eMedicine Specialties > Physical Medicine and Rehabilitation > Therapeutic Modalities

Nonoperative Treatment of Osteoporotic Compression Fractures

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

Introduction

Background

Osteoporosis and osteoporotic vertebral compression fractures are commonly encountered clinical problems. The definition of osteoporosis is diminished bone density measuring 2.5 standard deviations below the average bone density of healthy, 25-year-old, same-sex members of the population. In the United States, approximately 35% of women older than 65 years have osteoporosis. Vertebral compression fracture is the most common complication of osteoporosis. More than 700,000 new vertebral compression fractures occur every year in the United States alone, accounting for more than 100,000 hospital admissions and resulting in close to $1.5 billion in annual costs. (See image below and Image 1.)

Pathophysiology

Vertebral compression fractures characteristically demonstrate a wedge-shaped pattern with gross collapse of the anterior portion of the vertebral body and relative preservation of the posterior body height. (See images below and Images 3-4.) A second common form of fracture is a central crush fracture that may frequently occur in the lower lumbar spine. Cortical and trabecular bone loss, as well as disruption of the micro-architecture of bone, are all typical of osteoporosis. Spinal flexion and axial compression have been shown to place maximal stress on the superior endplate of the vertebral body. The asymmetry of the vertebral body produces maximal stress at the anterior aspect of the cortical shell. A combination of these factors, that is, decreased, asymmetric, and irregular bone density, is a hallmark of osteoporotic bone loss. Coupled with even minimal flexion and/or axial loading, these factors predispose the osteoporotic vertebrae to wedge-shapedcompression fractures, acquired kyphosis, and general height loss.

Frequency

United States

More than 24 million people have osteoporosis, placing them at risk for compression fractures. Vertebral compression fractures occur in 153 per 100,000 females and in 81 per 100,000 males. Of the 700,000 people with vertebral fractures in the United States, one third are symptomatic and require treatment.

Mortality/Morbidity

Osteoporotic vertebral compression fractures have been shown to adversely affect physical function, quality of life, and mental health and to increase mortality.

Women with vertebral fractures have been shown to have a 23% increase in age-adjusted mortality rate within 5 years of a normal compression fracture. Women with multiple or severe vertebral fractures have a 34% increase in mortality risk compared with age-adjusted controls. This is in contradistinction to hip fractures, in which a 20% increase in mortality rate occurs only within the first 6 months following the fracture.

Elderly patients prescribed pain medications and/or bed rest may experience multiple medical complications, including confusion, increased fall risk, gastrointestinal adverse effects, skin breakdown, thromboembolic events, and lung dysfunction.

Race

Osteoporosis occurs in all racial groups but is most common in white and Asian populations.

Sex

Vertebral compression fractures occur more commonly in females. Men also develop osteoporosis, but it tends to appear 5-10 years later than it does in women and to occur at one third the rate that it does in the female population.¹

Age

Osteoporotic vertebral compression fractures are most common in postmenopausal women. In the United States, 25% of women older than 70 years and 50% of women older than 80 years have radiographic evidence of vertebral compression fractures. Men older than 75 years typically begin to develop osteoporosis and are at increased risk of vertebral compression fracture.

Clinical

History

Most osteoporotic vertebral compression fractures are asymptomatic and are incidentally diagnosed on radiographic examination. Patients with nonpainful vertebral compression fractures may report height loss. Any patient with measurable height loss of more than 5 cm (2 in) should be evaluated for vertebral compression fracture, because even a single vertebral compression fracture is associated with height loss. The other common causes of height loss are kyphosis, scoliosis, and spondylolisthesis.

A patient with a painful vertebral compression fracture typically describes abrupt onset of pain during an atraumatic, low-exertion activity, such as bending forward, standing from a seated position, opening a window, coughing, or sneezing. Fifty percent of patients with painful vertebral fractures give a history of a recent fall. At the time of the physician visit, the patient may have difficulty localizing the precise level of back pain. The pain is often improved with lying down and resting and is worse with standing and exertion. Occasionally, the patient may report back pain radiating around his/her trunk in a dermatomal pattern. Symptoms related to bowel or bladder changes or neurologic deficits are not characteristic of a vertebral compression fracture and warrant further evaluation for alternate diagnoses.

Physical

Patients often present with increased thoracic kyphosis or flattening of the lumbar lordosis. A normally proportioned individual usually stands with fingertips hanging down at midthigh. Direct measure of height demonstrates a loss. Spinal shortening should be suspected in any patient whose fingertips reach the lower thigh or knee. Flexion tends to aggravate the pain more than extension. On palpation, localized spinal tenderness is often present. A detailed neurologic assessment is essential in any patient presenting with back pain.

Causes

The leading risk factor for developing an osteoporotic vertebral compression fracture is a previous vertebral compression or hip fracture. Nineteen percent of women who have had 2 prior vertebral fractures and who are taking only calcium/vitamin D experience a new fracture within a year. In females, the next leading risk factor for osteoporotic vertebral compression fracture is menopause or estrogen deficiency. Additional risk factors include advanced age, cigarette smoking, physical inactivity, and poor nutrition. In addition, renal failure, liver failure, cancer, diabetes mellitus, emphysema, and vitamin D deficiency may predispose a patient to osteoporotic vertebral compression fracture. In males, low testosterone may be associated with these fractures. Steroids, anticonvulsants, cytotoxic drugs, alcohol, thyroid replacement drugs, and heparin also may be associated with osteoporotic vertebral compression fracture.

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