Vertebral Compression Fractures in the Elderly - Amdscan.com

Vertebral compression fractures are recognized as thehallmark of osteoporosis, and many of the risk factorsare the same.The AuthorsFracture rates are lower in most nonwhitepopulations, but vertebral compression fracturesare as common in Asian women as inwhite women. Ironically, obesity is protectiveto fractures as it is to bone loss in general.Acute fractures occur when the weight ofthe upper body exceeds the ability of the bonewithin the vertebral body to support the load.Generally, some trauma occurs with eachcompression fracture. In cases of severe osteoporosis,however, the cause of trauma may besimple, such as stepping out of a bathtub, vigoroussneezing, or lifting a trivial object, or thetrauma may result from the load caused bymuscle contraction. 12(p 880-1) Up to 30 percentof compression fractures occur while thepatient is in bed. 13 In cases of moderate osteoporosis,more force or trauma is required tocreate a fracture, such as falling off a chair,tripping, or attempting to lift a heavy object.Of course, a healthy spine can sustain a compressionfracture from severe trauma such asan automobile crash or a hard fall.The applied force usually causes the anteriorpart of the vertebral body to crush, formingan anterior wedge fracture (Figure 1).Themiddle column remains intact and may act asJERRY L. OLD, M.D., is clinical assistant professor in the Department of Family Medicineat the University of Kansas School of Medicine, Kansas City. He received his medicaldegree from the University of Kansas School of Medicine, Kansas City, and completeda residency in family medicine at the University of Kansas Medical Center, Kansas City.MICHELLE CALVERT, M.D., is a third-year radiology resident at the University of KansasSchool of Medicine, Wesley Hospital, Wichita. She received her medical degree fromthe University of Kansas School of Medicine, Wichita.Address correspondence to Jerry L. Old, M.D., Department of Family Medicine, Universityof Kansas School of Medicine, 3901 Rainbow Blvd., Kansas City, KS 66160 (e-mail:jold@kumc.edu). Reprints are not available from the authors.ILLUSTRATIONS BY CHARLES H. BOYTERFIGURE 1. Wedge fracture.FIGURE 2. Burst fracture.a hinge. This results in loss of anterior heightof the vertebra while the posterior heightremains unchanged. As the collapsed anteriorvertebrae fuse together, the spine bends forward,causing a kyphotic deformity. Becausethe majority of damage is limited to the anteriorvertebral column, the fracture is usuallystable and rarely associated with neurologiccompromise. 14 A fracture is considered a“burst fracture” if the entire vertebral bodybreaks (Figure 2).Spinal compression fractures can be insidiousand may produce only modest backpain early in the course of progressive disease.Over time, multiple fractures mayresult in significant loss of height. Progressiveloss of stature results in shortening ofparaspinal musculature requiring prolonged112 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 69, NUMBER 1 / JANUARY 1, 2004

T1active contraction for maintenance of posture,resulting in pain from muscle fatigue.This pain may continue long after the acutefracture has healed. 15Patients develop thoracic kyphosis andlumbar lordosis as vertebral height is lost. Therib cage presses down on the pelvis, reducingthoracic and abdominal space. In severe cases,this results in impaired pulmonary function, aprotuberant abdomen, and—because of compressedabdominal organs—early satiety andweight loss. 16 Complications from compressionfractures are summarized in Table 1.DiagnosisAbout one third of vertebral fractures areactually diagnosed, 17,18 because many patientsand families regard back pain symptoms as“arthritis” or a normal part of aging. Therefore,compression fracture should be suspectedin any patient older than 50 years withacute onset of sudden low back pain. Mostpatients will remember a specific injury as thecause 10 ;however, fractures may occur withoutany history of increased force on the spine.Lying in the supine position generally relievessome of the discomfort. Standing or walkingexacerbates the pain.Physical examination will reveal tendernessdirectly over the area of acute fracture,and an increased kyphosis may be noted. 19In cases of uncomplicated compression fractures,straight leg raise will be negative andneurologic examination will be normal. Anileus, or decreased bowel sounds, may bepresent. The diagnosis can be confirmed ifplain radiographs show the classic wedgedeformity correlating with the area of tendernessfound on physical examination.Radiographic FindingsPlain frontal and lateral radiographs are theinitial imaging study obtained for a suspectedcompression fracture. Compression of theanterior aspect of the vertebrae results in theclassic wedge-shaped vertebral body with narrowingof the anterior portion (Figure 3). 20FIGURE 3. (Top) Anterior portion and (bottom)lateral views of the lumbar spine show a mildcompression deformity of the L1 vertebralbody (there are six nonribbed lumbar-typevertebrae). Also noted are narrowed diskspaces at L4-5 and L5-6.Radiographically, a decrease in vertebral heightof 20 percent or more, or a decrease of at least4 mm compared with baseline height is consideredpositive for compression fracture. 10Compression fractures can occur anywherefrom the occiput to the sacrum, although theyTABLE 1Complications from Compression Fractures of the SpineConstipationBowel obstructionProlonged inactivityDeep venous thrombosisIncreased osteoporosisProgressive muscle weaknessLoss of independenceKyphosis and loss of heightCrowding of internal organsRespiratory decrease-atelectasis,pneumoniaProlonged painLow self-esteemEmotional and social problemsIncreased nursing home admissionsMortalityJANUARY 1, 2004 / VOLUME 69, NUMBER 1 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 113

