Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Osteoporotic thoracolumbar vertebral compression fractures: Clinical manifestations and treatment

INTRODUCTION

Osteoporotic fractures (fragility fractures, low-trauma fractures) are those occurring from a fall from a standing height or less, without major trauma such as a motor vehicle accident. Vertebral compression fractures are the most common type of osteoporotic fracture [1]. They often occur at the midthoracic (T7-T8) spine and the thoracolumbar junction (T12-L1). Fractures may result in significant back pain, limited physical functioning and activities of daily living, and can lead to loss of independence, depression, and chronic pain. Osteoporotic fracture is an important risk factor for subsequent fracture.

This topic will review the clinical manifestations, diagnosis, and management of acute osteoporotic vertebral compression fractures. The diagnosis and treatment of osteoporosis are reviewed separately. (See "Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women" and "Clinical manifestations, diagnosis, and evaluation of osteoporosis in men" and "Overview of the management of osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men".)

CLINICAL MANIFESTATIONS

Symptoms and signs — Osteoporotic vertebral compression that occurs slowly over time is often asymptomatic. Old or healed fractures may be an incidental finding on radiographs of the chest or abdomen. In other patients, the presence of vertebral fractures may become apparent because of height loss or kyphosis [2]. In contrast, acute episodes of significant vertebral body compression are associated with pain. The pain may be tolerable and resolve without medical intervention (but the patient can often recall the episode of pain when a fracture is incidentally found on other imaging) or the pain may be incapacitating, requiring hospital admission and parenteral opioids. (See 'Height loss' below and 'Kyphosis' below.)

In patients who have acute symptomatic vertebral body fracture, there is often no history of preceding trauma. The typical patient presents with acute back pain after sudden bending, coughing, or lifting. Occasionally, minor trauma, such as going over speed bumps, may precipitate a fracture [3]. The pain is usually well localized to the midline spine but often refers in a unilateral or bilateral pattern into the flank, anterior abdomen, or the posterior superior iliac spine. By contrast, radiation of pain into the legs, as may be seen with a herniated disc, is rare with compression fractures, but may herald spinal cord or nerve root compression from retropulsed bone fragments.

The pain from a vertebral compression fracture is variable in quality and may be sharp or dull. Sitting, spine extension, Valsalva maneuver, and movement often aggravate the pain and may be accompanied by muscle spasms. Sleep may be disturbed by pain. On physical examination, the patient may experience pain upon palpation and percussion of the corresponding spinous process and paravertebral structures.

