Vertebral Compression Fracture

The most common complication of osteoporosis is vertebral compression fractures (VCF).

 Vertebral Compression Fracture

• It may be due to trauma or due to a weakening of the vertebra.

• This weakening is seen in patients with
osteoporosis or osteogenesis imperfect, lytic lesions from
metastatic disease or primary tumors, or infection.
• In healthy patient, it is most often seen in individuals suffering
extreme vertical shocks, such as ejecting from an ejection seat.
• Seen in lateral views in plain x-ray films, compression fractures
of the spine characteristically appear as wedge deformities,
with greater loss of height anteriorly than posteriorly and
intact pedicles in the anteroposterior view.
• In osteoporosis ,osteoclastic activity exceeds osteoblastic
activity resulting in a generalized decrease in bone density
• Sometimes the vertebral bone weakens to the point that
even mild forces can lead to a compression fracture.
• A simple action like reaching down to pull a pair of socks can
cause weakened vertebrae to fracture.
• The fracture is usually wedged shaped and without
correction, a wedge fracture invariably increases the degree
of kyphosis
• Symptoms
• pain
• 25% of VCF are painful enough that patients seek medical attention
• pain usually localized to area of fracture
• Physical examination
• 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
Investigations
• Spinal Radiography
• Loss of anterior, middle or
posterior vertebral height by 20%
or at least 4mm

• Vertebral osteoporosis manifests as

 pencilling of vertebrae
 loss of corticol bone and
trabecular bone (ghost vertebra)
 Compression fractures
• MRI scan
• usually not necessary for diagnosis
• useful to evaluate for
• spinal cord compression by disk or osseous material
• cord edema or hemorrhage
• acute vs chronic nature of compression fracture
• injury to anterior and posterior ligament complex

• CT scan
• usually not necessary for diagnosis
• indications
• fracture on plain film In this MRI, the bright appearance of
the fractured vertebra indicates
• neurologic deficit in lower extremity "edema," or inflammation, an
indication of a new fracture.
Management
• Non Surgical Management
• General Management - pain relief, bracing, rehabilitation
• Pain relief by analgesics (eg NSAIDS, muscle relaxant, opioids)

• Pharmacotherapy for osteoporosis can reduce osteoporotic fracture

• Vertebral Compression Fracture
• The symptoms of most VCFs are self-limited. They respond to simple measures such as rest, activity
modification, analgesics, and bracing.
• The fracture pain usually resolves within a few months.
• Young patient usually treated with TLSO(thoracolumbar sacral orthosis) bracing and rehabilitation, in
less restrictive corset or abdominal binder if pain is well controlled
• Early mobilization and occupational therapy to restore patients maximal level of function
• Bed rest but only for short term (complete bedrest is not recommended, as inactivity may result in
further bone loss and reconditioning)
Surgical Management
• In two thirds of patients, symptoms of VCFs subside in a few months
without surgical intervention.
• If the pain is debilitating and restricts the patient from getting out of bed, it
may be advisable to perform vertebral body augmentation to relieve the
pain.
• As with any fracture, pain from an unhealed VCF is believed to result from
motion of the fragmented bone.
• Neurologic issues that mandate open surgical treatment are rare in
osteoporotic VCFs.
• Decompression and stabilization may be needed in cases of neurologic
deficit.
• Vertebroplasty
• involves the injection of cement directly into the vertebral body.
• has higher rates of cement extravasation than kyphoplasty
• Kyphoplasty
• involves the inflation of a balloon within the body before cement placement. This
step creates a void for the cement and reduces cement extravasation, which may
assist with the reduction of the fractured vertebra.
• pain relief thought to be from elimination of micromotion
• Surgical decompression and stabilization (very rare, only done in patient
with neurological deficit)
• indications
• very rare in standard VCF
• Done only inprogressive neurologic deficit
 Kyphoplasty and Vertebroplasty
• Performed under fluoroscopic guidance
• Percutaensous transpedicular approach
used for canula
• Vertebroplasty
• PMMA(Polymethylmethacrylate- bone
cement) injected directly into the cancellous
bone without cavity creation
• requires greater pressure because no cavity is
created - increased risk of extravasation into
spinal canal is greater

• Kyphoplasty: cavity is created with

expansion device(eg balloon) prior to
PMMA injection