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Updated: Jun 23 2021

Osteoporotic Vertebral Compression Fracture

  • summary
    • Osteoporotic Vertebral Compression Fractures are very common fragility fractures of the spine that affect up to 50% of people over 80 years old.
    • Diagnosis can be made with lateral radiographs. Determining the acuity of a fracture requires an MRI or bones scan. 
    • Treatment is usually observation and pain management. Kyphoplasty is reserved for patients with recalcitrant symptoms after nonoperative treatment for 4-6 weeks fails. Assessment and management of osteoporosis is indicated in the presence of these injuries. 
  • Epidemiology
    • Incidence
      • 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
    • Demographics
      • affects up to
        • 25% people over 70 years
        • 50% people over 80 years
    • Risk factors
      • history of 2 VCFs
        • is the strongest predictor of future vertebral fractures in postmenopausal women
  • Etiology
    • Pathoanatomy
      • osteoporosis
        • 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
    • Associated conditions
      • 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
  • Presentation
    • Symptoms
      • 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
    • Physical exam
      • 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
  • Imaging
    • Radiographs
      • 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
    • CT scan
      • 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
  • Studies
    • Laboratory
      • 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
  • 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 fall
  • Treatment
    • Nonoperative
      • 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
    • Operative
      • 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
  • 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 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
  • Complications
    • Neurological 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 (aka Kummell's disease)
      • Delayed post-traumatic osteonecrosis
  • Prognosis
    • Mortality
      • 1-year mortality ~ 15% (less than hip fx)
      • 2-year mortality ~20% (equivalent to hip fx)
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