AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

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

INTRODUCTION

Section 2 of 11  

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

Background

The lumbar vertebrae are the 5 largest and strongest of all vertebrae in the spine. These vertebrae compose the lower back. They begin at the start of the lumbar curve (ie, the thoracolumbar junction) and extend to the sacrum. The strongest stabilizing muscles of the spine attach to the lumbar vertebrae. End-stage osteoporosis often culminates with bony fractures. Fractures occur most commonly in the hips, wrists, arms, and spine. Osteoporotic spine fractures are unique because they may occur without apparent trauma. A thorough diagnostic workup is always required to rule out malignancy.

In the past, treatment options were quite limited, with bracing and rest prescribed most often. While many patients improved with this regimen, some did not and were left with chronic, disabling pain. Suh and Lyles found that vertebral compression fractures were associated with significant performance impairments in physical, functional, and psychosocial domains in older women. However, this population now has new medical and surgical options that can relieve the severe pain and disability from a compression fracture.

Pathophysiology

The lumbar spine provides for both stability and support when humans ambulate. The posture of the spine (ie, a proper lumbar curve) allows humans to stay balanced in an upright position and is based on the proper rectangular shape of the spine and the elastic disks in between. Therefore, any injury that changes the shape of the lumbar spine invariably changes the posture of the spine and increases or decreases the lumbar curve. Consequently, this affects the other curves of the thoracic and cervical spine in a negative manner as the body attempts to maintain an upright posture.

Lumbar compression fractures, therefore, can be a devastating injury for 2 reasons. First, fractures can cause direct bony pain from the fracture itself, and this pain sometimes does not resolve. Second, the fracture can alter the mechanics of the posture. Most often, the result is an increase in thoracic kyphosis, sometimes to the point that the patient cannot stand upright. In trying to maintain their ability to walk, patients who are kyphotic report secondary pain in their hips, sacroiliac joints, and spinal joints. Patients with kyphotic posture are also at risk of falls and accidents, increasing the risk of secondary fractures in the spine and elsewhere.

Fractures in the lumbar spine occur for a number of reasons. In younger patients, fractures are usually due to violent trauma. Car accidents frequently cause flexion and flexion distraction injuries. Patients who jump or fall from high distances experience burst fractures. These fractures can also result in serious neurological injury. In older patients, the cause is usually nontraumatic or from a nonexternal trauma such as a fall. The most common reason these fractures occur in geriatric patients is underlying osteoporosis. Finally, other factors that can contribute to the occurrence of compression fractures include pathologic factors, including malignancy and infections.

Traumatic fractures

A few different types of fractures can occur in the lumbar (or thoracic) spine. Classification of these fractures is based on the 3-column anatomic theories of Denis. The Denis system, however, was created to classify traumatic fractures. A similar classification system does not exist for compression fractures. The main reason to use such a classification is to help determine if the fracture is stable. Instability in the Denis system implies that damage has occurred to at least 2 of the anterior, middle, or posterior columns of the lumbar spine.

• Wedge fractures are the most common type of lumbar fracture and are the typical compression fracture of malignancy or osteoporosis. They occur as a result of an axially directed central compressive force combined with an eccentric compressive force. A flexion bending moment occurs at the time of injury. In pure flexion-compression injuries, the middle column remains intact and acts as a hinge. Although wedge fractures are usually symmetric, 8-14% are asymmetric and are termed lateral wedge fractures.
• Another type of fracture involves flexion and distraction forces. These fractures are often due to lap belts in motor vehicle accidents. Commonly, the posterior columns are compromised in these injuries because the ligaments of the posterior elements are disrupted. This type of injury is quite common in young children. Most patients with flexion-distraction injuries remain neurologically intact.
• Burst fractures result from high-energy axial loads to the spine. Multiple classification systems exist for these fractures. The severity of the deformity, the severity of canal compromise, the degree of loss of vertebral body height, and the degree of neurologic deficit impact the determination of whether these injuries are unstable.

When any of the above injuries occurs with a severe rotational force, the degree of injury and amount of instability increases.

Nontraumatic fractures

In osteoporosis, osteoclastic activity exceeds osteoblastic activity, resulting in a generalized decrease in bone density. The osteoporosis softens the bone to the point even a minor fall on the tailbone, causing an axial load or flexion moment, results in one or more compression fractures (see Image 1). The fracture is usually wedge shaped. Without correction, a wedge fracture invariably increases the patient's degree of kyphosis.

