Vertebral osteoporotic compression fractures

General

The most common fragility fracture

Affects up to

25% people over 70 years
50% people over 80 years

risk of sustaining a new vertebral fracture after a previous fracture in untreated individuals = 20% within the first year.

See Osteoporosis

Risk factors

history of 2 VCFs

is the strongest predictor of future vertebral fractures in postmenopausal women

Clinical features

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

Natural history

Kim 2024

Most heal within 8 weeks
Vertebral collapse (VC) occurs in 7–37% of the patients with vertebral compression fractures

Ito 2002

Risk factor for osteoporotic vertebral collapse

Intravertebral cleft on X-ray
Burst fracture
Hyperintense signal up to posterior wall
Ligamentous injury/PLC (Posterior Ligamentous Complex)

Imaging

Xray

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 and MRI not really needed

Controversy Routine MRI for osteoporotic fractures

MRI may be used to assess if a fracture is acute or chronic. During the acute phase in fracture healing there may be a finding of haemorrhage and the normal fatty marrow can demonstrate significant marrow oedema that decreases over approximately three months (Brinckman et al., 2015; Piazzolla et al., 2015).
This can be appreciated as a high signal intensity on T2 weighted sequences or the T1 fat suppression technique called STIR.
Some recent studies have suggested that certain T1 and T2 characteristics of the acute fracture may help in predicting non- union (Tsujio et al., 2011; Takahashi et al., 2016).
Other indications for using MRI in the setting of osteoporotic fractures would be if there is concern that the fracture may be a pathological fracture due to bony metastasis.

This may be achieved by acquiring T1 postgadolinium and diffusion- weighted sequences (Pozzi et al., 2012).

AO spine DGOU Classification

Management

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 Kaneb et al 2021

Calcitonin

is a peptide naturally produced by the human body, released from the parathyroid gland.
Mech

binds to osteoclasts, inhibiting them from inducing bone resorption.
By unknown mechanisms, it also appears to cause endorphin release and mitigate pain.

medical management can consist of bisphosphonates

to prevent future risk of fragility fractures

Extension orthosis (Squires 2023)

May decrease pain up to 6 months post-injury
No difference in pain in long term f/u (48 wks)
No difference in radiographic parameters, opioid use, function, or quality of life at any time point
No difference between rigid and soft bracing

therefore, soft bracing may be an adequate alternative.

Operative

PSY:

Only treat if the fracture is not heading forming pseudoarthrosis with significant pain
Perform vertebroplasty at the index level and fix two up and two down.

Vertebroplasty

Indications

Controversial

AAOS recommends strongly against the use of vertebroplasty in 2011 but then changed their stance in 2014 based on recent studies

Techniques

PMMA injected directly into cancellous bone without cavity creation

Cement is made from methymethacrylate; an exothermic reaction when the cement is mixed is thought to provide some of the analgesic benefits.

performed when cement is more liquid
requires greater pressure because no cavity is created
increased risk of extravasation into spinal canal is greater

severe cardiopulmonary disease,
infection
an uncontrolled coagulopathy,
severe rigid collapse
significant retropulsion of bone into the canal

Outcomes

Buchbinder 2009

RCT have shown no beneficial effect of vertebroplasty in short or long term

Vertebroplasty has higher rates of cement extravasation and associated complications than kyphoplasty (McCall 2008)

	Vertebroplasty	Kyphoplasty
Neurological deficit	0.6%	0.03%
pulmonary embolism	0.6%	0.01%

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
When wedge fracture transform into a burst fracture

technique

to prevent possible failure due to osteoporotic bone

consider long constructs with multiple fixation points
consider combined anterior fixation

Anterior decompression via thoracotomy, costotransversectomy, or a retroperitoneal approach, corpectomy with structural allograft and anterior instrumentation.