COMPRESSION FRACTURE
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What is a Spine Compression Fracture?
A compression fracture of the spine is where one of the vertebral bones gets squished.
This fracture occurs mainly in the elderly because our bones become weaker as we get older, a condition called osteoporosis. Everyone develops osteoporosis with age, however some people get it worse than others. Unfortunately, our spine (the vertebral bones) are affected by osteoporosis more than any other bones in our body. Therefore with worsening osteoporosis our vertebre are at risk of breaking under forces that a healthy bone could easily withstand. People come in with back pain usually after some minor event, like sitting down on a hard chair with too much force, or falling down from standing height.
To give an idea of how common this fracture becomes in the aging population, many estimates believe that about 25% of people over 70, and 50% of people over 80 years old have experienced a vertebral compression fracture. About 700,000 compression fractures occur every year, leading to about 125,000 hospitalizations (its believed that about 25% of people with a compression fracture require hospitalization to control the associated pain).
How is a Spine Compression Fracture diagnosed?
A compression fracture, like any other broken bone, is painful.
Its uncommon for this type of fracture to injure the spinal cord, and typically pain is the only complaint (no numbness or weakness). However, sometimes the squished bone can entrap one of the nerves branching off the spinal cord. This will cause pain that radiates down the arm or leg.
The injury, like most other broken bones, is diagnosed with basic x-ray once the doctor is suspicious for this injury based on the patients story. The x-rays show a vertebral bone that has become squished, lost at least 20% of its height, by comparing it to the neighboring vertebrae. It is important to get x-rays of the entire spine, not just the area of localizing pain, because about 20% of the time there is another compression fracture in the spine.
A MRI is normally not required, unless someone has developed neurologic symptoms in addition to the pain, which would suggest a pinched nerve.
How is a Spine Compression Fracture treated?
These fractures are usually treated successfully with pain control medication, rest, and gradual return to normal activity.
A back brace also can often be helpful in alleviating pain by taking some of the pressure off the affected spine segment.
Treatment for the underlying osteoporosis is recommended to minimize the chance of another fracture occurring in the future. Bisphosphonates, a medication that slows down the turnover of our bone (prevents it from becoming thinner) has been studied as a way to prevent future spinal compression fractures and appears to have some positive effects. Also calcium and vitamin D can help prevent worsening osteoporosis.
Surgery is not necessary because even with significant crunching of the bone, this fracture is stable and there is little risk the injury will get worse.
However, if the pain is significant and does not improve after 6 weeks, there is a procedure called Kyphoplasty which can be used to treat the pain and has been shown to be effective at improving pain.
Kyphoplasty is a procedure that places a balloon into the compressed vertebral bone and the balloon gets inflated, which creates a central space within the bone and helps to return the bone to its normal height. The balloon is then taken out, and cement is used to fill this space created by the balloon. The cement holds the bone fragments together, and stops them from moving around (the motion of broken bone is believe to be a major cause of the back pain associated with this injury).
There is another procedure, called Vertebroplasty, which is not recommended by the American Academy of Orthopedic Surgeons. This procedure works by injecting a cement material directly into the broken bone without a balloon first inserted to create a space. The problem with this procedure is that the cement needs to be injected under high-pressure (because there is no space formed within the bone), and under high pressure the cement can pour out of the bone and cause all sorts of problems, like press directly onto the spinal cord. Therefore, most orthopedic surgeons recommend Kyphoplasty if a person's back pain continues after a few weeks.
What is the long term outcome?
Most patients report that the back pain will resolve with time, although it may take many weeks or months.
The bigger concern is the risk for repeat compression fractures in other vertebre. There is about a 20% risk of another fracture developing in neighboring vertebrae. Its therefore very important to treat the underlying disease, the osteoporosis, with Vitamin D, calcium, and bisphosphonates, to minimize the risk of this happening again.
References
1) Buchbinder R et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. NEJM 2009; 361: 557-68. full article. vertebroplasty no better than sham procedure.
2) Kallmes DF et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. NEJM 2009; 361: 569-79. full article. more evidence vertebroplasty doesnt help.
3) Esses S et al. The treatment of symptomatic osteoporotic spinal compression fractures. JAAOS 2011; 19: 176-82. full article. american orthopedic society recommendations.
4) Meunier PJ et al. The effects of strontium ranelate on the risk of vertebral fracture in women with postmenopausal osteoporosis. NEJM 2004; 350: 459-468. full article. bisphos reduces risk of future symptomatic compression fx.
5) Wardlaw D et al. Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): A randomised controlled trial. Lancet 2009. full article. kyphoplasty helps in subacute fx up to 1 year vs conservative rx.
6) Chen AT et al. Impact of nonoperative treatment, vertebroplasty, and kyphoplasty on survival and morbidity after vertebral compression fracture in the medicare population. JBJS 2013; 95: 1729-36. full article. kyphoplasty reduces 1 yr mortality.