                               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jun 2014. | This topic last updated: Jan 14, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Genant HK, Cooper C, Poor G, et al. Interim report and recommendations of the World Health Organization Task-Force for Osteoporosis. Osteoporos Int 1999; 10:259.
  2. Vogt TM, Ross PD, Palermo L, et al. Vertebral fracture prevalence among women screened for the Fracture Intervention Trial and a simple clinical tool to screen for undiagnosed vertebral fractures. Fracture Intervention Trial Research Group. Mayo Clin Proc 2000; 75:888.
  3. Aslan S, Karcioglu O, Katirci Y, et al. Speed bump-induced spinal column injury. Am J Emerg Med 2005; 23:563.
  4. Siminoski K, Warshawski RS, Jen H, Lee K. The accuracy of historical height loss for the detection of vertebral fractures in postmenopausal women. Osteoporos Int 2006; 17:290.
  5. Green AD, Colón-Emeric CS, Bastian L, et al. Does this woman have osteoporosis? JAMA 2004; 292:2890.
  6. Schlaich C, Minne HW, Bruckner T, et al. Reduced pulmonary function in patients with spinal osteoporotic fractures. Osteoporos Int 1998; 8:261.
  7. Wynne AT, Nelson MA, Nordin BE. Costo-iliac impingement syndrome. J Bone Joint Surg Br 1985; 67:124.
  8. Madsen JL. Bone scintigraphy in costo-iliac impingement syndrome. Clin Nucl Med 2008; 33:792.
  9. Lindsay R, Silverman SL, Cooper C, et al. Risk of new vertebral fracture in the year following a fracture. JAMA 2001; 285:320.
  10. Klotzbuecher CM, Ross PD, Landsman PB, et al. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 2000; 15:721.
  11. Black DM, Arden NK, Palermo L, et al. Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures. Study of Osteoporotic Fractures Research Group. J Bone Miner Res 1999; 14:821.
  12. Greendale GA, DeAmicis TA, Bucur A, et al. A prospective study of the effect of fracture on measured physical performance: results from the MacArthur Study--MAC. J Am Geriatr Soc 2000; 48:546.
  13. Papaioannou A, Watts NB, Kendler DL, et al. Diagnosis and management of vertebral fractures in elderly adults. Am J Med 2002; 113:220.
  14. Huang C, Ross PD, Wasnich RD. Vertebral fracture and other predictors of physical impairment and health care utilization. Arch Intern Med 1996; 156:2469.
  15. Rapado A. General management of vertebral fractures. Bone 1996; 18:191S.
  16. Genant HK, Wu CY, van Kuijk C, Nevitt MC. Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 1993; 8:1137.
  17. De Smet AA, Robinson RG, Johnson BE, Lukert BP. Spinal compression fractures in osteoporotic women: patterns and relationship to hyperkyphosis. Radiology 1988; 166:497.
  18. Campbell SE, Phillips CD, Dubovsky E, et al. The value of CT in determining potential instability of simple wedge-compression fractures of the lumbar spine. AJNR Am J Neuroradiol 1995; 16:1385.
  19. Mazanec DJ, Podichetty VK, Mompoint A, Potnis A. Vertebral compression fractures: manage aggressively to prevent sequelae. Cleve Clin J Med 2003; 70:147.
  20. Lee HM, Park SY, Lee SH, et al. Comparative analysis of clinical outcomes in patients with osteoporotic vertebral compression fractures (OVCFs): conservative treatment versus balloon kyphoplasty. Spine J 2012; 12:998.
  21. Agulnek AN, O'Leary KJ, Edwards BJ. Acute vertebral fracture. J Hosp Med 2009; 4:E20.
  22. Koester MC, Spindler KP. Pharmacologic agents in fracture healing. Clin Sports Med 2006; 25:63.
  23. Lyritis GP, Paspati I, Karachalios T, et al. Pain relief from nasal salmon calcitonin in osteoporotic vertebral crush fractures. A double blind, placebo-controlled clinical study. Acta Orthop Scand Suppl 1997; 275:112.
  24. Armingeat T, Brondino R, Pham T, et al. Intravenous pamidronate for pain relief in recent osteoporotic vertebral compression fracture: a randomized double-blind controlled study. Osteoporos Int 2006; 17:1659.
  25. Laroche M, Cantogrel S, Jamard B, et al. Comparison of the analgesic efficacy of pamidronate and synthetic human calcitonin in osteoporotic vertebral fractures: a double-blind controlled study. Clin Rheumatol 2006; 25:683.
  26. Theodorou DJ, Theodorou SJ, Duncan TD, et al. Percutaneous balloon kyphoplasty for the correction of spinal deformity in painful vertebral body compression fractures. Clin Imaging 2002; 26:1.
  27. Ledlie JT, Renfro MB. Kyphoplasty treatment of vertebral fractures: 2-year outcomes show sustained benefits. Spine (Phila Pa 1976) 2006; 31:57.
