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Vertebral compression fractures: Treatment and evaluation

Article  in  South Dakota journal of medicine · September 2006

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 Journal

Vertebral Compression Fractures:

Treatment and Evaluation
B y A a r o n B a b b a n d Wa l t e r O . C a r l s o n , M D

Abstract
Vertebral compression fractures can occur secondary to trauma, malignancies, or most commonly osteoporosis.
Osteoporosis causes almost 1.5 million fractures throughout the United States every year and nearly 700,000 of these
fractures are vertebral compression fractures.1 These fractures are frequently seen in elderly women; 40 percent of
women older than 80 years old are affected by vertebral compression fractures.1 These injuries can be treated both
conservatively and surgically. The conservative route includes bed rest, pain control, bracing, and strength training.
The surgical method includes percutaneous vertebroplasty and kyphoplasty, both minimally invasive procedures. This
article provides a general introduction to vertebral compression fractures and osteoporosis, the diagnostic methods
used to identify vertebral compression fractures, and the known treatments.

INTRODUCTION diagnosed each year. Many fractures are missed because

patients contribute the symptoms to arthritis or normal
Osteoporosis presents a significant risk for the elderly,
aging. When these compression fractures are diagnosed they
especially elderly women. Osteoporosis is defined as bone
are defined radiologically as a reduction in vertebral body
density measuring 2.5 standard deviations below the average
height of more than 15 percent.3 The two most common
bone density of a healthy 25-year-old of the same sex.
sites are the thoracolumbar and lower lumbar region, most
Approximately 35 percent of women older than 65 years of
frequently T8-T12, L1, or L4.3 The fractures usually conform
age suffer from osteoporosis.2 Additionally, secondary
to two types: wedge or burst fractures. The wedge fracture is
osteoporosis can occur due to steroid treatment, excessive
illustrated by loss of anterior height of the vertebra while
alcohol intake, hyperthyroidism, or diabetes mellitus.3
posterior height remains consistent. This type of fracture
Furthermore, osteoporosis leads to 1.5 million fractures each
occurs when the applied force is concentrated to the
year in the United States and nearly 700,000 of them are
anterior portion of the vertebral body. Wedge fractures are
vertebral compression fractures. These compression fractures
often associated with kyphosis, that is, the bending forward of
cause considerable back pain and numerous difficulties to the
the spine causing a hunchback appearance in the patient.
aging population. Although only one-third of these injuries
Burst fractures occur when the entire vertebral body breaks
are acutely symptomatic, all of them increase mortality and
and height loss is consistent across the vertebra.1
significantly decrease the functional status of the patient.3
Additionally, patients suffering from a vertebral compression
Specifically, women with vertebral fractures have been
fracture are five times more likely to experience another
shown to have a 34 percent increased mortality risk
fracture, including a 20 percent increased risk of having
compared with age-adjusted controls.1 These injuries occur
another vertebral fracture within one year.4
in 25 percent of all postmenopausal women in the United
States and affect nearly 40 percent of all women over 80 years DIAGNOSIS
old.1 Therefore, understanding the etiology and clinical Back pain is a common reason for patients to see a healthcare
presentation of, and treatment options for, vertebral provider and compression fractures, secondary to osteoporo-
compression fractures are vital to informing and caring for sis, greatly attribute to the prevalence of this symptom.
the patients with this illness. Therefore, it is important that the causes of back pain are
Only one-third of all vertebral compression fractures are recognized. Vertebral compression fractures are diagnosed

