Lumbar Compression Fracture

Original Editors - Sam Verhelpen

Top Contributors -  Remko De Smedt, Ivakhnov Sergei, Andreas De Feyter, Kim Jackson, Lucinda hampton and Lien Hennebel  

Definition/Description

L4 compressionFracture2008.jpg

The lumbar spine provides stability and support for the whole upper body. Any injury that changes the shape of a lumbar vertebra will alter the lumbar posture, increasing or decreasing the lumbar curve. The definition of a fracture is a complete or partial interruption of the continuity of the bone.[1] Compression fractures are either caused by osteoporosis or trauma. Most of the fractures (60%-75%) occur in the L1 segment, and are often associated with the thoracolumbar region. [2]

The image on the right is of an L4 compression fracture


The non-traumatic fractures can be caused by osteoporosis (especially in the postmenopausal women), because there is a decrease of the bone mineral density. Those are caused by pressure placed against the vertebrae due to lack of disc cushioning between the spinal bones. Osteoporotic spine fractures can be graded based on vertebral height loss as:

  • mild: 20-25%
  • moderate: 25-40%

Clinically Relevant Anatomy

Figure 1: Spine anatomy
The figure on the right gives an illustration of the anatomy of the lumbar spine:
Annulus fibrosus
Nucleus pulposus

The 5 lumbar vertebrae are the strongest and largest of all vertebrae in the spine. This anatomical structure offers them the opportunity to bear the whole upper body. The vertebra starts at the thoracolumbar junction in the beginning of the lumbar lordosis and extend to the promontorium of the sacrum. Those vertebrae are “stacked” together and can provide a movable support structure while also protecting the spinal cord from injury. The lower back region has a greater mobility in flexion and extension. Those segments are also involved in lateroflexion and rotation of the spine, but to a lesser extent.[5] Because of the increased mobility, the lumbar spine is more susceptible to injury. The lumbar disk works as a cushion for the mechanical loads.[6]

Epidemiology / Risk factors

Most of the time the compression fractures are caused by trauma, osteoporosis, infection and neoplasm.[2][7][8]

  • As mentioned before, most of the fractures occur at the thoracolumbar junction. This can be explained by looking at the transition zone (T12-L2): the thoracic vertebrae are more rigid in compare to the mobile lumbar region which means that the transition zone receives the biggest load during impacts.
  • ageing- above at the age of 80 years, 40% of the women have received at least one compression fracture.[2][8]
  • Female sex: Postmenopausal middle-aged (55-65) women go through hormonal changes which give them a higher change of developing osteoporosis.[7][9] One-fourth of the postmenopausal women will be affected with vertebral compression fractures.[10][11] The difference in incidence according to sex is nearly double for women, particularly as they age. In general, 10.7 per 1000 women have a vertebral compression fracture annually in the United States, compared with 5.7 fractures per 1000 men.[1]Bone loss is more common in women, especially post-menopausal women. This is due to the steep drop in estrogen, which goes on to makes bones lose density and become prone to fractures.
  • Certain medications: eg oral steroids, anti-depressants, diabetes drugs.
  • A pre-existing spinal fracture: Having one spinal fracture greatly increases your chances of having another.
  • Unhealthy lifestyle habits: Smoking, excessive alcohol consumption, and/or living a sedentary lifestyle affects bone density. Smoking and heavy alcohol consumption affects your body’s ability to absorb calcium.
  • Decreased pulmonary function[1]         
  • Decreased mobility and balance impairment[1]                   
  • Multiple compression fractures [1][2]An existing compression fracture increases the risk to five-times to obtain an other compression fracture in the future. Having 2 or more compression fractures increases the risk by 12 times to get another fracture. [7]There are several patient population studies who suggests an increased mortality rate in patients with osteoporosis vertebral compression fractures that correlates with the number of involved vertebrae.[10][11]
  • loss of height
  • Tumour cells in the vertebra in 80% of the situations are invaded by tumor cells from the breast or prostate cancer.[2] This cancer metastasis on the vertebrae, is the most common skeletal complication in vertebral compression fractures.[10]

