What is Vertebral Compression Fractures?
Vertebral compression fractures (VCFs) are breaks in the spinal column that happen due to high pressure or compressive forces, and less commonly, bending forces too. These forces cause the bone to fail and fracture. Importantly, VCFs affect the front part of the spine, resulting in damage to the front half of the vertebral body (the main part of a vertebra) and the ligament running along its front side, known as the anterior longitudinal ligament. This causes the spine to take on a specific wedge shape.
However, VCFs do not affect the back half of the vertebral body, nor do they harm the bone structures or ligaments at the back of the spine. This distinguishes a compression fracture from more severe fractures like burst fractures. The implications of these compression fractures depend on the stability of the fractured structure and the potential for the deformity to worsen. In general, compression fractures are usually seen as stable and don’t normally require surgery.
What Causes Vertebral Compression Fractures?
VCFs, or vertebral compression fractures, are most commonly caused by a condition called osteoporosis, which weakens bones. It makes VCFs the most common type of fractures that happen easily with minor falls or injuries. However, these fractures can also occur in younger patients due to high-energy accidents like a fall from a height or a vehicle crash.
Changes in the structure and ligaments of the spine from the chest (thoracic) region to the lower back (lumbar) region can cause certain areas to be unstable, making them more likely to be injured.
Traditionally, the spinal column is thought of as being divided into three main parts: the front column which includes the front part of the vertebral body and ligaments, the middle column containing the back part of the vertebral body and ligaments, and the back column that includes various ligaments and neural arch, facets. If two out of three of these sections are damaged, the injury is considered serious, or “unstable”, and the patient might need surgery.
Compression fractures, by their definition, only involve damage to the front part of the spinal column. This means these kinds of fractures are considered “stable” and usually don’t disrupt the overall stability of the spine. However, if the fracture involves the middle column, it’s classified as a burst fracture, which lacks the stability of a regular compression fracture.
Risk Factors and Frequency for Vertebral Compression Fractures
VCFs, or vertebral compression fractures, are the most common type of fracture that happen due to weak or brittle bones. Every year in the US, 1 to 1.5 million people experience a VCF. A quarter of women over the age of 50 and nearly half of all people over 80 have had at least one of these fractures. Often, these fractures might not become apparent until a person is being checked for another health problem.
Most VCFs occur in specific areas of the spine, specifically from the twelfth thoracic vertebra to the second lumbar vertebra, and from the second to fifth lumbar vertebrae. In younger people, half of these fractures are due to car accidents and a quarter are caused by falls.
This contrasts with older patients, where 30% of fractures happen even while the person is in bed. As our population grows older, more and more people are at risk for these low-energy fractures. Presently, 10 million Americans have osteoporosis, a condition that weakens bones and makes fractures more likely, and another 34 million have osteopenia, a less severe thinning of the bones. These numbers are expected to keep growing.
Research shows that each year, around 10.7 out of every 1000 women and 5.7 out of every 1000 men will experience a VCF.
Signs and Symptoms of Vertebral Compression Fractures
To begin assessing spine fractures, after the patient has been stabilized, what doctors do is examine the working of the arms, legs, bladder, and bowels. Doing a thorough exam requires being organized and patient. It’s important to remember that severe compression fractures, caused by intense force, can often come with additional injuries to the stomach, head, and limbs. These areas also need to be checked. The examination looks not only at how strong the sensations and reflexes are, but it’s also crucial to look at the skin along the back and note if there is any tenderness when touched. Documentation of these initial findings is extremely important because they’ll probably be used as the starting point for future evaluations.
Testing for Vertebral Compression Fractures
If a person is suspected to have experienced a back injury, a doctor will generally start by taking x-rays of the area from different angles. These initial x-rays are taken while the person lies flat on their back, taking precautions to protect the spine. Once the spine team has given the all-clear, or a brace was provided, standing x-rays may be taken. These x-rays can provide useful information for treatment, particularly since lying down can sometimes make a displaced fracture appear less severe than it actually is.
In addition to x-rays, a CT scan, which generates detailed images of the body, is also typically performed in trauma cases. If a doctor suspects a particular injury to the back that isn’t clearly seen on the CT scan, an MRI can be used. MRIs are very useful for revealing damage in the complex network of ligaments in the back. In cases where the x-rays show a specific bend in the spine of 30 degrees or significant bone loss in the spine, the injury is usually considered serious. However, new studies are challenging this assumption.
