Introduction
Osteoporotic vertebral fractures are the most prevalent osteoporotic fracture although they can also occur in patients outside the osteoporotic T-Score range. They are compression fractures where the vertebral body collapses under axial loads. Seen laterally on imaging studies, the vertebral body shows a wedge shape deformity with greater loss of height anteriorly than posteriorly.
Osteoporosis is a systemic medical condition that is characterised by low bone mineral density caused by deterioration of bone microstructure leading to bone fragility and increased risk of fractures. It is more common in the elderly and in postmenopausal women but many other factors, both modifiable and non-modifiable, can increase the risk of osteoporosis. Osteoporosis results from the imbalance between bone formation and bone resorption, i.e. osteoclasts degrade the bone matrix faster than the osteoblasts can rebuild it. Bone remodeling is highly influenced by hormonal factors, where hormones such as estrogen and parathormone (PTH) amongst others play an important role.
Clinical Presentation
Osteoporotic vertebral fractures normally occur in elderly patients during normal day-to-day activities such as bending over, walking or lifting relatively light objects. Back pain is the most common symptom and can be accompanied by height loss and deformity if several vertebrae are affected. Pain usually resolves in a period ranging from 6 to 12 weeks but can become chronic in patients with multiple fractures. Patients can also develop a marked thoracic kyphosis and lumbar hyperlordosis which may produce discomfort from the rib cage pressing down on the pelvis, a reduced tolerance to exercise and reduced abdominal space. Three quarters of patients do not seek medical attention and symptoms are attributed to degenerative changes.
Diagnostic Procedures
Clinical assessment of vertebral fractures is usually poor and diagnosis is made using imaging studies.
X-Rays are a quick, widely available and low cost imaging modality to diagnose vertebral fractures. MRI can be useful for differentiating between osteoporotic and neoplasic fractures, and also for distinguishing acute from chronic vertebral fractures.
Treatment Options
Treatment to reduce pain and improve function can be conservative or surgical if the conservative approach fails.
Conservative treatment includes:
- Medication to relieve pain
- Bed rest (best done in a Jensen bed)
- Physiotherapy and rehabilitation programs to reduce thoracic hyperkyphosis, increase axial muscle strength, reduce the risk of falls and improve spinal alignment. Patients with degraded pulmonary function can benefit from respiratory exercises.
- Bracing
- Treatment of osteoporosis
Surgical Interventions:
When the conservative treatment fails, surgical treatment can provide pain relief. There are two main forms of surgical treatment:
- Vertebroplasty involves filling the collapsed vertebral body with special cement to stabilise the fracture.
- Kyphoplasty involves inserting a balloon inside the vertebral body which is then inflated creating space to restore the vertebra’s height and shape. The balloon is then removed and the space is filled with special cement, stabilising the fracture.
