eMedicine Specialties > Physical Medicine and Rehabilitation > Therapeutic Modalities

Nonoperative Treatment of Osteoporotic Compression Fractures: Differential Diagnoses & Workup

Author: Grant Cooper, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, New York-Presbyterian Hospital, The University Hospitals of Columbia and Cornell
Coauthor(s): Julie Lin, MD, Assistant Professor, Department of Rehabilitation Medicine, Weill Medical College of Cornell University; Assistant Attending Physiatrist, Physiatry Department, Hospital for Special Surgery; Joseph M Lane, MD, Professor of Orthopedic Surgery, Weill Medical College of Cornell University; Chief, Metabolic Bone Disease Service, Hospital for Special Surgery
Contributor Information and Disclosures

Updated: May 5, 2009

Differential Diagnoses

Multiple Myeloma

Other Problems to Be Considered

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

Workup

Laboratory Studies

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

Imaging Studies

  • Plain radiography of the spine, including anteroposterior and lateral views, is usually adequate for making the diagnosis of fracture. The entire spine should be evaluated, because multiple fractures occur in up to 20% of cases. Lateral flexion and extension while standing may allow evaluation for gross instability. In addition to vertebral height loss and kyphotic deformity, radiographs must be evaluated for increased interpedicular space, involvement of the posterior cortex, or laminar fracture, because these features suggest a burst fracture, which may be unstable. (See image below and Image 5.)
A vertebral burst fracture.

A vertebral burst fracture.

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A vertebral burst fracture.

A vertebral burst fracture.

  • Computed tomography (CT) scanning may be performed prior to vertebroplasty or kyphoplasty, because it is the most sensitive test for identifying a defect in the posterior vertebral cortex (an exclusion criterion for either procedure). However, MRI is also adequate for this purpose.
  • Magnetic resonance imaging (MRI) should be performed to assess for spinal cord compression if the fracture is between the cervical spine through the second lumbar vertebrae (after this point, the spinal cord ends and the MRI is less useful). MRI may also be helpful if metastatic disease or multiple myeloma is suspected. MRI (fat suppression test) is needed to date the compression fracture, that is, to determine whether it is acute or chronic.
  • Nuclear bone scanning should be performed if metastatic disease is suspected (if, for example, pain is elicited on palpation of vertebral levels otherwise not identified as having a fracture on radiographic examination).

Other Tests

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

More on Nonoperative Treatment of Osteoporotic Compression Fractures

Overview: Nonoperative Treatment of Osteoporotic Compression Fractures
Differential Diagnoses & Workup: Nonoperative Treatment of Osteoporotic Compression Fractures
Treatment & Medication: Nonoperative Treatment of Osteoporotic Compression Fractures
Follow-up: Nonoperative Treatment of Osteoporotic Compression Fractures
Multimedia: Nonoperative Treatment of Osteoporotic Compression Fractures
References
Further Reading
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References

  1. Freedman BA, Potter BK, Nesti LJ, et al. Osteoporosis and vertebral compression fractures-continued missed opportunities. Spine J. Mar 14 2008;[Medline].

  2. Prather H, Watson JO, Gilula LA. Nonoperative management of osteoporotic vertebral compression fractures. Injury. Sep 2007;38 Suppl 3:S40-8. [Medline].

  3. Chiras J, Depriester C, Weill A, et al. [Percutaneous vertebral surgery. Technics and indications]. J Neuroradiol. Jun 1997;24(1):45-59. [Medline]. [Full Text].

  4. Karlsson MK, Hasserius R, Gerdhem P, et al. Vertebroplasty and kyphoplasty: new treatment strategies for fractures in the osteoporotic spine. Acta Orthop. Oct 2005;76(5):620-7. [Medline]. [Full Text].

  5. Lin JT, Lane JM. Nonmedical management of osteoporosis. Curr Opin Rheumatol. Jul 2002;14(4):441-6. [Medline].

  6. Phillips FM. Minimally invasive treatments of osteoporotic vertebral compression fractures. Spine. Aug 1 2003;28(15):S45-53. [Medline].

