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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)
  • Thoracolumbar Compression Fracture

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)

History
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]

Introduction

General

  • 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

Compression fracture of L1 causing angular deformity of the vertebral endplate[7]

History

  • Up to 2/3 of patients are asymptomatic and diagnosed incidentally[8]
  • People most commonly report back pain
  • Typically acute or subacute with no clear trauma mechanism
  • Worse with position changes, coughing, sneezing, lifting

Physical Exam: Physical Exam Neck, Physical Exam Back

  • 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

Marrow edema of L4 and L5 consistent with acute compression fractures. No significant loss in vertebral body height or discoligamentous injury[9]

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[10]
    • 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

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[12]
  • 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/Work

  • Needs to be updated

Prognosis and Complications

Prognosis

  • Patients tend to do well with both conservative and surgical management[13]
    • 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

Complications

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

See Also

Internal

External


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. Case courtesy of Sajoscha A. Sorrentino, Radiopaedia.org, rID: 20123
  8. 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
  9. Case courtesy of Andrew Dixon, Radiopaedia.org, rID: 31757
  10. Adami S, Gatti D, Rossini M, et al. The radiological assessment of vertebral osteoporosis. Bone. 1992;13(Suppl 2):S33–S36.
  11. 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
  12. 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
  13. 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
Created by:
John Kiel on 4 July 2019 09:28:39
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Last edited:
23 April 2023 20:54:15
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