eMedicine Specialties > Physical Medicine and Rehabilitation > Lumbar Spine Disorders

Lumbar Compression Fracture

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, Leonard A Miller School of Medicine, University of Miami
Nizam Razack, MD, FACS, Assistant Professor of Neurological Surgery, Orthopedics, and Rehabilitation, University of Miami; Neurosurgeon, Spine and Brain Neurosurgery Center; Chairman, Department of Neurosurgery, Orlando Regional Medical Center

Updated: Oct 28, 2009

Introduction

Background

The lumbar vertebrae are the 5 largest and strongest of all vertebrae in the spine. These vertebrae comprise 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. Fractures of lumbar vertebrae, therefore, occur in the setting of either severe trauma or pathologic weakening of the bone. Osteoporosis is the underlying cause of many lumbar fractures, especially in postmenopausal women. Osteoporotic spinal fractures are unique in that they may occur without apparent trauma. However, a thorough diagnostic workup is always required to rule out spinal malignancy. (See image below and Image 1.)

Anteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture.

Pathophysiology

The lumbar spine provides both stability and support, allowing humans to walk upright. Proper function of the lumbar spine requires that it have a normal posture (ie, a normal lumbar curve). Any injury that changes the shape of a lumbar vertebra will alter the lumbar posture, increasing or decreasing the lumbar curve. As the body attempts to compensate for the alteration in the lumbar spine in order to maintain an upright posture, this will tend to distort the curves of the thoracic and cervical spine.

Lumbar compression fractures can be a devastating injury, therefore, for 2 reasons. First, the fracture itself can cause significant pain, 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 with kyphosis report secondary pain in their hips, sacroiliac joints, and spinal joints. These patients are also at risk for 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. Jumps or falls from heights cause burst fractures. These fractures can also result in serious neurological injury. In older patients, lumbar compression fractures usually occur in the absence of trauma, or in the context of minor trauma, such as a fall. The most common underlying reason for these fractures in geriatric patients, especially women, is osteoporosis. Other disorders that can contribute to the occurrence of compression fractures include malignancy, infections, and renal disease.

Traumatic fractures

Different types of fractures can occur in the lumbar (or thoracic) spine. Classification of these fractures is based on the 3-column anatomic theory of Denis, which describes anterior, middle, and posterior spinal columns consisting of aspects of the spine and their corresponding ligaments and other soft-tissue elements. 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 whether a fracture is stable. Instability in the Denis system implies that damage has occurred to at least 2 of the 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. 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.
• Fractures involving flexion and distraction forces 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 extent of loss of vertebral body height, and the degree of neurologic deficit affect 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 of instability increases.

Nontraumatic fractures

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

Malignancies that result in spinal fractures are most commonly metastases rather than primary bone cancers. Primary cancers that often spread to the spine via hematologic dissemination include cancers of the prostate, kidneys, breasts, and lungs. Melanoma is a less common but more aggressive cause of spinal metastasis. The most common primary cancer of the spine is multiple myeloma, but others, including a variety of sarcomas,² can also manifest as a spinal fracture. Nonmalignant lesions that can cause fractures include aneurysmal bone cyst and hemangioma.

Spinal infections usually start in the lumbar intervertebral disk. From the disk, the infection spreads to bone, resulting in osteomyelitis. Severe pain is the hallmark symptom. 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. The National Osteoporosis Foundation (NOF) estimates that currently, 10 million individuals in the United States have osteoporosis, and 34 million more have low bone mass.³ In 2005, osteoporosis was responsible for more than 2 million fractures; approximately 547,000 of those were vertebral fractures. Approximately one third of osteoporotic vertebral 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, neurologic damage from traumatic spine injuries can result in problems such as loss of lower extremity strength and sensation and loss of bowel and bladder control.

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 etiologic 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, most lumbar fractures are traumatic in origin. High-velocity falls can cause burst fractures, and seat-belt injuries can cause wedge fractures. As stated above, women 51-65 years old develop type 1 osteoporosis. After age 75 years, men also begin to develop type 2 osteoporosis.

