Compression fractures of the back

Answer 1

Definition

Compression fractures of the back are broken vertebrae, which are the bones of the spine.

Alternative Names

Vertebral compression fractures

Causes, incidence, and risk factors

In a compression fracture of the vertebra, the vertebral bone collapses. More than one vertebra may be affected. This condition may be caused by:

• Osteoporosis(the most common cause), which is caused by weakening of the bone due to the loss of calcium and other factors.
• Trauma to the back
• Tumors that started in the bone or spread to the bone from elsewhere

When the fracture occurs as a result of osteoporosis, the vertebrae in the chest (thoracic) or the lower back are usually affected. During the early stages, a break in the bone can get worse without any symptoms. Pain or other symptoms may be worse with walking, and are often not present when resting.

Multiple fractures may lead to kyphosis, a hump-like curvature of the spine (like the Hunchback of Notre Dame).

Symptoms

Compression fractures may cause no symptoms and only be discovered when x-rays of the spine are done for other reasons. Over time, the following symptoms may occur:

• Back pain with chronic or gradual onset
• Loss of height, as much as 6 inches over time
• Stooped over posture or kyphosis, also called a "dowager's hump"

Compression fractures may also occur suddenly, causing severe back pain that is:

• Most commonly felt in mid to lower part of the spine, but may also be felt on the sides or in the front.
• Described as "knifelike" and usually disabling, often taking weeks to months to go away

Pressure on the spinal cord from kyphosis may rarely produce symptoms of:

• Numbness
• Tingling
• Weakness
• Difficulty walking
• Loss of control of the bowel or bladder

Signs and tests

• Physical examination may show hunchback (kyphosis). There is also tenderness over the injured vertebrae.
• A spine x-rayshows at least one compressed vertebra that is shorter than the other vertebrae.

Other tests that may be done:

• A bone density test to evaluate for osteoporosis
• A CT or MRI scan if there is concern that the fracture was caused by a tumor, or if the fracture was caused by high-energy trauma (such as a fall from a height or car accident)

Treatment

Most compression fractures are found in elderly patients with osteoporosis. These fractures generally do not cause injury to the spinal cord. In these patients, the osteoporosis is treated with prescription medications and calcium supplements.

Otherwise, the pain from these fractures is treated with pain medicines and bed rest at first. Narcotics are often needed. Some health care providers recommend back braces, but these may further weaken the bones and increase your risk of developing more fractures in the future.

Patients may benefit from some physical therapy to help with movement and building up muscle strength around the spine.

Surgery is rarely considered. However, if 2 months or more of bed rest, pain medicines, and physical therapy cannot relieve the back pain, surgery can be option. Two minimally invasive techniques are available:

• Balloon kyphoplasty: A large needle is inserted into the compressed vertebra. A balloon is inserted into the bone through the needle and inflated, restoring the height of the vertebra. Cement is injected into this space to make sure it does not collapse again. This procedure is generally done under general anesthesia.
• Vertebroplasty: This is a similar procedure in which cement is injected into the bone of the vertebra. This procedure is done under local anesthesia and sedation.

If the fracture is caused by a tumor, a piece of the bone may need to be surgically removed and examined under a microscope (biopsy). Then the tumor is treated.

Fractures from trauma often require a brace for 6 - 10 weeks to protect the bone as it heals. If there is bone in the spinal canal, you may need surgery to remove the bone and fuse the vertebrae together to stabilize the spine.

Surgery is almost always necessary if there is any loss of function because of bone pressing on the spinal cord or spinal nerves.

Expectations (prognosis)

Most compression fractures from trauma will heal in 8 - 10 weeks with rest, bracing, and pain medications. Recovery time will be many weeks longer if surgery is necessary.

Fractures due to osteoprosis usually become less painful with rest and pain medications, but some can cause chronic pain and disability.

While medications to treat osteoporosis can help prevent future fractures, the collapse of the vertebrae that has already occurred cannot be reversed.

For compression fractures caused by tumors, the outcome depends on the type of tumor involved. Some common tumors that involve the spine include:

• Breast cancer
• Lung cancer
• Lymphoma
• prostate cancer

Complications

• Failure of the bones to fuse (if surgery is necessary)
• Hunchback (kyphosis)
• Spinal cord or nerve root compression

Calling your health care provider

Call your health care provider if you have back pain and suspect you may have a compression fracture.