Characteristics/Clinical Presentation

Even though these fractures are most common with osteoporosis, there is also a possibility they are caused by high load impact trauma with a flexion compression mechanism.[12][2] A lumbar compression fracture is a serious injury, both when caused by osteoporosis or by trauma. There is a risk of neurological damage, when this is the case, surgery is recommended,[10] Neurologic deficits are quite uncommon. [2]

Midline back pain is the hallmark symptom of lumbar compression fractures. The pain is axial, nonradiating, aching, or stabbing in quality and may be severe and disabling. The location of the pain corresponds to the fracture site, as seen on radiographs. In elderly patients with severe osteroporosis, however, there may be no pain at all as the fracture occurs spontaneously.[13]

A fracture has influence on quality of life and the disability can last at least 5 years [1] and the pain for 2-4 years.               

Classification of Fractures

There are several typical types of fractures:Wedge fracture [1][5] Burst/crush fracture [1][5] Biconcave fracture (meaning the walls of the vertebrae stays intact but the center portion is compressed).[6]
In some books the types of vertebral compression fractures are categorised by the applied forces of impact: [7]

  • Flexion compression with damage in posterior ligamentous structures.
  • Lateral compressions that can be the cause of scoliotic deformation.
  • Axial compression causing burst fractures.

In some other resources this pathology is subdivided by the damage in the included endplate. There are four subtypes for compression fractures. [8]

Type A: Both endplates are involved. = Axial load → 16%
Type B: The superior endplate is damaged. = Axial load + flexion → 62%
Type C: Inferior endplate is damaged = Axial load + flexion → 6%
Type D: Both endplates are intact. = Axial load + rotation → 15%


Each type of (compression) fracture is divided into two groups: Fractures with union and fractures with non-union. It is proven that fractures involving the anterior and middle column, have a higher incidence for non-union than the compression fractures of the anterior column (p< 0.05).[12] Both fractures will be either stable or unstable. It is only for the unstable fractures a surgery is needed, the stable fractures can be treated conservatively. [9]

Patients with osteoporosis vertebral compression fractures might be asymptomatic at the time of diagnosis. Also the age of the fracture is impossible to determine.[11]

Differential Diagnosis

  • Coccyx pain: Coccygodynia (Coccydynia, Coccalgia, Tailbone Pain)
  • Lumbar facet arthropathy: Lumbar Facet Syndrome
  • Mechanical low back pain (Clinical pain presentations)
  • Lumbar degenerative disc disease
  • Lumbar Spondylolysis and Spondylolisthesis
  • Primary OsteoporosisSecondary osteoporosis

Diagnostic Procedures

A patient’s physical examination might reveal hyper¬kyphosis, or excessive thoracic spine curvature. The finding indicates likelihood of vertebral compression fractures.[11]
It is important to ask the patient about height. The loss of height that results from a compression fracture may lead to kyphotic deformity of the spine, especially for multiple compression fractures with significant height loss. [1]
The definitive diagnosis of vertebral compression fracture usually is accomplished using a number of medical imaging modalities. Many vertebral compression fractures are identified incidentally on chest radiographs but not addressed by the treating clinician. [11].

Radiographprovides the following diagnostic information. [1]:

  • Identification of a vertebral compression fracture, including type (wedge, biconcave, or crush). In cases of complete ompression fractures there is a reduction in both posterior and anterior height. [2]
  • Measurement of a vertebra’s height loss; a mini¬mum of 20% must be lost compared with normal portions of the vertebral body for a vertebral compression fracture to be diagnosed. [1][1]
  • Measurement of increased distance between the processes or pedicles, indicating vertebral disruption. [1][1]
  • Estimation of how much a vertebra has moved out of alignment along its anterior and posterior lines can be seen on erect projections.[1][1]
    Radiograph of the lumbar spine.jpg

The most widely available and cost-effective initial imaging study is a lateral X-ray of the thoracic or lumbar spine (Figure 6).[1] Comparisons to pre-existing spine X-rays allows the clinician to diagnose and judge the age of the vertebral fracture. In patients without prior spinal imaging, certain radiographic criteria may aid in diagnosis. A plain radiograph may be all that is necessary for a majority of compression fractures, especially if one proceeds with conservative, medical management.