Clinical

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 location of the pain corresponds to the fracture site, as seen on radiographs. In elderly patients with severe osteroporosis, however, there may be no pain at all as the fracture occurs spontaneously.

Young adults may present with severe back pain following an accident, such as a fall or a motor vehicle accident. Lower extremity weakness or numbness are important symptoms of neurologic injury from the fracture.

Vertebral fractures may also cause referred pain. Gibson et al presented a study of 350 patient encounters in 288 patients with 1 or more compression fracture without conus medullaris compromise or spinal nerve compression. They found that nonmidline pain was present in 240 of the 350 encounters. 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.⁴

Alternatively, many compression fractures are painless. Osteoporosis is a silently progressive disease. Osteoporotic 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 magnetic resonance imaging (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 manifestation that leads to the diagnosis of malignancy. However, patients may also 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 fractured vertebra; the fracture essentially turns the lateral conformation of the vertebra from a square to a triangle.

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 principal underlying cause of lumbar compression fractures is osteoporosis. In women, the leading risk factor for 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 nonhormonal risk factors apply; however, low testosterone levels also may be associated with compression fractures.

Renal failure and liver failure are both associated with osteopenia. 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 can occur in the spine and is called Pott disease.

Differential Diagnoses

Other Problems to Be Considered

Spinal malignancy resulting in fracture
Renal failure
Hemangioma of vertebral body
Osteomyelitis
Pott disease

Workup

Laboratory Studies

• Blood tests: Perform a complete blood cell count with differential, prostate-specific antigen testing (in middle-aged and older men), and erythrocyte sedimentation rate determination.
  • Serum protein electrophoresis is indicated in selected cases, to assess 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.
• Computed tomography (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 vertebral 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 radiographic absorptiometry (DRA) scanning
  • DRA scanning is currently the most widely used method to measure bone mineral density. The American College of Radiology recommends posterior-anterior spine DRA as the most appropriate study for the identification of low bone density and fracture risk in postmenopausal women older than 50 years and men older than 50 with risk factors for osteoporosis.⁵
  • When compared with radiographic absorptiometry or single energy radiographic absorptiometry, DRA 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 DRA scanning have shown that people with osteoporosis have substantially lower bone density measurements than healthy, age-matched people.
  • DRA scanning can be used to assess the response to treatment of osteoporosis over time.
• Positron emission tomography (PET) scanning

  PET scanning has been used to differentiate benign compression fractures from malignant ones. However, therapy with bone marrow–stimulating agents may result in false-positive scans for malignant fracture.⁶

Procedures

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

Treatment

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 over the ensuing months is important, because some fractures can worsen to the point at which they require surgical stabilization.

Occupational Therapy

Used primarily when a patient requires inpatient rehabilitation, occupational therapy is essential to restore the 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.
  • Prolonged bed rest in an elderly individual can worsen underlying osteoporosis and increase the risk of additional fractures.
• Pathologic fractures
  • All patients with 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, malignancy, infection, renal disease), proper medical treatment is needed.
• Traumatic injuries
  • As in nontraumatic injuries, early mobilization is important in patients with traumatic injuries, to prevent secondary complications.
  • These patients can also have neurologic injury affecting the bowel and bladder, 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 just as important. Urinary retention and urinary and fecal incontinence are very important signs that indicate the need for emergency surgery.
  • The extent of neurologic problems also depends on whether there is compression of the lower portion of the spinal cord (conus medullaris) or lumbar nerve roots (cauda equina).
  • Clinical instability is manifested primarily by severe pain that does not improve or that 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 in which the ligamentous disruption is severe, canal compromise occurs to a degree that neurologic symptoms are present, and movement of the fracture fragments is seen on dynamic or motion radiographs. These fractures almost always need surgical fixation, although on rare occasions a rigid brace will suffice. 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 an anterior or a posterior approach 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.^7,8
• 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 individual patients, depending on their 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