August 2006 343

 Journal
through physical examination and diagnostic testing. These
fractures are associated with acute back pain that can be
severe and debilitating. Physical examination will depict
point tenderness over the fracture site. The pain is generally
constant and dull, but patients will also experience an
increased sensation of pain with activity. The patient may
also present with kyphosis or lordosis, the latter being
exaggeration of the normal lumbar spinal curvature.
Furthermore, pulmonary complications can be present as the
forward bending decreases the vital capacity of the lungs.4 It
is estimated that the vital capacity of the lungs decreases by
nine percent for every compression fracture the patient
experiences.4 Abdominal symptoms such as early satiety or
abdominal bloating can also occur because the shortening of
the spine compresses the abdominal cavity. The patient’s
fracture can often be traced back to some incidence of
trauma, but the trauma may be as simple as the force caused
by muscle contraction in severely osteoporotic patients.
Furthermore, 30 percent of these injuries occur while the
patient is in bed.1 On the other hand, vertebral compression
fractures can occur in younger patients as a result of high-
energy traumas or from metastatic malignancies that have
spread to the vertebral column.
Vertebral compression fractures can be diagnosed radiologically
by numerous techniques. AP and lateral x-rays are often the
primary studies obtained. This plain technique is often
enough to diagnose the injury and allow conservative treatment
if indicated. However, magnetic resonance imaging (MRI),
computed tomography (CT), and scintigraphy are used in
advanced diagnostic testing. MRI is very useful if there is no
history of trauma because of its high sensitivity to bone
marrow edema.5 Due to this high sensitivity, MRI can
illustrate malignancy, infection, and the age of the fracture.
CT scans are often useful in determining the extent of the
fracture and provide the physician with additional bone
density information. CT scanning and MRI are also very
important in considering differential diagnoses because spinal
canal narrowing and specific vertebral composition can be
determined. Single-photon emission computed tomography
(SPECT) can also assist in determining the extent of the
fracture and osteoporotic levels because of its ability to
determine bone density.1 Scintigraphy, which is a diagnostic
technique using gamma radiation detection to determine the
condition of a tissue or an organ, can also be an important
technique to predict the outcome of certain surgical
techniques.5
TREATMENT
Conservative and surgical methods are both used to treat
vertebral compression fractures. If the patient is stable and
the pain is tolerable, conservative treatment is indicated.
344
Conservative treatment can be initiated and monitored in
most cases by the primary care provider without consultation
of a specialist. Initially, a short period of bedrest is
recommended following acute fractures to give pain time to
subside. The period of bedrest should, however, be limited to
four days to prevent muscle weakness, deep vein thrombosis,
and emotional complications. Pain control is vital in the
initial phase of treatment. The use of analgesics can also help
avoid complications associated with prolonged bedrest.
Opioid analgesics may be necessary for the management of
some pain; however, constipation and cognitive impairment
are significant concerns that must be monitored throughout
the treatment.3 The use of narcotics should be limited and
used primarily in the initial pain relief period, especially in
elderly patients where side effects are prevalent.3 Nasal
calcitonin may also be beneficial for patients with vertebral
compression fractures because of its analgesic activity and its
inhibition of osteoclast function, thereby preventing bone
resorption and further osteoporotic complications.3 It is also
important to avoid nonsteroidal anti-inflammatory drugs
(NSAIDs) whenever possible in older patients because of the
associated risks of congestive heart failure, renal insufficiency,
and gastropathy.3
One important aspect of conservative treatment that is often
underestimated is the use of bracing to decrease pain and
assist healing of vertebral compression fractures. Bracing can
be utilized immediately, but should only be continued for two
to three months.3 Bracing can make a significant difference
in the ability of vertebrae to heal. There are various types of
back braces available for treatment and the physician, in
consultation with a physical therapist or orthotist, determines
the correct brace for each patient. Most braces are intended
to be worn until pain resolves, or surgical treatment is sought.
Since most compression fractures occur in the thoraco-
lumbar region of the spine, most braces are developed for this
area of the back. A shell-type brace is a thoracolumbosacral
orthosis (TLSO) used to provide stability during rotation,
flexion, and extension.6 These braces are useful in the
treatment of high-energy traumatic fractures, multiple
fractures, and severe kyphosis. Because these braces have an
encasing plastic shell design, they are more expensive and
patients sometimes complain of uncomfortable itching and
sweating underneath the brace. A Boston-type brace is very
similar to the shell-type but is made of a softer, semi-flexible
plastic.7 Another type of brace, the Jewett-type device, is a
hyperextension brace that is useful for osteoporotic fractures
that result in kyphosis. The Jewett device prevents flexion
and encourages extension of the back, which counteracts the
kyphosis.7 These devices are less bulky, more comfortable,
and less expensive than the shell-type brace, but they may

cause physical discomfort if existing scoliosis is present. The
final type of brace is a semi-rigid thoraco-lumbar corset that
includes shoulder straps to encourage extension of the spine.
Additionally, with the use of any back brace, it is important
to monitor the weakening of back, abdominal, and chest
muscles. Bracing for an extended period of time can cause
undesirable instability of the back due to muscle loss, and
physical therapy is a necessary portion of conservative treat-
ment.7 Consequently, with appropriate bracing and x-ray
monitoring, this method can be very beneficial for patients to
make a full recovery from a compression fracture.
If a patient’s pain does not resolve with the conservative
treatment, a referral to an orthopedic surgeon for specialty
care is recommended. Surgical methods are generally the last
resort if conservative measures do not provide the desired
reduction in back pain. The two most prominent techniques
used to correct vertebral compression fractures are percuta-
neous vertebroplasty and balloon kyphoplasty. These spinal
procedures are both minimally invasive and are associated
with fewer complications than other spinal techniques.
Percutaneous vertebroplasty, inititally performed in 1984,
was the first of these two methods.8 Vertebroplasty involves
the insertion of minimally viscous bone cement into the
fractured vertebra under high pressure for stabilization.
Balloon kyphoplasty was introduced in 1998 as an additional
treatment for compression fractures with the added benefits
of fracture reduction and use of less pressure during injection
of bone cement.3
Balloon kyphoplasty is an improvement over vertebroplasty
as it addresses the problems of deformity and loss of vertebral
body height and is a much safer technique. Kyphoplasty
Figure 1. Figure 2.
Pre-operative film, compression fracture of Post-operative film, kyphoplasty for third
third lumbar vertebra. lumbar verebra compression fracture.
Journal
utilizes a balloon-like inflatable bone tamp that is inserted
into the vertebra and inflated under image guidance.12 The
balloon catheter is inflated to a pressure of up to 300 psi to
provide enough force to create a cavity.13 After the inflation,
the balloon catheter is deflated and removed. Viscous and
partially cured cement is then inserted into the cavity.12 The
cement fills the void made by the fractured vertebra and
helps to restore height and stability to the spine (Figures 1
and 2). The procedure is usually done as an outpatient oper-
ation, however, under certain situations patients are observed
overnight. The number of vertebrae treated depends on the
patient’s health and ability to tolerate anesthesia, but our
practice has had a case where seven vertebrae were treated in
one patient with a successful outcome (Figure 3). The
timing of kyphoplasty can be essential to the success of the
procedure. Kyphoplasty is most successful in correcting
vertebral height if performed in the first six to eight weeks,
but many clinicians use conservative treatment initially to
observe whether or not the bone will heal on its own. Also,
some patients may find relief from the procedure a year after
their fracture; however, the benefits appear to be increased
greatly if the procedure is done within six months of the
onset of symptoms.4
There is a significant difference between the injection of
bone cement during vertebroplasty and the injection during
kyphoplasty. During the vertebroplasty procedure, the
cement is less viscous and injected with more pressure
because there is less space for the cement to fill. However,
during kyphoplasty the cement used is more viscous and the
injection is done at lower pressures.11,15 The cavity made by
the cathether allows for the cement to be inserted under the
Figure 3.
Seven level kyphoplasty.
August 2006 345

