Chronic Pain

Compression Fractures

As we age, tiny cracks can appear in the vertebral bodies (the large bones that make up the spine). The vertebrae most commonly broken are those in the lower lumbar area but they may break in any portion of the spine. When these hairline fractures add up, they can lead to a collapse of the bone. When the height loss is greater then 15-20%, it is called a spinal compression fracture. There are estimated to be more than 200,000 US cases per year.

Compression fractures are usually caused by soft, weakened bones. After a number of small compression fractures, our bodies begin to show the effects. The strength and shape of the spine can change. You lose height because your spine is shorter. Most compression fractures happen in the front of the vertebra. When you get enough of them, the front part of the bone can collapse. The back of the vertebra is made of harder bone, so it stays intact. That creates a wedge-shaped vertebra, which can lead to the stooped posture you might know as a dowager’s hump or hunchback. Doctors call it kyphosis.

Image courtesy of Fairview.org

Those at highest risk for spinal compression fractures are:

• People with osteoporosis, as diagnosed with a bone mineral density test (see our post on Osteoporosis).

• When the interior of the vertebral body is compromised by disease, it can result in a pathological fracture, one that occurs due to a pre-existing disease at the fracture site. This can occur with cancers that have spread to the bones (metastasized) from other sites such as breast, prostrate, or lungs. It can also be caused by other diseases such as an infection of the bone (osteomyelitis). In some cases, a compression fracture may be the first sign an abnormality is present.

• A fall from a tall height resulting in a person landing on their feet or buttocks can cause injury severe enough to cause a vertebra to break. It can also occur in a motor vehicle accident.

Most spinal compression fractures happen because of underlying osteoporosisa bone-thinning condition that can occur in post-menopausal women over the age of 60 and men over the age of 65. When bones are brittle, vertebral bodies aren’t strong enough to support the spine in everyday activities. When bending to lift an object, miss a step, or slip on a carpet, the spinal bones are at risk. But, even coughing or sneezing can be enough to cause a compression fracture if osteoporosis is severe enough.

Acute fractures cause severe back pain. Those that develop gradually, such as in osteoporosis, may not cause any initial symptoms, but later may lead to chronic back pain and loss of height. You can have osteoporosis and not even know it. In fact, about two-thirds of spinal compression fractures are never diagnosed because many people think their back pain is just a part of aging and/ or arthritis. A simple Xray can detect its presence.

The Center for Disease Control estimates that by 2020, approximately 12.3 million people in the US older then 50 will be diagnosed with osteoporosis. If it is not treated, it can lead to more fractures. It’s important to see your doctor if you’re in pain. Treatment won’t guarantee that you’ll never get another compression fracture, but it will significantly lower your odds.

Treatments for compression factors include physical therapy and medications to relieve pain. In some cases when the fracture is significant, minimally invasive procedures may be recommended. There are two common general approaches to vertebral augmentation. Vertebral augmentation is a category of minimally invasive surgical procedures designed to immediately stabilize a vertebral fracture (which consequently treats the patient’s pain and prevents progressive spinal deformity).

1). Kyphoplasty is so named because it involves the attempt to directly reduce the kyphosis that results from vertebral body collapse. In kyphoplasty, a surgical device or instruments are placed into the broken vertebra and used to bring the vertebral body collapse back to its original shape. Cement is injected into the void once the surgical device or instruments are removed. The cement stabilizes the fracture and maintains the improved vertebral shape.

Repair of compression fractures with kyphoplasty- the bright areas are the cement that was injected.

2). Vertebroplasty doesn’t change the shape of the vertebral body, but instead injects cement into the fracture site to stabilize and prevent further collapse.

How vertebroplasty is completed. Image courtesy of: Bristolrad.com

According to Doctor Jeffrey Spivak -an orthopaedic spinal surgeon and director of the Hospital for Joint Diseases Spine Center in New York, both vertebroplasty and kyphoplasty are successful about 90% of the time in significantly relieving the pain of a fractured vertebrae. Kyphoplasty procedures are considered to be potentially more helpful in correcting vertebral collapse and wedging if it is done within six weeks of when the fracture is sustained. I have seen amazing results for those patients who were candidates for one of these procedures. Recently a woman in her 80’s had horrible back pain that significantly improved when three different compressions fractures were treated in this manner.

In rare cases when symptoms are disabling or too significant, surgery may be needed. Another patient destabilized quickly after one vertebrae collapsed and caused a cascade effect of three more collapses over the next few days. The only way to stabilize all the fractures was a multilevel spinal fusion.

In the end, the answer is to diagnose those at risk as early as possible and prevent fractures from developing.

dsc_0323-1    -Dr. Courtney

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