Spine Fractures & Osteoporosis

Updated: Nov 26, 2020

A spinal fracture due to osteoporosis (bones with very low calcium) is commonly referred to as a compression fracture, but can also be called a vertebral fracture, osteoporotic fracture, or wedge fracture.


A compression fracture is usually defined as a vertebral bone in the spine that has decreased at least 15 to 20% in height due to fracture.


These compression fractures can occur in vertebrae anywhere in the spine, but they tend to occur most commonly in the upper back (thoracic spine), particularly in the lower vertebrae of that section of the spine (e.g. D10, D11, D12). They rarely occur above the D7 level of the spine. They often occur in the upper lumbar segments as well, such as L1.


This article provides in-depth information on vertebral compression fractures, including symptoms, diagnosis, and treatments.


Osteoporosis
















Types of Fracture

The term "wedge fracture" is used because the fracture usually occurs in the front of the vertebra, collapsing the bone in the front of the spine and leaving the back of the same bone unchanged. This process results in a wedge-shaped vertebra.


While wedge fractures are the most common type of compression fracture, there are other types as well, such as:

  • Crush fracture. If the entire bone breaks, rather than just the front of the vertebra, it may be called a crush fracture.

  • Burst fracture. This type of fracture involves some loss of the height in both the front and back walls of the vertebral body (rather than just the front of the vertebra). Making this distinction is important because burst fractures can be unstable and result in progressive deformity or neurologic compromise.

Compression Fracture Symptoms

Vertebral fractures are usually followed by acute back pain, and may lead to chronic pain, deformity (thoracic kyphosis), loss of height, crowding of internal organs, and loss of muscle and aerobic conditioning due to lack of activity and exercise.


A combination of the above problems from vertebral fractures can also lead to changes in the individual's self-image, which in turn can adversely affect self-esteem and ability to carry on the activities of daily living.


Spinal Fractures are Common

Spinal compression fractures that occur as a result of osteoporosis are actually quite common, occurring in approximately 700,000 people each year.


Osteoporosis is especially common in postmenopausal women. In fact, it is estimated that approximately 25% of all postmenopausal women in the India have had a vertebral compression fracture.


While osteoporosis is far more prevalent in women - approximately four times as many women have low bone mass or osteoporosis as men - it still occurs in men. As many as 25% of men over age 50 will suffer a bone fracture (e.g. hip or spine) due to osteoporosis.


The problem is that the fracture is not always recognized or accurately diagnosed - instead, the patient's pain is often just thought of as general back pain, such as from a muscle strain or other soft tissue injury, or as a common part of aging. As a result, approximately two thirds of the vertebral fractures that occur each year are not diagnosed and therefore not treated.


Vertebral Fracture Symptoms

Because osteoporosis is a "silent" disease, meaning that there are typically no symptoms until a fracture occurs, it is not uncommon for someone with back pain to be unaware of the fact that he or she has actually fractured a vertebra (or multiple vertebrae) in their spine.


Typical Compression Fracture Symptoms

The main clinical symptoms of vertebral fractures typically include one or a combination of the following symptoms:

  1. Sudden onset of back pain

  2. Standing or walking will usually make the pain worse

  3. Lying on one's back makes the pain less intense

  4. Limited spinal mobility

  5. Height loss

  6. Deformity and disability

As a general rule, a compression fracture should be suspected in any patient over the age of 50 with acute onset of back pain. For women, especially those with risk factors for osteoporosis, many physicians believe that a vertebral fracture should be suspected in any women over age 45 with sudden onset of back pain.


Sometimes a compression fracture in the spine may not cause any back pain or other symptoms. Therefore, even if there is not back pain, middle age or elderly persons (especially women) need to be concerned about potential fractures if there is height loss, limited ability to twist and bend the back, and/or deformity that develops in the spine.


Typical Progression of Compression Fracture Symptoms

When osteoporosis results in a vertebral fracture, it is usually marked by the sudden onset of back pain. Most patients diagnosed with a compression fracture in the spine describe the onset of pain immediately after a fairly routine activity that slightly strains or jars the back, such as:

  1. Lifting - opening a window or picking up a bag of groceries

  2. Bending - picking something up off the floor

  3. Falling - jarring the spine by missing a step or slipping on ice.

For people with advanced osteoporosis, the fracture can even occur with extremely minor activity, such as sneezing, coughing, getting in or out of the bathtub, or simply turning over in bed.


