Management of vertebral osteoporotic fractures

Vertebral compression fractures (VCF) are associated with significant impacts on physical and mental health, ranging from pain to depression to spinal deformities. It is associated with a 15% higher mortality rate.⁴ Furthermore, the estimated annual medical cost of VCF management in the UK was approximately ‚¬14.7 million.² It is crucial therefore to try to prevent these VCF or to treat them early, in order to alleviate the medical and economical consequences. Prevention targets the management of the principal risk factor osteoporosis. Active management, on the other hand, involves the early recognition and treatment of VCF with pain killers, bed rest and the two minimally invasive techniques of verterbroplasty and kyphoplasty. 

AetiologyThe most important underlying risk factor for VCF is osteoporosis, in particular, within the elderly population. Although trauma, infection and malignancy can all be contributory factors. VCF in the elderly osteoporotic patients most commonly occur following trivial events including lifting objects, vigorous coughing or sneezing, falling or even turning in bed in severe cases of osteoporosis.From an annual incidence of 0.9% and prevalence of 5€“10% in middle aged women (50s€“60s) VCF rates increase to an annual incidence of 1.7% and prevalence of >30% among the over 80s⁵ reflecting the association with age. In these women the risk of VCF is increased due primarily to menopause associated osteoporosis. Osteoporosis is characterised by decreasing bone density and strength. The definition of osteoporosis arises from measurement of bone mass density (BMD). BMD is measured using a dual-energy X-ray absorptiometry (DEXA) scan, which is a very precise method and is considered to be the €œgold standard€. It works by detecting the amount of calcium in bone. In accordance with WHO osteoporosis is defined as a BMD that is 2.5 standard deviations (SD) below the mean peak value in young adults of the same race and sex (T score of -2.5). T-scores are commonly used for the diagnosis of osteoporosis; it shows the number of SD the BMD of an individual is from that of the ethnicity matched 30 year old women. A T-score of between -1 and -2.5 is described as osteopenia. In cases of severe osteoporosis a Z-score is sometimes used. The Z-score is the comparison of an individual’s BMD to age, sex and ethnicity matched normal. It is typically used in individuals under the age of 50 years. When the Z-score is below 2 SD it is helpful in looking for co-existing illnesses that may contribute to osteoporosis. The condition affects millions of people worldwide and is the principal risk factor for low impact fractures of the hip, wrist and spine.Studies have found associations between the risks of developing VCF with the number of previous VCF. Having one previous VCF increases your risk five-fold whereas having two or more is said to increase the risk by 12-fold,⁷ independent of bone density. Early identification and treatment is therefore key in preventing future complications. Furthermore, if BMD is decreased by 2 SD, the risk of developing a VCF increases by 4€“6-fold.⁷

Presentation of VCFThese fractures most commonly occur in the mid-thoracic or thoracolumbar transition zone of the spine. Many are insidious and are detected incidentally.⁸ The most important presenting feature is back pain that is sudden in origin. The pain is worse when sitting up, standing or on palpation of the back. It is important to distinguish VCF from other causes of back pain.Rarely neurologic symptoms may arise from spinal cord or cauda equina compression due to the retropulsion of fracture fragments. This is an emergency. Symptoms include weakness and loss of sensation of the lower extremities along with loss of bowel and bladder sphincter control. VCF can cause sagittal imbalance from €œloss of height€ and spinal deformities eg. kyphosis. This is more common following multiple VCF. The use of the paraspinal muscles to maintain posture may induce fatigue in these patients. Chronic back pain in combination with feeling of tiredness can significantly impair the quality of these patients’ lives. Fracture risk assessment tool (FRAX) is a tool used to determine the 10-year risk of developing a major osteoporotic fracture (including in the spine). It was developed by WHO in 2008. It uses a series of validated risk factors for osteoporosis with or without the BMD (only BMD that is calculated at the femoral neck is used) to achieve this estimated risk. It is used in adults aged between 40€“90 years of age and is very useful in guiding clinical management.

