Lumbar Compression Fracture 

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

Overview

Practice Essentials

The lumbar vertebrae are the 5 largest and strongest of all vertebrae in the spine. These vertebrae make up 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. The image below reveals a wedge compression fracture. (See Pathophysiology.)

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

Diagnosis and management

Perform a complete blood cell count with differential, prostate-specific antigen testing (in middle-aged and older men), and erythrocyte sedimentation rate determination. The urine can be sampled for markers of increased bone turnover, which occur in persons with osteoporosis.

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. Computed tomography (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. Magnetic resonance imaging (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. Dual energy radiographic absorptiometry (DRA) scanning is currently the most widely used method to measure bone mineral density.

When malignancy is strongly suspected, a vertebral biopsy is indicated. These biopsies are usually carried out under CT-scan 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.

In the past, treatment options for lumbar fractures were quite limited, with bracing and rest prescribed most often. While many patients improved with this regimen, some did not and were left with chronic, disabling pain. Suh and Lyles found that vertebral compression fractures were associated with significant performance impairments in physical, functional, and psychosocial domains in older women.[1] However, medical and surgical options are now available that can relieve the severe pain and disability from these fractures.

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 making up the multidisciplinary team participate in the comprehensive program. In most cases, rehabilitation begins with the patient in a thoracic-lumbar-sacral orthosis (TLSO).

Surgical intervention is required when neurologic dysfunction and/or instability occurs as a result of the lumbar fracture. 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.

Two related procedures, vertebroplasty and kyphoplasty, are available for the patient with a lumbar wedge fracture who continues to experience pain despite aggressive conservative treatment. Vertebroplasty involves injecting a form of cement polymer into the fractured vertebral body. Kyphoplasty is similar to vertebroplasty, except a balloon is used to expand the volume of the fractured segment prior to introducing the cement polymer.[2, 3, 4]

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.[5] 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.[6] 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. 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,[7] 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.

Epidemiology

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.[8] 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.

A study by Imai et al indicated that in patients with an osteoporotic hip fracture, the coexistence of a vertebral compression fracture significantly increases mortality risk. The study involved 182 patients with osteoporotic hip fracture (average age 85 years at the time of fracture), with lumbar spine radiographs revealing vertebral compression fracture in approximately 78% of these individuals. At 1-year following hip fracture, the investigators found the mortality rate to be significantly higher in patients with a coexistent vertebral compression fracture.[9]

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.

 

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.

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.

 

DDx

Diagnostic Considerations

These include the following:

  • Spinal malignancy resulting in fracture

  • Renal failure

  • Hemangioma of vertebral body

  • Osteomyelitis

  • Pott disease

Differential Diagnoses

 

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.

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.[12]

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.[13]

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.[14]

Procedures

When malignancy is strongly suspected, a vertebral biopsy is indicated. These biopsies are usually performed under CT-scan 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 making up 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.

In a study of patients with benign, conservatively managed thoracic or lumbar A1 compression fractures (as identified using the AOSpine thoracolumbar spine injury classification system), Piazzolla et al found that vertebral bone marrow edema slowly decreased over 3 months, with corresponding improvement in clinical symptoms. Patients in the study were treated with a C35 hyperextension brace, bed rest, and, for those with osteoporotic fractures, antiresorptive therapy and vitamin D supplementation.[15]

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.[16, 17, 18]

  • 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.[2] 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

Two related procedures, vertebroplasty and kyphoplasty, are available for the patient with a lumbar wedge fracture who continues to experience pain despite aggressive conservative treatment.[4]

Vertebroplasty

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.[19] A prospective study from the Netherlands with 36-month follow-up found an immediate, significant, and lasting reduction in the average and worst back pain with vertebroplasty.[20]

In another study, Rapan et al concluded that in patients with vertebral compression fracture who undergo vertebroplasty, the degree of pain reduction that occurs by 24 hours postprocedure predicts the intensity of pain patients will be experiencing 3 months later. Treatment was administered to a total of 28 thoracic and 57 lumbar vertebrae; patients in the study had sustained vertebral fractures from spinal metastases or osteoporosis.[21]

Prior to vertebroplasty, the patients' average pain score on the Visual Analog Scale (VAS) was 8.36, while 24 hours postprocedure it had fallen to an average of 2.23. At 3-month follow-up, the reduction in the VAS score remained nearly the same. Among the study's patients, 1 serious complication, paraparesis resulting from cement leakage into the spinal canal, occurred.[21]

Another study, by study by Kim et al, found percutaneous vertebroplasty to be an effective treatment for osteoporotic vertebral compression fractures. The investigators determined that back pain improved in 92% of the study’s 673 patients, who underwent single-level or multilevel vertebroplasty. A total of 1174 of the procedures were performed, with more cement needed for the lumbar vertebrae than for the thoracic vertebrae.[22]

