summary Osteoporotic vertebral compression fractures are very common fragility fractures of the spine that affect up to 50% of people >80 y/o Diagnosis can be made with lateral radiographs. MRI or bone scan can help determine the acuity of a fracture Treatment is usually observation and pain management. Kyphoplasty is reserved for patients with recalcitrant symptoms after failure of nonoperative treatment for 4-6 weeks. Assessment and management of osteoporosis are indicated in the presence of these injuries Epidemiology Incidence vertebral compression fracture (VCF) is the most common fragility fracture 700,000 VCFs per year in the U.S. 70,000 hospitalizations annually $15 billion in annual costs Demographics affects up to 25% people >70 y/o 50% people >80 y/o Risk factors history of 2 VCFs strongest predictor of future vertebral fractures in postmenopausal women Etiology Pathoanatomy osteoporosis characteristics bone quality is normal, but quantity is decreased cortices are thinned cancellous bone has decreased trabecular continuity bone mineral density (BMD) in the lumbar spine peaks at females: 33-40 y/o males: 19-33 y/o peak BMD is widely variable based on demographic factors and location in the body decreases with age following peak mass correlates well with bone strength and is a good predictor of fragility fracture WHO defines osteoporosis as a T score below -2.5 Associated conditions compromised pulmonary function increased kyphosis can affect pulmonary function each VCF can result in up to 9% reduction in FVC increased risk of mortality from pulmonary dysfunction Presentation Symptoms pain 25% of VCFs are painful enough that patients seek medical attention pain is usually localized to the area of the fracture may wrap around rib cage in a dermatomal distribution Physical exam focal tenderness pain with deep palpation of spinous process multiple compression fractures can lead to local kyphosis spinal cord injury (very rare) may see nerve root deficits with compression fractures of lumbar spine that lead to severe foraminal stenosis Imaging Radiographs entire spine (concomitant spine fractures in 20%) will see loss of anterior, middle, or posterior vertebral height by 20% or at least 4 mm CT scan usually not necessary for diagnosis indications fracture on plain films neurologic deficit in the lower extremity inadequate plain films MRI usually not necessary for diagnosis useful to evaluate for: acute vs. chronic nature of the compression fracture injury to anterior and/or posterior ligamentous complex spinal cord compression by disc or osseous material cord edema or hemorrhage osteoporotic vs. metastatic etiology Studies Laboratory a full medical workup (including CBC and BMP) should be performed ESR may help to rule out infection urine and serum protein electrophoresis may help rule out multiple myeloma Differential 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 a fall Treatment Nonoperative observation, bracing, and medical management indications majority of patients can be treated with observation and a gradual return to activity PLL is intact (even if >30° kyphosis or > 50% loss of vertebral body height) technique if the fracture is <5 days old calcitonin can be used for 4 weeks to decrease pain medical management can include bisphosphonates to prevent future risk of fragility fractures some patients may benefit from an extension orthosis (compliance can be an issue) Operative vertebroplasty indications controversial AAOS strongly recommended against the use of vertebroplasty in 2011, but then changed their stance in 2014 based on newer 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 recommended that kyphoplasty may be used, but recommendation strength is limited technique kyphoplasty is different from vertebroplasty in that a cavity is created by balloon expansion. Cement can be injected with less pressure into the cavity created by the balloon pain relief is 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 long constructs with multiple fixation points should be considered consider combined anterior fixation Techniques Kyphoplasty vs. vertebroplasty performed under fluoroscopic guidance percutaneous transpedicular approach used for cannula vertebroplasty PMMA injected directly into cancellous bone without cavity creation performed when cement is less viscous requires greater pressure because no cavity is created increased risk of extravasation into spinal canal 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 Complications Neurologic injury 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 (Kümmell's disease) delayed post-traumatic osteonecrosis Prognosis Mortality 1-year mortality: ~15% (less than hip fracture) 2-year mortality: ~20% (equivalent to hip fracture)