The most common malignancy-related factor in the spine that can cause a fracture is metastasis. Primary cancers that spread through hematologic dissemination are the most common to metastasize to the spine. These include cancers of the prostate, kidneys, breasts, and lungs. Melanoma is less common but more aggressive. The most common primary cancer of the spine is multiple myeloma, but others (eg, osteosarcoma, aneurysmal bone cyst, hemangioma) can also manifest as a spine fracture.

Spinal infections usually start in the lumbar disk. From the disk, the infection spreads to bone, resulting in osteomyelitis. Severe pain is the hallmark sign. The exception is spinal tuberculosis or Pott disease. In this case, the disk spaces are typically spared and a compression fracture may be the initial manifestation that leads to its discovery.

Frequency

United States

Most fractures of the lumbar spine that require operative treatment occur at the thoracolumbar junction. These injuries are primarily traumatic in origin. Most nontraumatic lumbar fractures are osteoporotic in origin. These are almost invariably wedge-type compression fractures. Osteoporosis affects 30 million people in the United States. In 1992, at least 1.2 million fractures occurred due to osteoporosis, and the number surely has increased since then. Approximately 50% of all osteoporotic fractures are vertebral. Approximately one third of those injuries are lumbar, one third are thoracolumbar, and one third are thoracic in origin. Additionally, 75% of women older than 65 years who have scoliosis have at least 1 osteoporotic wedge fracture.

Mortality/Morbidity

• Mortality from a lumbar fracture is rare; however, morbidity can be significant.
• In elderly patients with acute osteoporotic fractures, pain and prolonged bed rest can lead to multiple secondary medical complications.
• In younger persons, traumatic spine injuries can result in neurologic loss of lower extremity strength and sensation, bowel and bladder function, and other problems.

Sex

Osteoporosis occurs primarily in postmenopausal women. Type 1 osteoporosis occurs in women aged 51-65 years and is associated with wrist and vertebral fractures. Estrogen deficiency is the main pathogenic factor. Type 2 osteoporosis (senile type) is observed in women and men older than 75 years, in a 2:1 ratio of women to men.

Age

In young and middle-aged adults, the most common form of lumbar fracture is traumatic in origin. High-velocity falls can cause burst fractures, and seat-belt injuries can cause wedge fractures. As stated above, women aged 51-65 years develop type 1 osteoporosis. After age 75 years, men also begin to develop type 2 osteoporosis.

CLINICAL

Section 3 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
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History

Midline back pain is the hallmark symptom of lumbar compression fractures. The pain is axial, nonradiating, aching, or stabbing in quality and may be severe and disabling. The patient should report back pain at the level where the fracture is seen on radiographs. Young adults may present with severe back pain after a trauma such as a fall or motor vehicle accident. Reports lower extremity weakness or numbness are important signs of neurologic injury from the fracture.

Recently, Gibson et al presented a study of 350 patients with 1 or more compression fracture without conal compromise or spinal nerve compression. They found 240 of the 350 patients complained of additional nonmidline pain. The pain was typically in the ribs, hip, groin, or buttocks. Treatment of the fracture with vertebroplasty (see Other Treatment) resulted in 83% of those patients gaining pain relief. Therefore, the possibility of the fracture causing referred pain outside the spine may be very real (Gibson, 2006).

Alternatively, many compression fractures are painless. Osteoporosis is a silently progressive disease. Compression fractures are often diagnosed when an elderly patient presents with symptoms such as progressive scoliosis or mechanical lower back pain and the physician obtains routine lumbar radiographs.

Finally, patients may present with a known (or unknown) malignancy. Routine spinal screening via MRI (if focal or referred pain occurs), or via bone scan (as a survey if pain has not occurred) reveals the pathologic fracture. The most common malignancies leading to spinal involvement in the form of fractures are metastasis and multiple myeloma. Often, the compression fracture is the presenting symptom or finding that leads to the diagnosis of malignancy. However, patients may have unexplained fevers, night sweats, past history of malignancy, or weight loss.

Finally, patients who have recently traveled outside of the United States, or who live in the inner city, may have symptoms of infection, such as general malaise, fever, or severely increasing pain. In these patients, osteomyelitis and Pott disease (tuberculosis spondylitis) must be ruled out.

