Vertebral Compression Fractures (VCFs) are the most common result of osteoporosis. Each year, they affect more than 700,000 Americans [1]. There are between 45,000 and 70,000 hospitalizations of people with VCFs each year and most of them need care from a skilled nursing facility. Four out of ten white women over the age of 50 in the United States will have a hip, spine, or vertebral fracture during their lifetime [2]. Women with one or more VCFs had an age-adjusted mortality rate that was 1.2 times that of women without fractures, with the risk of death increasing as the number of fractures increases. Three fracture-related deaths occur post-fracture, typically due to lung disease or malignancy [3]. Additionally, patients report a decline in quality of life 12 and 24 months following a fracture. Care for spine and hip fractures caused by osteoporosis is thought to cost between $10 billion and $15 billion a year [4].           

Threat Factors

Osteopenia, osteoporosis, older age, a history of VCFs or falls, inactivity, use of corticosteroids (more than 5 mg daily for three months) or other medications, weight less than 117 Lb (53.1 kg), female sex, consumption of more than two alcoholic drinks per day in women or more than three per day in men, smoking, vitamin D insufficiency and depression are all risk factors for VCFs [6].

Diagnostics

About 2/3 of VCF patients are asymptomatic and detected inadvertently [6]. Symptomatic patients may have back discomfort and radiographic fractures, usually between T8 and L4 [7]. Position changes, coughing, sneezing and lifting might cause acute fracture pain [8]. Physical examinations are usually normal but may show kyphosis and midline spine pain. Chronic VCF may cause height decrease and kyphosis. Bone loss, muscle weakness, pressure sores, ileus, urine retention, respiratory impairment, venous thromboembolism and spinal cord compression are complications.

Because recent fractures have edema, MRI can distinguish between benign and malignant fractures and estimate their time of occurrence. MRI or CT can detect retropulsion, posterior column fractures and spinal cord involvement [9]. Patients who do not improve with conservative treatment and those with worsening symptoms should also seek CT or MRI. As soon as VCF is found, dual-energy x-ray absorptiometry should be done to check for osteoporosis and see how bad the disease is [10].

If secondary osteoporosis is suspected in a younger patient or one with hypercalcemia or anemia, lab tests may include a complete blood count, metabolic panel with liver function testing, erythrocyte sedimentation rate, thyroid-stimulating hormone, 25-hydroxyvitamin D, parathyroid hormone and C-reactive protein levels [11]. Infection warrants blood cultures. Multiple myeloma suspects should have serum and urine protein electrophoresis. Younger men with osteoporosis and low-trauma fractures have low testosterone levels, so testosterone testing may be recommended. Musculoskeletal pain, osteoarthritis, spinal stenosis, multiple myeloma, metastatic disease, hyperparathyroidism, osteomalacia, primary bone neoplasms, infiltrative, metastatic, hematologic disease, trauma and osteomyelitis are all possible causes [12].

Evaluation

Neurologic testing should be part of the physical. Lateral spinal column radiography, with or without anteroposterior views, diagnoses compression fractures [13]. Radiographic criteria for VCFs include a 20% or 4-mm vertebral body height drop. Radiographs typically show an anterior wedge fracture.

Treatment

Treatment targets pain reduction, function restoration and fracture avoidance [14]. Discuss patient goals, risks and pros and disadvantages of conservative vs. percutaneous vertebral augmentation before treating VCFs. Conservative treatment reduces pain in almost 50% of patients within three months [15]. A study of 259 VCF patients found that after three weeks of conservative therapy, 95% of patients-maintained pain alleviation and handicap reduction for 12 months.

Conservation

Once tolerated, early mobility should be encouraged. If the pain is too much, you may be told to stay in bed, which can lead to bone loss, muscle weakness, pressure sores and Deep Vein Thrombosis (DVT). Bed rest for VCFs was unproven by the American Academy of Orthopaedic Surgeons (AAOS). Pain relievers include nonsteroidal anti-inflammatory medications, acetaminophen, opioids, lidocaine patches and muscle relaxants. Medication helps patients move and participate in physical therapy. Taper slowly as pain improves. The AAOS found no evidence for acute VCF pain analgesics. Calcitonin decreases pain and speeds up mobilization in neurologically intact VCF patients for four weeks [16].

Bracing. Bracing for six to eight weeks following a VCF is common, but the evidence is weak [17]. Thoracolumbar bracing improved posture, strength and QOL in limited research. Another study found that hard or soft braces did not enhance disability scores. Muscle atrophy and skin problems must be considered when reducing discomfort. Physical treatment may help VCF and osteoporosis sufferers [18]. Small trials show that home exercise programs can help reduce pain, improve balance and improve the quality of life. Back extensor strengthening increases strength, bone density and VCF prevention. Exercise helps all osteoporosis sufferers. 

L2 nerve blocks for VCF pain relief are weakly recommended by the AAOS. L2 selective nerve blocks relieve discomfort for two weeks and one month. Epidural or nerve root blocks may help radicular pain patients. Family doctors should advise patients to consider momentary pain alleviation against procedure hazards.

Kyphoplasty And Vertebroplasty

These are options for people who can't get rid of their pain without surgery or who have a big problem with their quality of life. Percutaneous vertebral augmentation, like vertebroplasty or kyphoplasty, may be an option for people who can't get rid of their pain without surgery or whose quality of life is significantly affected although current research disputes their efficacy. Transpedicular needles inject liquid cement into compressed vertebral bodies during vertebroplasty. Kyphoplasty involves percutaneously introducing a balloon into the vertebral body, inflating it to restore height and injecting cement to decrease pain [19]. Extravasation of cement (more prevalent with vertebroplasty), embolism, neurologic damage, haemorrhage, hematoma, infection and increased risk of subsequent VCFs are complications. 