The pain from an osteoporotic spinal fracture typically lasts about four to six weeks as the bone heals, after which most patients report that the more severe pain has subsided and has turned into more of a chronic, achy pain concentrated in the area of the back where the fracture occurred.


This pain will usually get better after a few weeks, but for some people it can continue for several months. Additionally, some patients experience back pain long after the fractured bone has healed due to changed mechanics in the back and possibly due to inactivity.


Other Types of Fracture Pain Patterns

The above describes the course of events that is experienced by most patients with a vertebral compression fracture. However, not everyone has a typical experience. Examples of other types of pain patterns include:

  • If the bone collapses gradually rather than due to an activity, the pain will usually be more gradual and mild.

  • Some patients with vertebral fractures report that they felt no back pain or other symptoms.

  • For others, instead of pain the symptoms of deformity that start to show up after multiple fractures may be the patient's first indication that he or she has vertebral fractures from osteoporosis.

Multiple Compression Fractures

Unlike many other conditions that can be treated before a serious complication develops, usually a fracture is the first sign that someone has osteoporosis. By the time a fracture occurs, the osteoporosis is usually advanced and the individual is then at risk for sustaining more vertebral fractures.

Osteoporosis: The Primary Cause of Collapsed Vertebrae

Choice of treatment for a spine compression fracture depends first on getting an accurate diagnosis of the cause of the fracture.


Osteoporosis

Osteoporosis is by far the most common cause of vertebral compression fractures, especially in women over the age of 50. It is also more common than most people think in people age 40-50, and it is reasonably common in men over age 50.


Osteoporosis causes bones to thin and become more brittle and weak. The thinning bones can collapse during normal activity, leading to a spinal fracture. These compression fractures can cause a great deal of pain and can permanently alter the shape and strength of the spine.


Spinal fractures due to osteoporosis often occur while doing something that causes relatively minor trauma to the spine, such as opening a window, an insignificant fall, or twisting while lifting.


Advanced cases of osteoporosis can even lead to a vertebral fracture with routine activities that would normally not cause any trauma, such as sneezing, coughing, or turning over in bed.


Trauma

Trauma to the spinal vertebrae can also lead to minor or severe fractures. Such trauma could come from a fall, a forceful jump, a car accident, or any event that stresses the bones in the spine past its breaking point.


Cancer/Tumor

Some types of cancer can also cause a weakening of the vertebrae in the spine to the point where they may fracture. It is not uncommon for metastatic cancer that starts in another part of the body to spread to bones in the spine.


A compression fracture of the spine that appears for little or no reason may be the first indication that an unrecognized cancer has spread to the spine. Cancer or multiple myeloma should be considered in patients who also have hypercalcemia, otherwise unexplained anemia, weight loss, or proteinuria.


The first step in obtaining the best treatment is to get an accurate diagnosis of the compression fracture and the underlying cause of the fracture.


Diagnosing Vertebral Compression Fractures

It is important to accurately diagnose vertebral compression fractures due to osteoporosis, as there are a number of potential adverse effects if a diagnosis is missed and there is no treatment. In general, vertebral fractures are associated with both increased morbidity (unwanted side effects) and mortality (death).

  1. Morbidity (side effects) associated with vertebral fractures often includes continued pain, decreased physical function, deformity, and potentially social isolation, all of which negatively impact the individual's overall quality of and enjoyment of life.

  2. Mortality is also associated with vertebral fractures, as women diagnosed with a compression fracture of the spine have a 15% higher mortality rate than those who do not experience fractures.

The presence of one vertebral fracture increases the risk of any subsequent vertebral fracture 5-fold. Of women who have had a recent vertebral fracture, it is estimated that approximately 20% will sustain a new fracture within the next 12 months.