  28. Kaufmann TJ, Jensen ME, Schweickert PA, et al. Age of fracture and clinical outcomes of percutaneous vertebroplasty. AJNR Am J Neuroradiol 2001; 22:1860.
  29. AAOS Guideline on the Treatment of Osteoporotic Spinal Compresson Fractures, Summary of Recommendations http://www.aaos.org/research/guidelines/SCFsummary.pdf (Accessed on May 08, 2013).
  30. National Institute for Health and Care Excellence. Vertebral fractures -vertebroplasty and kyphoplasty (TA279), issued April 2013. http://guidance.nice.org.uk/TA279 (Accessed on May 08, 2013).
  31. Ma XL, Xing D, Ma JX, et al. Balloon kyphoplasty versus percutaneous vertebroplasty in treating osteoporotic vertebral compression fracture: grading the evidence through a systematic review and meta-analysis. Eur Spine J 2012; 21:1844.
  32. Xing D, Ma JX, Ma XL, et al. A meta-analysis of balloon kyphoplasty compared to percutaneous vertebroplasty for treating osteoporotic vertebral compression fractures. J Clin Neurosci 2013; 20:795.
  33. Liu JT, Liao WJ, Tan WC, et al. Balloon kyphoplasty versus vertebroplasty for treatment of osteoporotic vertebral compression fracture: a prospective, comparative, and randomized clinical study. Osteoporos Int 2010; 21:359.
  34. Robinson Y, Olerud C. Vertebroplasty and kyphoplasty--a systematic review of cement augmentation techniques for osteoporotic vertebral compression fractures compared to standard medical therapy. Maturitas 2012; 72:42.
  35. Papanastassiou ID, Phillips FM, Van Meirhaeghe J, et al. Comparing effects of kyphoplasty, vertebroplasty, and non-surgical management in a systematic review of randomized and non-randomized controlled studies. Eur Spine J 2012; 21:1826.
  36. Anderson PA, Froyshteter AB, Tontz WL Jr. Meta-analysis of vertebral augmentation compared with conservative treatment for osteoporotic spinal fractures. J Bone Miner Res 2013; 28:372.
  37. Edidin AA, Ong KL, Lau E, Kurtz SM. Mortality risk for operated and nonoperated vertebral fracture patients in the medicare population. J Bone Miner Res 2011; 26:1617.
  38. McCullough BJ, Comstock BA, Deyo RA, et al. Major medical outcomes with spinal augmentation vs conservative therapy. JAMA Intern Med 2013; 173:1514.
  39. Voormolen MH, Mali WP, Lohle PN, et al. Percutaneous vertebroplasty compared with optimal pain medication treatment: short-term clinical outcome of patients with subacute or chronic painful osteoporotic vertebral compression fractures. The VERTOS study. AJNR Am J Neuroradiol 2007; 28:555.
  40. Rousing R, Andersen MO, Jespersen SM, et al. Percutaneous vertebroplasty compared to conservative treatment in patients with painful acute or subacute osteoporotic vertebral fractures: three-months follow-up in a clinical randomized study. Spine (Phila Pa 1976) 2009; 34:1349.
  41. Rousing R, Hansen KL, Andersen MO, et al. Twelve-months follow-up in forty-nine patients with acute/semiacute osteoporotic vertebral fractures treated conservatively or with percutaneous vertebroplasty: a clinical randomized study. Spine (Phila Pa 1976) 2010; 35:478.
  42. Blasco J, Martinez-Ferrer A, Macho J, et al. Effect of vertebroplasty on pain relief, quality of life, and the incidence of new vertebral fractures: a 12-month randomized follow-up, controlled trial. J Bone Miner Res 2012; 27:1159.
  43. Klazen CA, Lohle PN, de Vries J, et al. Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial. Lancet 2010; 376:1085.
  44. Miller FG, Kallmes DF, Buchbinder R. Vertebroplasty and the placebo response. Radiology 2011; 259:621.
  45. Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 2009; 361:557.
  46. Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 2009; 361:569.
  47. Bono CM, Heggeness M, Mick C, et al. North American Spine Society: Newly released vertebroplasty randomized controlled trials: a tale of two trials. Spine J 2010; 10:238.
  48. Weinstein JN. Balancing science and informed choice in decisions about vertebroplasty. N Engl J Med 2009; 361:619.
  49. Schmelzer-Schmied N, Cartens C, Meeder PJ, Dafonseca K. Comparison of kyphoplasty with use of a calcium phosphate cement and non-operative therapy in patients with traumatic non-osteoporotic vertebral fractures. Eur Spine J 2009; 18:624.
  50. Lieberman IH, Dudeney S, Reinhardt MK, Bell G. Initial outcome and efficacy of "kyphoplasty" in the treatment of painful osteoporotic vertebral compression fractures. Spine (Phila Pa 1976) 2001; 26:1631.
