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Vertebral Compression Fractures

by: Nyla Azam

A vertebral compression fracture (VCF) is a collapse of the vertebral body, the bones that serve as the building blocks of the spine. This can happen for several reasons. Most commonly, though, VCF is caused by osteoporosis and age, but it can also be caused by cancerous tumors in the spine or infection. In most cases the condition develops gradually and the pain is mild at first, but progressively becomes more acute over time.

The Basics of a Vertebral Compression Fracture

Vertebral compression fractures can also occur in healthy people who experience extreme vertical shocks, such as a pilot who gets ejected from an aircraft. In those cases the pain onset is immediate. VCF can also commonly leads to loss of height.

Although vertebral compression fractures rarely require hospitalization, and are often asymptomatic, they can lead to chronic debilitating pain. At the Ainsworth Institute of Pain Management, we specialize in treating vertebral compression fractures. Our board certified pain management specialists can offer a combination of treatment options, many not available anywhere else.

Vertebral Compression Fractures can be caused by a variety of factors. Some, you have no control over. Others are lifestyle choices and habits that can be modified or changed. The good news is that, either way, the doctors at the Ainsworth Institute of Pain Management are experts in treating VCF.

What are Vertebral Compression Fractures?

Vertebral Compression FractureVertebral bodies are the largest part of the vertebra, they are cylindrical in shape and made of trabecular bone. Trabecular bone is responsible for absorbing stress placed on the spine with movement and activity. Aging and decreased bone mineral density changes the bone matrix and weakens it. This leads to a fragile bone that is unable to handle the same amount of stress it used to, thus becoming prone to fracture. As the bone weakens, its ability to carry the load of the body decreases, and it eventually fractures.

Vertebral compression fractures tend to occur more often in the elderly as likelihood of suffering a VCF increases with age. The general population has a 40% chance of having a VCF by the age of 80. Women are more likely to be affected and approximately 25% of postmenopausal women will have a vertebral compression fracture at some point in their lifetime.[1] Although the most common cause of a VCF is osteoporosis, these fractures can also occur in up to 30% of patients with cancer due to either a tumor originating in the vertebral bodies or a metastasis (spreading) into the spine.[2]

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Screen Shot 2015-07-29 at 2.09.15 PMVertebral Compression Fractures-A Closer Look

The majority of vertebral compression fractures occur in the lower thoracic, upper lumbar region of the back – around the T12 to L2 levels. This region is considered to be a transition zone between the rigid thoracic spine and the mobile lumbar spine, putting it at a higher risk for fractures. When a VCF occurs, the vertebral body will collapse on itself and appear crushed on an X-ray; as a result, the bone will lose its height. A loss in height greater than 50% can lead to instability in the spine. Vertebrae adjacent to a fractured one will need to handle a greater amount of stress to compensate. Because adjacent vertebrae are likely to be similarly osteoporotic, they are at risk for fracture themselves. Having one vertebral fracture puts the person at a greater risk for even more.[1]

What are the Symptoms?
Back pain – moderate to severe
Pain in the midline of the back
Deep ache
Pain that gets worse with movement – especially when going from seated to standing position, bending, lifting objects, and prolonged sitting or standing
Pain worse with coughing, sneezing and bowel movements
Pain relieved by laying down

Pain associated with a VCF is usually slow-onset and may be mild initially. Pain may occur without any major trauma or any serious accident.[1]

What are the Causes?

As mentioned above, there are number of risk factors that can increase the likelihood of a VCF – those that can be modified, and those that cannot.

Modifiable risk factors (those you have control over):

Osteoporosis Vertebral Compression FractureOsteoporosisIn a patient with osteoporosis, the inner network of the bone becomes abnormally thin, leading to increased space and weaker connections throughout the vertebral body. Patients with moderate osteoporosis can have compression fractures with moderate activity, such as lifting heavy objects or tripping and falling.[1] In severe osteoporosis, fractures can occur with just a simple movement of the back due to the muscles of the spine contracting and causing a weakened bone to easily fracture. This can occur with light activity, such as lifting an object, or turning in bed. Incidence of osteoporosis can be decreased with medication, diet, and exercise.

Other modifiable risk factors include:

Alcohol consumption
Tobacco use
Estrogen deficiency
Early menopause
Surgery – bilateral salpingo-oophorectomy
Premenopausal amenorrhea > 1 year
Sedentary lifestyle/lack of exercise
Low body weight
Dietary calcium and/or Vitamin D deficiency
Anticonvulsant & antiepileptic medication use
Non-modifiable risk factors:

Cancer – In addition to osteoporosis, cancer is another leading cause of VCF. A tumor either originating in the vertebrae (primary bone tumor) or metastasis to the spine can cause the body of the vertebra to weaken the bone’s architecture, making it more prone to fracture. Tumors in the breast, prostate and lung are the most likely to spread to the spine.[5] Radiation therapy, most commonly for treatment of tumor within the spinal column, can also weaken bone structure and lead to fractures.[1]

Other non-modifiable risk factors include:

Advanced age
Female gender
Caucasian race
Dementia
Susceptibility to falling
Personal or family history of fractures
History of treatment with steroids
Vertebral Compression Fracture
What are my Treatment Options?