Difficulty in Diagnosing an Osteoporosis Fracture

Unlike many other conditions, diagnosing a vertebral compression fracture is not as straightforward as one would think. For example:

  • When an elderly person complains of back pain, it is often assumed to be just general back pain, spinal arthritis, or a normal part of the aches and pains associated with aging. This assumption may be made by the patient, by his or her family or caregivers, and/or by the treating physician. When this happens, the patient is often not even checked for a vertebral fracture.

  • In most cases of an osteoporosis-related hip or wrist fracture, the fractured bone is easily identified by a standard x-ray. However, in the spine a compression fracture may be missed on an x-ray, and if this is the case it may be assumed that the patient's pain is due to general muscle strain or just the aches and pains that accompany aging.

Diagnostic Process

The diagnostic process includes a complete history of the patient's condition, medical history, and family history. A number of questions related to the patient’s pain will probably be asked, such as:

  • When did the pain start? Was it sudden or gradual?

  • Where is the pain? What is the intensity of the pain?

  • What activities or positions tend to make the pain feel better or worse?

  • Does the pain radiate down the leg or arm or to other parts of the body?

After taking the patient's history, the physician will do a physical examination, with the objective of trying to determine the cause of the pain and ruling out other possible problems.


If a vertebral compression fracture is suspected, the doctor will test for tenderness and sensitivity near specific vertebrae along the spine. Based on the patient's history and physical exam, if a vertebral fracture is suspected, an x-ray will be ordered to confirm the diagnosis.


Diagnostic Tests

Depending on the physician's findings from the patient's history, physical exam, and x-ray, additional diagnostic tests may also be needed, such as:

  1. A CAT scan, to see whether or not the fractured bone is stable and/or to see if the adjacent nerves near the fracture are being irritated or may be affected by the fracture. Because a CAT scan can show soft tissue (e.g. nerves) as well as bone, and because it can take cross-sectional images of the spine, it provides the physician more information than an x-ray.

  2. An MRI scan may be ordered if the doctor suspects that there may be some other cause of the patient’s pain (e.g. a herniated disc), or if there is a chance that nerves near the fracture are affected. An MRI scan shows a high level of detail of the soft tissues (e.g. nerves, discs) surrounding the fracture that may be affected. An MRI scan can also tell if the fracture is old or new. In a new fracture the bone will be particularly dark on one sequence of films (the T1 weighted sagittal images).

  3. A nuclear bone scan may be used to help determine when the fracture occurred. The age of the fracture is sometimes important to know to help guide treatment options.

Compression Fracture Treatment

Treatment of a spinal fracture caused by osteoporosis is usually two-pronged, including both treatment of the fracture, and treatment of the underlying osteoporosis that led to the fracture.


Fracture treatment

Treatment for the vertebral fracture will typically include surgical care along with ancillary care such as rest, pain medication, use of heat or ice for local pain, and slow return to mobility. The two most common types of surgery for this type of fracture are vertebroplasty and kyphoplasty. Both types of surgery can help the fracture heal.


Vertebroplasty. This minimally invasive treatment is designed to help reduce or eliminate pain caused by a fractured vertebra and stabilize the bone. Low viscosity cement is injected directly into the collapsed vertebral body under high pressure, with the goal of stabilizing the fracture and relieving the associated back pain.


Kyphoplasty. Similar to vertebroplasty, kyphoplasty is a minimally invasive procedure designed to reduce or stop the pain caused by a spinal fracture, to stabilize the bone, and to restore some or all of the lost vertebral body height due to the compression fracture.


Other type of surgeries like Minimally Invasive Spinal Fusion (MISS), are also sometimes advised depending upon patient’s condition and type of anatomy the fracture is having.


Helping prevent future fractures by treating the osteoporosis

After sustaining one vertebral fracture, the patient is at risk for more fractures, so treatment of the patient’s underlying osteoporosis is an important part of the treatment plan.


Osteoporosis treatment will typically include one or a combination of the following: calcium supplements, increased vitamin D, weight-bearing exercises, and hormone replacement therapy for women.


Because of the significant health and deformity risks related to multiple vertebral fractures, it is advisable for patients who suspect their back pain may be from a fracture to get an accurate diagnosis and a pursue a comprehensive treatment plan.

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