Osteoporotic Vertebral Fractures

Definition / Description

Osteoporotic (fragile) fractures are mechanically induced fractures that, according to the National Institute for Health and Care Excellence (NICE) clinical guidelines, usually do not result in fractures [1].

Vertebral compression fractures (VCFs) of the spine:

• Secondary to axial/compressive (and to a lesser extent buckling) loading, biomechanical failure of the bone results in fracture.
• Damage to the anterior column of the spine, thereby damaging the anterior vertebral body (VB) and anterior longitudinal ligament (ALL).
• Do not involve the posterior half of the VB, nor the posterior osteoligamentous complex. The former distinguishes compression fractures from burst fractures.
• It is generally considered stable and does not require surgical instruments. [2]

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Etiology

• The most common cause of VCF is osteoporosis, making these fractures the most common fragility fractures.
• Compression fractures exhibit a bimodal distribution, and younger patients suffer from these injuries due to high-energy mechanisms (falling from heights, MVA, etc.).
• By definition, compression fractures involve damage to the anterior column only.
• VCF is considered a stable fracture pattern.

Epidemiology

Population studies have shown that the annual incidence of VCF is 10.7 per 1000 women and 5.7 per 1000 men.

• VCF is the most common fragility fracture reported in the literature.
• Approximately 1 to 1.5 million VCFs occur annually in the United States (US) alone.
• An estimated 40% to 50% of patients over the age of 80 have acute VCF, or are discovered incidentally during clinical workup for an isolated condition.
• The thoracolumbar junction (i.e., the portion from T12 to L2) is most commonly affected (60% to 75% of VCF), with another 30% occurring in the L2 to L5 region

In the elderly patients

• 30% of VCFs occur while the patient is in bed
• As the population continues to age, the number of people at risk of persistent low-energy fragility fractures will continue to increase.
• Mostly unreported, probably more common radiographically (in one study, up to 14% of women over 60 years of age) [4]
• Currently, 10 million Americans have been diagnosed with osteoporosis and another 34 million have osteopenia.

The short video below provides a brief overview of compression fractures

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Clinical Presentation

Vertebral fractures present with pain and loss of mobility. [4]

Symptoms of a vertebral fracture may include

• Back pain is common in elderly patients. Decreases when supine. [6][7].
• Three quarters of patients with vertebral fractures do not seek medical attention, and as many as 70% of vertebral fractures may not result in overt severe symptoms [8].
  Loss of height and severe pain. The height loss of vertebral bodies in osteoporotic fractures may be mild (20-25%) moderate (25-40%) or severe (>40%). It usually affects the thoracolumbar region, although any vertebra may be disturbed.
• The pain of an acute fracture usually lasts 4 to 6 weeks, with severe pain at the fracture site.
• Pain subsides within 6 to 12 weeks.
• Patients with multiple compression fractures, height loss, and low bone density (also due to structural changes or osteoarthritis) may also experience chronic pain.
• Radiological VCF may be asymptomatic. The greater the deformity, the greater the likelihood of pain and disability.
• As height falls, patients experience discomfort as the chest cavity presses down on the pelvis.
• Patients present with excessive thoracic kyphosis and/or excessive lumbar lordosis [8], which may lead to decreased exercise tolerance and reduced abdominal space, leading to early saturation weight loss.
• Sleep disturbance and decreased self-esteem/- depression may occur.
• Self-care can become difficult. [9][10][11].
• Associated with increased morbidity and mortality [8][12]

Diagnostic Procedures

Compression fracture of the third lumbar vertebra

Diagnosis is by x-ray when the vertebral body has lost more than 20% of its anteromedial or posterior height.

Osteoporotic spine fractures can be graded according to vertebral height loss as:

• Mild: up to 20-25%
• Moderate: 25-40%
• Severe: >40%

Chronicity of the fracture indicates its temporal relationship to symptoms and is therefore an important determinant.

On routine imaging, signs of acute fracture include cortical disruption or trabecular impaction; in the absence of these signs, the fracture is chronic.

In cases of uncertainty, MRI signs of edema (acute) and the presence of radiotracer uptake on bone scintigraphy (acute) help determine the age of the fracture.

Outcome Measures

1. Overall Pain Visual Analog Scale (VAS).
2. Quality of Life Questionnaire: This can be measured using the Quality of Life Questionnaire from the European Osteoporosis Foundation (QUALEFFO). Another possibility is to use the Assessment of Quality of Life (AQoL) questionnaire or the European Quality of Life – 5 Dimensions (EQ–5D) Scale.
3. Physical function: Measured by a modified 23-item Roland-Morris Disability Questionnaire.
4. Pain at night and at rest (VAS score) [13]
5. Studies have shown that the four-factor Mini-BESTest model can effectively assess multiple aspects of homeostasis in older adults with femoral or vertebral fractures and can help therapists make clinical decisions after considering factors indicative of functional decline [14].

Examination

Clinical assessment of vertebral fractures is usually poor, and diagnosis relies on imaging studies [10].