Vertebral Compression Fracture Osteoporosis PreventionThe most common means of diagnosing a VCF is a standard X-ray film. Physical exam is generally not enough to make a diagnosis of VCF as the symptoms can be vague and difficult to distinguish from other types of back pain. Patients will typically have pain and tenderness at the fracture site, however this is not always the case.

Patients may appear shorter and even have an abnormal curve in their spine that might even be visible to the naked eye. The most common type of abnormal curve from a VCF is known as kyphosis – hunchback. Kyphosis is a decrease in vertebral body height of 4 centimeters can lead to a 15-degree curvature.[4]

Once a VCF is seen on X-ray, the next step is to get an MRI with a special sequence known as STIR (short inversion-recovery sequences) – this will allow your doctor to tell if the fracture is new (acute) or old (chronic). An MRI will also show if there is a tumor, swelling, or if the spinal cord is being affected. This will help your doctor decide what is the best course of treatment.

Read More About Kyphoplasty

Prevention

The best way to treat a VCF is to prevent it. There are a number of steps one can take to decrease the likelihood of a VCF. The first and most important step is prevention and treatment of osteoporosis:[1]

1) Bone density scan – the gold standard test is the DEXA-scan, or dual-energy x-ray absorptiometry
2) Vitamin D and calcium supplementation by your physician
3) Discontinuing alcohol and cigarette smoking
4) Participating in a daily weight-bearing exercise regimen, as approved by your physician
5) Pharmacologic treatment for osteoporosis, e.g., biphosphanates, calcitonin

Conservative management includes bed rest for a short period of time, followed with gradual mobilization and the use of a brace for a few months. Young patients tend to tolerate brace devices better than elderly ones, who may end up needing bed rest for a longer time. Analgesics are given to control pain and allow mobilization. Radiation therapy can provide pain relief if the fracture is due to tumor.

There is no time frame for conservative management, but prolonged bed rest should be avoided as it can lead to blood clots, pneumonia and increased rate of bone density loss.[4]

Interventional Pain Management Treatments

Interventional techniques can offer faster onset and more definitive pain relief. These treatments are indicated in the presence of severe pain that has failed medical treatment, or neurologic deficits. The interventional procedures most commonly performed to treat VCF are known collectively as vertebral augmentation.

Vertebroplasty – This procedure involves placing a thin needle-like device into the collapsed vertebral body and injecting a type of plaster known as polymethylmethacrylate (PMMA). This method has shown to have good results, with short term results showing that 75% to 100% of patients had good to moderate pain relief following the procedure. Some patients have been able to wean off of pain medications completely.[1] Vertebroplasty is most effective if performed on a fracture that is less than 6 months old. It allows restoration of functional ability by stabilizing the vertebral body and preventing further collapse

Kyphoplasty – This procedure is very similar to vertebroplasty however an inflatable balloon pump is inserted into the fractured vertebral body using fluoroscopic guidance before the plaster is injected. The balloon can restore vertebral body height and reverse spine curvature. Kyphoplasty has best results if performed within 3 months of onset of symptoms or fracture, with short term results showing 85% to 100% pain relief.

***In the case of a VCF caused by a bone tumor or metastatic cancer spreading to the spine, a special variation of vertebral augmentation can be performed to not only repair the fracture but potentially destroy the tumor in the vertebra at the same time. The procedure is known as the STAR™ Tumor Ablation System by DFine™. Our doctors at the Ainsworth Institute are specially trained to perform the STAR procedure and are currently the only pain physicians performing this procedure in New York City.

Surgery

Major Surgery – Procedures like decompression and/or stabilization with hardware were considered the initial treatments of choice for patients that failed to respond after conservative management. Unfortunately, patients did not respond as well as hoped due to the quality of bone involved in repair being brittle, frail and generally un-amenable to major surgical repair.[4] Because of this, procedures like vertebroplasty and kyphoplasty are the preferred intervention of choice by most physicians for treating VCF’s.

The Ainsworth Institute is Here to Help

The doctors at the Ainsworth Institute of Pain Management specialize in treating vertebral compression fractures. Dramatic improvements in pain and quality of life are a single phone call away. Schedule an appointment today with one of our board certified pain management experts to discuss what options for treatment may best suit your needs.

References

[1]Alexandru D, So W. Evaluation and management of Vertebral Compression Fractures. Perm J 2012; 16: 46-51.

[2]Patel B, DeGroot H. Evaluation of the risk of pathological fractures secondary to metastatic bone disease. Orthopedics 2001;24:612-617.

[3]Bunting R, Lamont-Havers W, Schweon D, et al. Pathological fracture risk in rehabilitation of patients with bony metastases. Clin Orthop Relat Res 1985; 192:222-227.

[4]Benzon H, Raja S, Liu S. Essentials of Medicine. 3rd Edition. Elsevier Saunders. Philadelphia, 2011.[5]Buijs J T, van der Pluijm G. Osteotropic cancers: from primary tumor to bone. Cancer Lett 2009;273:177-193

[6]Mont’Alverne F, Vallee JN, Cormier E, et al. Percutaneous vertebroplasty for metastatic involvement of the axis. Am J Neuroradiol 2005;26:1641-1645.

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