A study by Han et al of 120 patients who underwent percutaneous vertebroplasty for osteoporotic compression fracture indicated that the procedure is less effective in patients with such fractures of the lower lumbar spine than it is in those with higher lumbar fractures. At a median follow-up period of 22 months after percutaneous vertebroplasty, only 55.7% of patients with osteoporotic compression fractures at the L4 or L5 level of the spine (63 patients) reported reduced pain and improved function, compared with 71.7% with L3 fractures (57 patients). The investigators also found that 46% of the patients with L4 or L5 fractures required additional lumbar procedures, compared with 16% of those in the L3 group.[23]

Kyphoplasty

Kyphoplasty (seen in the image below) is similar to vertebroplasty, except a balloon is used to expand the volume of the fractured segment prior to introducing the cement polymer.[2, 3]

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.[24] 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. Fluoroscopic view of a kyphoplasty procedure.

Risks and benefits

The main risk from 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.[19, 24]

Another risk from vertebroplasty is subsequent vertebral body fracture, often of an adjacent vertebra.[25] 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.[26]

Adjacent-level fractures are often reported with kyphoplasty, but research is ongoing to try to reduce the frequency of this complication.

A retrospective, comparative study by Lee et al indicated that in patients who have been treated for osteoporotic vertebral compression fractures (via vertebroplasty, kyphoplasty, or conservative therapy), the risk for the development of new osteoporotic compression fractures is greater in persons with a low bone mineral density T-score of the lumbar spine and in patients who underwent treatment with cement augmentation.[27]

On the other hand, a literature review by Zhang et al indicated that in cases of osteoporotic vertebral compression fracture, neither percutaneous vertebroplasty nor kyphoplasty are associated with an increased incidence of new compression fractures at untreated levels of the spine, including adjacent-level fractures, despite previous reports to the contrary. The study compared new fracture incidence in patients receiving vertebral augmentation with polymethyl methacrylate and those who underwent conservative (nonoperative) treatment, finding no significant difference between the two groups with regard to new-level vertebral fractures.[28]

Another study, a longitudinal cohort investigation by Deibert et al, indicated that following kyphoplasty for osteoporotic vertebral compression fractures, additional symptomatic compression fractures are relatively uncommon and may develop long after kyphoplasty was initially performed. The study also found that in cases of a single symptomatic thoracic or lumbar fracture, there was an equal incidence of remote and adjacent-level fractures, while in all patients who suffered simultaneously from a thoracic and lumbar fracture, any additional fracture occurred at an adjacent level.[29]

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.[7] Fluoroscopy is used in a manner similar to that used in vertebroplasty.

 

Medication

Medication Summary

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.[30] 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.

However, a retrospective study by Huang et al reported that in patients with lumbar osteoporotic compression fractures, percutaneous dorsal root ganglion block provides immediate and prolonged pain relief when conservative treatment has failed or residual pain exists follow vertebroplasty. Dramatic pain relief was achieved on the first day, with improvement still significant at 1-year follow-up.[31]

Analgesics

Class Summary

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.

Oxycodone (OxyContin, OxyIR, Roxicodone)

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

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.

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.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderate to severe pain.

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.

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.

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.

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.

Parathyroid hormones, recombinant

Class Summary

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.

Antiosteoporotic agents

Class Summary

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.

Bisphosphonates

Class Summary

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.

Selective estrogen modulators

Class Summary

May act like estrogen to prevent bone resorption.

Raloxifene hydrochloride (Evista)

Selective estrogen receptor modulator that decreases bone loss.

 

Follow-up

Further Outpatient Care

See the list below:

  • 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.

Further Inpatient Care

See the list below:

  • 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.

Inpatient & Outpatient Medications

See the list below:

  • 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

See the list below:

  • 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

See the list below:

  • 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.[32]

Complications

See the list below:

  • 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

See the list below:

  • 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.[33] Similarly, another retrospective study found that two thirds of patients with spinal tuberculosis had persistent, painful disability.[34]

  • Since not all patients heal adequately with cement procedures, it would be helpful if one could predict who would or would not benefit. One study from Japan found radiographically, an intravertebral cleft larger than half the height of the fractured vertebral body (FVB) was a significant key factor in the complete pain relief group after 3 months. Further, 40% or more of the spinal canal occupied by bony fragments of the FVB was related to incomplete pain relief.[35]

Patient Education

See the list below:

  • Patient education is essential to preventing osteoporosis and lumbar fractures because good nutrition and proper exercise are significantly beneficial in prevention.

  • For patient education resources, see the Back, Ribs, Neck, and Head Center and Osteoporosis and Bone Health Center, as well as Osteoporosis and Vertebral Compression Fracture.

 

Questions & Answers

Overview

What is a lumbar compression fracture?

How are lumbar compression fractures diagnosed?

What is the indication for a vertebral biopsy in the workup of lumbar compression fracture?

What are the treatment options for lumbar compression fracture?

What is the indication for rehabilitation in lumbar compression fracture?

