Osteoporotic Vertebral Fracture
Causes and Risk Factors
Osteoporotic vertebral fractures are typically caused by: [Ref]
- Low-energy trauma (typically falling from standing height or less)
- Notably, osteoporotic vertebral fractures can be caused by even routine daily activities (e.g. lifting objects, bending forward, coughing, sitting down on a low chair)
Relevant Anatomy
Osteoporotic vertebral fractures affect the anterior column of the vertebrae [Ref]
Frequently affected area: [Ref]
- Thoracolumbar junction (T12-L2) – most common (~60-75% cases)
- Lumbar spine (L2-L5) – 2nd most common (~30% cases)
Clinical Features and Complications
It is very common for osteoporotic vertebral fractures to be asymptomatic (seen in 1/3 to 2/3 cases) [Ref]
Suspect osteoporotic vertebral fractures in an older man / postmenopausal woman / osteoporotic patient with any of the following: [Ref]
- Back pain
- Kyphosis
- Unexplained height loss
- Midline spine tenderness
- Neurological symptoms of spinal cord compression (rare)
If symptomatic, symptoms typically have a gradual onset and might only be apparent months after the fracture has occurred
Since many patients do not experience a distinct “trauma” event and it can be completely asymptomatic, one should have a high index of suspicion for an osteoporotic vertebral fracture in an older or osteoporotic patient.
Risk factors for osteoporotic vertebral fractures are largely the same as those for osteoporosis in general. See the Osteoporosis article for further details.
Investigation and Diagnosis
Choice of imaging: [Ref]
- Initial choice: X-ray of the spine (lateral views)
- MRI can
- Detect less obvious fractures or fractures that are not clearly visible on X-ray
- Differentiate between benign and malignant fractures
- Estimate the age of the fracture
- Assess for any spinal cord or nerve root involvement
- CT provides more detailed assessment of the bony anatomy and fracture morphology
Interpretation: [Ref]
- A compression fracture is defined as a ≥20% decrease in vertebral height, or >4 mm decrease compared to the patient’s baseline vertebral height
- A vertebral fracture can be classified according to vertebral height loss:
- Wedge fracture: loss of anterior vertebral height with relative preservation of posterior height, producing a wedge-shaped vertebra and contributing to kyphosis
- Biconcave fracture: collapse of the central superior and inferior endplates with relative preservation of the anterior and posterior vertebral margins
- Crush fracture: more uniform loss of both anterior and posterior vertebral height, causing marked flattening of the vertebral body
Management
Fracture Management
1st line management: conservative (non-operative) management with [Ref]
- Analgesia
- Bracing (spine orthoses) for 6-8 weeks
- Aim: to limit ROM, improve posture, reduce kyphotic deformity and provide biomechanical stability
- Early mobilisation (as soon as tolerated)
- Physiotherapy
Surgical management is generally reserved for those with: [Ref]
- Failed conservative management (e.g. persistent pain that prevents walking after 4-6 weeks of conservative management, analgesia is inappropriate)
- Presence of neurological deficit
- Severe vertebral body collapse (>50%)
The mainstay of surgical treatment is vertebral augmentation (percutaneous vertebroplasty or percutaneous balloon kyphoplasty), which aims to consolidate the fracture and restore vertebral height [Ref]
Secondary Fracture Prevention
Following a fragility fracture (in post-menopausal women, and men >50 y/o):
- Start bone-sparing treatment (1st line: oral bisphosphonates) promptly
- Fracture risk assessment (informed by DEXA) is performed to guide the choice of drug treatment, not primarily to determine the necessity of intervention
See the Osteoporosis article for more information.