Physical

A detailed neurologic examination is essential in all patients presenting with back pain, spine deformity, or traumatic spine injury. Most interventional procedures to alleviate pain in compression fractures are contraindicated in cases of neurologic compromise. Thus, a rectal examination is required to assess for rectal tone and sensation in trauma patients.

Upon inspection of the spine, the patient typically has a kyphotic posture that cannot be corrected. The kyphosis is caused by the wedge shape of the fracture, essentially turning squares to triangles.

Hip flexor contractures due to iliopsoas shortening are typically present.

Palpation is important to correlate any reports of pain to the radiographic level of injury. Extreme pain elicited with superficial palpation is often observed in patients with spinal infections. Moderate pain is usually present at the level of the fracture.

Causes

The main risk factor leading to an increased frequency of lumbar compression fractures is osteoporosis. In females, the leading risk factor increasing the likelihood of osteoporosis is menopause, or estrogen deficiency. Additional risk factors that may worsen the severity of osteoporosis include cigarette smoking, physical inactivity, use of prednisone and other medications, and poor nutrition. In males, all of the above risk factors apply; however, low testosterone levels also may be associated with compression fractures.

Renal failure and liver failure are both associated with osteopenia of bones. Nutritional deficiencies can decrease bone remodeling and increase osteopenia. Finally, genetics also play a role in the development of compression fractures; osteoporosis can be observed in closely related family members.

Malignancy may manifest initially as a compression fracture. The most common malignancy in the spine is metastasis. Typical malignancies that metastasize to the spine are renal cell, prostate, breast, and lung, although other types can metastasize to the spine on rare occasions. The 2 most common primary spine malignancies are multiple myeloma and lymphoma.

Infection that results in osteomyelitis can also result in a compression fracture. Typically, the most common organisms in a chronic infection are staphylococci or streptococci. Tuberculosis in the spine can occur and is called Pott disease.

DIFFERENTIALS

Section 4 of 11  

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Other Problems to be Considered

Malignant fracture
Renal failure
Hemangioma of vertebral body
Osteomyelitis
Pott disease

WORKUP

Section 5 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Blood tests: Perform a complete blood cell count with differential, prostate-specific antigen testing (for males), and erythrocyte sedimentation rate determination.
• In specific cases, serum protein electrophoresis is necessary to search for multiple myeloma.
• Urine: The urine can be sampled for markers of increased bone turnover, which occur in persons with osteoporosis. In specific cases, urine for Bence-Jones proteins is necessary to search for multiple myeloma.

Imaging Studies

• Radiography
• • Radiography is the standard imaging study for spine fractures. Anteroposterior and lateral views of the lumbar and thoracic spines are usually the minimum studies needed. Evaluation of the entire spine is important because up to 20% of all spinal fractures are multiple. Additionally, lateral flexion and extension studies, standing if possible, can be helpful to look for gross instability.
  • In burst fractures, the lateral radiograph may show decreased vertebral body height. The anteroposterior view is important because the presence of increased interpedicular space may indicate an unstable fracture.
• CT scanning
• • CT scanning is an invaluable tool to evaluate the complexity of fractures seen on radiographs and to spot subtler fractures not readily seen on radiographs. CT scanning accurately visualizes the amount of spinal canal compromise and middle canal involvement.
  • All patients with wedge fractures with more than 50% loss of height should undergo CT scanning to rule out middle column and burst fractures. In one study, 25% of fractures diagnosed initially as wedge fractures were actually burst fractures. Sagittal reconstructions can add information to the plain axial study.
  • Finally, CT scanning is the best test to visualize fractures of the posterior elements and laminae of the neural arch.
• MRI
• • MRI is required when the patient describes lower extremity motor or sensory loss. Radicular pain is another indication for MRI.
  • When canal compromise is suspected, MRI is required.
  • MRI is important because it produces the best visualization of the neural structures of the spine. Additionally, MRI, when performed with contrast enhancement, can visualize hemorrhage, tumor, and infection with the greatest sensitivity.
• Dual energy x-ray absorptiometry scanning
• • Dual energy x-ray absorptiometry (DEXA) scanning is currently the most widely used method to measure bone mineral density.
  • When compared with radiographic absorptiometry or single energy x-ray absorptiometry, DEXA scanning more precisely documents small changes in bone mass and is also more flexible because it can be used to examine both the spine and the extremities.
  • Studies using DEXA scanning have shown that people with osteoporosis have substantially lower bone density measurements than healthy, age-matched people.
  • DEXA scanning can be used to assess the treatment of osteoporosis over time.