  7. Lane JM, Russell L, Khan SN. Osteoporosis. Clin Orthop Relat Res. Mar 2000;139-50. [Medline].

  8. Sinaki M, Itoi E, Wahner HW, et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone. Jun 2002;30(6):836-41. [Medline].

  9. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. Oct 1984;65(10):593-6. [Medline].

  10. Huntoon EA, Schmidt CK, Sinaki M. Significantly fewer refractures after vertebroplasty in patients who engage in back-extensor-strengthening exercises. Mayo Clin Proc. Jan 2008;83(1):54-7. [Medline]. [Full Text].

  11. Skedros JG, Holyoak JD, Pitts TC. Knowledge and opinions of orthopaedic surgeons concerning medical evaluation and treatment of patients with osteoporotic fracture. J Bone Joint Surg Am. Jan 2006;88(1):18-24. [Medline].

  12. Tanigawa N, Komemushi A, Kariya S, et al. Relationship between cement distribution pattern and new compression fracture after percutaneous vertebroplasty. AJR Am J Roentgenol. Dec 2007;189(6):W348-52. [Medline]. [Full Text].

  13. He SC, Teng GJ, Deng G, et al. Repeat vertebroplasty for unrelieved pain at previously treated vertebral levels with osteoporotic vertebral compression fractures. Spine. Mar 15 2008;33(6):640-7. [Medline].

  14. McDonald RJ, Trout AT, Gray LA, et al. Vertebroplasty in multiple myeloma: outcomes in a large patient series. AJNR Am J Neuroradiol. Jan 17 2008;[Medline]. [Full Text].

  15. Lin WC, Cheng TT, Lee YC, et al. New vertebral osteoporotic compression fractures after percutaneous vertebroplasty: retrospective analysis of risk factors. J Vasc Interv Radiol. Feb 2008;19(2):225-31. [Medline].

  16. [Best Evidence] Bischoff-Ferrari HA, Willett WC, Wong JB, 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].

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Keywords

compression fracture, osteoporosis, back pain, spine surgery, kyphoplasty, vertebroplasty, kyphosis, compression fractures, spine fracture, vertebral fracture, spinal fracture, osteoporosis fracture, osteoporosis spine, vertebral fractures, vertebral compression fracture, spine fractures, osteoporotic, spinal fractures, wedge fracture, osteoporotic vertebral compression fractures, diminished bone density, wedge-shaped compression fractures, acquired kyphosis, bone density loss, central crush fracture

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Contributor Information and Disclosures

Author

Grant Cooper, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, New York-Presbyterian Hospital, The University Hospitals of Columbia and Cornell
Grant Cooper, MD is a member of the following medical societies: Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Julie Lin, MD, Assistant Professor, Department of Rehabilitation Medicine, Weill Medical College of Cornell University; Assistant Attending Physiatrist, Physiatry Department, Hospital for Special Surgery
Julie Lin, MD 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, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Joseph M Lane, MD, Professor of Orthopedic Surgery, Weill Medical College of Cornell University; Chief, Metabolic Bone Disease Service, Hospital for Special Surgery
Joseph M Lane, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of University Professors, American Federation for Aging Research, American Orthopaedic Association, American Society for Bone and Mineral Research, Association of Bone and Joint Surgeons, Medical Society of the State of New York, Musculoskeletal Tumor Society, National Osteoporosis Foundation, North American Spine Society, and Orthopaedic Research Society
Disclosure: P & G; Roche; Lilly: Aventis: Novartis: Spinewave; biomimetics; Zimmer; DFine; Innovative Solutions; Honoraria Speaking and teaching

Medical Editor

Everett C Hills, MD, MS, Medical Director, Penn State Hershey Rehabilitation Hospital, Assistant Professor of Orthopaedics and Rehabilitation, Assistant Professor of Neurology, Penn State Milton S. Hershey Medical Center and Penn State University College of Medicine
Everett C Hills, MD, MS is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Congress of Rehabilitation Medicine, American Medical Association, American Society of Neurorehabilitation, Association of Academic Physiatrists, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

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.

 
 
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