lower pressure, which also lowers the complication rate due
to cement leakage.14 The overall complication rate for
kyphoplastay has been reported between 0.4 to 1.2 percent
per patient.4 Furthermore, the use of the balloon catheter
assists in the recovery of vertebral height and correction of
kyphotic deformity, which vertebroplasty is unable to do.16 It
has been reported that kyphoplasty reduces pain in 90 to 100
percent of patients and restores up to 97 percent of vertebral
height in some patients.4 Studies have also determined that
the earlier the procedure is performed, the more vertebral
height can be restored. It is possible to repair the compression
fracture up to one year after the injury has occurred, but the
results may vary. Consequently, kyphoplasty is an improvement
over percutaneous vertebroplasty as it is a useful technique to
stabilize the compression fracture, restore vertebral height,
and is a safer procedure.
In certain situations, vertebroplasty is indicated for patients
instead of kyphoplasty. Patients unable to tolerate anesthesia
due to medical complications are more likely to have success
with vertebroplasty. Also, kyphoplasty is not recommended
for patients who have fractured vertebrae compressed to less
than 8 mm because the insertion of the balloon is impossible.
Finally, it is essential to note that neither kyphoplasty nor
vertebroplasty should be used on acute traumatic fractures of
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About The Author:
Walter O. Carlson, MD, is an orthopedic surgeon with the Orthopedic Institute in Sioux Falls, SD. He is certified by the American Board of Orthopedic Surgery.
Dr. Carlson’s interests include pediatric orthopedics, adult spine surgery, total joint replacement, and general orthopedics. (wcarlson@ortho-i.com)
Aaron Babb graduated from St. John’s University in Collegeville, MN in the spring of 2005 with a degree in chemistry. He will begin his education at Georgetown
University School of Medicine in Washington, DC in August. (acbabb@csbsju.edu)
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Journal
non-osteoporotic vertebrae.17, 18 Trial studies are being
performed, but the possibility of cement leakage is very high
in these cases and other complications are likely to arise.19
These injuries should be initially managed by bracing and
pain management with follow-up by an orthopedic surgeon.
CONCLUSION
Vertebral compression fractures have caused many patients
debilitating back pain, and as our population ages, the
prevalence of these fractures will be on the rise. Since these
fractures can occur from primary or secondary osteoporosis,
malignancies, or trauma, how the fracture occurred is
important in order to determine the correct course of
treatment. Conservative treatments are initially prescribed
by the primary care provider; however, if these efforts fail to
provide the desired relief, referral to an orthopedist is
recommended. Kyphoplasty is an appropriate, minimally
invasive technique for the surgical treatment of most
compression fractures. This technique has been proven to be
a safer method than vertebroplasty as it is performed under
lower injection pressure, and it has a lower complication rate.
Therefore, with the correct diagnosis and treatment plan,
vertebral compression fractures can be treated and the
patient can return to the desired activities of life.
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CompressionFractures as a Result of Multiple Myeloma. Journal of Clinical
Oncology 2002; 20(9):2382-2387.
13. Hart RA. Percutaneous Treatment of Osteoporotic Spinal Compression
Fractures. Current Women’s Health Reports 2003;3:72-74.
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Treatment of Painful Osteoporotic Vertebral Compression Fractures.
Spine2001;26(14):1631-1637.
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Comparisonof the Potenitla for Extravertebral Cement Leak After
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August 2006 347