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The vertebrae in the spine are major load-bearing structures and must be strong enough to carry a person's body weight. Because of this, the vertebrae are at high risk for fractures when the bones become thin from osteoporosis.

There are an estimated 700,000 pathological vertebral body compression fractures in the United States each year of which over 1/3 become chronically painful. The majority of these fractures (about 85%) are the result of primary osteoporosis, the remainder due to secondary osteoporosis or osteolytic spinal metastases (e.g. bone cancer) and trauma.

Vertebral compression fractures affect approximately 25 percent of all postmenopausal women in the United States. The prevalence of this condition steadily increases with advancing age, reaching 40 percent in women 80 years of age. Although only about a third are acutely symptomatic, nearly all are associated with a 15% higher mortality rate than those who do not experience fractures.

Although less common in older men, compression fractures also are a major health concern in this group. Because the age group of those older than 65 years is now the fastest growing segment of the U.S. population, the incidence of this age-specific fracture is likely to increase Compression fractures lead to progressive deformity and changes in spinal biomechanics, and are believed to contribute to an increased risk of further fracture. Whether the fracture is painful or not, spinal deformity caused by two or more fractures dramatically impacts health, daily living, medical costs, loss of lung capacity, reduced mobility, chronic pain, loss of appetite and/or clinical depression.

Risk Factors

• Advanced age
• Female gender
• Caucasian race
• Presence of dementia
• Susceptibility to falling
• History of fractures in adulthood
• History of fractures in first degree relatives
• Alcohol and or tobacco use
• Estrogen deficiency
• Early menopause
• Bilateral removal of ovaries
• Premenopausal amenorrhea for more than one year
• Frailty
• Impaired eyesight
• Insufficient physical activity
• Low body weight
• Dietary calcium and or vitamin D deficiency
• Osteoporosis
• Trauma
• Malignancy

Pathophysiology and Symptoms

Vertebral compression fractures are a result of an applied force which usually causes the anterior part of the vertebral body to crush, forming an anterior wedge fracture. The middle column remains intact and may act as a hinge. This results in loss of anterior height of the vertebra while the posterior height remains unchanged. As the collapsed anterior vertebrae fuse together, the spine bends forward, causing a kyphotic deformity. Because the majority of damage is limited to the anterior vertebral column, the fracture is usually stable and rarely associated with neurologic compromise. This thoracic spinal deformity is referred to as "kyphosis" or Dowager's Hump.

Vertebral compression fractures can be insidious and may produce only modest back pain early in the course of progressive disease. Over time, multiple fractures may result in significant loss of height. Progressive loss of stature results in shortening of paraspinal musculature requiring prolonged active contraction for maintenance of posture, resulting in pain from muscle fatigue. This pain may continue long after the acute fracture has healed.

Patients develop thoracic kyphosis and lumbar lordosis as vertebral height is lost. The rib cage presses down on the pelvis, reducing thoracic and abdominal space. In severe cases, this results in impaired pulmonary function, pneumonia, a protuberant abdomen, and--because of compressed abdominal organs--early satiety leading to anorexia and eventual weight loss, a particular concern in elderly patients who are already frail. Other abdominal symptoms include; abdominal bloating, constipation and bowel obstruction.

As the kyphosis develops, more force is transmitted to adjacent, already osteoporotic vertebrae, increasing the risk of additional fractures. Studies have shown that the presence of one or more vertebral compression fractures increases the risk of an additional fracture fivefold during the following year.

With multiple vertebral fractures, bending, lifting, reaching, climbing and walking become difficult. Patients may become anxious and depressed as they try to cope with pain, lifestyle changes and the physical limitations of daily living. Loss of self-esteem may also result from the disfigurement caused by the deformity.

As pain persists individuals may experience prolonged inactivity which may lead to deep venous thrombosis and increased osteoporosis.

If individuals have severe osteoporosis, fractures can occur with minor stress such as sneezing, coughing, transferring out of a bathtub, attempting to lift a heavy object, rolling over in bed etc. Greater stresses may include falling out of a chair, falling from a standing position, MVA etc.

Most fractures occur in the Thoracic spine and upper levels of the Lumbar spine.

Diagnosis

About one third of vertebral fractures are actually diagnosed, because many patients and families regard back pain symptoms as "arthritis" or a normal part of aging. Therefore, compression fracture should be suspected in any patient older than 50 years with acute onset of sudden low back pain. Most patients will remember a specific injury as the cause however, fractures may occur without any history of increased force on the spine. Lying in the supine position generally relieves some of the discomfort. Standing or walking exacerbates the pain.

