Lumbar Compression Fracture Follow-up

  • Author: Andrew L Sherman, MD, MS; Chief Editor: Rene Cailliet, MD   more...
 
Updated: Mar 25, 2010
 

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, only patients with either a neurologic injury associated with the fracture or a comorbid condition will qualify for inpatient rehabilitation. Patients who do not qualify may be forced to enter a skilled nursing facility for a period of time.
Next

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 the patient for progression of the fracture, which can lead to worsening kyphosis. Therefore, obtain serial radiographs for 1 year after the initial injury.
Previous
Next

Inpatient & Outpatient Medications

  • 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 (NSAIDs) 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 NSAIDs 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 in postmenopausal women.
    • 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 widely used for treatment of osteoporosis.
Previous
Next

Transfer

  • If the need for inpatient rehabilitation has been established, transfer to an inpatient unit 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.
Previous
Next

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.
  • Calcium supplementation with vitamin D is essential to prevent osteoporosis in women considered to be at high risk due to hysterectomy or genetic family history. However, the most effective calcium supplementation occurs in a woman's third and fourth decades of life, serving as a type of "bank" from which withdrawals will occur later in life.
  • A meta-analysis was performed to evaluate the efficacy of oral supplemental vitamin D in preventing nonvertebral and hip fractures among older individuals (65 y or older). The meta-analysis included 12 double-blind, randomized, controlled trials (RCTs) for nonvertebral fractures (n = 42,279) and 8 RCTs for hip fractures (n = 40,886) and compared oral vitamin D (with or without calcium) with either calcium alone or placebo. The results showed that nonvertebral fracture prevention with vitamin D is dose dependent, and a higher dose reduced fractures by at least 20% for individuals aged 65 years or older.[19]
Previous
Next

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.
Previous
Next

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.
  • Patients with spinal infections have a guarded prognosis. A retrospective study of long-term functional outcome in pyogenic spinal infection found that two thirds of patients had an adverse outcome at a median followup of 61 months.[20] Similarly, another retrospective study found that two thirds of patients with spinal tuberculosis had persistent, painful disability.[21]
Previous
Next

Patient Education

Previous
 
Contributor Information and Disclosures
Author

Andrew L Sherman, MD, MS  Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman, Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency Programs, Department of Rehabilitation Medicine, University of Miami, Leonard A Miller School of Medicine

Andrew L Sherman, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Pfizer Honoraria Speaking and teaching

Coauthor(s)

Nizam Razack, MD  FACS, JD, Assistant Professor of Neurological Surgery, Orthopedics, and Rehabilitation, University of Central Florida Medical School; Neurosurgeon, Spine and Brain Neurosurgery Center; Chairman, Department of Neurosurgery, Orlando Regional Medical Center

Nizam Razack, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, Congress of Neurological Surgeons, Florida Medical Association, and Society for Neuro-Oncology

Disclosure: Nothing to disclose.

Specialty Editor Board

Curtis W Slipman, MD  Director, University of Pennsylvania Spine Center; Associate Professor, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center

Curtis W Slipman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, International Association for the Study of Pain, and North American Spine Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Patrick M Foye, MD  Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Kelly L Allen, MD  Medical Director, Medevals

Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD  Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center

Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association

Disclosure: Nothing to disclose.

References

  1. Suh TT, Lyles KW. Osteoporosis considerations in the frail elderly. Curr Opin Rheumatol. Jul 2003;15(4):481-6. [Medline].

  2. Rapan S, Jovanovic S, Gulan G. Vertebroplasty for vertebral compression fracture. Coll Antropol. Sep 2009;33(3):911-4. [Medline].

  3. Sundaresan N, Rosen G, Boriani S. Primary malignant tumors of the spine. Orthop Clin North Am. Jan 2009;40(1):21-36, v. [Medline].

  4. Fast Facts on Osteoporosis. National Osteoporosis Foundation. Available at http://www.nof.org/osteoporosis/diseasefacts.htm. Accessed May 26. 2009.

  5. Gibson JE, Pilgram TK, Gilula LA. Response of nonmidline pain to percutaneous vertebroplasty. AJR Am J Roentgenol. Oct 2006;187(4):869-72. [Medline]. [Full Text].

  6. American College of Radiology. ACR Appropriateness Criteria® osteoporosis and bone mineral density. National Guideline Clearinghouse. Available at http://guideline.gov/summary/summary.aspx?doc_id=11559. Accessed May 26, 2009.

  7. Bredella MA, Essary B, Torriani M, Ouellette HA, Palmer WE. Use of FDG-PET in differentiating benign from malignant compression fractures. Skeletal Radiol. May 2008;37(5):405-13. [Medline]. [Full Text].

  8. Hsieh PC, Koski TR, Sciubba DM, Moller DJ, O'Shaughnessy BA, Li KW, et al. Maximizing the potential of minimally invasive spine surgery in complex spinal disorders. Neurosurg Focus. 2008;25(2):E19. [Medline].

