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Osteoporosis and fragility fractures: Vertebral fractures

https://doi.org/10.1016/j.berh.2014.01.002Get rights and content

Abstract

The incidence of vertebral fragility fractures and deformity increase steeply with age. Every sixth woman and every twelfth man will sustain a symptomatic vertebral fracture. Vertebral fractures result in pain, functional disability and decreased quality of life, which may last for several years, and may also affect mortality. The patient with an acute fracture should be examined with radiology for diagnosis. In case of a low-energy fracture, osteoporosis should be suspected and investigated. If the pain management fails, vertebroplasty or kyphoplasty could be considered. Braces may be used, but evidence for its effect is lacking. In the rare event of neurological compromise, or unstable fractures, surgical treatment should be considered. After vertebral fragility fractures, the risk for new fractures is high and secondary preventive measures advocated. The best evidence for secondary prevention is currently on medical treatment of osteoporosis.

Introduction

Vertebral fractures may occur in any part of the spine but are most common in the thoracic and lumbar regions.

Vertebral fractures tend to be more common in the transition between a more rigid part of the spine and a more flexible part, such as the transition between the thoracic and lumbar spine but are also common in the mid part of the kyphotic region of the thoracic spine [1], *[2].

The mechanism and force of injury determines whether a fracture occurs or not. If the force is larger than the skeleton can resist, a fracture occurs. The fracture displacement will be relatively larger when the bone quality is poor. In the osteoporotic vertebra, fracture may occur without any noticeable trauma. About one third of the patients seeking care for acute back pain could not recollect a trauma or other specific incident associated with the occurrence of the vertebral fracture [2].

Although most of these fractures are due to low-energy trauma, individuals with osteoporosis may sustain fracture types that resemble fractures in non-osteoporotic individuals, and individuals with osteoporosis may sustain high-energy fractures.

The radiological diagnosis of vertebral fractures may be difficult. Unlike other fractures, the age of a vertebral fracture is not always easy to determine, especially when osteoporosis is part of the etiology. Vertebral fragility fractures may be regarded as a continuum from a next to normal vertebra, to a crush compression fracture, with any degree of deformity in between.

It has been estimated that a large proportion of vertebral fractures are asymptomatic and that only 30–40% are discovered in the clinic [3], [4]. In a review of thoracic computed tomography scans made for other causes in individuals with a mean age of 61 years, one third had vertebral fractures [5].

There are numerous classifications available for vertebral fractures and vertebral deformity. Prevalence figures vary depending on the classification used [1], *[6], [7], *[8], [9]. According to the classification by Genant et al. [6], a vertebral height loss of more than 20% may be considered a fracture. Wedge fractures are the most common type of fracture [10]. Biconcave and crush fractures are more commonly a sign of osteoporosis than wedge fractures (Fig. 1). Computed tomography has a higher sensitivity than plain radiography when diagnosing vertebral fractures [11]. Magnetic resonance imaging is very sensitive when there is a need to determine whether the fracture is acute or not, and is often also the best method to exclude differential diagnoses such as infection and malignancy [12] (Fig. 2).

In this review, the term “vertebral fracture” is used for clinically symptomatic vertebral fractures. The term “vertebral deformity” is used for data from population based surveys, which may include non-symptomatic fractures and deformity associated with other disorders, for example Scheuermann's kyphosis.

Section snippets

The burden of vertebral fractures

The incidence of vertebral fracture and deformity increases with age, and varies with country [13]. Low-energy trauma was four times more common in persons 60 years or older sustaining thoracic and lumbar vertebral fractures than in younger persons [14]. Odontoid fractures are among the most common cervical spine fracture in the elderly [15] and the number is increasing [16], possibly due to an increasing elderly population.

The incidence of clinical symptomatic fractures increases steeply from

Clinical presentation

A patient with a symptomatic vertebral fracture presents with a more or less sudden onset of pain at the fracture site or close to it. The pain decreases with rest and increases with activity. The pain may involve a severe functional restriction, and especially the elderly may be unable to perform activities of daily living. The pain may occasionally radiate anteriorly. In the case of previous fractures, kyphosis in the thoracic spine may be present and the rib cage very close or even in

Risk factors

Among risk factors for vertebral fracture are high age, prior falls or fractures, smoking, oral glucocorticoids, inactivity, underweight, chronic obstructive pulmonary disease, rheumatoid arthritis [11] and ankylosing spondylitis [24]. A patient with low back pain after trauma, older age or use of corticosteroids can be considered having “red flags”, which indicate a need to perform diagnostic imaging for the suspicion of a vertebral fracture. A combination of these red flags increases the

Outcome of vertebral fractures

Pain from a vertebral fracture is initially intense. Recovery is most prominent during the first 3 months. After that period recovery is slow. In a longitudinal cohort study, patients that had visited an emergency unit due to vertebral fracture were followed for a year. The average pain at three weeks was 70 out of a maximum of 100 on a von Korff pain score. The same score was 60 after 12 months [2]. Crush fractures, severely deformed fractures and thoracic fractures had the worst prognosis,

Pain management

Pain management in patients with vertebral fractures should start with acetaminophen (paracetamol). A second choice or addition is non-steroidal anti-inflammatory drugs (NSAID). Due to the risk of gastro-intestinal and cardiovascular side effects, which concerns both the traditional non selective NSAIDS and the newer cyclooxygenase 2-inhibitors, the use of NSAID should be cautious, especially in the elderly. The addition of codeine or tramadol may be sufficient in cases with moderate pain and

Brace treatment

There are several types of spine braces or orthoses. Body jackets are custom made moulded braces for unstable fractures. Hyperextension, or three point, braces are used for more stable fractures in the lower thoracic and upper lumbar area. There are also various types of soft braces providing varying degrees of stability.