Procedures

• When malignancy is strongly suspected, a vertebral biopsy is indicated. Usually performed under CT, this should not be performed when the suspected tumor is a chordoma or other aggressive primary spine tumor that spreads via direct extension.

TREATMENT

Section 6 of 11  

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• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Rehabilitation Program

Physical Therapy

The indications for surgical management of lumbar compression fractures are discussed in Surgical Intervention. Nonoperative treatment consists of pain relief, bracing, and rehabilitation.

Traumatic injuries with neurologic compromise usually require comprehensive inpatient rehabilitation. Mobility and strength rehabilitation programs are individualized to each patient's capabilities. All therapy disciplines comprising the multidisciplinary team participate in the comprehensive program. In most cases, rehabilitation begins with the patient in a thoracic-lumbar-sacral orthosis (TLSO). More information on comprehensive spinal cord rehabilitation is available in Spinal Cord Injury and Aging.

Elderly patients with osteoporotic compression fractures are often treated with TLSO bracing and rehabilitation. To facilitate progress in the rehabilitation program, some patients can be treated in a less restrictive corset or abdominal binder if their pain is well controlled. Early mobilization is important to prevent secondary complications of immobility. The therapy occasionally begins in an inpatient setting and then moves to an outpatient setting. Weight-bearing exercises are usually part of the program and are believed to be the main type of therapy required to prevent progression of the osteoporosis in the future. Extension exercises are also considered beneficial. Radiographic monitoring of the fracture is important because some fractures can worsen over the ensuing months, at which point they might require surgical stabilization.

Occupational Therapy

Used primarily when a patient requires inpatient rehabilitation, occupational therapy is essential to restore each patient's maximal level of function.

Recreational Therapy

Recreational therapy is an essential component of the inpatient rehabilitation program. For many patients, recreational therapists bridge the gap between the hospital and the community.

Medical Issues/Complications

Early mobilization is extremely important to decrease the frequency of secondary medical complications. Complications can occur in young adults and in elderly patients.

• Osteoporotic lumbar fractures
  • Many of these patients have comorbid medical illnesses such as heart disease, lung disease, or diabetes. Often, a period of bed rest can worsen these and other conditions.
  • Other common complications that can occur during bed rest include pneumonia, deep vein thrombosis, pulmonary embolism, skin breakdown, and gastric ulceration.
  • Finally, prolonged bed rest in an elderly individual actually can worsen the underlying osteoporosis and increase the risk of more fractures.
• Pathologic fractures
  • All compression fractures require a thorough examination to make certain the fracture is not a secondary manifestation of a systemic illness.
  • If a systemic disease is identified (eg, malignancies, infections, renal disease), proper medical treatment is needed.
• Traumatic injuries
  • As in nontraumatic injuries, early mobilization is important in traumatic injuries to prevent the secondary complications of injury.
  • These patients can also have neurologic injury to the bowel and bladder organ systems, in addition to the complications listed above. Therefore, programs for catheterization and bowel evacuation are required.

Surgical Intervention

Surgical intervention is required when neurologic dysfunction and/or instability occurs as a result of the lumbar fracture.