  9. Selznick LA, Shamji MF, Isaacs RE. Minimally invasive interbody fusion for revision lumbar surgery: technical feasibility and safety. J Spinal Disord Tech. May 2009;22(3):207-13. [Medline].

  10. Castellon AT, Meves R, Avanzi O. Intraoperative neurophysiologic spinal cord monitoring in thoracolumbar burst fractures. Spine (Phila Pa 1976). Nov 15 2009;34(24):2662-8. [Medline].

  11. Dalbayrak S, Onen MR, Yilmaz M, et al. Clinical and radiographic results of balloon kyphoplasty for treatment of vertebral body metastases and multiple myelomas. J Clin Neurosci. Feb 2010;17(2):219-24. [Medline].

  12. Layton KF, Thielen KR, Koch CA, Luetmer PH, Lane JI, Wald JT, et al. Vertebroplasty, first 1000 levels of a single center: evaluation of the outcomes and complications. AJNR Am J Neuroradiol. Apr 2007;28(4):683-9. [Medline]. [Full Text].

  13. Muijs SP, Nieuwenhuijse MJ, Van Erkel AR, Dijkstra PD. Percutaneous vertebroplasty for the treatment of osteoporotic vertebral compression fractures: evaluation after 36 months. J Bone Joint Surg Br. Mar 2009;91(3):379-84. [Medline].

  14. Lo YP, Chen WJ, Chen LH, Lai PL. New vertebral fracture after vertebroplasty. J Trauma. Dec 2008;65(6):1439-45. [Medline].

  15. Trout AT, Kallmes DF, Kaufmann TJ. New fractures after vertebroplasty: adjacent fractures occur significantly sooner. AJNR Am J Neuroradiol. Jan 2006;27(1):217-23. [Medline].

  16. Wardlaw D, Cummings SR, Van Meirhaeghe J, Bastian L, Tillman JB, Ranstam J, et al. Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. Lancet. Mar 21 2009;373(9668):1016-24. [Medline].

  17. Taylor RS, Fritzell P, Taylor RJ. Balloon kyphoplasty in the management of vertebral compression fractures: an updated systematic review and meta-analysis. Eur Spine J. Aug 2007;16(8):1085-100. [Medline]. [Full Text].

  18. [Best Evidence] Ohtori S, Yamashita M, Inoue G, et al. L2 spinal nerve-block effects on acute low back pain from osteoporotic vertebral fracture. J Pain. Aug 2009;10(8):870-5. [Medline].

  19. [Best Evidence] Bischoff-Ferrari HA, Willett WC, Wong JB, Stuck AE, Staehelin HB, Orav EJ, et al. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med. Mar 23 2009;169(6):551-61. [Medline].

  20. O'Daly BJ, Morris SF, O'Rourke SK. Long-term functional outcome in pyogenic spinal infection. Spine. Apr 15 2008;33(8):E246-53. [Medline].

  21. Luzzati R, Giacomazzi D, Danzi MC, Tacconi L, Concia E, Vento S. Diagnosis, management and outcome of clinically- suspected spinal infection. J Infect. Apr 2009;58(4):259-65. [Medline].

  22. 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].

  23. 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.

  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].

  25. 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].

  26. Harrington KD. Vertebral compression fractures: differentiation between benign and malignant causes. Iowa Orthop J. 1993;13:85-96.

  27. 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].

  28. Kai MC, Anderson M, Lau EM. Exercise interventions: defusing the world's osteoporosis time bomb. Bull World Health Organ. 2003;81(11):827-30.

  29. Shaffrey CI, Shaffrey ME, Whitehill R, Nockels RP. Surgical treatment of thoracolumbar fractures. Neurosurg Clin N Am. Oct 1997;8(4):519-40. [Medline].

  30. 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].

  31. Siris ES, Chen YT, Abbott TA, et al. Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med. May 24 2004;164(10):1108-12.

  32. Teng MM, Cheng H, Ho DM, Chang CY. Intraspinal leakage of bone cement after vertebroplasty: a report of 3 cases. AJNR Am J Neuroradiol. Jan 2006;27(1):224-9. [Medline].

  33. Viljakainen HT, Natri AM, Karkkainen M, et al. A positive dose-response effect of vitamin D supplementation on site-specific bone mineral augmentation in adolescent girls: a double-blinded randomized placebo-controlled 1-year intervention. J Bone Miner Res. Jun 2006;21(6):836-44.

  34. Von Feldt JM. Managing osteoporotic fractures: minimizing pain and disability. Rev Rhum Engl Ed. Jun 30 1997;64(6 Suppl):78S-80S. [Medline].

 
Previous
Next
 
Anteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture.
Fluoroscopic view of a kyphoplasty procedure.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.