• Vertebroplasty has been available for many years. This procedure involves injecting a form of cement polymer into the fractured vertebral body. The vertebral body then has better resistance 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.
  • A Mayo Clinic review of the first 1000 compression fractures treated by vertebroplasty at that institution found a high rate of success and a low rate of complications, the most common being rib fractures. Most patients reported significant pain relief at the 2-hour postprocedure evaluation.⁹ A prospective study from the Netherlands with 36-month followup found an immediate, significant, and lasting reduction in the average and worst back pain with vertebroplasty.¹⁰
  • The main risk of vertebroplasty, other than spread of the cement to neural structures, is subsequent vertebral body fracture, often of an adjacent vertebra.¹¹  This occurs with increased frequency in patients who have recently undergone vertebroplasty. Trout and colleagues found the risk for subsequent fracture to be 4 1/2 times greater in patients who underwent the procedure versus those who did not.¹²
• Kyphoplasty is similar to vertebroplasty, except a balloon is used to expand the volume of the fractured segment prior to introducing the cement polymer¹³ (see image below and Image 2).
  • Kyphoplasty may be the treatment of choice in patients with secondary posture kyphosis, because the procedure appears to be able to partly restore vertebral height and thereby reduce kyphotic deformity.¹⁴  Extrusion of cement into the spinal canal is less likely with kyphoplasty than with vertebroplasty, 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.

Fluoroscopic view of a kyphoplasty procedure.

• The main risk for vertebroplasty and kyphoplasty is migration of bone or cement fragments into the spinal canal. Leakage of cement into the venous circulation, with subsequent pulmonary embolism, has also been reported.^9,14 Adjacent-level fractures are often reported with kyphoplasty, but research is ongoing to try to reduce the frequency of this complication.
• Despite the risks, vertebroplasty and kyphoplasty have proved so successful that 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 use of these procedures 2-6 weeks after the fracture in selected patients.
• Malignant fractures are more often treated surgically with cement, but vertebroplasty and kyphoplasty are also used to provide palliation of pain and symptom relief.² Fluoroscopy is used in a manner similar to that used in vertebroplasty.

Medication

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. A variety of agents may be used for this purpose, including parathyroid hormone, antiosteoporotic agents, bisphosphonates, and selective estrogen modulators.

Patients with spinal cord injuries need many different medications to assist with their rehabilitation and daily function (eg, to treat spasticity or autonomic dysreflexia).

Ohtori et al found that an L2 spinal nerve block may provide temporary relief of low back pain from acute osteoporotic lumbar vertebral fractures.³¹ In a randomized, controlled study, 60 patients with acute L3 or L4 osteoporotic vertebral fractures received 1.5 mL of 1% lidocaine in a spinal nerve root block or a subcutaneous injection. Patients who received the L2 block showed greater improvement in pain relief, as measured by the visual analog scale score, at 1 hour, 1 week, and 2 weeks after treatment (P <.05). From 1 month to 4 months after treatment, however, significant pain-score differences between the groups no longer existed (P >.05). The authors concluded that, although L2 spinal nerve blocks had no long-term effects on pain and social function, they provided effective pain relief for 2 weeks.

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 fractures or other trauma.

Acetaminophen with codeine (Tylenol with codeine)

A centrally acting analgesic, often appropriate in elderly patients with moderate back pain.

Dosing

Adult

1 tab PO q4-6h prn; often a tid/qid dosing schedule can prevent cycling of pain; not to exceed 4000 mg/d; codeine can then be given independent of acetaminophen

Pediatric

Administer weight-based dosing

Interactions

Toxicity increases with CNS depressants or TCAs

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in patients dependent on opiates because this substitution may result in acute opiate withdrawal symptoms; caution in severe renal or hepatic dysfunction

Oxycodone (OxyContin, OxyIR, Roxicodone)

Reserved for patients with more severe back pain from their fracture; can be given in short- or long-acting form.

Dosing

Adult

5-10 mg PO q4-6h prn; 10-20 mg of long-acting form can be given bid with fewer fluctuations in pain level

Pediatric

Not established

Interactions

Phenothiazines may antagonize analgesic effects; MAOIs, general anesthesia, CNS depressants, and TCAs may increase toxicity

Contraindications

Documented history of dependence or abuse of these medications; need to operate heavy machinery or drive

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Pregnancy category D if used for prolonged periods or in high doses at term; caution in COPD, emphysema, and renal insufficiency

Acetaminophen (Tylenol, Panadol, Feverall)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.