  51. Grafe IA, Da Fonseca K, Hillmeier J, et al. Reduction of pain and fracture incidence after kyphoplasty: 1-year outcomes of a prospective controlled trial of patients with primary osteoporosis. Osteoporos Int 2005; 16:2005.
  52. Wardlaw D, Cummings SR, Van Meirhaeghe J, et al. Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. Lancet 2009; 373:1016.
  53. Boonen S, Van Meirhaeghe J, Bastian L, et al. Balloon kyphoplasty for the treatment of acute vertebral compression fractures: 2-year results from a randomized trial. J Bone Miner Res 2011; 26:1627.
  54. Watts NB, Harris ST, Genant HK. Treatment of painful osteoporotic vertebral fractures with percutaneous vertebroplasty or kyphoplasty. Osteoporos Int 2001; 12:429.
  55. Bernhard J, Heini PF, Villiger PM. Asymptomatic diffuse pulmonary embolism caused by acrylic cement: an unusual complication of percutaneous vertebroplasty. Ann Rheum Dis 2003; 62:85.
  56. Shapiro S, Abel T, Purvines S. Surgical removal of epidural and intradural polymethylmethacrylate extravasation complicating percutaneous vertebroplasty for an osteoporotic lumbar compression fracture. Case report. J Neurosurg 2003; 98:90.
  57. Choe DH, Marom EM, Ahrar K, et al. Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty. AJR Am J Roentgenol 2004; 183:1097.
  58. Kim YJ, Lee JW, Park KW, et al. Pulmonary cement embolism after percutaneous vertebroplasty in osteoporotic vertebral compression fractures: incidence, characteristics, and risk factors. Radiology 2009; 251:250.
  59. Walker DH, Mummaneni P, Rodts GE Jr. Infected vertebroplasty. Report of two cases and review of the literature. Neurosurg Focus 2004; 17:E6.
  60. Yu SW, Chen WJ, Lin WC, et al. Serious pyogenic spondylitis following vertebroplasty--a case report. Spine (Phila Pa 1976) 2004; 29:E209.
  61. Abdelrahman H, Siam AE, Shawky A, et al. Infection after vertebroplasty or kyphoplasty. A series of nine cases and review of literature. Spine J 2013; 13:1809.
  62. Huang KY, Yan JJ, Lin RM. Histopathologic findings of retrieved specimens of vertebroplasty with polymethylmethacrylate cement: case control study. Spine (Phila Pa 1976) 2005; 30:E585.
  63. Uppin AA, Hirsch JA, Centenera LV, et al. Occurrence of new vertebral body fracture after percutaneous vertebroplasty in patients with osteoporosis. Radiology 2003; 226:119.
  64. Trout AT, Kallmes DF, Kaufmann TJ. New fractures after vertebroplasty: adjacent fractures occur significantly sooner. AJNR Am J Neuroradiol 2006; 27:217.
  65. Trout AT, Kallmes DF, Layton KF, et al. Vertebral endplate fractures: an indicator of the abnormal forces generated in the spine after vertebroplasty. J Bone Miner Res 2006; 21:1797.
  66. Tanigawa N, Kariya S, Komemushi A, et al. Percutaneous vertebroplasty for osteoporotic compression fractures: long-term evaluation of the technical and clinical outcomes. AJR Am J Roentgenol 2011; 196:1415.
  67. Mudano AS, Bian J, Cope JU, et al. Vertebroplasty and kyphoplasty are associated with an increased risk of secondary vertebral compression fractures: a population-based cohort study. Osteoporos Int 2009; 20:819.
  68. Ma X, Xing D, Ma J, et al. Risk factors for new vertebral compression fractures after percutaneous vertebroplasty: Qualitative evidence synthesized from a systematic review. Spine (Phila Pa 1976) 2013.
  69. Martinez-Ferrer A, Blasco J, Carrasco JL, et al. Risk factors for the development of vertebral fractures after percutaneous vertebroplasty. J Bone Miner Res 2013; 28:1821.
  70. Francis RM, Aspray TJ, Hide G, et al. Back pain in osteoporotic vertebral fractures. Osteoporos Int 2008; 19:895.
  71. Stadhouder A, Buskens E, Vergroesen DA, et al. Nonoperative treatment of thoracic and lumbar spine fractures: a prospective randomized study of different treatment options. J Orthop Trauma 2009; 23:588.
  72. Malmros B, Mortensen L, Jensen MB, Charles P. Positive effects of physiotherapy on chronic pain and performance in osteoporosis. Osteoporos Int 1998; 8:215.
  73. Dusdal K, Grundmanis J, Luttin K, et al. Effects of therapeutic exercise for persons with osteoporotic vertebral fractures: a systematic review. Osteoporos Int 2011; 22:755.
  74. Giangregorio LM, Macintyre NJ, Thabane L, et al. Exercise for improving outcomes after osteoporotic vertebral fracture. Cochrane Database Syst Rev 2013; 1:CD008618.
  75. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil 1984; 65:593.