Vertebral compression fracture
A compression fracture is a collapse of a vertebra. It may be due to trauma or due to a weakening of the vertebra. This weakening is seen in patients with osteoporosis or osteogenesis imperfecta, lytic lesions from metastatic or primary tumors, or infection. In healthy patients, it is most often seen in individuals suffering extreme vertical shocks, such as ejecting from an ejection seat. Seen in lateral views in plain x-ray films, compression fractures of the spine characteristically appear as wedge deformities, with greater loss of height anteriorly than posteriorly and intact pedicles in the anteroposterior view.
Signs and symptoms
Acute fractures usually present with back pain, with other possible signs including reduced range of motion and even nerve deficits. Additionally, presence of a bruise or scrape combined with localized back pain may indicate the need to further investigate for evidence of a compression fracture. Chronic compression fractures, such as in osteoporosis, may initially be asymptomatic, but will later often lead to back pain, spinal deformities, loss of height, and neurologic issues.Causes
Traumatic compression fractures tend to occur after a significant fall or impact, but in those with low bone density even daily activities can result in a fracture. Atraumatic fractures are usually attributable to an underlying issue such as osteoporotic bone, tumors, and infections.Risk factors include osteoporosis, history of previous compression fractures, elderly age, and postmenopausal status.
Mechanism
The pathophysiology of vertebral compression fractures stems from decreasing trabecular bone in vertebral bodies, usually from an imbalance in bone resorption and formation, leading to weakened vertebrae prone to fracture. Factors that can contribute to trabecular bone loss include lack of physical activity, nutrition, aging, medications, genetics, and systemic disease. Women in postmenopause are especially prone to increased trabecular bone loss as a result of hormonal changes.Diagnosis
Compression fractures are usually diagnosed on spinal radiographs, often incidentally, where a vertebral deformity may be visible or there may be loss of height of the vertebra. Compression fractures are frequently classified using the Genant classification based on the pattern of vertebral height loss: wedge, biconcave, and crush. In addition, bone density measurement may be performed to evaluate for osteoporosis. When a tumor is suspected as the underlying cause, or there is evidence of nerve deficits, CT or MRI scans may be performed. Clinical guidelines can help determine appropriate imaging for individuals with newly diagnosed symptomatic fractures, back pain with history of prior compression fractures, and history of malignancy.Treatment
Conservative treatment
- Back brace for support while the bone heals; rigid braces have demonstrated pain relief for up to 6 months in acute vertebral compression fractures.
- Opioids or non-steroidal anti-inflammatory drugs for pain management, especially in the short-term setting. For osteoporotic patients, calcitonin may be helpful.
Surgical treatment
- Vertebroplasty and kyphoplasty are minimally invasive procedures that inject cement into the vertebra that is fractured. These surgeries are similar, except that kyphoplasty inserts a balloon before the cement is introduced, which can result in some vertebral height restoration. The effectiveness of these procedures is debated, but recent studies demonstrate improved pain relief and an association with decreased mortality.