CT  scans allows for the best imaging of bony anatomy and improved assessment of loss of height, fragment retropulsion, and canal compromise. [1]

Magnetic resonance imaging (MRI) is the best study for judging fracture age, as it will show bony edema (T2) for an
acute fracture, allows for the evaluation of neural compromise secondary to compression and will also reveal integrity of the
spinal ligamentous complex, which can be important during surgical evaluation of fracture stability. [1]

DEXA scan: Without a history of trauma, spontaneous vertebral compression fractures are typically pathognomonic for osteoporosis. After the diagnosis of a compression fracture on initial imaging, bone density should be assessed by DEXA scan. Roughly half of patients with vertebral fractures have osteoporosis (T score , −2.5) and another 40% have osteopenia (T score −1 to −2.5). [5]

Outcome Measures

American Society of Anesthesiologists Physical Status score (ASA) is a predictive outcome measure of mortality in a surgical population of vertebral compression fractures. [6]

Visual analogue scale for overall pain (VAS).

Quality of Life Questionnaire of the European Foundation for osteoporosis (QUALEFFO).

Assessment of Quality of Life (AQoL) questionnaire

EQ–5D

Roland–Morris Disability Questionnaire.

The Patient-Specific Functional Scale (PSFS)

Quebec Back Pain Disability Questionnaire

Medical Management

There are several medical management methods to treat a lumbar compression fracture.
Before anything else you need to control the pain:

Acute pain control may include: [1]

NSAIDs are often first-line drugs for back pain as they do not have sedating effects. However, they do have gastric toxicity and an increased risk of cardiac events for patients with hypertension and coronary artery disease  [12]
Opioids and muscle relaxants may provide strong relief when NSAIDs are inadequate but have significant sedative effects as well as the risk of dependency. As such their use needs to be carefully balanced in the geriatric patient. ' [5]

Preventative Medicine[1]

Other than acute pain control, medical therapy should be aimed at improving bone quality and thus reducing the risk of future fracture. Agents for treating osteoporosis include:
           

  • Bisphosphonates
  • Selective estrogen receptor modulators
  • Recombinant parathyroid hormone
  • Calcitonin
  • Vitamin D

These agents act through either antiresorptive or osteogenic mechanisms. The bisphosphonate alendronate is a first-line medication given its favorable safety profile and efficacy in reducing fracture risk. Hormone replacement therapy may be an option for younger postmenopausal women. Finally, while calcium and vitamin D are insufficient alone in reducing fracture risk, supplementation may be necessary for deficient patients. Interestingly, several medications for osteoporosis treatment also play a role in acute pain relief. Calcitonin has been found in multiple randomized controlled trials to provide pain relief for acute compression fractures

Surgical Management

A surgical management is required when neurological deficits, instability, prevention of kyphosis and pain occurs caused by the lumbar fracture. Also when several nonoperative treatments didn’t help, surgery is recommended. In most patients kyphoplasty and vertebroplasty are good options. [10] Vertebroplasty involves the percutaneous injection of bone cement into the affected vertebra to stabilize the fractured vertebral body, and results in immediate pain relief. Kyphoplasty is a type of vertebroplasty in which inflatable bone tamps are used to restore vertebral height. After removing the balloons, the resulting intravertebral cavity is filled with bone cement to stabilize the vertebral body.  [5] 
Several studies have demonstrated that both, kyphoplasty and vertebroplasty, results in immediate and sustained pain relief in most patients. [10] McGirt et al published a review in 2009 of all studies of vertebral augmentation outcomes over a 20-year period. The authors found level I evidence that vertebroplasty provides superior pain control over medical management in the first 2 weeks, and level II–III evidence that within the first 3 months there are superior outcomes in analgesic use, disability, and general health, and finally level II–III evidence that by 2 years there is a similar level of pain control and physical function. With regards to kyphoplasty, there was level II–III evidence of improvement in daily activity, physical function, and pain control at 6 months, compared to medical management. [6]