Dosing

Adult

375-650 mg PO q4-6h prn or 1000 mg PO q6-8h prn; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h

Interactions

Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; known G-6-P deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in people with long-term alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative doses exceeding recommended maximum dose

Tramadol hydrochloride (Ultram, Ultram ER)

Centrally acting analgesics. Although mode of action is not completely understood, from animal tests, at least 2 complementary mechanisms appear applicable: binding of parent and M1 metabolite to micro-opioid receptors and weak inhibition of reuptake of norepinephrine and serotonin.

Dosing

Adult

Ultram: 50-100 mg PO q6-8h
Ultram ER: 100-300 mg PO qd

Pediatric

Not established

Interactions

Significantly decrease carbamazepine effects; cimetidine increases toxicity; risk of serotonin syndrome with coadministration of antidepressants

Contraindications

Documented hypersensitivity; opioid-dependent patients; concurrent use of MAOI or within 14 d; use of SSRIs, TCAs, or opioids; acute alcohol intoxication

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Seizures have been reported in patients receiving Ultram within the recommended dosage range; spontaneous postmarketing reports indicate that seizure risk is increased with doses of Ultram above the recommended dosing range; risk of convulsions may also increase in patients with epilepsy, history of seizures, or a recognized risk for seizure (eg, head trauma, metabolic disorders, alcohol and drug withdrawal, CNS infections); in Ultram overdose, naloxone administration may increase risk of seizure; administer Ultram cautiously in patients at risk for respiratory depression; may impair mental and or physical abilities required for performance of potentially hazardous tasks such as driving car or operating machinery

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderate to severe pain.

Dosing

Adult

1-2 tab/cap PO q4-6h prn for pain

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone PO q4-6h prn

Interactions

Phenothiazines may decrease analgesic effects; toxicity increases with coadministration of either CNS depressants or TCAs

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly patients; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg acetaminophen in 24 h; higher doses may cause liver toxicity

Hydromorphone (Dilaudid)

Potent semisynthetic opiate agonist similar in structure to morphine. Approximately 7-8 times as potent as morphine on mg-to-mg basis with shorter or similar duration of action.

Dosing

Adult

1-4 mg PO q4-6h prn; alternatively, 1-2 mg IV/IM/SC q4-6h prn; adjust dose according to pain scale assessment

Pediatric

Not established

Interactions

Hydantoins may decrease effects; phenothiazines, CNS depressants, and TCAs may increase toxicity

Contraindications

Documented hypersensitivity; obstetrical analgesia, increased intracranial pressure, respiratory depression, ulcerative colitis, Crohn disease, abdominal cramping and distention

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Pregnancy category D in prolonged use or high doses at term; caution in patients with head injuries because may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution postoperatively and with history of pulmonary disease (suppresses cough reflex); increased dosing levels, due to tolerance, may aggravate or cause seizures (even without prior history); adjust dose in renal insufficiency (do not use in severe renal dysfunction); normeperidine metabolite accumulation may induce CNS toxicity; monitor closely for morphine-induced seizure activity if prior seizure history

Fentanyl (Duragesic)

A synthetic opioid that is 75-200 times more potent with much shorter half-life than morphine sulfate. Has less hypotensive effects and is safer in patients with hyperactive airway disease than morphine because of minimal-to-no associated histamine release. By itself, it causes little cardiovascular compromise, although addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.
Highly lipophilic and protein-bound. Prolonged exposure leads to accumulation in fat and delays weaning process.
Consider continuous infusion because of short half-life.
Parenteral form is DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia and during immediate postoperative period.
Excellent choice for pain management and sedation of short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone.
After initial parenteral dose, subsequent parenteral doses should not be titrated more frequently than q3h or q6h thereafter.
Transdermal form is used only for chronic pain conditions in opioid-tolerant patients. When using transdermal dosage form, most patients are controlled with 72-h dosing intervals; however, some require dosing intervals of 48 h.

