Vertebral compression fracture
Osteoporosis is the most common cause of vertebral compression fractures, followed by trauma. The most common levels of compression fractures are at T7-8 and T12-L1. Osteoporosis causes low trauma fractures that can be asymptomatic. On the other hand, acute, fairly severe compression fractures can be painful. This pain is fairly localized. If there is retropulsion of bony elements, this can narrow the central canal, causing nerve-related pain. Back pain can be reproduced with sitting, spinal extension, movement, or bearing down. There is often tenderness to palpation on examination. Neurologic examination should be performed to rule out nerve injury. Typically acute pain subsides after 3 to 6 weeks, although it may take longer for others to heal. It usually takes 3 months for full healing to occur. Multiple fractures in the thoracic spine can lead to thoracic kyphosis. If severe pain persists, this may indicate an additional compression fracture. There is a 19% risk of recurrent fracture over a year. Women are 4 times more likely to get another compression fracture. Diagnosis can be made with plain radiographs, which will show anterior wedging of the vertebrae due to vertebral collapse. An MRI of the lumbar spine can be performed to determine the acuity, evaluate neurologic compromise, and rule out infection or malignancy (if there is a high suspicion of either metastatic disease or infection). First line of treatment for pain includes Tylenol or NSAIDs. Intranasal calcitonin (200 units daily) can also be considered if over-the-counter treatment is not enough for mild to moderate pain. If severe pain is present, short-term opioids may be considered during the acute phase. Physical therapy can work on core strengthening and ambulation once activity can be tolerated. Exercise is also beneficial to improve bone density. Aquatic therapy is a great alternative exercise strategy for pain sufferers. Bracing has not been proven to be effective, but can be used as a kinesthetic reminder to limit flexion. If severe pain persists for over 6 weeks, opioids are poorly tolerated, and activities of daily living are compromised, vertebral augmentation (vertebroplasty and kyphoplasty) may be considered. The difference between vertebroplasty and kyphoplasty is that kyphoplasty uses a balloon mechanism to expand the vertebral space before cement is injected in the collapsed space. Vertebroplasty is easier to perform and more cost effective.