Non Medical Management

Non-operative treatment consists of[7] 

  • Pain relief (NSAIDs,muscle relaxants,narcotic pain medication →see medical management)
  • Orthesis
  • Rehabilitation program

Non-operative treatment goals[8]

  • Pain control
  • Early mobilisation
  • Prevention of deformity
  • Functional Restoration

Physical Therapy Management

Subjective Examination

Exercise older person.jpg
Any notable event the patient experienced in the history, causing the symptoms and complaints.
High-Risk Mechanism of injury [2]
  • Accident with a vehicle with a higher speed than 70 kph
  • Fall from 3m or higher
  • Ejection from a vehicle seat
  • Check for Red Flags in Spinal Conditions                           

Objective Examination

It is important to know that there are no fully validated screenings for diagnosing lumbar compression fractures. Therefore radiologists have an important role in diagnosing spinal fractures.
Input from radiologists is needed because there is a lack in knowledge for diagnosing those fractures without images and the symptoms might be absent or it is difficult to determine the cause of the complaints.[2]

Inspection

Look at: 

  1. Sagittal convexity [11]
    • Thoracic kyphosis
    • Lumbar Lordosis
    • Dowager’s hump (indication for osteoporosis)
  2. Swelling or hypertonic muscles
  3. Posture
  4. Antalgic stand

Acute phase: Localised tenderness over the involved level is a known characteristic for acute fracture. However, this does not distinguish whether the anterior or posterior column is involved. [11]

Changes in the size of the thoracic kyphosis/lumbar lordosis: [11][10]

  • Can lead to a reduction of the abdominal space and/or a decreased ventilator capacity.[10]
  • Can lead to multiple anterior wedge fractures: increased thoracic convexity[11]
  • Can lead to an increased thoracic kyphosis with missing prevalent fracture of the vertebrae in older adults.[11]

Testing          

  • Active ROM- will be restricted with most acute fractures (flexion/extension/retroflexion/rotation)[10]
  • Gait          
  • Provoking movements - flexion, extension, rotation, sneezing/coughing [11]                  

Specific clinical signs in physical examination:

  1. Patient is standing in the front of a mirror with the examiner behind him. That way the therapist can gauge their reaction. Using firm, closed-fist percussion the spine will be examined over the entire length. [11] Positive test: Patient is complaining about sharp, sudden, fracture pain.[11]Sensitivity: 87,5, Specificity: 90 %
  2. Patient is gently asked to take place on the examination couch and lie supine, using only one pillow.[11] Positive test: Patient is unable to lie supine, because the severe pain is the limitation factor. [11] Sensitivity: 81,25 Specificity: 93,33 %
  3. Physical examination reveals- tenderness when palpating or directly percussion over the area of the fracture, spasm in paraspinal muscles.[1]mostly in acute phase [11]
  4. Osteoporotic patients might have a loss of height. We look at the fingertips;Positive test: When the patient’s fingertips hit the knee or lower thigh during standing [11]

    Note: Signs 1 and 2 are useful adjuncts in evaluation symptomatic osteoporotic vertebral compression fractures and are reliable indicators of the presence of a fracture. When the test is positive there is reason to rationalise and refer the patient for a MR scan. [11]

Treatment

Education in activities of daily living and mobility in ways to avoid pain is essential for this impaired patient population that is often elderly. [8] It is important that the patient overcomes his fear of movement (kinesiophobia) and continues with his/her activities. Rest is not recommended, it’s important that the patient remains active.[9]

