From the Guidelines
A lumbar compression fracture with 50% height loss is generally considered an unstable fracture. The stability of a vertebral fracture depends on several factors, with height loss being a significant indicator. Fractures with more than 40-50% height loss typically indicate substantial structural compromise and are classified as unstable, as noted in the Spinal Instability Neoplastic Score (SINS) system 1. This system, developed by the Spine Oncology Study Group (SOSG), evaluates spinal stability based on clinical and radiographic data, including location, pain, bone quality, alignment, vertebral body collapse, and posterolateral involvement.
According to the SINS system, a spinal segment can be classified as stable (0-6), potentially unstable (7-12), and unstable (13-18) 1. The presence of a pathologic vertebral compression fracture (VCF) is one of the categories within the SINS system. The SINS has excellent interobserver and intraobserver reliability and is routinely used by spine oncologic surgeons and spine radiation oncologists to guide management 1.
Management of unstable fractures usually requires more aggressive intervention than stable fractures, potentially including bracing, activity modification, and in some cases surgical stabilization. The concern with unstable fractures is the risk of progressive deformity, neurological compromise, and chronic pain if not properly treated. The degree of pain, neurological symptoms, and overall patient factors will influence the specific treatment approach. Early evaluation by a spine specialist is essential to determine the appropriate management strategy and prevent potential complications.
Some key points to consider in the management of lumbar compression fractures include:
- The use of calcitonin for 4 weeks following the onset of fracture may be beneficial in reducing pain 1.
- Vertebroplasty is not recommended for the treatment of symptomatic osteoporotic spinal compression fractures 1.
- Kyphoplasty may be considered for the treatment of symptomatic fractures in patients who are neurologically intact 1.
- The use of ibandronate and strontium ranelate may be considered to prevent additional symptomatic fractures 1.
Overall, the management of a lumbar compression fracture with 50% height loss requires a comprehensive approach, taking into account the patient's overall health, pain level, and neurological symptoms, as well as the potential risks and benefits of different treatment options 1.
From the Research
Fracture Stability
- A lumbar compression fracture with 50% height loss is generally considered unstable 2.
- The stability of a fracture is an important factor in deciding the treatment plan, with unstable fractures often requiring operative management 3, 4.
- Factors that determine instability include decrease in vertebral body height, local kyphosis, involvement of posterior column, and/or canal compromise 3.
Treatment Options
- Surgical options for unstable fractures include anterior, posterior, or combined anteroposterior approaches, each with unique advantages and disadvantages 4.
- Minimally invasive spinal stabilization techniques have improved significantly over the past decade, but may not be recommended for fractures with severe vertebral height loss 5.
- A novel, percutaneous, self-expanding, forceful reduction screw system has been developed to address thoracolumbar fractures with severe vertebral height loss, showing significant improvement in vertebral height restoration and kyphosis correction 5.
Diagnostic Methods
- Plain films alone are not sufficient to determine the stability of simple wedge-compression fractures of the lumbar spine, with CT scans providing more accurate information 2.
- The thoracolumbar injury classification system (TLICS) is used to determine the treatment plan, with scores of 4 or more indicating the need for surgical intervention 3.