InvestigationsThe most widely used initial imaging modality for VCF are plain radiographs. A lateral x-ray of the thoracic or lumbar spine is adequate and cost-effective in most cases. Spinal alignment disruption, estimated loss of vertebral height and fractures can be elicited from these images. Previous spinal X-rays are useful for comparison, in particular, when trying to identify the ages of the fractures. The major disadvantage is the inability of x-rays to pick up ligamentous injury.⁹Computed tomography (CT) can also be used in the assessment of VCF. They are particularly useful in complex fractures and help detect instability of an anterior wedge compression fracture as well as bony injuries (CT scans allow for the best imaging of bony anatomy). They can also identify chronic fractures through the presence of cortication. However, this imaging modality is expensive and comes at a cost of radiation exposure.MRI imaging is not usually necessary. However, it is very good at fracture ageing and is essential following neurological symptoms indicating cord compression.It is important to exclude tumour secondaries, osteomalacia, metabolic abnormalities, endocrinopathies as well. So patients will need blood tests and serum/urine electropheresis. 

Treatment of osteoporosisInitially, lifestyle modification involving a change in diet and more regular weight-bearing exercise should be implemented. Also advise on smoking and excess alcohol. These changes help strengthen the bones and the supporting musculature. The management of osteoporosis involves a wide range of agents including: bisphosphonates, calcium, vitamin D, calcitionin, teriparatide, estrogen and selective estrogen receptor modulators. Postmenopausal women with osteoporosis should be treated with 1500mg calcium and 400 IU vitamin D daily.¹⁰ Treating osteoporosis is the first step in managing VCF.Bisphosphonates inhibit osteoclast activity and thereby increase BMD. They are used in both the prevention and management of osteoporosis. Examples include alendronate and risedronate€”the two most commonly administered. Intravenous pamidronate and zoledronate are used in situations where oral medication cannot be tolerated. Numerous studies have shown the efficacy of alendronate in reducing both primary and secondary VCF¹¹ as well as increasing BMD. Similar results were obtained with calcitonin use. In a five-year, double-blind, randomised, placebo controlled study in women with osteoporosis, 200 IU of calcitonin was found to reduce the risk of VCF by 33%.¹² Teriparatide and oestrogen were also noted to increase BMD and thereby prevent VCF. Oestrogens have shown to reduce the risk of VCF by 50% compared to placebo.¹³

Non-surgical management of VCFThe initial treatment of VCF should aim to control the associated pain.  Methods of pain control include bed rest, non-steroidal anti-inflammatory drugs (NSAIDs), opiates, neuropathic pain agents, local analgesic, nerve blocks etc.¹⁴  The first-line treatment for back pain is NSAIDs and if they are not effective enough, muscle relaxants and opiates can be used. Interestingly, osteoporosis medications including bisphosphonates and calcitonin improve the pain associated with VCF.¹⁵Bracing of the back is used in the first few months until the back pain resolves. However, the braces are less well tolerated by the elderly. One prospective randomised trial on the six month use of a thoraco-lumbar orthoses showed improvement of VCF symptoms.¹⁶ Exercise regimes should be prescribed through a physiotherapist. The aim of physical therapy is to improve the patients balance and axial musculature strength in order to prevent further falls. An example of such a programme is the Spinal Proprioception Extension Exercise Dynamic (SPEED) designed by Sinaki.¹⁷ It is a four week programme, which was found to improve back pain and strength as well as reducing the risk of falls.

Surgical management of VCFSurgical management of VCF are indicated in those with intractable back pain who have failed conservative measures. It is also indicated if there are signs of neurological deficit. Surgical management produces quick, significant and sustained improvements in back pain, function, and quality of life. Although many surgical approaches are possible in the treatment of VCF, the most popular are the two minimally invasive percutaneous procedures: vertebroplasty and kyphoplasty. They are performed under moderate anaesthesia with local anaesthesia or under general anaesthesia.Vertebroplasty involves the insertion of a cannulated tochar under fluoroscopic guidance into the vertebral body via a transpedicular or parapedicular approach. This is used to inject polymethylmethacrylate (PMMA) into the fracture. The material used is radio-opaque. The aim of this procedure is to provide structural support and restore lost vertebral height. A bipedicular approach can be used to distribute the cement more evenly.In kyphoplasty an identical approach is used, except just before the injection of PMMA cement a balloon tamp is inflated within the vertebral body (in the fracture). This compacts the cancellous bone and reduces the fracture. Cement is then injected into this expanded cavity. These are both day procedures and the patient is discharged home on the same day.¹⁸These methods have both been shown to result in immediate pain relief within 24 hours. They have also shown to improve activity and decrease pain in patients debilitated by painful VCFs. Complications include tissue irritation due to cement extravasation, but significant clinical complications are reported to be as low as 1€“3%.¹⁹