Dosing

Adult

Emergency: 0.5-2 mcg/kg/dose IM/IV
Analgesia: 0.5-1 mcg/kg/dose IM/IV q30-60min
Transdermal: Apply a 25-mcg/h system q48-72h

Pediatric

<2 years: 2-3 mcg/kg/dose IM/IV q30-60min
2-12 years: 1-2 mcg/kg/dose IM/IV q60min
>12 years: Administer as in adults

Interactions

Phenothiazines may antagonize analgesic effects of opiate agonists; TCAs may potentiate adverse effects when both drugs are used concurrently

Contraindications

Documented hypersensitivity; hypotension or potentially compromised airway in which establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction known as chest wall rigidity syndrome may require neuromuscular blockade in order to increase ventilation

Morphine sulfate (Roxanol, MSIR, MS Contin)

DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.

Dosing

Adult

Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC; reassess hemodynamic effects of dose

Pediatric

Infants and children: 0.1-0.2 mg/kg dose IV/IM/SC q2-4h prn; not to exceed 15 mg/dose; may initiate at 0.05 mg/kg/dose

Interactions

Phenothiazines may antagonize analgesic effects of opiate agonists; TCAs, MAOIs, and other CNS depressants may potentiate adverse effects

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Tramadol 37.5 mg /APAP 325 mg (Ultracet)

Centrally acting pain medication that combines tramadol hydrochloride with acetaminophen. Clinical trials demonstrated that the combination offers better pain relief over either medication alone. Indicated for the short-term (5 days or less) management of acute pain.

Dosing

Adult

2 tab PO q4-6h prn pain for 8 d maximum

Pediatric

Not established

Interactions

Tramadol decreases carbamazepine effects significantly; cimetidine increases toxicity; risk of serotonin syndrome increases with coadministration of antidepressants

Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; opioid-dependent patients; concurrent use of MAOI or within 14 days; use of SSRIs, TCAs, opioids; acute alcohol intoxication; known G-6-PD deficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tramadol can cause dizziness, nausea, constipation, sweating, pruritus; additive sedation with alcohol and TCAs; abrupt discontinuation can precipitate opioid withdrawal symptoms; adjust dose in liver disease, myxedema, hypothyroidism, hypoadrenalism; pregnancy, breast-feeding; seizure; development of tolerance or dependency with extended use

Hepatotoxicity possible with acetaminophen in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose

Parathyroid hormones, recombinant

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

Teriparatide (Forteo)

Recombinant human parathyroid hormone rhPTH(1-34), which has identical sequence to 34 N-terminal amino acids (biologically active region) of 84-amino acid human parathyroid hormone. Acts as endogenous parathyroid hormone, thus regulating calcium and phosphate metabolism in bone and kidney. Works primarily to stimulate new bone by increasing number and activity of osteoblasts (bone-forming cells). Additional physiological actions include regulation of bone metabolism, renal tubular reabsorption of calcium and phosphate, and intestinal calcium absorption. When administered with calcium and vitamin D, teriparatide increases bone mineral density and decreases risk of fractures in patients with osteoporosis.

Dosing

Adult

20 mcg SC qd

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; increased risk for osteosarcoma (including those with Paget disease of bone or unexplained elevations of alkaline phosphatase, open epiphyses, or prior radiation therapy involving the skeleton); children or growing adults; patients with bone metastases or history of skeletal malignancies and those with metabolic bone diseases other than osteoporosis

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor for hypercalcemia; may cause orthostatic hypotension (particularly following first several doses), dizziness, or leg cramps

Antiosteoporotic agents

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

Calcitonin (Miacalcin, Osteocalcin)

Administered most often intranasally. Advantage is that it also can relieve some of the back pain associated with fracture.

Dosing

Adult

1 puff 200 IU/d in alternating nostrils; 100 IU SC qd/qod

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hypocalcemia may occur; examine urine sediment during prolonged therapy

Bisphosphonates

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

Alendronate (Fosamax)

A bisphosphonate that acts as a specific inhibitor of osteoclast-mediated bone resorption. Patients should be upright and not lie down for 30 min after taking medication.