• Neurologic impairment
  • Neurologic problems may manifest in many ways. Reduced leg strength (paresis) or complete weakness (paralysis) is an obvious problem. Loss of sensation in the lower extremities and in the perianal area (saddle anesthesia) can be more salient but just as important. Urinary retention and incontinence of bowel and bladder function are very important signs that indicate emergency surgery is necessary.
• • The extent of neurologic problems also depends on whether the lower portion of the spinal cord (conus medullaris) or lumbar nerve roots (cauda equina) is being compressed.
  • Clinical instability is manifested primarily by severe pain that does not improve or worsens with time. Patients with clinical instability may require surgery. This information is corroborated radiographically by visualizing kyphotic deformity on plain radiographs and disruption of the interspinous ligaments on MRIs.
  • Radiographic instability refers to cases when the ligamentous disruption seen is severe, when canal compromise occurs to a degree that neurologic symptoms are present, and when movement of the bones is seen on dynamic or motion radiographs. These fractures almost always need surgical fixation, although, on rare occasions, a rigid brace still suffices. Some patients who initially are braced may show gradual worsening of symptoms on radiographs, with findings of progressive kyphosis with loss of vertebral body height. These patients also require surgical intervention.
• Types of surgery
• • The surgical procedure used for correction of a lumbar fracture depends on certain factors. These critical factors include the degree of bony canal compromise seen on axial images, the angulation on sagittal views, the level of fracture, neurologic examination findings, and the patient's premorbid health status.
  • The choice of going anterior or posterior for decompression is dictated by the location and severity of bony canal compromise. The fractured segment also must be stabilized, a procedure that is often performed with instrumentation using various plating and rod techniques. Anterior procedures involving the upper lumbar vertebrae (ie, L1, L2) may require the diaphragm to be mobilized because the crura attach at these levels. Fractures in the lower lumbar levels (eg, L5) are difficult to decompress anteriorly and are often stabilized surgically using a posterior method. Minimally invasive techniques are becoming more pervasive and popular and soon should impact the ability to perform surgery in these complex cases.
• Postoperative bracing
• • Once a patient has undergone surgery, a brace is prescribed in the postoperative period depending on the etiology of the fracture.
  • The time period is variable for each individual patient, depending on his or her health status.

Consultations

In patients thought to have a pathologic cause for lumbar fractures, appropriate consultations with medical specialists are required to assist with either the diagnostic workup or medical management of these conditions.

• Orthopedic and neurosurgical specialists are consulted in traumatic injuries to assist with surgical management and to help decide if the fracture can be managed nonoperatively via kyphoplasty. Consultation with a surgeon also may be required in nontraumatic lumbar fractures if radiographic progression occurs or if the pain does not improve.
• A rheumatologist is often helpful in the treatment of generalized osteoporosis.
• A physiatrist should almost always be consulted in these cases to assist with rehabilitation, brace management, pain management, and functional restoration of the fracture patient.
• A specialist who performs vertebroplasty (eg, physiatrist, radiologist, surgeon, pain management specialist) should be consulted if kyphoplasty cannot be performed and the pain is not improving with bracing over the first 2-6 weeks.

Other Treatment

Two related procedures (ie, vertebroplasty, kyphoplasty) are now available when the patient with a lumbar wedge fracture continues to experience pain despite aggressive conservative treatment.

• Vertebroplasty has been available for many years. This procedure involves injecting a form of cement polymer into the fractured vertebral body. This procedure allows better resistance of the vertebral body to physiologic loads when the patient is upright, thus decreasing the amount of pain associated with the fracture. The procedure may be performed with the patient under local or general anesthesia. A percutaneous trocar or large needle is introduced into the fractured body through the pedicle, and the cement is injected. Fluoroscopy is used to guide the surgeon for correct localization.

  The main risk of vertebroplasty, other than spread to the neural structures, is subsequent vertebral body fracture. This occurs with increased frequency in patients who have recently undergone vertebroplasty. Trout et al found the risk for subsequent fracture to be 4 and 1/2 times greater in patients who underwent the procedure versus those who did not (Trout, 2006).

• Kyphoplasty is similar to vertebroplasty, except a balloon is used to help expand the volume of the fractured segment prior to introducing the cement polymer. Kyphoplasty may be the treatment of choice in patients with secondary posture kyphosis because this procedure potentially allows for better correction of the deformity caused by the fracture. A 2004 study also showed an ability to increase vertebral height with kyphoplasty. Kyphoplasty also makes extrusion of cement into the spinal canal less likely because the cement is delivered into a closed balloon. Unfortunately, kyphoplasty cannot be performed for every fracture. Canal compromise usually contraindicates kyphoplasty (and sometimes vertebroplasty). An extremely severe fracture may not allow the balloon to enter.
• Malignant fractures are more often treated surgically with cement similar to that used in vertebroplasty. Fluoroscopy is used in a manner similar to that used in vertebroplasty.
• The main risk for both vertebroplasty and kyphoplasty is migration of bone or cement fragments into the spinal canal. Adjacent-level fractures are often reported with kyphoplasty, but research is ongoing to try to reduce the frequency of this complication.
• Despite the risks, these procedures have become so successful they are now being advocated earlier in the course of treatment. At first, they were used after brace failure 10-12 weeks after the fracture occurred; however, many authorities now advocate the procedure 2-6 weeks after the fracture onset in selected patients.

