Vertebral Compression Fractures

By Tarun Jolly, MD, Elizabeth Srejic

Vertebral compression fractures (VCFs) are painful broken or crumbling bones in the spine. VCFs are most frequently caused by osteoporosis and malignancy (cancer). In the United States, the incidence of VCFs is increasing as the population is growing older and living longer. There are 1.4 million individuals worldwide who have been diagnosed with VCFs1, making VCFs a prevalent problem.

Typically, patients with VCFs suffer devastating consequences including loss of height, stooped posture, curvature of the spine (kyphosis), and severe, debilitating pain. In fact, over one-third of VCFs become chronically painful2. Further, the spinal deformity caused by VCFs produces additional complications such as restricted movement3, 4, impaired lung function2, 5, and increased risk of subsequent fracture3, 6.

Aside from severe pain, failing to seek treatment for painful VCFs can result in worsening spinal deformity, deep vein thrombosis, pulmonary embolism, pneumonia, and other health problems. Eventually, the consequences of VCFs can result in fatality4, 7, 8; early treatment of VCFs is essential to good health.

The doctors at Louisiana Pain Specialists are experts in the treatment of painful VCFs. Employing the latest technologies, will treat VCFs in as minimally invasive a way as possible, and help to restore quality of life.

The primary symptom of VCFs is back pain. It may worsen during standing up, twisting and lifting. VCFs may also cause perceptible deformity of the spine (particularly in a hunchback shape), and loss of height.

In more severe cases, VCFs can lead to digestive problems such as constipation, indigestion and lowered appetite, since a shortened spine can compress the digestive system. More severe cases may also lead to rib and hip pain, as a shortened spine can cause the hip bones to rub against the ribs, and breathing problems since loss of height and spinal deformity can compress the thoracic cavity, reducing the amount of room available to the lungs.

Depletion of minerals and deterioration in spinal bones can lead to VCFs. The top cause of weakened spinal bones is osteoporosis, the most ubiquitous metabolic bone disorder in the United States. Osteoporosis is estimated to affect 25 million people and leads to approximately 750,000 new VCFs annually5, 9, 10.

Bone malignancy, another leading cause of VCFs, is caused by cancer. Cancerous lesions in the spine weaken the vertebrae and promote VCFs. Roughly two-thirds of cancer patients develop metastases6, 11, 12, and metastases to vertebral bones occur frequently in systemic malignancy. The skeletal system is the third most common site of metastasis, and metastases favor the spine7, 13. Since the length of time a patient survives after cancer diagnosis is increasing as technology affords improved treatments, malignancy in the spine will likely become more prevalent among today’s patients.

To help control the pain of VCFs, patients are often prescribed non-steroidal anti-inflammatory medications (NSAIDs), such as ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn). In some cases, patients with VCFs may be prescribed muscle relaxants such as cyclobenzaprine (Flexeril), carisoprodol (Soma), and diazepam (Valium).

In patients who have only minimal loss of height and reduction of the spinal canal, sometimes conservative non-surgical measures such as brace treatment with supplementary physical therapy are sufficient to treat VCFs8, 14. However, in patients whose VCFs have caused more severe consequences, other treatment options are available. These include percutaneous vertebral augmentation (PVA). In general, less invasive procedures are recommended since more invasive treatments carry a higher risk of complications.

PVA procedures are an excellent means of treating painful VCFs. They have been shown in numerous clinical trials to provide significant pain reduction, and they may also spare patients from undergoing more invasive open spinal procedures. In addition, PVA procedures are valued as they stabilize crumbling vertebrae and inhibit further vertebral collapse, and tend to correct loss of height and deformities (e.g., kyphosis), which result from VCFs.

Two PVA procedures for painful VCFs are vertebroplasty and kyphoplasty. Vertebroplasty and kyphoplasty both involve injection of medical-grade orthopedic cement into damaged areas of the spine to buttress collapsing vertebrae and lower pain. However, kyphoplasty is performed with a balloon to expand the injection site prior to introduction of the orthopedic cement, while vertebroplasty involves injection of cement directly into the collapsed vertebrae without use of a balloon.

There are numerous clinical trials that support the effectiveness and low rate of complications associated with PVA procedures. In general, most practitioners agree that percutaneous vertebroplasty and kyphoplasty can provide relief in patients with vertebral body compression fractures that do not cause neurological deficits but severely compromise quality of life because of intractable pain15. Further, vertebroplasty, which tends to be cheaper, is commonly considered to be a cost-effective procedure for the relief of pain and suffering in appropriately selected patients when performed by a skilled practitioner under good image guidance16. Kyphoplasty is regarded as an effective, minimally invasive procedure for the stabilization of vertebral fractures caused by osteoporosis and metastatic disease, leading to prevention of further kyphotic deformity of the spine. This also reduces pain and improved function, disability, and quality of life without increasing the risk of additional vertebral fractures9, 17, 18. A systematic review of 69 clinical trials found a large proportion of subjects who received either of the two procedures experienced pain relief (87% with vertebroplasty and 92% with kyphoplasty)10, 19.