Prevention

Treating and preventing osteoporosis is the most effective way to prevent these fractures.

References

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(9668):1016-24.

Freedman BA, Potter BK, Nesti LJ, Giuliani JR, Hampton C, Kuklo TR. Osteoporosis and vertebral compression fractures-continued missed opportunities. Spine J. 2008;8:756-762.

Kim DH, Vaccaro AR. Osteoporotic compression fractures of the spine; current options and considerations for treatment. Spine J. 2006 Sep-Oct;6(5):479-87.

Answer 2

Definition

Compression fractures of the back are broken vertebrae, which are the bones of the spine.

Alternative Names

Vertebral compression fractures

Causes, incidence, and risk factors

Compression fractures of the vertebra may be caused by:

• Osteoporosis(the most common cause),
• Trauma to the back
• Tumors that started in the bone or spread to the bone from elsewhere
• Tumors that start in the spine, such as multiple myeloma

Multiple fractures may lead to kyphosis, a hump-like curvature of the spine.

Symptoms

Compression fractures may occur suddenly, causing severe Back pain that is:

• Most commonly felt in mid to lower part of the spine, but may also be felt on the sides or in the front.
• Described as “knifelike” and usually disabling, often taking weeks to months to go away

Compression fractures due to osteoporosis may cause no symptoms at first and may only be discovered when x-rays of the spine are done for other reasons. Over time, the following symptoms may occur:

• Back pain that starts slowly, which gets worse with walking but is not felt when resting
• Loss of height, as much as 6 inches over time
• Stooped over posture or kyphosis, also called a "dowager's hump"

Pressure on the spinal cord from hunched over posture may rarely produce symptoms of:

• Numbness
• Tingling
• Weakness
• Difficulty walking
• Loss of control of the bowel or bladder

Signs and tests

Your doctor will perform a physical exam. This may reveal:

• A humpback, or kyphosis
• Tenderness over the affected spinal bone or bones

A spine x-rayshows at least one compressed vertebra that is shorter than the other vertebrae.

Other tests that may be done:

• A bone density test to evaluate for osteoporosis
• A CT or MRI scan if there is concern that the fracture was caused by a tumor or severe trauma (such as a fall from a height or car accident)

Treatment

Most compression fractures are seen in older people with osteoporosis. These fractures generally do not cause injury to the spinal cord. The condition is usually treated with medicines and calcium supplements to prevent further fractures.

Pain may be treated with:

• Pain medicine, including narcotics
• Bed rest

Other treatments may include:

• Back braces, but these may further weaken the bones and increase your risk of more fractures
• Physical therapy to improve movement and strength around the spine
• A medicine called calcitonin to help relieve bone pain

Surgery may be done if you have severe and disabling pain for more than 2 months that does not get better with other treatments. Surgery can include:

• Balloon kyphoplasty done under general anesthesia.
• Vertebroplasty done under local anesthesia and sedation.

Other surgery may be done to remove some bone if the fracture is due to a tumor.

After surgery you may need:

• A brace for 6-10 weeks if the fracture was due to an injury
• More surgery to join certain spine bones together or to relieve pressure on a nerve

Expectations (prognosis)

Most compression fractures due to injury heal in 8 - 10 weeks with rest, bracing, and pain medications. However, recovery can take much longer if you had surgery.

Fractures due to osteoprosis usually become less painful with rest and pain medications, but some can lead to long-term (chronic) pain and disability.

Medicines to treat osteoporosis can help prevent future fractures. However, they cannot reverse damage that has already occured.

For compression fractures caused by tumors, the outcome depends on the type of tumor involved. Some common tumors that involve the spine include:

• Breast cancer
• Lung cancer
• Lymphoma
• Prostate cancer

Complications

Complications may include:

• Failure of the bones to fuse after surgery
• Humpback
• Spinal cord or nerve root compression

Calling your health care provider

Call your health care provider if:

• You have back pain and you think you may have a compression fracture
• Worsening symptoms or difficulty with controlling your bladder and bowel function

Prevention

Treating and preventing osteoporosis is the most effective way to prevent these fractures.

References

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 Sep 25;376(9746):1085-92.

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(9668):1016-24.

Reviewed By

Review Date: 12/01/2011

David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc., and C. Benjamin Ma, MD, Assistant Professor, Chief, Sports Medicine and Shoulder Service, UCSF Department of Orthopaedic Surgery.