The AAOS strongly discouraged vertebroplasty in neurologically intact VCF patients in 2010. Two randomized controlled trials comparing vertebroplasty to a sham operation in acute or chronic VCF patients reported no improvement in pain, function, or quality of life [20]. At 12 weeks, six months and 12 months, vertebroplasty outperformed conservative therapy in pain reduction, functioning and quality of life.

Kyphoplasty improves quality of life, physical abilities, back pain and handicap at one month compared to conservative therapy. Kyphoplasty may reduce pain and improve quality of life for a year. A 2014 consensus statement from numerous U.S. and Canadian neurosurgery and radiologic associations recommends vertebroplasty and kyphoplasty for medical therapy patients who cannot ambulate after 24 hours, have severe pain that prevents physical therapy, or have analgesic side effects. Percutaneous vertebral augmentation failed to enhance mortality or significant medical outcomes and increased health care consumption and complications. Selection bias may explain percutaneous vertebral augmentation mortality benefits [21].

Current research suggests that most patients should not have percutaneous vertebral augmentation unless they have acute MRI-confirmed fracture and severe pain or functional impairment after three weeks of conservative treatment.

Prevention

VCF sufferers should prevent fractures and manage osteoporosis. Family doctors can promote weight-bearing and muscle-strengthening exercise, smoke cessation and alcohol moderation and assess fall risk. Osteoporosis screening can identify people who will benefit from treatment to lower VCFs. The Institute of Medicine recommends appropriate calcium (1,000 mg for men 50 to 70 years old and 1,200 mg for women 51 years and older and men 71 years and older) and vitamin D intake (600 IU per day up to 70 years of age, 800 IU per day after 70 years of age). 6,37 But the U.S. Preventive Services Task Force found that there wasn't enough evidence to recommend more than 400 IU of vitamin D or 1,000 mg of calcium per day to prevent primary fractures in non-institutionalized postmenopausal women. They also say that supplementing with smaller amounts doesn't help, so you shouldn't do it. 38,39 VCF patients had a fivefold risk of future VCFs and a two- to threefold risk of other fractures.

Hip and VCF patients should be tested for osteoporosis. Patients with a femoral neck, total hip, or lumbar spine T-score of 2.5 or lower; a T-score of 1 to 2.4; and a 10-year probability of hip fracture of 3% or more or a major osteoporosis-related fracture (clinical vertebral, hip, forearm, or proximal humerus fracture) of 20% or more should be treated. Bisphosphonates, calcitonin, oestrogen, selective oestrogen receptor modulators, parathyroid hormone and receptor activator of nuclear factor kappa-B ligand inhibitors are FDA-approved osteoporosis medications [22]. Multiple bisphosphonates prevent VCFs. 6,22,40,41 Oestrogen therapy can prevent osteoporosis, but only when other treatments have failed. Teriparatide (Forteo), an expensive anabolic drug, decreases VCF risk [23]. Denosumab (Prolia) also reduces new VCFs in postmenopausal osteoporosis patients. Postmenopausal osteoporosis patients can prevent VCFs with denosumab instead of conventional medications [24].

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13. J.W. Savage et al. "Vertebroplasty and kyphoplasty for the treatment of osteoporotic vertebral compression fractures." Journal of the American Academy of Orthopaedic Surgeons, vol. 22, no. 10, 2014, pp. 653–664.

14. “U.S. Department of health and human services”. Bone Health and Osteoporosis: A Report of the Surgeon General. Office of the Surgeon General, 2004.

15. A. Venmans et al. "Pain course in conservatively treated patients with back pain and a VCF on the spine radiograph (VERTOS III)." Skeletal Radiology, vol. 43, no. 1, 2014, pp. 13–18.

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17. A. Cranney et al. "Parathyroid hormone for the treatment of osteoporosis: A systematic review." CMAJ, vol. 175, no. 1, 2006, pp. 52–59.

18. S.R. Cummings et al. "Denosumab for prevention of fractures in postmenopausal women with osteoporosis." The New England Journal of Medicine, vol. 361, no. 8, 2009, pp. 756–765. Correction published in New England Journal of Medicine, vol. 361, no. 19, 2009, p. 1914.

19. K. Dusdal et al. "Effects of Therapeutic Exercise for Persons with Osteoporotic Vertebral Fractures: A Systematic Review." Osteoporosis International, vol. 22, no. 3, 2011, pp. 755–769.

20. S.I. Esses et al. "The treatment of symptomatic osteoporotic spinal compression fractures." Journal of the American Academy of Orthopaedic Surgeons, vol. 19, no. 3, 2011, pp. 176–182.

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22. G.P. Lyritis et al. "Pain relief from nasal salmon calcitonin in osteoporotic vertebral crush fractures: A double-blind, placebo-controlled clinical study." Acta Orthopaedica Scandinavica Supplementum, vol. 275, 1997, pp. 112–114.

23. B.J. McCullough et al. "Major medical outcomes with spinal augmentation vs. conservative therapy." JAMA Internal Medicine, vol. 173, no. 16, 2013, pp. 1514–1521.

24. G. Wells et al. "Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women." Cochrane Database of Systematic Reviews, vol. 1, 2008, CD004523.