What is a compression fracture of the spine?

Vertebral Compression Fractures: Diagnosis and Management

A vertebral compression fracture (VCF) is a collapse of a vertebral body that commonly occurs due to osteoporosis, trauma, or pathologic processes such as malignancy. Medical management is the first-line treatment for most symptomatic osteoporotic vertebral compression fractures for the initial 3 months, with vertebral augmentation procedures reserved for cases with persistent pain, spinal deformity, or pulmonary dysfunction. 1

Radiographic Appearance and Diagnosis

Vertebral compression fractures typically appear on imaging as a collapse or reduction in height of the vertebral body. The classic "chalk stick" fracture refers to a complete, horizontal fracture through a vertebral body that resembles a broken piece of chalk.

Diagnostic Imaging

• Plain radiographs: Initial imaging modality that can identify height loss and deformity of vertebral bodies 1
• CT scan: Superior to radiographs for detecting fracture details, especially in trauma settings 1
• MRI: Best for determining:
  • Acuity of fracture (presence of bone marrow edema indicates acute fracture)
  • Soft tissue involvement
  • Spinal cord compression
  • Differentiating between osteoporotic and pathologic fractures 1, 2

Classification Based on Etiology

1. Osteoporotic VCFs (most common)

   • Age-related bone loss leading to weakened vertebrae
   • May occur with minimal or no trauma
   • Typically affect thoracic and lumbar spine

2. Traumatic VCFs

   • Result from significant trauma
   • May be associated with neurological deficits
   • Can occur at any level of the spine 1, 3

3. Pathologic VCFs

   • Due to underlying disease (malignancy, infection)
   • Require different management approach
   • Often need biopsy for definitive diagnosis 1

Management Algorithm

1. Initial Assessment

• Determine etiology (osteoporotic, traumatic, or pathologic)
• Assess neurological status
• Evaluate pain severity and functional limitations
• Check for "red flags" suggesting malignancy or instability 1

2. Osteoporotic VCFs Without Neurological Deficits

• First 3 months: Medical management 1

  • Pain control with analgesics
  • Calcitonin for 4 weeks (shown to reduce pain in acute fractures) 1
  • Limited bed rest (brief periods only) 4
  • Bracing (individualized decision) 1
  • Physical therapy once acute pain subsides

• After 3 months if persistent symptoms: 1

  • Consider vertebral augmentation (vertebroplasty or kyphoplasty) if:
    • Persistent pain despite medical management
    • Spinal deformity (≥15% kyphosis, ≥10% scoliosis)
    • Pulmonary dysfunction
    • Progressive vertebral collapse

3. Pathologic VCFs

• Requires multidisciplinary approach: 1

  • Biopsy to confirm diagnosis
  • Radiation oncology consultation
  • Surgical consultation
  • Interventional radiology consultation

• Management options: 1

  • For severe pain: Percutaneous vertebral augmentation or thermal ablation
  • For spinal deformity: Percutaneous vertebral augmentation
  • For neurological deficits: Surgical decompression and stabilization

4. Traumatic VCFs with Neurological Deficits

• Urgent surgical intervention: 1
  • Corticosteroid therapy initially
  • Surgical decompression as soon as possible
  • Spinal stabilization

Important Clinical Considerations

Pain Management

• Acute pain typically improves over 2-12 weeks with conservative management 1
• However, approximately 20% of patients develop chronic pain 1
• The VERTOS II trial showed 40% of conservatively treated patients had no significant pain relief after 1 year despite higher-class prescription medication 1

Complications of Untreated VCFs

• Progressive spinal deformity (kyphosis)
• Decreased pulmonary function
• Reduced mobility and physical functioning
• Increased risk of subsequent fractures
• Increased mortality 1, 5

Vertebral Augmentation Procedures

• Vertebroplasty: Injection of bone cement into fractured vertebra
• Kyphoplasty: Creation of cavity with balloon before cement injection
• Both procedures provide immediate pain relief and stabilization 1, 5
• Most effective when performed within 3 months of fracture onset 1

Prevention of Future Fractures

• Osteoporosis treatment with bisphosphonates
• Ibandronate and strontium ranelate are options to prevent additional symptomatic fractures 1
• Calcium and vitamin D supplementation
• Fall prevention strategies

Pitfalls to Avoid

1. Delaying diagnosis and appropriate treatment
2. Failing to identify pathologic fractures (always consider malignancy)
3. Prolonged bed rest (increases risk of complications)
4. Overlooking the need for osteoporosis treatment after fracture
5. Missing neurological deficits that require urgent surgical intervention

Vertebral compression fractures represent a significant cause of pain and disability, particularly in the elderly population. Early diagnosis and appropriate management can significantly improve outcomes and prevent complications.