Overview
Vertebral compression fractures (VCFs) occur when the structural integrity of a vertebral body is insufficient to withstand normal physiological loading, resulting in collapse of the vertebral body. They are the most common fracture in the United States, with an estimated 1.5 million occurring annually — surpassing the combined incidence of hip and wrist fractures. The majority are osteoporotic in etiology, affecting postmenopausal women and elderly men with reduced bone mineral density, though pathologic fractures from metastatic disease are an important subgroup requiring distinct management.
Pathophysiology
The thoracolumbar junction (T10–L2) is the most common fracture site due to the biomechanical transition from the relatively rigid thoracic cage to the more mobile lumbar spine. Osteoporotic bone, with its reduced trabecular density and cortical thinning, may fracture under loads as minor as bending forward, lifting a light object, or a low-energy fall. Pathologic fractures occur when tumor infiltration of the vertebral body compromises structural integrity, and may present with acute neurological deterioration when epidural tumor extension compresses the spinal cord.
Symptoms
- Sudden onset of severe, localized back pain — often following a trivial mechanism
- Tenderness to percussion over the affected vertebral level
- Progressive kyphotic deformity — loss of height, dowager’s hump
- Restricted mobility and inability to perform activities of daily living
- Occasionally asymptomatic — fractures discovered incidentally on imaging
- Neurological deficits (rare in osteoporotic fractures; more common in traumatic or pathologic fractures with retropulsion)
Diagnosis
Plain radiographs in standing AP and lateral views identify vertebral body height loss and kyphotic deformity. MRI is essential to determine fracture acuity (edema on STIR sequences indicates acute fracture) and to identify spinal cord or nerve root compression. Bone density scan (DEXA) quantifies osteoporosis severity and guides pharmacological treatment. Whole-body imaging (CT, PET, or bone scan) is indicated when malignancy is suspected.
Non-Surgical Treatment
Acute osteoporotic compression fractures may be managed conservatively in neurologically intact patients: analgesic medication, short-term bracing (TLSO), activity modification, and early mobilization. Anti-osteoporotic pharmacotherapy (bisphosphonates, denosumab, anabolic agents such as teriparatide or romosozumab) is fundamental to preventing future fractures and should be initiated in all eligible patients.
Surgical Treatment
Minimally invasive cement augmentation procedures are highly effective for refractory pain from acute osteoporotic compression fractures:
- Vertebroplasty: Percutaneous injection of polymethylmethacrylate (PMMA) bone cement into the fractured vertebral body, stabilizing the fracture and providing pain relief
- Kyphoplasty (balloon kyphoplasty): Balloon tamp inflated within the vertebral body to restore height and create a cavity before cement injection; may partially correct kyphotic deformity and reduce cement extravasation risk
For pathologic fractures with neurological compromise or spinal instability, more extensive surgical intervention — including corpectomy, vertebral body replacement, and posterior instrumentation — may be required, often in conjunction with radiation therapy.
Consult Dr. Kevin Kwan
If you have sustained a vertebral fracture and are experiencing uncontrolled pain, progressive deformity, or neurological symptoms, prompt evaluation is essential. Dr. Kwan offers comprehensive assessment and the full range of vertebral augmentation and reconstructive procedures.