compression fracture is menopause or estrogen deficiency. Additional risk factors include advanced age, cigarette smoking, physical inactivity, and poor nutrition. In addition, renal failure, liver failure, cancer, diabetes mellitus, emphysema, and vitamin D deficiency may predispose a patient to osteoporotic vertebral compression fracture. In males, low testosterone may be associated with these fractures. Steroids, anticonvulsants, cytotoxic drugs, alcohol, thyroid replacement drugs, and heparin also may be associated with osteoporotic vertebral compression fracture.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to Be Considered

Osteoporotic vertebral compression fracture (primary or secondary to bone marrow disease, endocrinopathies, osteomalacia)
Trauma
Tumor metastasis
Spinal cord compression
Arthritis
Disc degeneration
Discogenic back pain
Zygapophyseal joint disease
Hemorrhagic cyst

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Studies include serum calcium, albumin, 25-hydroxyvitamin D, phosphorus, bone alkaline phosphatase, creatinine, blood urea nitrogen, complete blood cell count with differential, prostate-specific antigen, and immuno-electrophoresis of blood and/or urine.
• Urine should be investigated for levels of calcium excretion, collagen N-telopeptides, and other markers for increased bone turnover typical of osteoporosis.

Imaging Studies

• Plain radiography of the spine, including anteroposterior and lateral views, is usually adequate for making the diagnosis of fracture. The entire spine should be evaluated, because multiple fractures occur in up to 20% of cases. Lateral flexion and extension while standing may allow evaluation for gross instability. In addition to vertebral height loss and kyphotic deformity, radiographs must be evaluated for increased interpedicular space, involvement of the posterior cortex, or laminar fracture, because these features suggest a burst fracture, which may be unstable.
• Computed tomography (CT) scanning may be performed prior to vertebroplasty or kyphoplasty, because it is the most sensitive test for identifying a defect in the posterior vertebral cortex (an exclusion criterion for either procedure). However, MRI is also adequate for this purpose.
• Magnetic resonance imaging (MRI) should be performed to assess for spinal cord compression if the fracture is between the cervical spine through the second lumbar vertebrae (after this point, the spinal cord ends and the MRI is less useful). MRI may also be helpful if metastatic disease or multiple myeloma is suspected. MRI (fat suppression test) is needed to date the compression fracture, that is, to determine whether it is acute or chronic.
• Nuclear bone scanning should be performed if metastatic disease is suspected (if, for example, pain is elicited on palpation of vertebral levels otherwise not identified as having a fracture on radiographic examination).

Other Tests

• Dual-energy radiographic absorptiometry (DRA) is helpful in establishing a diagnosis of osteoporosis.⁷
• Iliac crest bone biopsy may be indicated as a means of providing a direct evaluation of bone status when marrow disease or osteomalacia is being considered.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Rehabilitation Program

Physical Therapy

The critical element in deciding a treatment regimen is pain and percentage of vertebral collapse. If a patient rates his/her pain as being greater than 4 out of 10 (when 10 equals worst pain imaginable and 0 equals no pain) or the vertebral bodies are collapsed more than 40%, then kyphoplasty or vertebroplasty is indicated as an initial intervention. Other patients may initially attempt more conservative care.

Patients with osteoporotic vertebral compression fractures are usually treated nonoperatively. Heat, massage, analgesic medications, and bed rest may provide symptomatic relief.

Bracing used to be common. However, the use of extension bracing has become controversial because of concerns regarding the placement of increased stress on the posterior elements of the spine.

Patients should be treated for their osteoporosis with anti-osteoporotic medications, including second-generation bisphosphonates, as well as (daily) with 1500 mg of elemental calcium and 400 IU of vitamin D.

A structured exercise program is essential and should be tailored to enhance axial muscle strength. Early mobilization should be employed to prevent secondary complications of immobility. Back strengthening exercises may improve kyphotic deformity.⁸ Back extension exercises should be used preferentially over abdominal flexion exercises.^{9, 10} Weight-bearing exercises are considered the mainstay of therapy to prevent extension of osteoporosis. Crunches and sit-ups should be excluded. Many consider pilates to be an excellent physical exercise regimen. If balance is impaired, Tai Chi Chuan is recommended.