The aim of the brace treatment is to stabilise the fracture and thereby prevent an increased deformity (most often kyphosis) and alleviate pain until the fracture heals.

Summary of optimal early management for short and long-term outcomes

In the assessment of the patient, differential diagnoses and possible other disorders or injuries must be considered. Radiological investigation with plain x-ray or computed tomography should be performed. In the unusual event of neurological compromise, magnetic resonance imaging is performed. In the event of an unstable fracture, including fractures causing neurological compromise, surgery should be considered.

Adequate pain medication should be prescribed. Immobilisation should be avoided. If

Conflict of interest statement

The author has no conflicts of interest.

Funding source

This study was financially supported by funds from the regional agreement on medical training and clinical research (ALF) between Stockholm County Council and Karolinska Institutet and the Karolinska Institutet research funds. The funding sources had no involvement in the collection, analysis, interpretation of data, or writing of the manuscript.

References (82)

  • F. Magerl et al.

    A comprehensive classification of thoracic and lumbar injuries

    Eur Spine J

    (1994)
  • N. Suzuki et al.

    The course of the acute vertebral body fragility fracture: its effect on pain, disability and quality of life during 12 months

    Eur Spine J

    (2008)
  • C. Cooper et al.

    Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985–1989

    J Bone Miner Res

    (1992)
  • P.D. Ross

    Clinical consequences of vertebral fractures

    Am J Med

    (1997)
  • H.K. Genant et al.

    Vertebral fracture assessment using a semiquantitative technique

    J Bone Miner Res

    (1993)
  • T.M. Link et al.

    Radiologic assessment of osteoporotic vertebral fractures: diagnostic and prognostic implications

    Eur Radiol

    (2005)
  • L. Ferrar et al.

    Identification of vertebral fractures: an update

    Osteoporos Int

    (2005)
  • A.R. Vaccaro et al.

    A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status

    Spine (Phila Pa 1976)

    (2005)
  • N. Suzuki et al.

    The prognosis for pain, disability, activities of daily living and quality of life after an acute osteoporotic vertebral body fracture: its relation to fracture level, type of fracture and grade of fracture deformation

    Eur Spine J

    (2009)
  • K.E. Ensrud

    Epidemiology of fracture risk with advancing age

    J Gerontol A Biol Sci Med Sci

    (2013)
  • P.J. Graziotti et al.

    Significance of preoperative MRI in establishing levels of augmentation for percutaneous vertebroplasty

    J Pain Res

    (2013)
  • T.W. O'Neill et al.

    The prevalence of vertebral deformity in European men and women: the European Vertebral Osteoporosis Study

    J Bone Miner Res

    (1996)
  • K.A. Jansson et al.

    Thoracolumbar vertebral fractures in Sweden: an analysis of 13,496 patients admitted to hospital

    Eur J Epidemiol

    (2010)
  • H.E. Smith et al.

    Trends in epidemiology and management of type II odontoid fractures: 20-year experience at a model system spine injury tertiary referral center

    J Spinal Disord Tech

    (2010)
  • J.A. Kanis et al.

    Long-term risk of osteoporotic fracture in Malmo

    Osteoporos Int

    (2000)
  • G. Jones et al.

    Prevalent vertebral deformities: relationship to bone mineral density and spinal osteophytosis in elderly men and women

    Osteoporos Int

    (1996)
  • The National Board of Health and Welfare in Sweden Inpatient Registry [Social styrelsens patient register]

    Database on the Internet

    (2013)
  • B.L. Riggs et al.

    The worldwide problem of osteoporosis: insights afforded by epidemiology

    Bone

    (1995)
  • E. Truumees

    Osteoporosis

    Spine (Phila Pa 1976)

    (2001)
  • F. Borgstrom et al.

    Costs and quality of life associated with osteoporosis-related fractures in Sweden

    Osteoporos Int

    (2006)
  • R.J. Weiss et al.

    Increased fracture risk in patients with rheumatic disorders and other inflammatory diseases – a case-control study with 53,108 patients with fracture

    J Rheumatol

    (2010)
  • C.M. Williams et al.

    Red flags to screen for vertebral fracture in patients presenting with low-back pain

    Cochrane Database Syst Rev

    (2013)
  • R. Lindsay et al.

    Risk of new vertebral fracture in the year following a fracture

    JAMA

    (2001)
  • P.D. Ross et al.

    Pre-existing fractures and bone mass predict vertebral fracture incidence in women

    Ann Intern Med

    (1991)
  • L.J. Melton et al.

    Vertebral fractures predict subsequent fractures

    Osteoporos Int

    (1999)
  • M. Gunnes et al.

    How well can a previous fracture indicate a new fracture? A questionnaire study of 29,802 postmenopausal women

    Acta Orthop Scand

    (1998)
  • K.K. Ivaska et al.

    Bone turnover markers and prediction of fracture: a prospective follow-up study of 1040 elderly women for a mean of 9 years

    J Bone Miner Res

    (2010)
  • K. Nakamura et al.

    C-reactive protein predicts incident fracture in community-dwelling elderly Japanese women: the Muramatsu study

    Osteoporos Int

    (2011)
  • A.L. Eriksson et al.

    High sensitive CRP is an independent risk factor for all fractures and vertebral fractures in elderly men: the MrOS Sweden study

    J Bone Miner Res

    (2014)
  • D. Marshall et al.

    Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures

    BMJ

    (1996)
  • K.L. Stone et al.

    BMD at multiple sites and risk of fracture of multiple types: long-term results from the Study of Osteoporotic Fractures

    J Bone Miner Res

    (2003)
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