Physical examination will reveal tenderness directly over the area of acute fracture, and an increased kyphosis may be noted. In cases of uncomplicated compression fractures, straight leg raise will be negative and neurologic examination will be normal. An ileus, or decreased bowel sounds, may be present. The diagnosis can be confirmed if plain radiographs show the classic wedge deformity correlating with the area of tenderness found on physical examination.

Plain frontal and lateral radiographs are the initial imaging study obtained for a suspected compression fracture. Compression of the anterior aspect of the vertebrae results in the classic wedge-shaped vertebral body with narrowing of the anterior portion (Figure 1). Radiographically, a decrease in vertebral height of 20 percent or more, or a decrease of at least 4 mm compared with baseline height is considered positive for compression fracture.

FIGURE 1. (Left) Anterior portion and (right) lateral views of the lumbar spine show a mild compression deformity of the L1 vertebral body (there are six nonribbed lumbar-type vertebrae). Also noted are narrowed disk spaces at L4-5 and L5-6.

Your health care provider will probably x-ray the entire spine because 20 to 30 percent of vertebral compression fractures are multiple. When multiple, the fractures occur at different levels or in one to five consecutive vertebral bodies. Computed tomography (CT) and magnetic resonance imaging (MRI) are used for evaluating the posterior vertebral wall integrity and for ruling out other causes of back pain (Figure 2). CT can be helpful for identifying a fracture that is not well visualized on plain films (nml x-rays), for distinguishing a compression fracture from a burst fracture, and for further evaluation of a complex fracture . Although compression fractures are typically discovered on plain anteroposterior and lateral radiographs, these films do not provide information about the age of the fracture. MRI can help determine whether the fracture is old or recent, and whether it is due to osteoporosis or to malignancy, both of which may affect decision-making regarding treatment.

FIGURE 2. Magnetic resonance imaging of the thoracic cord shows a wedge-shaped deformity with increased signal intensity of T7 indicating an acute severe compression fracture. There are older compression deformities of T8 and T12.

A nuclear medicine bone scan (Figure 3) is useful when surveying the entire skeleton for osteoporotic fractures, especially when symptoms are atypical. It is particularly helpful in diagnosing sacral insufficiency fractures, which are common in osteoporosis but difficult to visualize on radiographs. On bone scan, they appear as increased radiotracer activity in an "H" or "butterfly" pattern across the sacrum. Bone scans also can differentiate between an acute versus healed compression fracture because new fractures will appear "hot."

FIGURE 3. Bone scan revealing an area of increased uptake at the level of L3, consistent with acute compression fracture.

Bone density studies are beneficial for evaluating the severity of osteoporosis and in advising patients of the likelihood of subsequent fractures.

Treatment

Traditional treatment is nonoperative and conservative. Your Dr. may suggest some of the following:

• Limited bed rest. The hazards of prolonged bed rest in the elderly include deconditioning, accelerated bone loss, deep venous thrombosis, pneumonia, decubitus ulcers, disorientation, and depression.
• Analgesic use, in addition to relieving pain, its use may permit earlier ambulation and avoidance of the complications of prolonged bed rest.
• Calcitonin, given subcutaneously, intranasally, or rectally, has an analgesic effect in compression fractures due to osteoporosis and in patients with metastatic bone pain. In osteoporotic vertebral compression fractures, calcitonin also inhibits osteoclast function, thereby preventing bone resorption.
• Opioid analgesics may be necessary in some patients to relieve pain adequately. However, in older, immobilized patients, opioid-associated constipation and mental impairment are significant concerns, and a prophylactic laxative program should be started at the same time the opioid is prescribed. As the spouse or caregiver, watch closely for mental status changes and if present, contact your Dr.
• Bracing may also be used. Braces help control pain and promote healing by stabilizing the spine. By restraining forward flexion, they reduce the load on the anterior column and the vertebral body. Definitive studies comparing different types of braces are lacking, but in general, all spine braces, whether made of cloth, metal, or plastic, or whether rigid or flexible, use a three-point pressure system. If possible, the brace should be lightweight and easy to use. The optimal duration of bracing is not well studied. Two to 3 months is adequate for most patients. Excessively prolonged bracing may lead to weakening of trunk muscles, skin breakdown, increased segmental motion at the upper and lower end of the brace, and diminished pulmonary capacity. As the acute fracture pain subsides, a walking program can begin, with gentle strengthening exercises focusing on spinal extensor muscles. In some patients, a home physical therapist can encourage and assist with early ambulation and mobilization. A carefully supervised rehabilitation program should be started after 3 to 4 months to more aggressively strengthen the spinal extensor rand abdominal muscles.
• Most patients can make a full recovery or at least significant improvements from their compression fracture after six to 12 weeks. In addition to the above a well-balanced diet, calcium and vitamin D supplements, smoking cessation, and medications to treat osteoporosis (such as bisphosphonates) may help prevent additional compression fractures. Age should never preclude treatment.
• Patients who do not respond to conservative treatment or who continue to have severe pain may be candidates for Percutaneous Vertebroplasty. In response to the limited results of medical and surgical modalities, to stabilize and strengthen the collapsed vertebral bodies, interventional neuroradiologists, first in France and now the United States, have begun percutaneous (through a small skin puncture) bone cement injections. Direct cement injection, or vertebroplasty, has been shown to reduce or eliminate fracture pain. This is of significant benefit, as it allows a rapid return to mobility, preventing the known bone loss caused by bed rest. While vertebroplasty can reduce or eliminate fracture pain, it does not address the spinal deformity or secondary problems of the deformity (i.e. the loss of lung function, the protuberant abdomen). Also, this technique requires cement injection under high pressure using low viscosity cement thus increasing the risk of cement leaks. In four recent studies, cement leaks were observed in 30%-80% of procedures. The majority of these leaks had no clinical consequences; however, cement leaks are always a clinical concern.
• Kyphoplasty is a newer technique having evolved from the vertebroplasty experience combined with the balloon catheter technology developed for angioplasty (used in cardiac procedures). Kyphoplasty has a number of potential advantages over vertebroplasty. It involves inserting a cannula (tube) into the vertebral body under fluoroscopic x-ray guidance, followed by insertion of an inflatable bone tamp. Once inflated, the tamp restores the vertebral body back toward its original height, while creating a cavity to be filled with bone cement. The cement injection is done under relatively low pressure in an attempt to reduce the risk of leakage.