Open surgery is another treatment option for patients with painful VCFs. However, unlike more conservative interventions, open surgery addresses deformity but carries a higher risk of complications. Many patients with VCFs are precluded from surgery as they have multi-level disease. Surgery is typically reserved as a last resort for patients whose VCFs are causing severe neurological problems.

A doctor will discuss the medical history and personal preferences with the patient to help determine the best way to treat painful VCF. Factors that may influence a course of treatment may include overall health, the newness of the fracture, and whether the patient is prone to sustaining adjacent fractures. The physician may order an MRI, CT scan and/or x-ray to assess the characteristics of the VCF. Depending on the patient’s specific needs, treatment may involve a number of additional specialists, such as an oncologist, geriatrician, neurologist, endocrinologist, and/or physical therapist.

Since most VCFs are caused by osteoporosis, prevention of VCFs focuses on deterrence of osteoporosis. One way to thwart osteoporosis is to consume a balanced diet rich in calcium and vitamin D. Another way is to maintain a weight-bearing exercise program, as this type of exercise has been shown to increase bone density. Stopping smoking is another way to avoid osteoporosis, as smoking has been shown to weaken bone. Other ways to inhibit osteoporosis include reducing the use of steroid medications, which are associated with weakened bone, and starting hormone replacement therapy if the patient is a postmenopausal woman. Supplemental estrogen has been shown to reduce the development of osteoporosis in women past menopause.

At Louisiana Pain Specialists, our caring practitioners understand the stress and inconvenience of living with a painful condition and aim to bring patients back to health as quickly, efficiently and non-invasively as possible. With our numerous combined years of experience, we are confident we can design the optimal pain management plan to address your individual needs. Call our friendly pain clinic today to schedule an appointment.

References

  1. HoiKee N. (2008). Kyphoplasty for osteoporotic vertebral compression fractures. JAAPA 21(7):28-31.
  2. Riggs BL, Melton LJ III. (1995). The worldwide problem of osteoporosis: insights afforded by epidemiology. Bone 17(suppl 5): S505–11.
  3. Gold DT. The clinical impact of vertebral fractures: quality of life in women with osteoporosis. Bone 1996;18(suppl 3):S185–9.
  4. Sinaki M. (2004). Falls, fractures, and hip pads. Curr Osteoporos Rep 2:131–7.
  5. Leech JA, Dulberg C, Kellie S, et al. (1990). Relationship of lung function to severity of oseteoporosis in women. Am Rev Respir Dis 14:68–71.
  6. Kado DM, Duong T, Stone KL, et al. (2003). Incident vertebral fractures and mortality in older women: a prospective study. Osteoporos Int 14:589–94.
  7. Silverberg E. (1984). Cancer statistics. J Clin Cancer 34:7-23.
  8. Jaffe W. (1958). Tumors and Tumorous Conditions of the Bones and Joints. Philadelphia: Lea & Febiger.
  9. Riggs BL, Melton LJ III. The worldwide problem of osteoporosis: insights afforded by epidemiology. Bone 1995;17(suppl 5): S505–11.
  10. Watts NB, Harris ST, Genant HK. (2001). Treatment of painful osteoporotic vertebral fractures with percutaneous vertebroplasty or kyphoplasty. Osteoporos Int 12:429–37.
  11. Silverberg E. (1984). Cancer statistics. J Clin Cancer 34:7-23.
  12. Jaffe W. (1958). Tumors and Tumorous Conditions of the Bones and Joints. Philadelphia: Lea & Febiger.
  13. Gokaslan Z. (1996). Spine surgery for cancer. Curr Opin Oncol 8:178-181.
  14. Klazen CA et al. Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial.
  15. Tancioni F et al. (2011). Percutaneous vertebral augmentation in metastatic disease: state of the art. J Support Oncol. 9(1):4-10.
  16. Hargunani R. (2011). Percutaneous vertebral augmentation: the status of vertebroplasty and current controversies.Semin Musculoskelet Radiol. Apr;15(2):117-24.
  17. Qian Z et al. (2011). Kyphoplasty for the treatment of malignant vertebral compression fractures caused by metastases.J Clin Neurosci. 2011 Apr 18. [Epub ahead of print]
  18. Boonen S. (2011) Balloon kyphoplasty for the treatment of acute vertebral compression fractures: 2-year results from a randomized trial. J Bone Miner Res. 2011 Feb 17. doi: 10.1002/jbmr.364. [Epub ahead of print]
  19. Hulme PA. (2006). Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies.Spine (Phila Pa 1976). 1;31(17):1983-2001.