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Lumbar Compression Fracture Workup

  • Author: Andrew L Sherman, MD, MS; Chief Editor: Stephen Kishner, MD, MHA  more...
 
Updated: May 23, 2016
 

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.

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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.

A study by Karaca et al indicated that dual energy CT scanning is comparable to MRI with regard to identifying vertebral compression fractures after acute trauma. In identifying vertebral edema, dual energy CT scanning had, when MRI was used as the reference standard, a sensitivity, specificity, positive-predictive value, negative predictive value, and accuracy of 89.3%, 98.7%, 95.4%, 96.9%, and 96.6%, respectively.[6]

MRI

MRI is required when the patient describes lower extremity motor or sensory loss. Radicular pain is another indication for MRI. Also, 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.[7]

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.[8]

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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.

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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, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

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, Florida Medical Association, Society for Neuro-Oncology, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

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

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Additional Contributors

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, North American Spine Society

Disclosure: Nothing to disclose.

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Anteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture.
Fluoroscopic view of a kyphoplasty procedure.
 
 
 
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