Occupational Therapy

This is primarily used in an inpatient setting.

Recreational Therapy

This is primarily used in an inpatient setting. Along with occupational therapy, recreational therapy is an important component of a patient's transition from an inpatient setting to an outpatient setting.

Medical Issues/Complications

Analgesic medications are often poorly tolerated, especially in an elderly population. Complications from anti-inflammatory and narcotic medications include confusion, increased falling risk, and gastrointestinal symptoms. Bed rest and immobilization result in disuse, osteopenia, and an increased risk of a thrombo-embolic event. All vertebral compression fractures require a systematic examination to rule out an underlying systemic illness, such as malignancy, infection, or renal or liver disease.

Surgical Intervention

The 2 main minimally invasive surgical procedures are kyphoplasty and vertebroplasty (see Other Treatment).^{3, 4, 5, 6} More aggressive surgical intervention in an osteoporotic spine is fraught with difficulties. The patient's advanced age, comorbid diseases, and difficulty in securing fixation to weakened osteoporotic bone make surgical intervention an absolute last resort. However, surgical intervention may be required in patients with neurologic impairment, such as paresis, paralysis, saddle anesthesia, or bowel or bladder changes. Surgical intervention may also be required in a patient who is clinically unimproved despite adequate conservative care.

Surgery may be indicated in a patient with radiographic evidence of instability. This is exhibited by ligamentous disruption with potential pending canal compromise or when movement is exhibited on dynamic or motion radiographic examination. The advancement of kyphosis despite adequate conservative care may also be an indication for surgery.

Consultations

• In patients with an underlying systemic disease, appropriate medical consultations are required.
• Consulting a physiatrist is appropriate, and consultation can help to assess functional limitations.
• A rheumatologist is an appropriate consultation for osteoporosis management.
• Consulting an orthopedic surgeon or a neurosurgeon is appropriate if surgery is being considered.¹¹

Other Treatment

Two minimally invasive alternatives that are available for the treatment of osteoporotic vertebral compression fractures include vertebroplasty and kyphoplasty.^{3, 4, 5, 6}

Vertebroplasty was first introduced in France in 1987 and involves the percutaneous injection of polymethylmethacrylate (PMMA) directly into the fractured vertebral body under fluoroscopic guidance.¹² This procedure stabilizes the fracture. Substantial pain relief has been noted in the majority of patients treated with this procedure.¹³

Kyphoplasty is a newer percutaneous procedure that addresses the kyphotic deformity as well as the fracture pain. Kyphoplasty involves the percutaneous insertion of an inflatable bone tamp into the fractured vertebral body under fluoroscopic guidance. The bone tamp is then inflated, elevating the endplates and restoring the vertebral body toward its original height. Thick PMMA is then injected in a controlled manner under low pressure into the cavity of the body. The bone tamp is deflated and removed. Kyphoplasty has been shown to provide significant pain relief as well as substantial improvement in the height of the collapsed vertebral body and has been found to reduce the spinal kyphosis.

The indications for vertebroplasty include stabilization of painful osteoporotic vertebral fractures, painful vertebra due to metastases or multiple myeloma, Kümmell disease, and painful vertebral hemangioma.¹⁴ Indications for kyphoplasty include painful or progressive osteoporotic and osteolytic vertebral compression fractures. Neither procedure should be performed on more than 3 levels at a single time. Contraindications and precautions for vertebroplasty include sepsis, coagulopathy, posterior vertebral body wall deficiency or fracture, inadequate intra-operative visualization of the fracture, anatomic variant limiting vertebral body access, neurologic compromise related to the fracture, and localized spine infection.

Partial or complete relief of pain symptoms is experienced by 60-100% of patients within 72 hours following vertebroplasty. This improvement has been noted to persist for at least 4 years. Kyphoplasty is a newer procedure with shorter follow-up available. However, one study found that in 1439 patients with 2194 vertebral fractures, 90% of vertebral fractures had significant pain relief within 2 weeks of kyphoplasty. In addition to pain relief, kyphoplasty has been shown to produce a 70-97% reversal of kyphotic deformity in patients.