MEDICATION

Section 7 of 11  

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Oral medications are useful in patients with lumbar fractures for many reasons. The initial goal for most patients is pain relief. In geriatric patients, the goal of pain relief must be balanced by the potential adverse effects of some of the stronger pain medications. Often, the strongest pain medications can cause severe disorientation, respiratory depression, and constipation.

The second goal is to prevent further osteoporosis in these patients. Patients with spinal cord injuries need many different medications to assist with their rehabilitation and daily function. These medications are discussed in other articles on spinal cord injuries.

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or sustained fractures.

Drug Category: Parathyroid hormones, recombinant

Stimulate new bone formation on trabecular and cortical (periosteal and/or endosteal) bone surfaces by preferential stimulation of osteoblastic activity over osteoclastic activity.

Drug Category: Antiosteoporotic agents

Used to prevent worsening of osteoporosis and occasionally can reverse the process.

Drug Category: Bisphosphonates

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

Drug Category: Selective estrogen modulators

May act like estrogen to prevent bone resorption.

FOLLOW-UP

Section 8 of 11  

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• Follow-up
• Miscellaneous
• Multimedia
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Further Inpatient Care

• Comprehensive inpatient rehabilitation is required when a traumatic lumbar fracture results in severe neurologic injury to the spinal cord, conus, or cauda equina region. Elderly patients may require inpatient rehabilitation when their fractures render them unable to function independently in their home environment. Typically, however, either a neurologic injury associated with the fracture or a comorbid condition is required to allow for the rehabilitation to occur in an inpatient setting. If the patient does not qualify, then they may be forced to enter a skilled nursing facility for a period of time.

Further Outpatient Care

• Physical therapy
• • Weight-bearing exercise is extremely important to prevent progression of osteoporosis and prevent future lumbar fractures.
  • If spinal stenosis is not a concern, extension exercises may help speed healing of the fracture and reduce morbidity.
  • Outpatient therapy also should focus on fall prevention and functional activities.
• Medical survey
• • Throughout the year following the initial lumbar injury, the rehabilitation physician needs to monitor each patient for progression of his or her fracture.
  • Progressive kyphosis can occur when the fracture progresses. Therefore, obtain serial radiographs for 1 year after the initial injury.

In/Out Patient Meds

• Pain relief
• • Pain relief is required to make the patient comfortable and enable him or her to begin rehabilitation.
  • In the acute stage, narcotic pain medications may be required; however, these medications must be titrated to avoid adverse effects. Elderly patients can frequently become confused when taking these medications and can have falls and further injuries. Constipation is also a significant concern in the elderly.
  • Calcitonin (Miacalcin), taken intranasally to prevent osteoporosis, has been found anecdotally by clinicians to reduce the severity of pain from compression fractures.
  • The use of nonsteroidal anti-inflammatory drugs had been discouraged in this setting because they may reduce radiographic healing; however, in the case of a stable wedge fracture, this reduction in healing may not be a factor, permitting use of nonsteroidal anti-inflammatory drugs for pain relief. The pain should be characterized and classified as bony or axial pain versus radicular or neuropathic pain, because the latter type of pain is treated differently.
• Osteoporosis
• • Treatment options for osteoporosis have increased over the last few years. Estrogen replacement is still believed to be the most effective way to prevent and even reverse osteoporosis.
  • Calcium supplementation is recommended. Intranasal calcitonin can arrest the osteoporosis and can decrease pain from the vertebral fracture.
  • Alendronate (Fosamax) and raloxifene hydrochloride (Evista) are recent and popular medications used to treat the underlying osteoporosis.

Transfer

• Transfer to an inpatient unit occurs after the need for inpatient rehabilitation has been established. The transfer occurs once the patient has achieved spinal and medical stability. Surgery can be performed in certain difficult cases to speed up the patient's transfer to the rehabilitation service.

Deterrence

• The key to preventing nontraumatic lumbar compression fractures is to prevent or minimize osteoporosis and to minimize potential falls. Good evidence indicates that a weight-bearing exercise program accomplishes both objectives.
• It is well described that calcium supplementation with vitamin D is essential to prevent osteoporosis in women considered to be high risk due to hysterectomy or genetic family history. However, the most effective calcium supplementation occurs when the female is in her third and fourth decade of life, serving as a type of "bank" from which withdrawals will occur later in life.

