Thoracolumbar Vertebral Compression Fractures

Key Points

• Vertebral compression fractures are common, especially in the elderly. Causing significant disability, deconditioning, and pain.

• The most common site for fractures is thoracolumbar junction (T12-L1).

• Family physicians can prevent compression fractures and sequelae by identifying high-risk patients, educating patients, and encouraging lifestyle modification.

Vertebral compression fractures are common, especially in elderly persons. Vertebral fractures can cause significant pain and impairment in activities of daily living, leading to potentially life-threatening disability and deconditioning in the elderly patient. Patients with preexisting vertebral fractures have greater risk of future vertebral as well as nonvertebral (especially hip) fractures than those without prior fractures.

The most common site for fractures is the thoracolumbar junction (T12-L1) because the change in facet provides poor resistance to anteroposterior displacement. The other common location is the midthoracic region (T7-T8). Osteoporosis is the most frequent cause of vertebral compression fractures in the elderly population. Other causes should be suspected if fracture occurs in a person neither elderly nor postmenopausal or if solitary fracture higher than T7 is seen, ruling out osteomalacia, hyperparathyroidism, granuloma-tous disease, and hematologic disease.

Clinical Features

Most thoracolumbar compression fractures are asymptomatic, diagnosed as incidental findings on chest or abdominal plain radiographs. Patients with symptomatic fractures usually have no preceding history of trauma, and even minimal trauma (coughing, sneezing) can cause the fracture. The pain from a vertebral compression fracture is variable in quality and sharp or dull. Movements aggravate the pain. The classic patient presents with acute back pain radiating to the anterior abdomen, unlike radiation into the legs seen in herniated disk. Physical examination may reveal tenderness directly over the area of fracture. Thoracic kyphosis and lumbar lordosis may be noted secondary to vertebral height lost. Straight-leg raise and neurologic exam are normal in uncomplicated fractures. Acute episodes usually resolve after 4 to 6 weeks; if pain lasts longer, the physician should suspect more fractures, with chronic pain or other diagnosis.

Diagnostic Testing

A complete blood count, erythrocyte sedimentation rate, and alkaline phosphatase, serum calcium, phosphorus, vitamin D, and parathormone levels should be obtained to rule out malignancy, hyperparathyroidism, or infection, if a cause other than osteoporosis is suspected. Plain radiographs are obtained if compression fracture is suspected. Radiographic characteristics of compression fractures include anterior wedging of one or more vertebrae, with vertebral collapse, demin-eralization, and vertebral end-plate irregularity. Advanced imaging is not routinely necessary unless the patient has a neurologic abnormality, which may indicate fracture fragments in the spinal canal. Imaging also helps rule out other causes of back pain.

Treatment

Initial management involves pain control and resumption of exercise as early as possible. When osteoporosis is present, inactivity could lead to further bone loss and subsequent fractures. Nonnarcotic analgesics should be used for pain relief. If narcotics are required, laxatives should be used because straining with defecation can cause further fractures. Nasal calcitonin may be a useful adjunct to these analgesics for acute pain relief. Treating the underlying disease is important. Muscle relaxants, external back braces, and physical therapy also may help. Immediate surgical referral should be made if fracture fragments are impinging on the chord and causing neurologic symptoms, or if the fracture is unstable.

Most patients respond to conservative treatment, with significant improvements or full recovery after 6 to 12 weeks. Patients who do not respond to conservative treatment may be candidates for percutaneous vertebroplasty or kyphoplasty.

The family physician can help patients prevent compression fractures and the sequelae by identifying high-risk patients, educating patients about measures to prevent falls, and encouraging lifestyle modifications. A regular weight-bearing exercise program, adequate calcium and vitamin D supplement intake, smoking cessation, and medications to treat osteoporosis may help prevent additional compression fractures.

KEY TREATMENT

Conservative management (pain management, back braces, physical therapy) is the first line of therapy for stable compression fractures (Old and Calvert, 2004) (SOR: B). Patients nonresponsive to conservative treatment may be candidates for percutaneous vertebroplasty or kyphoplasty (Predley et al., 2002) (SOR: B).

Diagnosing and treating osteoporosis reduces the incidence of compression fractures of the spine (Old and Calvert, 2004) (SOR: A). Regular activity and muscle-strengthening exercises have been shown to decrease vertebral fractures and back pain (Sinaki et al., 2002) (SOR: B).

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