Complications from vertebroplasty include radiculopathy, rare cement leakage into the epidural space (necessitating surgical decompression), and frequent, asymptomatic leakage of PMMA into the perivertebral veins.^{3, 4, 5, 6} This leakage has prompted concern about potential embolization of PMMA to the lungs via the venous system. Kyphoplasty uses much lower pressure to inject the cement and has been shown to have a lower rate of intravenous and transcortical leakage of contrast. However, research indicates that kyphoplasty and vertebroplasty can increase the risk of adjacent vertebral body fracture. This risk remains under active investigation.¹⁵

When kyphoplasty has been performed within 1 month of fracture, easier endplate elevation and restoration of vertebral body height has been observed. Current care emphasizes conservative medical care for approximately 1-2 months. Earlier kyphoplasty or vertebroplasty may be more appropriate when analgesic medications are insufficient for pain relief or in patients with significant kyphosis. Patients with fractures at the thoracolumbar junction may also benefit from early kyphoplasty, because this fracture location is prone to produce more significant kyphosis. However, the potential risk of future adjacent body compression fracture should be taken into consideration.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Oral medications have many roles in the treatment of patients with osteoporotic vertebral compression fractures. Pain relief is often the initial goal. Patients with osteoporosis need to be placed on anti-osteoporotic medications. As always, the benefits of the medications need to be weighed against the adverse effects. Anti-inflammatory medications may produce gastrointestinal adverse effects. Strong analgesic medications may cause confusion, disorientation, increased risk of falling, constipation, and respiratory depression.

Drug Category: Analgesic medications

Essential for providing initial pain relief.

Drug Category: Anti-osteoporotic agents

Needed to prevent progression of osteoporosis.

Drug Category: Bisphosphonates

Analogues of pyrophosphate. Act by binding to hydroxyapatite in bone matrix, thereby inhibiting the dissolution of crystals. Prevent osteoclast attachment to the bone matrix and osteoclast recruitment and viability.

Drug Category: Selective estrogen receptor modulators

May act like estrogen to prevent bone resorption.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Inpatient care is not generally required for patients with osteoporotic vertebral compression fractures. However, if neurologic injury has occurred and/or another underlying systemic disease has been detected, inpatient care may be appropriate.

Further Outpatient Care

• All patients with osteoporosis should be involved in structured, weight-bearing exercises in a physical therapy program to prevent progression of osteoporosis. Balance training programs, particularly Tai Chi Chuan, have been shown to improve balance, which is important in preventing falls.
• Serial radiographs should be obtained for 1 year following injury to be sure no kyphotic progression occurs.

In/Out Patient Meds

• Pain relief is of paramount concern. Pain medications have been discussed and may be used for a short period, typically 1-2 months. However, if pain requiring medication persists for longer than 1 month, vertebroplasty or kyphoplasty should be strongly considered. If pain medications do not provide adequate pain relief during the first month, these procedures should be considered sooner.
• Anti-osteoporotic medications are essential. Miacalcin may be taken intranasally and has been purported to reduce the pain from compression fractures.

Transfer

• Transfer to an inpatient facility is indicated in the setting of a patient with pending neurologic compromise and for patients who are unable to care for themselves at home.

Deterrence

• The key to the prevention of osteoporotic vertebral compression fractures is the prevention of osteoporosis via education of the younger population. By emphasizing a diet high in calcium and vitamin D and encouraging weight-bearing exercise in the adolescent population, the risk of osteoporosis may be minimized. In addition, modifiable risk factors should be addressed. These include smoking, low body weight, low calcium intake, estrogen deficiency (not always easy to modify because of other factors, such as heart disease), alcoholism, and inadequate physical activity. These modifiable activities should be addressed as early as possible.

Complications

• Progressive kyphosis, additional fractures, and neurologic changes are potential complications. These complications can be minimized with appropriate, expeditious care.

Prognosis

• The majority of osteoporotic vertebral compression fractures are asymptomatic. Most patients who develop significant back pain from a fracture have resolution of pain without intervention in 6-8 weeks. Many patients do, however, continue to have disabling pain. For these patients, kyphoplasty and vertebroplasty have shown excellent results, substantially relieving pain in approximately 90% of patients.