Complications

• Complications can occur, both early in the course of compression fractures and later during the follow-up phase. One study reported on 22 patients who developed late neurologic leg symptoms within a year after their injury, when no neurologic symptoms were present initially. Progressive kyphosis can also occur and occasionally restricts function, necessitating surgical correction.

Prognosis

• In general, prognosis after simple compression fractures is excellent for most patients to improve with little or no residual back pain and no functional impairments. Vertebroplasty and kyphoplasty have improved the outlook in many patients who develop chronic back pain that does not improve with initial conservative treatments. These procedures have become so successful they are used earlier in the course of treatment. Patients with traumatic spine injuries have a prognosis based more on neurologic level and whether their spinal cord or root injuries are complete or incomplete.

Patient Education

• Patient education is essential to preventing osteoporosis and lumbar fractures because good nutrition and proper exercise are significantly beneficial in prevention.
• For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center and Bone Health Center. Also, see eMedicine's patient education articles Osteoporosis and Vertebral Compression Fracture.

MISCELLANEOUS

Section 9 of 11  

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• Differentials
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• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Often, lumbar compression fractures create legal issues. Trauma victims often have lawsuits pending, which sometimes can interfere with obtaining proper medical care. The treating physician needs to investigate for a primary medical cause, other than osteoporosis, for the compression fracture. Compression fractures in males younger than 75 years are unusual without trauma, and the patient should be examined thoroughly for endocrine or prostate abnormalities. Malignancy should always be considered, even if a clear traumatic injury was present at onset.

Special Concerns

• Geriatric patients present special concerns because the fracture indicates that some other primary process is occurring. Whether it is benign osteoporosis or a malignant breast cancer, these primary conditions must be identified and treated along with the fracture itself.

MULTIMEDIA

Section 10 of 11  

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• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Anteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture.
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Media type:  X-RAY

Media file 2:  Fluoroscopic view of a kyphoplasty procedure.
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Media type:  X-RAY

REFERENCES

Section 11 of 11

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

• Benzel EC, Ball PA. Management of low lumbar fractures by dorsal decompression, fusion, and lumbosacral laminar distraction fixation. J Neurosurg. Apr 2000;92(2 Suppl):142-8. [Medline].
• Crandall D, Slaughter D, Hankins PJ, et al. Acute versus chronic vertebral compression fractures treated with kyphoplasty: early results. Spine J. Jul-Aug 2004;4(4):418-24.
• Dunnagan SA, Knox MF, Deaton CW. Osteoporotic compression fracture with persistent pain. Treatment with percutaneous vertebroplasty. J Ark Med Soc. Dec 1999;96(7):258-9. [Medline].
• Garfin SR, Yuan HA, Reiley MA. New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine. Jul 15 2001;26(14):1511-5. [Medline].
• Gibson JE, Pilgram TK, Gilula LA. Response of nonmidline pain to percutaneous vertebroplasty. AJR Am J Roentgenol. Oct 2006;187(4):869-72.
• Harrington KD. Vertebral compression fractures: differentiation between benign and malignant causes. Iowa Orthop J. 1993;13:85-96.
• Hu SS, Capen DA, Rimoldi RL, Zigler JE. The effect of surgical decompression on neurologic outcome after lumbar fractures. Clin Orthop. Mar 1993;(288):166-73. [Medline].
• Kai MC, Anderson M, Lau EM. Exercise interventions: defusing the world''s osteoporosis time bomb. Bull World Health Organ. 2003;81(11):827-30.
• Scott MP, Weiner AJ, Hazelrigg TI. The molecular organization of the Antennapedia locus of Drosophila. Cell. Dec 1983;35(3 Pt 2):763-76.
• Shaffrey CI, Shaffrey ME, Whitehill R, Nockels RP. Surgical treatment of thoracolumbar fractures. Neurosurg Clin N Am. Oct 1997;8(4):519-40. [Medline].
• Sinaki M, Wollan PC, Scott RW, Gelczer RK. Can strong back extensors prevent vertebral fractures in women with osteoporosis?. Mayo Clin Proc. Oct 1996;71(10):951-6. [Medline].
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Article Last Updated: Feb 10, 2007