When is surgical intervention indicated for the management of lumbar compression fracture?

What is the role of vertebroplasty and kyphoplasty in the management of lumbar compression fracture?

What are the mechanics of lumbar compression fractures?

What is the impact of a lumbar compression fracture?

What are common causes of lumbar compression fracture?

How are different fractures in the lumbar (or thoracic) spine classified?

What are the different types of traumatic fractures?

What is the pathophysiology of a lumbar compression fracture in osteoporosis?

What is the role of malignancy in the pathogenesis of lumbar compression fracture?

What is the prevalence of lumbar compression fracture in the US?

What is the mortality and morbidity associated with lumbar compression fracture?

How does the incidence of lumbar compression fracture vary by sex?

What are the age predilections of lumbar compression fracture?

Presentation

What are the signs and symptoms of lumbar compression fractures?

Which clinical history of pain suggests lumbar compression fracture?

What clinical history of malignancies suggests lumbar compression fracture?

What is the significance of symptoms of infections in the evaluation of lumbar compression fracture?

What is the indication for a neurologic exam in lumbar compression fracture?

What are the physical findings characteristic of lumbar compression fracture?

What is the most common underlying cause of lumbar compression fractures?

What is the role of malignancy in the etiology of lumbar compression fracture?

What is the role of infection in the etiology of lumbar compression fracture?

DDX

What conditions should be considered in the differential diagnoses of lumbar compression fracture?

What are the differential diagnoses for Lumbar Compression Fracture?

Workup

What is the role of blood tests in the workup of lumbar compression fractures?

What is the role of urine testing in the workup of lumbar compression fracture?

What is the role of radiography in the workup of lumbar compression fracture?

What is the role of CT scanning in the workup of lumbar compression fracture?

What is the role of MRI in the workup of lumbar compression fracture?

What is the role of dual energy radiographic absorptiometry (DRA) scanning in the workup of lumbar compression fracture?

What is the role of PET scanning in the workup of lumbar compression fracture?

When is a biopsy indicated in the evaluation of lumbar compression fracture?

Treatment

What are the nonoperative treatment options for lumbar compression fracture?

When is inpatient rehabilitation indicated in the treatment of lumbar compression fractures?

What are the treatment options for elderly patients with osteoporotic lumbar compression fractures?

What is the efficacy of conservative management of lumbar compression fractures?

What is the indication for occupational therapy in lumbar compression fractures?

What is the indication for recreational therapy in lumbar compression fractures?

How can the frequency of secondary medical complications be decreased in patients with lumbar compression fractures?

What are co-morbidities and complications of osteoporotic lumbar fractures?

What are comorbidities and complications in pathologic fractures?

What are comorbidities and complications in traumatic lumbar compression fractures?

What is the indication for surgical intervention in lumbar compression fracture?

What are possible neurological impairments of lumbar compression fractures?

What are the surgical options for the treatment of lumbar compression fractures?

What is the indication for postoperative bracing of lumbar compression fractures?

Which specialist consultations are recommended for the treatment of lumbar compression fractures?

What is the indication for a vertebroplasty and kyphoplasty in the treatment of lumbar compression fracture?

What does a vertebroplasty involve in the treatment of lumbar compression fracture?

What is the efficacy of a vertebroplasty for the treatment of lumbar compression fractures?

What does a kyphoplasty for lumbar compression fractures involve?

What is the indication for kyphoplasty for the treatment of lumbar compression fracture?

What are the possible risks of vertebroplasty and kyphoplasty for the treatment of lumbar compression fracture?

What are the benefits of vertebroplasty and kyphoplasty for the treatment of lumbar compression fracture?

Medications

What are the goals of medications in the treatment of lumbar compression fracture?

Which medications are needed for lumbar compression fracture in patients with spinal cord injuries?

What is the role of spinal nerve block in the treatment of lumbar compression fractures?

Which medications in the drug class Selective estrogen modulators are used in the treatment of Lumbar Compression Fracture?

Which medications in the drug class Bisphosphonates are used in the treatment of Lumbar Compression Fracture?

Which medications in the drug class Antiosteoporotic agents are used in the treatment of Lumbar Compression Fracture?

Which medications in the drug class Parathyroid hormones, recombinant are used in the treatment of Lumbar Compression Fracture?

Which medications in the drug class Analgesics are used in the treatment of Lumbar Compression Fracture?

Follow-up

What should be included in outpatient physical therapy for lumbar compression fractures?

How frequently should radiographic monitoring of lumbar compression fractures be performed?

When is inpatient rehabilitation indicated for lumbar compression fractures?

What is the role of pain medications in the treatment of lumbar compression fractures?

How is osteoporosis managed in patients with lumbar compression fractures?

What is the indication for transfer of patients with lumbar compression fractures?

How are lumbar compression fractures prevented?

When do complications of lumbar compression fractures occur?

What is the prognosis of lumbar compression fractures?

What information about lumbar compression fractures should patients receive?