Prevention (Guidelines from the National Osteoporosis Foundation)

Building strong bones, especially before the age of 30, can be the best defense against developing osteoporosis, and a healthy lifestyle can be critically important for keeping bones strong.

There are several steps you can take to prevent osteoporosis. Osteoporosis is largely preventable for most people. Prevention of this disease is very important because, while there are treatments for osteoporosis, there is currently no cure. There are five steps to prevent osteoporosis. No one step alone is enough to prevent osteoporosis but all five may.

NOF's Five Steps to Bone Health and Osteoporosis Prevention:

• Get your daily recommended amounts of calcium and vitamin D
• Engage in regular weight-bearing exercise
• Avoid smoking and excessive alcohol
• Talk to your doctor about bone health
• Have a bone density test and take medication when appropriate

Calcium

Calcium is needed for the heart, muscles and nerves to function properly and for blood to clot. Inadequate calcium is thought to contribute to the development of osteoporosis. National nutrition surveys have shown that many women and young girls consume less than half the amount of calcium recommended to grow and maintain healthy bones. Depending on your age, an appropriate calcium intake falls between 1000 and 1300 mg a day. If you have difficulty getting enough calcium from the foods you eat, you may take a calcium supplement to make up the difference.

Vitamin D

Vitamin D is needed for the body to absorb calcium. Without enough vitamin D, you will be unable to absorb calcium from the foods you eat, and your body will have to take calcium from your bones. Vitamin D comes from two sources: through the skin following direct exposure to sunlight and from the diet. Experts recommend a daily intake between 400 and 800 IU per day, which also can be obtained from fortified dairy products, egg yolks, saltwater fish and liver.

Exercise

Exercise is also important to good bone health. If you exercise regularly in childhood and adolescence, you are more likely to reach your peak bone density than those who are inactive. The best exercise for your bones is weight-bearing exercise such as walking, dancing, jogging, stair-climbing, racquet sports and hiking. If you have been sedentary most of your adult life, be sure to check with your healthcare provider before beginning any exercise program.

Medications for Prevention and Treatment

Although there is no cure for osteoporosis, currently bisphosphonates (alendronate and risedronate), calcitonin, estrogens, parathyroid hormone and raloxifene are approved by the US Food and Drug Administration (FDA) for the prevention and/or treatment of osteoporosis.

Bone Mineral Density Tests

A Bone Mineral Density test (BMD) is the only way to diagnose osteoporosis and determine your risk for future fracture. Since osteoporosis can develop undetected for decades until a fracture occurs, early diagnosis is important. A BMD measures the density of your bones (bone mass) and is necessary to determine whether you need medication to help maintain your bone mass, prevent further bone loss and reduce fracture risk. A bone mineral density (BMD) test is a special type of test that is accurate, painless and noninvasive. It is never too early or too late to start your prevention program.

At The Rejuvenation Center, you can obtain bone density testing. We use Dexa Technology which is approximately 98% accurate. Please see section under Other Services for a complete description of what we offer.