Dosing

Adult

10 mg PO qd; must take at least 30 min before first food intake of day

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; abnormalities of the esophagus that delay esophageal emptying; inability to sit upright for at least 30 min; hypocalcemia

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hypocalcemia must be corrected before initiating treatment; not recommended for patients with renal insufficiency

Selective estrogen modulators

May act like estrogen to prevent bone resorption.

Raloxifene hydrochloride (Evista)

Selective estrogen receptor modulator that decreases bone loss.

Dosing

Adult

60 mg PO qd

Pediatric

Not established

Interactions

Concomitant use with estrogen replacement medication not recommended; coadministration of cholestyramine not recommended

Contraindications

Documented hypersensitivity; breastfeeding; women who could become pregnant; history of thromboembolic events

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Not associated with an increased risk of breast cancer; hot flashes and leg cramps are most common adverse effects

Follow-up

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.

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.

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.

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.

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.¹⁵

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.
• 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.¹⁶ Similarly, another retrospective study found that two thirds of patients with spinal tuberculosis had persistent, painful disability.¹⁷

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 Osteoporosis and Bone Health Center. Also, see eMedicine's patient education articles Osteoporosis and Vertebral Compression Fracture.

Miscellaneous

Medicolegal 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

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

Media file 2: Fluoroscopic view of a kyphoplasty procedure.

References

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

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

4. 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].

5. American College of Radiology. ACR Appropriateness Criteria® osteoporosis and bone mineral density. National Guideline Clearinghouse. Available at http://www.guideline.gov/summary/summary.aspx?doc_id=11559&nbr=005990. Accessed May 26, 2009.

6. 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].

7. 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].

8. 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].

9. 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].

10. 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].

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

12. 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].

13. 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].

14. 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].

15. [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].

16. 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].

17. 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].

18. 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].

19. 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.

20. 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].

21. 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].

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

23. 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].

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

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

26. 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].

27. 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.

28. 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].

29. 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.

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

31. [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].

Keywords

lumbar compression fracture, compression fracture, kyphoplasty, vertebroplasty, burst fracture, wedge fracture, balloon kyphoplasty, percutaneous vertebroplasty, spine compression fracture, lumbar spine compression fracture, lumbar crush fracture, osteoporotic fracture, collapse fracture, osteoporosis, vertebra fracture, vertebral fracture, spinal wedge fracture

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, Leonard A Miller School of Medicine, University of Miami
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 College of Sports Medicine, American Medical Association, American Paraplegia Society, American Spinal Injury Association, and Association of Academic Physiatrists
Disclosure: pfizer Honoraria Speaking and teaching

Coauthor(s)

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

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, 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, FAAPMR, FAAEM 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.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
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.

Related eMedicine topics:
Lumbar Spine Fractures and Dislocations
Lumbar Spine, Trauma
Nonoperative Treatment of Osteoporotic Compression Fractures
Vertebral Fracture
Vertebroplasty and Kyphoplasty, Percutaneous

Clinical guidelines:
ACR Appropriateness Criteria® osteoporosis and bone mineral density. American College of Radiology - Medical Specialty Society.  1998 (revised 2007).  12 pages.  NGC:005990

Clinical trials:
Comparison of Balloon Kyphoplasty, Vertebroplasty and Conservative Management in Acute Osteoporotic Vertebral Fractures (OSTEO-6)

Comparison of Balloon Kyphoplasty and Vertebroplasty in Subacute Osteoporotic Vertebral Fractures (OSTEO+6)

KAVIAR Study - Kyphoplasty And Vertebroplasty In the Augmentation and Restoration of Vertebral Body Compression Fractures

Tapentadol IR vs Oxycodone IR vs Placebo in Acute Pain From Vertebral Compression Fracture Associated With Osteoporosis

To Evaluate Success of Cement Treatment of Spinal Compression Fractures

Treatment of Malignant Vertebral Fractures With Percutaneous Balloon Kyphoplasty. (KYPHOK)

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