Patient Education

• Education of patients is essential in osteoporosis. Good nutrition and weight-bearing exercise may prevent or delay the development of osteoporosis and may reduce the risk of osteoporotic compression fractures. In addition to taking anti-osteoporotic medications, as well as (daily) 1500 mg of elemental calcium and 400 IU of vitamin D, patients should be taught to modify their activities by employing fall-prevention strategies. Patients should also be given the pneumococcal vaccine and undergo yearly influenza vaccinations to reduce their risk of severe coughing. Moreover, they should be instructed in proper weight-bearing exercises and extension exercises.
• For excellent patient education resources, visit eMedicine's Osteoporosis and Bone Health Center. Also, see eMedicine's patient education articles Osteoporosis, Understanding Osteoporosis Medications, and Vertebral Compression Fracture.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Osteoporotic vertebral compression fractures require a thorough evaluation for an underlying primary systemic illness, such as a tumor. In men younger than 75 years, compression fractures should mandate an investigation for endocrine or prostate abnormalities.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. Freedman BA, Potter BK, Nesti LJ, et al. Osteoporosis and vertebral compression fractures-continued missed opportunities. Spine J. Mar 14 2008;[Medline].
2. Prather H, Watson JO, Gilula LA. Nonoperative management of osteoporotic vertebral compression fractures. Injury. Sep 2007;38 Suppl 3:S40-8. [Medline].
3. Chiras J, Depriester C, Weill A, et al. [Percutaneous vertebral surgery. Technics and indications]. J Neuroradiol. Jun 1997;24(1):45-59. [Medline].
4. Karlsson MK, Hasserius R, Gerdhem P, et al. Vertebroplasty and kyphoplasty: new treatment strategies for fractures in the osteoporotic spine. Acta Orthop. Oct 2005;76(5):620-7. [Medline]. [Full Text].
5. Lin JT, Lane JM. Nonmedical management of osteoporosis. Curr Opin Rheumatol. Jul 2002;14(4):441-6. [Medline].
6. Phillips FM. Minimally invasive treatments of osteoporotic vertebral compression fractures. Spine. Aug 1 2003;28(15):S45-53. [Medline].
7. Lane JM, Russell L, Khan SN. Osteoporosis. Clin Orthop Relat Res. Mar 2000;139-50. [Medline].
8. Sinaki M, Itoi E, Wahner HW, et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone. Jun 2002;30(6):836-41. [Medline].
9. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. Oct 1984;65(10):593-6. [Medline].
10. Huntoon EA, Schmidt CK, Sinaki M. Significantly fewer refractures after vertebroplasty in patients who engage in back-extensor-strengthening exercises. Mayo Clin Proc. Jan 2008;83(1):54-7. [Medline].
11. Skedros JG, Holyoak JD, Pitts TC. Knowledge and opinions of orthopaedic surgeons concerning medical evaluation and treatment of patients with osteoporotic fracture. J Bone Joint Surg Am. Jan 2006;88(1):18-24. [Medline].
12. Tanigawa N, Komemushi A, Kariya S, et al. Relationship between cement distribution pattern and new compression fracture after percutaneous vertebroplasty. AJR Am J Roentgenol. Dec 2007;189(6):W348-52. [Medline].
13. He SC, Teng GJ, Deng G, et al. Repeat vertebroplasty for unrelieved pain at previously treated vertebral levels with osteoporotic vertebral compression fractures. Spine. Mar 15 2008;33(6):640-7. [Medline].
14. McDonald RJ, Trout AT, Gray LA, et al. Vertebroplasty in multiple myeloma: outcomes in a large patient series. AJNR Am J Neuroradiol. Jan 17 2008;[Medline].
15. Lin WC, Cheng TT, Lee YC, et al. New vertebral osteoporotic compression fractures after percutaneous vertebroplasty: retrospective analysis of risk factors. J Vasc Interv Radiol. Feb 2008;19(2):225-31. [Medline].

Article Last Updated: Apr 16, 2008