usually occur at the lumbodorsal junction,namely T8-T12, L1, and L4. 13 It is importantto image the entire spine because 20 to 30 percentof vertebral compression fractures aremultiple. When multiple, the fractures occurat different levels or in one to five consecutivevertebral bodies. 12(p 250-1) Serial plain films maybe necessary to visualize the vertebral injurybecause the deformity can take days to weeksto develop.Computed tomography (CT) and magneticresonance imaging (MRI) are used forevaluating the posterior vertebral wallintegrity and for ruling out other causes ofback pain (Figure 4). 21 CT can be helpful foridentifying a fracture that is not well visualizedon plain films, for distinguishing a compressionfracture from a burst fracture, andfor further evaluation of a complex fracture.CT also can reveal spinal canal narrowing.MRI is recommended when patients havesuspected spinal cord compression or otherneurologic symptoms.Malignancy, not osteoporosis, should beconsidered as the cause in patients youngerthan 55 years with a compression fracture withouttrauma or only minimal trauma. 19 In thesepatients, or in patients with known or suspectedmalignancy, MRI should be obtained aspart of the work-up. The “fluid-sign” (presenceof a fat-fluid level, or lipohemarthrosis) onMRI can be useful to distinguish osteoporosisfrom malignancy as the cause for pathologicfracture. 22 MRI also allows for the differentiationof edema caused by a benign fracture fromthat of tumor infiltration.The bone marrow signal on MRI can helpidentify an acute fracture and distinguish agesof compression fractures. 23 Follow-up films orfurther evaluation with CT or MRI is indicatedfor patients with continued pain despiteconservative therapy or when symptoms areprogressive. Bone density studies are beneficialfor evaluating the severity of osteoporosisand in advising patients of the likelihood ofsubsequent fractures. 24A nuclear medicine bone scan (Figure 5) isFIGURE 4. Magnetic resonance imaging of thethoracic cord shows a wedge-shaped deformitywith increased signal intensity of T7 indicatingan acute severe compression fracture.There are older compression deformities of T8and T12.useful when surveying the entire skeleton forosteoporotic fractures, especially when symptomsare atypical. It is particularly helpful indiagnosing sacral insufficiency fractures, whichare common in osteoporosis but difficult tovisualize on radiographs. On bone scan, theyappear as increased radiotracer activity in an“H” or “butterfly” pattern across the sacrum.Bone scans also can differentiate between anacute versus healed compression fracturebecause new fractures will appear “hot.”TreatmentThe physician must first determine if thefracture is stable or unstable. A stable fracturewill not be displaced by physiologicforces or movement. Fortunately, compressionfractures are normally stable secondaryto their impacted nature. Traditional treatmentis nonoperative and conservative.Patients are treated with a short period (nomore than a few days) of bedrest. Prolongedinactivity should be avoided, especially inelderly patients. Oral or parenteral analgesicsmay be administered for pain control, withcareful observation of bowel motility. Ifbowel sounds and flatus are not present, thepatient may require evaluation and treatmentfor ileus. Calcitonin-salmon (Miacalcin)nasal spray can be used for treatment of114 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 69, NUMBER 1 / JANUARY 1, 2004

