by Nicole Berardoni M.D, Tory McJunkin M.D, and Paul Lynch M.D
Vertebral Body Fracture Anatomy
The bony spine is positioned so that individual vertebrae provide a flexible support structure while also protecting the spinal cord. Certain conditions that can produce chronic pain affecting the vertebrae include spinal stenosis, vertebral body fractures, osteoporosis, osteoarthritis, spondylolisthesis, neoplasms (primary vs. metastatic lesions), and infections. Vertebroplasty and kyphoplasty are extremely effective treatment for many of these conditions.
Vertebral Body Fracture PathologyHealthy bones are able to withstand the normal amount of pressure exerted on them. They are designed to provide strength, flexibility, and support to the spinal canal. However, if the force put on the vertebrae exceed the threshold they can tolerate, or the threshold is lowered due to pathology to the vertebrae, then they will fracture and collapse. Most commonly seen in patients with vertebral compression fractures is preexisting osteoporosis. Osteoporosis is a disease frequently seen in postmenopausal women, as well as some men, that affects the density of the bones.
The bones become thin and weak and are more prone to fractures. Spinal compression fractures are the most common fracture seen in these patients and by the age of 80, 40% of these patients will have a compression fracture (Old 2004). Metastatic cancer that spreads to the vertebrae can also cause a compression fracture. The boney spine is a common place for certain cancers to spread to. The lytic lesions in the spine cause weakness and may eventually cause collapse of the vertebrae. Any cancer patient who has a sudden onset of back pain or lower extremity neurological change should be immediately evaluated for metastatic disease. Another cause of vertebral compression fractures is trauma to the vertebrae such as blunt trauma, a fall, or motor vehicle accident. Any force that surpasses the ability the spine is able to support can cause collapse of the vertebrae.
Vertebral Body Fracture Diagnosis
All patients over the age of 50 who present with the acute onset of lower back pain should be evaluated for vertebral body fractures. The pain may be relieved by lying down and is exacerbated with activity. Your physician will perform a physical exam and may find tenderness over the vertebrae as well as kyphosis (curving of the spine). Other manifestations of nerve involvement include constipation, loss of lower extremity reflexes, and loss of sensory function. The physician may also order radiological imaging. The X-ray may be diagnostic enough because commonly seen is the classic wedge-shaped vertebral body with narrowing of the anterior portion in most compression fractures. However, depending on the clinical suspicion and history obtained, the physician may want to order additional studies such as MRI, CT scan, or a bone scan.
Vertebral Body Fracture TreatmentPharmacologic treatments such as NSAIDs and analgesics are used in the acute management of pain. Although these may help relieve discomfort, they do not correct the underlying problem causing the pain. Also, an unfortunate side effect to NSAIDs is that they have been shown to increase gastrointestinal bleeding in the elderly. Patients can also be treated with a short time of bed rest, however, prolonged inactivity is contraindicated.
In the past few years there has been a lot of research surrounding non-surgical procedures and their effectiveness in treating back pain associated with vertebral body fractures. Patients who do not respond to the more conservative management described above may be good candidates for minimally-invasive procedures by your pain physician that have been proven effective, including vertebroplasty and kyphoplasty (Old 2004). Results of a clinical research trial concluded that both vertebroplasty and kyphoplasty significantly reduce pain and improve mobility in patients with vertebral fracture (De Negri 2007).
- Vertebroplasty: This procedure involves injecting acrylic cement into the fractured vertebra to stabilize and strengthen the vertebrae.
- Kyphoplasty: This is a newer method that involves placing an inflatable balloon into the vertebral body. When the balloon is inflated, it makes a space in the center of the vertebrae where an acrylic is injected.
There is good evidence that diagnosing and treating osteoporosis reduces the incidence of compression fractures of the spine (Kim 2006). Consistent exercise and activity to help with muscle strengthening and flexibility should also be done to help decrease vertebral fractures and back pain associated with osteoporosis. Certain treatments aiming to reduce the effects of osteoporosis are bisphosphonates, hormone replacement therapy, selective estrogen receptor modulators, calcitonin, the 1-34 fragment of parathyroid hormone, calcium, and vitamin D supplements (Christodoulou 2003).
- Osteoporotic compression fractures of the spine; current options and considerations for treatment Kim DH, Vaccaro AR. Spine J. 2006 Sep-Oct;6(5):479-87 PMID: 16934715
- Vertebral Compression Fractures in the Elderly. Old, Jerry; Calvert, Michelle. American Family Physician. January 1, 2004
- What is osteoporosis? Christodoulou C, Cooper C. Postgrad Med J. 2003 Mar;79(929):133-8. PMID: 12697910
- Treatment of painful osteoporotic or traumatic vertebral compression fractures by percutaneous vertebral augmentation procedures: a nonrandomized comparison between vertebroplasty and kyphoplasty. De Negri P, Tirri T, Paternoster G, Modano P. Clin J Pain. 2007 Jun;23(5):425-30 PMID: 17515741