ConclusionVCF are commonly found in postmenopausal osteoprotic women. The main symptom is sudden pain. VCF are reported to have a significant impact on the daily lives of patients, keeping many of them bed-bound. The initial management of VCF is conservative with analgesic, bed rest, braces and exercise. This approach is at least trialled for six weeks. Thereafter, surgical approaches may be indicated namely vertebroplasty and kyphoplasty. These have both shown to be effective in relieving the associated pain immediately. As many of these patients with VCF are osteoprotic, management of the osteoporosis can have a substantial impact in reducing the number of VCF.

Conflict of interest: none declaredReferences1.NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy, March 7€“29, 2000: highlights of the conference. South Med J 2001; 94: 569€“732.Finnern HW, Sykes DP. The hospital cost of vertebral fractures in the EU: estimates using national datasets. Osteoporos Int 2003; 14(5): 429€“363.Cauley JA, Palermo L, Vogt M, et al. Prevalent vertebral fractures in black women and white women. J Bone Miner Res 2008; 23(9): 1458€“674.Cooper C, Atkinson EJ, Jacobsen SJ, O’Fallon WM, Melton LJ 3rd. Population-based study of survival after osteoporotic fractures. Am J Epidemiol 1993; 137(9): 1001€“10055.Melton LJ 3rd, Lane AW, Cooper C, Eastell R, O’Fallon WM, Riggs BL. Prevalence and incidence of vertebral deformities. Osteoporos Int 1993; 3(3): 113€“196.Ross PD, Davis JW, Epstein RS, Wasnich RD. Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Intern Med 1991; 114(11): 919€“237.Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 1996; 312(7041): 1254€“598.Nakai Y, Noth R, Wexler J, et al. Computer-based screening of chest X-rays for vertebral compression fractures as an osteoporosis index in men. Bone 2008; 42(6): 1214€“18 9.Epstein O, Ludwig S, Gelb D, Poelstra K, O’Brien J. Comparison of computed tomography and plain radiography in assessing traumatic spinal deformity. J Spinal Disord Tech 2009; 22(3): 197€“201. 10.Meunier PJ, Delmas PD, Eastell R, et al. Diagnosis and management of osteoporosis in postmenopausal women. Clin Ther 1999; 21(6): 1025€“44.  11.Pols HA, Felsenberg D, Hanley DA et al. Multinational, placebo-controlled, randomized trial of the effects of alendronate on bone density and fracture risk in postmenopausal women with low bone mass. Osteoporos Int 1999; 9: 461€“6812.Martens MG. Risk of fracture and treatment to prevent osteoporosis-related fracture in postmenopausal women. A review. J Reprod Med 2003; 48: 425€“3413.Lufkin EG, Wahner HW, O`Fallon WM et al. Treatment of postmenopausal osteoporosis with transdermal estrogen. Ann Intern Med 1992; 117: 1€“914.Francis RM, Baillie SP, Chuck AJ, et al. Acute and long-term management of patients with vertebral fractures. QJM 2004; 97(2): 63€“7415.Vaccaro AR, Kim DH, Brodke DS, et al. Diagnosis and management of thoracolumbar spine fractures. Instr Course Lect 2004; 53: 359-7316.Pfeifer M, Begerow B, Minne HW. Effects of a new spinal orthosis on posture, trunk strength, and quality of life in women with postmenopausal osteoporosis. Am J Phys Med Rehabil 2004; 83(3): 177€“8617.Sinaki M. Exercise for patients with osteoporosis: management of vertebral compression fractures and trunk strengthening for fall prevention. PM&R 2012; 4(11): 882€“8818.Gardner M, Demetrakopoulos D, et al,. Osteoporosis and Skeletal Fractures. HSSJ 2006; 2: 62€“6919.Barr JD. Point of view: An in vivo comparison of the potential for extravertebral cement leak after vertebroplasty and kyphoplasty. Spine 2002; 27: 2178€“79