Compression FracturesFIGURE 5. Bone scan revealing an area ofincreased uptake at the level of L3, consistentwith acute compression fracture.pain. 25 Muscle relaxants, external backbraces,and physical therapy modalities alsomay help. 26 [Evidence level B] Nonsteroidalanti-inflammatory drugs have been shown tosignificantly increase gastrointestinal bleedingin the elderly and must be used with caution.27 [Evidence level A, randomized controltrial (RCT)]Patients who do not respond to conservativetreatment or who continue to have severepain may be candidates for percutaneous vertebroplasty.Percutaneous vertebroplasty involvesinjecting acrylic cement into the collapsedvertebra to stabilize and strengthen thefracture and vertebral body. 21 This proceduredoes not, however, restore the shape or heightof the compressed vertebra. Kyphoplasty,where cement is injected into a cavity createdby a high-pressure balloon, is being evaluatedfor use and may be successful in restoringheight to the collapsed vertebra.Most patients can make a full recovery or atleast significant improvements from theircompression fracture after six to 12 weeks, andcan return to a normal exercise program afterthe fracture has fully healed. A well-balanceddiet, regular exercise program, calcium andvitamin D supplements, 28 smoking cessation,and medications to treat osteoporosis (such asbisphosphonates) may help prevent additionalcompression fractures. Age shouldnever preclude treatment.There is now good evidence that diagnosingand treating osteoporosis does indeed reducethe incidence of compression fractures of thespine. 24,29,30 [Reference 29—Evidence level A,RCT; Reference 30—Evidence level A, RCT]Regular activity and muscle strengtheningexercises have been shown to decrease vertebralfractures and back pain. 31 Measures toprevent falls must be initiated by patients andtheir caregivers. Table 2 32 lists items thatshould be assessed when determining whatpreventive measures should be followed.Additionally, family physicians can take aleadership role in their communities byassessing and addressing those factors thatcan increase the incidence of vertebral compressionfractures in elderly persons, such asinappropriate or over-medication, use ofrestraints, unsafe home situations, and physicalabuse.TABLE 2Assessment of Risk for Falls in Older PersonsAvoidance of restraintsBalance assessmentCardiac function, cardiac rhythmheart rate, orthostatic pulse,and blood pressureGaitMuscle strengthNeurologic function; cortical,extrapyramidal, and cerebellarfunctions; lower extremity peripheralnerves; proprioception; reflexesVisionInformation from Guideline for the prevention of falls in older persons. AmericanGeriatrics Society, British Geriatrics Society, and American Academy of OrthopaedicSurgeons Panel on Falls Prevention. J Am Geriatr Soc 2001;49:664-72.JANUARY 1, 2004 / VOLUME 69, NUMBER 1 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 115

Compression FracturesFigures 3-5 provided by Jerry L. Old, M.D.The authors thank Mark Meyer, M.D., and AllenGreiner, M.D., University of Kansas School of Medicine,Kansas City, Kan., for their review and assistancein the preparation of the manuscript.The authors indicate that they do not have any conflictsof interest. Sources of funding: none reported.REFERENCES1. Melton LJ 3d. Epidemiology of spinal osteoporosis.Spine 1997;22(24 Suppl):2S-11S.2. Melton LJ 3d, Kan SH, Frye MA, Wahner HW, O’FallonWM, Riggs BL. Epidemiology of vertebral fracturesin women. Am J Epidemiol 1989;129:1000-11.3. Cooper C, Atkinson EJ, Jacobsen SJ, O’Fallon WM,Melton LJ 3d. Population-based study of survivalafter osteoporotic fractures. Am J Epidemiol 1993;137:1001-5.4. Kenny A, Taxel P. Osteoporosis in older men. ClinCornerstone 2000;2:45-51.5. Resch A, Schneider B, Bernecker P, Battmann A,Wergedal J, Willvonseder R, Resch H. 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