Osteoporotic Vertebral Compression Fracture - Spine (2024)

• vertebral compression fractures (VCF) are the most common fragility fracture

• 700,000 VCF per year in US

• 70,000 hospitalizations annually

• 15 billion in annual costs

• affects up to

  • 25% people over 70 years

  • 50% people over 80 years

• history of 2 VCFs

  • is the strongest predictor of future vertebral fractures in postmenopausal women

• osteoporosis

  See Also

  Fractured Spine (Vertebrae): Types, Long-Term Effects & TreatmentFractures of the Thoracic and Lumbar Spine - OrthoInfo - AAOSSpinal Fractures: Types, Causes, Symptoms, Diagnosis, and TreatmentsVertebral Fracture: Practice Essentials, Epidemiology, Pathophysiology

  • characteristics

    • bone is normal quality but decreased in quantity

      • cortices are thinned

      • cancellous bone has decreased trabecular continuity

    • bone mineral density in the lumbar spine (BMD)

      • peaks at

        • between 33 to 40 yrs in women

        • between 19 to 33 years in men

          • peak BMD is widely variable based on demographic factors and location in body

      • decreases with age following peak mass

      • correlate well with bone strength and is a good predictor of fragility fracture

  • definition

    • WHO defines osteoporosis as T score below -2.5

• compromised pulmonary function

  • increased kyphosis can affect pulmonary function

  • each VCF leads up to 9% reduction in FV

  • increased risk of mortality from pulmonary dysfunction

• pain

  • 25% of VCF are painful enough that patients seek medical attention

  • pain usually localized to area of fracture

    • but may wrap around rib cage if dermatomal distribution

• focal tenderness

  • pain with deep palpation of spinous process

• local kyphosis

  • multiple compression fractures can lead to local kyphosis

• spinal cord injury

  • signs of spinal cord compression are very rare

• nerve root deficits

  • may see nerve root deficits with compression fractures of lumbar spine that lead to severe foraminal stenosis

• obtain radiographs of the entire spine (concomitant spine fractures in 20%)

• will see loss of anterior, middle, or posterior vertebral height by 20% or at least 4mm

• usually not necessary for diagnosis

• indications

  • fracture on plain film

  • neurologic deficit in lower extremity

  • inadequate plain films

MRI

• usually not necessary for diagnosis

• useful to evaluate for

  • acute vs chronic nature of compression fracture

  • injury to anterior and posterior ligament complex

  • spinal cord compression by disk or osseous material

  • cord edema or hemorrhage

  • osteoporotic vs metastatic etiology

• a full medical workup should be performed with CBC, BMP

• ESR may help to rule out infection

• Urine and serum protein electrophoresis may help rule out multiple myeloma

Metastatic cancer to the spine

• must be considered and ruled out

• the following variables should raise suspicion

  • fractures above T5

  • atypical radiographic findings

  • failure to thrive and constitutional symptoms

  • younger patient with no history of fall

• observation, bracing, and medical management

  • indications

    • majority of patients can be treated with observation and gradual return to activity

    • PLL intact (even if > 30 degrees kyphosis or > 50% loss of vertebral body height)

  • technique

    • if the fracture is less than five days old

      • calcitonin can be used for four weeks to decrease pain

    • medical management can consist of bisphosphonates

      • to prevent future risk of fragility fractures

    • some patients may benefit from an extension orthosis

      • although compliance can be an issue

• vertebroplasty

  • indications

    • controversial

      • AAOS recommends strongly against the use of vertebroplasty in 2011 but then changed their stance in 2014 based on recent studies

  • outcomes

    • randomized, double-blind, placebo-controlled trials have shown no beneficial effect of vertebroplasty

    • vertebroplasty has higher rates of cement extravasation and associated complications than kyphoplasty

• kyphoplasty

  • indications

    • patient continues to have severe pain symptoms after 6 weeks of nonoperative treatment

    • AAOS recommend may be used, but recommendation strength is limited

  • technique

    • kyphoplasty is different than vertebroplasty in that a cavity is created by balloon expansion and therefore the cement can be injected with less pressure

    • pain relief thought to be from elimination of micromotion

• surgical decompression and stabilization

  • indications

    • very rare in standard VCF

    • progressive neurologic deficit

    • PLL injury and unstable spines

  • technique

    • to prevent possible failure due to osteoporotic bone

      • consider long constructs with multiple fixation points

      • consider combined anterior fixation

• performed under fluoroscopic guidance

• percutaneous transpedicular approach used for cannula

• vertebroplasty

  • PMMA injected directly into cancellous bone without cavity creation

  • performed when cement is more liquid

  • requires greater pressure because no cavity is created

    • increased risk of extravasation into spinal canal is greater

• kyphoplasty

  • cavity created with expansion device (e.g., balloon) prior to PMMA injection

  • performed when cement is more viscous

  • may be possible to obtain partial reduction of fracture with balloon expansion

• can be caused by extravasation of PMMA into spinal canal

  • higher risk with vertebroplasty than kyphoplasty

  • important to consider defects in the posterior cortex of the vertebral body

Vertebral body osteonecrosis (aka Kummell's disease)

• Delayed post-traumatic osteonecrosis

• 1-year mortality ~ 15% (less than hip fx)

• 2-year mortality ~20% (equivalent to hip fx)