An MRI will also be necessary if the person shows signs of a neurological problem stemming from the back injury. That said, older people who’ve suffered low-energy compression fractures, a type of fracture commonly seen in patients with osteoporosis, may not need an MRI. Regular x-rays taken at follow-up appointments will help the doctor to monitor the fracture’s progression and the body’s healing process.
Treatment Options for Vertebral Compression Fractures
Deciding whether to perform surgery can often spark debate. In 2005, a system called the Thoracolumbar Injury Classification and Severity (TLICS) Scale, was introduced to make this decision more consistent. The TLICS scale looks at factors like injury type, nerve function, and the stability of the posterior ligament complex (PLC), and assigns a score from one to ten to guide treatment. Lower scores (less than four) usually suggest a non-surgical approach, while higher scores (greater than four) indicate surgery might be needed. A score of four could go either way, depending on doctor’s judgement. However, these guidelines mainly apply to trauma patients, and each case should be examined individually. Interestingly, recent studies have shown that in patients with no nerve damage, factors such as loss of height in the spinal column, kyphosis (forward rounding of the back), and narrowing of the spinal canal, do not necessarily mean surgery is required. So far, no trials have compared surgery with brace treatment in cases of “unstable” compression fractures.
Supportive devices or braces are used in non-surgical management, usually for a period of four to 12 weeks. The brace can be removed when x-rays show recovery and the patient feels no pain at the fracture spot. For mid-back or upper lower back fractures, a brace covering the chest, back, and lower back (thoracolumbosacral orthosis or TLSO) could be used. Lower back fractures may need a lumbosacral corset for proper immobilization. Bracing can bring its own challenges, especially for people with large chests, lung issues or obesity, which should be taken into account. Pain relievers and braces can be hard for some patients to tolerate. If this is the case, doctors might consider minimally invasive procedures to stabilize the fracture.
Surgery decisions largely depend on fracture aspects and nerve damage. Compression fractures rarely require advanced surgical stabilization. The most common surgical methods for these patients are vertebroplasty or kyphoplasty, which involve the injection of cement into the fractured vertebra. Vertebroplasty, developed originally for spine tumors, is a low-invasive procedure where the patient is positioned on their back, but the procedure does not aim to improve alignment. Kyphoplasty, on the other hand, first seeks to correct the alignment of the fractured vertebra with a balloon before injecting cement. For patients whose non-surgical treatments have failed, or who are admitted to the hospital due to pain or reduced function, cement injection should be considered. Recent studies have shown that kyphoplasty can significantly and swiftly improve life quality, function, pain, and mobility.
What else can Vertebral Compression Fractures be?
If a patient comes in with back pain and the doctor suspects a vertebral compression fracture (VCF), it’s important to rule out other possible causes first. These could include issues related to the muscles, lungs, abdomen, kidneys, or blood vessels, depending on where the pain is located.
If an imaging test reveals a fracture in the spine, the doctor needs to examine the back of the vertebral body and the structures in the back of the spine very closely. This is to make sure there isn’t a more severe, unstable fracture.
What to expect with Vertebral Compression Fractures
In older people who have osteoporotic compression fractures (broken bones due to weakened bones), the death rate is higher compared to others of the same age. Studies show the survival rates to be 53.9% after 3 years, 30.9% after 5 years, and just 10.5% after 7 years.
Possible Complications When Diagnosed with Vertebral Compression Fractures
If these types of fractures are not treated, it can result in continuous back pain and a worsening hunchback-like condition. Additionally, the affected part of the spine may further collapse, and there’s a strong chance of experiencing more fractures in the future.
On the other hand, a method called cement augmentation which aims to stabilize the fracture using a kind of cement has its own associated risks. Complications include, but are not limited to:
- Reports of rare instances of nerve damage during the procedure
- Increased stiffness in the cement-filled part of the spine — this can put extra stress on the surrounding areas and potentially cause more fractures
- Cement leakage — although this is common and usually doesn’t have substantial health impacts
- Rare but serious complications such as blockages in the lungs or brain if the cement travels to these areas
However, it should be noted that patients with these types of fractures often have a high risk of complications, even without surgical treatment.