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Compression Fracture

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Other Names

  • Cervical Compression Fracture
  • Thoracic Compression Fracture
  • Lumbar Compression Fracture
  • Wedge Fracture
  • Anterior Wedge fracture
  • Biconcave fracture
  • Crush fracture
  • Vertebral Compression Fracture (VCF)
  • Osteoporotic Vertebral Compression Fracture (OVCF)

Background

  • This page refers to the class of compression fractures of the Vertebral Body
    • This can occur in cervical, thoracic and lumbar spine
    • Subtypes include wedge-shaped (anterior), biconcave (middle), or crush (posterior)

Epidemiology

  • There are 1.5 million Osteoporosis associated fractures per year, of which 700,000 are compression fractures[1]
  • Incidence believed to be higher due to large number of asymptomatic or undetected cases[2]
  • Annual incidence of 0.9%, prevbalence of 5-10% among women in 50s and 60s[3]
    • Increases to incidence of 1.7%, prevalence of more than 30% among women in their 80s[4]

Pathophysiology

  • Defined as at least 15% loss of vertebral height
  • Most commonly occur in thoracolumbar spine, can occur in cervical spine
  • Rarely is there retropulsion of fragments causing spinal cord injury, cauda equina syndrome

Associated Conditions


Risk Factors

  • Systemic
  • Demographic
    • White > Black, Asian[6]
    • Female > Male
    • Age > 70
  • Lifestyle
    • Inactivity
    • Alcohol consumption >2 drinks per day
    • Smoking
  • History of Corticosteroid use (more than 5 mg daily for three months)

Differential Diagnosis

Differential Diagnosis Neck Pain

Differential Diagnosis Back Pain


Clinical Features

  • General: Physical Exam Neck, Physical Exam Back
  • History
    • Up to 2/3 of patients are asymptomatic and diagnosed incidentally[7]
    • People most commonly report back pain
    • Typically acute or subacute with no clear trauma mechanism
    • Worse with position changes, coughing, sneezing, lifting
  • Physical Exam
    • Overall, physical exam may be normal
    • They may demonstrate a kyphoscoliotic deformity of the spine and appear hunched over
    • Point tenderness on the fractured vertebral bodies is not uncommon

Evaluation

Radiographs

  • Standard imaging of the affected spinal segments
  • Often adequate to make diagnosis
  • Can assess
    • Identification and characterization of fractures
    • Estimate loss of height (by definition, loss of 20% of height compared to unaffected portion of vertebral body)
    • Assess spinal alignment
    • Degree of fragment retropulsion
  • Features[8]
    • Increased lucency
    • Loss of horizontal trabeculae
    • Decreased cortical thickness but increased relative opacity of the end-plates and vertical trabeculae

CT

  • Allows for further characterization of bony anatomy
  • Useful in the setting of acute trauma

MRI

  • Useful for evaluating fracture age
    • Bone edema present in acute injuries
  • Better evaluation of spinal cord and soft tissue structures
  • May be indicated if oncologic process suspected

Other

  • Can consider bone scan, DEXA scan as adjuncts
  • If secondary osteoporosis is suspected, laboratory workup is indicated

Classification

  • Classified based on portion of vertbral body affected
    • Either wedge-shaped (anterior)
    • Biconcave (middle)
    • Crush (posterior)

Management

Prognosis

  • Patients tend to do well with both conservative and surgical management[9]
    • In this study, about 2/3 of patients were sucesfully treated with conservative management only
    • Patients who underwent kyphoplasty had better outcomes in the first month, but not at 1 year
    • The authors also noted that patients who had pain relief and reduced disability at 3 weeks had a 95% chance of maintaining that relief at 1 year

Nonoperative

  • First line treatment in most cases
  • Relative rest followed by early mobilization
    • Goal is to avoid loss of bone mass, muscle strength, pressure sores and DVT
  • Medications
  • Intercostal Nerve Block
  • Brace: Thoracolumbar Orthoses (TLO)
    • Most research were in braces used in acute burst fractures, less consensus on compression fractures
    • Pfeifer et al: improvement in trunk muscle strength, posture, and body height compared to control[11]
  • Physical Therapy
    • Critical in both the acute phase and prevention of further injuries
    • Goal: Strengthen the supportive axial musculature, especially extensors
    • Goal: Improve patients proprioceptive reflexes, improve posture, decrease risk of falls
  • Prevention
    • Goal is to improve quality of bone
    • Bisphosphonates
    • Selective estrogen receptor modulators
    • Recombinant parathyroid hormone
    • Calcitonin

Operative

  • Indications
  • Technique
    • Kyphoplasty
    • Vertebroplasty
    • Polyether Ether Ketone Implants (PEEK)

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Needs to be updated

Complications

  • Surgical
    • Overall, complication rates are low
    • Cement extravasation is rare
  • Chronic pain

See Also


References


  1. Riggs BL, Melton LJ., III The worldwide problem of osteoporosis: insights afforded by epidemiology. Bone 1995;17(5, Suppl):505S–511S
  2. Cooper C. Epidemiology and public health impact of osteoporosis. Baillieres Clin Rheumatol. 1993;7(3):459–477
  3. Nevitt MC, Cummings SR, Stone KL, et al. Risk factors for a first-incident radiographic vertebral fracture in women > or = 65 years of age: the study of osteoporotic fractures. J Bone Miner Res. 2005;20(1):131–140
  4. Melton LJ, 3rd, Lane AW, Cooper C, Eastell R, O’Fallon WM, Riggs BL. Prevalence and incidence of vertebral deformities. Osteoporos Int. 1993;3(3):113–119.
  5. Whooley MA, Kip KE, Cauley JA, Ensrud KE, Nevitt MC, Browner WS; Study of Osteoporotic Fractures Research Group. Depression, falls, and risk of fracture in older women. Arch Intern Med. 1999;159(5):484–49
  6. Cauley JA, Palermo L, Vogt M, et al. Prevalent vertebral fractures in black women and white women. J Bone Miner Res. 2008;23(9):1458–1467
  7. ink HA, Milavetz DL, Palermo L, et al.; Fracture Intervention Trial Research Group. What proportion of incident radiographic vertebral deformities is clinically diagnosed and vice versa? J Bone Miner Res. 2005;20(7):1216–1222
  8. Adami S, Gatti D, Rossini M, et al. The radiological assessment of vertebral osteoporosis. Bone. 1992;13(Suppl 2):S33–S36.
  9. Lee HM, Park SY, Lee SH, Suh SW, Hong JY. Comparative analysis of clinical outcomes in patients with osteoporotic vertebral compression fractures (OVCFs): conservative treatment versus balloon kyphoplasty. Spine J. 2012;12(11):998–1005
  10. Knopp JA, Diner BM, Blitz M, Lyritis GP, Rowe BH. Calcitonin for treating acute pain of osteoporotic vertebral compression fractures: a systematic review of randomized, controlled trials. Osteoporos Int. 2005;16(10):1281–1290
  11. Pfeifer M, Begerow B, Minne HW. Effects of a new spinal orthosis on posture, trunk strength, and quality of life in women with postmenopausal osteoporosis: a randomized trial. Am J Phys Med Rehabil. 2004;83(3):177–186
Created by:
John Kiel on 4 July 2019 09:28:39
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Last edited:
17 November 2020 15:47:51
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