2 tests help practitioners more accurately predict which patients will have acute vertebral fractures [15].

1. Closed-fist percussion sign[15]
   The test has a sensitivity of 875% and a specificity of 90%, which is great. Standing behind the patient and the patient standing in front of the mirror, you can see the patient’s reaction. Examine the entire length of the spine with a firm fist blow. clinical The signal is positive when the patient complains of sudden severe pain.
2. Supine sign [15] The test has a sensitivity of 8125% and a specificity of 9333%, which is also pretty good. The patient is asked to lie supine with only one pillow on the head. Clinical signs were positive when the patient was unable to lie supine due to severe pain.

Medical Management

Conservative Management of Acute Osteoporotic Compression Fractures – Goals: Pain Relief and Functional Status Including

• Acetaminophen, ibuprofen, opioids,
• Physiotherapy
• Rehabilitation programs
• Bed rest.
• Braces for compression fractures are generally for patient comfort and are less likely to affect spinal stability. A small study does support the use of semi-rigid thoracolumbar orthoses to improve gait.
• Recommended for the treatment of the underlying disease (osteoporosis).

Surgical intervention is necessary for persistent pain and failure of conservative treatment.

• Vertebroplasty is usually an outpatient procedure that takes one to two hours in which a needle is inserted into the vertebral body and bone cement is injected under imaging guidance. This cement hardens quickly and stabilizes the fracture.
• Kyphoplasty is a very similar procedure, but in this case, a balloon is used to dilate the vertebral body before the bone cement is injected. [16]

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Physical Therapy Management

After a short period of bed rest, the patient should begin mobility through a rehabilitation and exercise program. The goals of rehabilitation are to prevent falls, reduce thoracic kyphosis, increase axial muscle strength and provide correct spinal alignment [18].

Treatment approaches include:

• Strengthen exercise stability, exercise balance training, stretching and relaxation techniques, manual therapy and taping [19][20].
• Exercise such as walking can help maintain or improve bone density in people with osteoporosis.
• Strengthening exercises with weights or resistance bands can help maintain or increase bone density at the site of targeted muscle attachment [21]. Maintaining bone health is important, especially in older adults, as bone mass typically declines with age.
• Strengthening and flexibility exercises improve overall body function and postural control (important for reducing the risk of falls) [22].
• A combined balance and progressive strength training program produced the best results in maintaining leg strength balanced bone mineral density and physical function compared to either balance or strength training alone [23][24][25].
• A spinal extensor strengthening program and a dynamic proprioceptive program increase bone density and reduce the risk of VCF. [26].
• Back extensor exercises improve muscle strength, provide better dynamic-static posture and reduce kyphosis. Kyphosis correction can also relieve pain, increase mobility, and improve quality of life [27].

Posture stickers can help keep your poses aligned. Tape is applied to the skin to provide more proprioceptive feedback on postural alignment, improve thoracic spine extension, reduce pain, and promote postural muscle activity and balance [28]. E.g;

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Clinical Bottom Line

• Osteoporotic vertebral fractures are fractures of one or more vertebrae due to osteoporosis.Osteoporosis causes bones to be weaker and more likely to break. Osteoporotic vertebral fractures usually occur during normal everyday activities such as bending, twisting, walking or lifting relatively light objects.
• The pain of an acute fracture usually lasts 4 to 6 weeks, with severe pain at the fracture site. Patients with multiple compression fractures, height loss, and low bone density may also experience chronic pain. Although this could be due to structural changes or osteoarthritis.
• Vertebral fractures are not only caused by osteoporosis. Vertebral fractures may also result from trauma or displacement. The diagnosis of osteoporosis can be confirmed by dual-energy X-ray absorptiometry (DXA).
• Outcome measures commonly used to assess patient progression are: Visual Analog Scale (VAS) for overall pain and daytime and nighttime pain Quality of Life Questionnaire and Physical Function Questionnaire (modified 23-item Roland-Morris Disability Version questionnaire).
• Conservative treatment (bed analgesics, physical therapy and bracing) remains the preferred method of drug therapy. Vertebral fractures can also be treated surgically with vertebroplasty and kyphoplasty.
• Managed as physical therapy, there are many treatments, including strengthening, movement, stability, exercise, balance training, stretching, relaxation techniques, manual therapy, and taping.

Key Research

The following articles are key evidence for physical therapy interventions:

• Exercise interventions to reduce fall-related fractures and their risk factors in individuals with low bone mineral density: a systematic review of randomized controlled trials [30]
• A multicomponent exercise program for the prevention of functional decline and bone fragility in home-dwelling older women: a randomized controlled trial [31]
• Positive effect of exercise on risk of falls and fractures in osteoporotic women [32]
• Reducing the risk of falls in osteoporotic women with kyphotic posture through proprioceptive dynamic posture training: a randomized pilot study
• Recognition of osteoporotic vertebral fractures [33]
• Position statement of the Korean Society for Bone and Mineral Research [33]

Resources

www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx

www.nos.org.uk/about-osteoporosis