Vertebral Compression Fractures

What is a Compression Fracture?

The spine (vertebral column) is comprised of 24 vertebrae, and the sacrum and coccyx bones. The spine is flexible due to this segmented anatomy. The curved shape of the spine makes balance possible when standing upright and increases carrying strength. The increased flexibility and shape of the spine make it more susceptible to injury.

A vertebral compression fracture (VCF) is a broken vertebral spinal bone that has decreased by in height due to a fracture. This condition occurs when vertebrae in the spine are squashed and collapse. Abnormal spinal curvatures may occur as a result of multiple compression fractures, such as kyphosis, which is a hump-like curvature of the spine.

Causes and Risk Factors

Osteoporosis is the most common compression factor cause (osteoporotic compression fracture). Osteoporosis is a disease that causes bone loss over time. As the disease progresses, usually undetected, the density and quality of bone are reduced, causing the bones to become porous and fragile. In turn, the risk of compression fractures is greatly increased. Osteoporosis often exhibits no symptoms until the first fracture occurs.

In patients with osteoporosis, vertebral compression fractures are the most common type of fracture, afflicting approximately 750,000 people (U.S.) annually, the majority of which are women. According to the American Association of Neurological Surgeons:

An estimated 10 million Americans have osteoporosis, and an additional 34 million are estimated to have low bone mass, placing them at increased risk for developing this condition. Of the 10 million Americans with osteoporosis, 8 million women and 2 million men have this condition.

Risk factors for herniated discs can include: 

Other causes of compression fracture may include:

• Trauma to the back
• Tumors in the bone and spine

Besides osteoporosis, other risk factors include:

• Female sex, especially post-menopausal women
• Previous compression fracture(s)

Preventing and treating osteoporosis is the best way to decrease the risk for compression fractures.

Symptoms

The most common compression fracture symptoms may include one or more of the following:

• Sudden onset of back pain
• Limited spinal mobility
• Gradual height loss
• Numbness or tingling
• Weak muscles
• Problems walking
• Trouble controlling the bowels or bladder due to nerve damage
• Increase in pain intensity while standing or walking
• Decrease in pain intensity while lying on the back
• Eventual deformity and disability

Diagnosis

A thorough health history and a physical examination are required. Imaging tests are often ordered to confirm the diagnosis. These tests are also useful for determining a prognosis and the best course of treatment. Diagnostic imaging techniques include:

• X-rays
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Dual-energy x-ray absorptiometry (DXA or DEXA) or bone densitometry

Treatment

Immediate compression fracture treatment is essential to relieving the pain and complication risks of the compression fracture. However, prevention of subsequent fractures is just as important and often discussed at the same time as the initial fracture treatment. Bone-strengthening drugs (bisphosphonates) may be prescribed to help stop and/or restore bone loss.

Conservative, non-surgical treatment options have proven to have limited effectiveness, as well as invasive surgical procedures. Some compression fractures are treated with a wait and watch approach, allowing them to heal naturally, if possible. The pain is usually secondary to the fracture itself and caused by the resulting vertebral instability. The pain associated with this method may last up to three months or longer; however, a significant pain decrease is usually seen in the first few days or weeks.

Though some bed rest may be prescribed, prolonged inactivity should be avoided. Certain activities should be limited. Over-the-counter pain medications, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), are generally effective in relieving pain. Narcotic pain medications, such as opioids, and muscle relaxants may be prescribed, but for a short time period due to the high addiction risk.

Back bracing provides external support by greatly limiting the normal spinal motion of fractured vertebrae. This limitation of spinal mobility may help reduce pain.

If conservative treatment options are ineffective, minimally invasive surgical procedures may be considered.

Vertebroplasty

• Usually done as an outpatient surgery, though may require an overnight hospital stay.
• Takes from one to two hours depending on the number of vertebrae being treated.
• Local anesthetic and intravenous sedation or general anesthesia are used.
• X-ray guidance is used to insert a small needle into the collapsed vertebra.
• A specially formulated acrylic bone cement is injected and hardens in minutes, strengthening and stabilizing the fractured vertebra.
• Mechanical support and stability provided by the bone cement are thought to relieve pain.

Kyphoplasty

• Similar to vertebroplasty with an added balloon procedure before cement is injected into the vertebra.
• Two small incisions are made.
• A probe is placed into the space where the fracture is located.
• The vertebra is drilled and a small balloon (bone tamp) is inserted on each side of the bone.
• The balloons are inflated with contrast medium (using x-ray image guidance) until they expand to the desired height.
• The two balloons are removed.
• The spaces created by the balloons are filled with cement.

Kyphoplasty is a newer procedure and has the added benefit of restoring some height to the spine. Although a large percentage of patients report significant pain relief after vertebroplasty and kyphoplasty procedures, there is no guarantee that surgery will help all patients. Not all patients are candidates for surgical treatment options, and there are many criteria that may bar a patient from undergoing one of these treatments.

If a cancerous tumor is the cause of the fracture, radiation therapy as well as surgery to remove some of the bone and treat the tumor may be required. If a traumatic injury is the cause of the fracture, a fusion surgery may be required to repair the bone and join the vertebrae together.