Lumbar Compression Fracture Clinical Presentation

Updated: Oct 12, 2018
  • Author: Andrew L Sherman, MD, MS; Chief Editor: Stephen Kishner, MD, MHA  more...
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Presentation

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 one or more compression fractures 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. [10]  Acute radiculopathy can also be experienced after lumbar compression fractures; the incidence rises with descending spinal levels. [11]

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.

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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.

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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.

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