Supervised Physical Therapy:

  1.  Postural taping: from anterior aspect of each shoulder, posteriorly and obliquely down to opposite rib cag[11]
  2. Soft tissue massage: performed in prone to erector spinae, rhomboids, upper trapezius -stroking, circular frictions and petrissage  [11]
  3. Strengthening-exercises: It is important to improve the lumbar stabilization by strengthening the muscles of the lower back, strengthening the patient’s supportive axial musculature (in particular the spinal extensors) but also the muscles of the trunk. Exercises should focus on strengthening back extension and may include weighted or unweighted prone position extension exercises, isometric contraction of the paraspinal muscles, and careful loading of the upper extremities.  [1],[1]
  4. Physiotherapy program with manual techniques, clinician-led exercises, and home exercises designed to reduce pain, increase back extensor and lower limb muscle strength, and improve posture, trunk stability and trunk mobility.  [11]
  5. The Spinal Proprioception Extension Exercise Dynamic (SPEED) program designed by Sinaki9 is an example of a regimen that focuses on strengthening the spinal extensors using a weighted kypho-orthosis and postural and proprioceptive training, through twice-daily, 20-minute exercise sessions.  [2]
  6. Strengthening of abdominal, gluteal and hip muscles is important to support spinal structures with noncompressive forces and can be done for integrating the exercises into a more functional rehabilitation programme. Functional exercises that use all planes of motion and stimulate activities of daily living may be more beneficial for the patiënt. [8]

Example of Exercise Program: [11]

Exercise Dosage Weeks
Elbows back in sitting
Hands behind head with elbows pointing out to side. Pressing elbows back by performing
scapular retraction
5 sec hold × 5 reps 1-10 daily
Trunk mobility in sitting
Hands on shoulders, gentle rotation in both directions and lateral flexion to each side
5 reps in each direction 1-10 daily
Four point kneeling with transversus abdominus
Push into floor with hands, knees and feet then draw navel up and in. Hold 5sec
8-10 reps × 2

3×/week

Four point kneeling with one arm and leg lift
As above, then lift one arm off ground. Progress to also lifting extended leg off ground at same time
8-10 reps × 2 3-10
3×/week
Bridging in supine
Knee bent and feet flat on ground. Pushing through feet to lift back and pelvis off ground
5-10 sec hold × 5 1-2
3×/week
Hip extension in prone
8-10 reps × 2 3-10 Raising one leg off the ground and then the other
8-10 reps × 2 3-10
3×/week
Seated row with dumbbells
Upright sitting and pull hands up towards chest by bending elbows and then lowering
8-10 reps × 2 1-10
3×/week


Patients who followed a back extensor-strengthening program have a smaller chance to relapse into a new lumbar fracture in the future.[1]

Note- if the patient continues to have a lot of pain, or there is no progression at all, it is advised to send the patient to a doctor or preferably an orthopedic surgeon for a review and possible surgery. [10]

Orthotics

Figure 8: Thoracolumbar orthesis
The rehabilitation starts with a thoracic-lumbar-sacral orthosis. The physiotherapist learns the patient how to use that orthosis. It is recommended to wear the brace/orthosis for 6 to 12 weeks, followed by supervised physical therapy.[5]

It is important to highlight that there isn’t really any true evidence on the effectiveness of a brace in the healing of the vertebrae itself, but we can be sure a brace improves the body posture. It increases the trunk muscle strength in patients with osteoporotic fractures in the vertebrae.  [2] The use of a spinal orthosis maintains neutral spinal alignment and limits flexion, thus reducing axial loading on the fractured vertebra. In addition, the brace allows for less fatigue of the paraspinal musculature and muscle spasm relief. [1]

Fractures in the thoracic spine may be treated with thoracolumbar orthesis. Examples include the Jewitt, cruciform anterior spinal hyperextension, and Taylor brace. Braces which extend to the sacrum are termed thoracolumbar sacral orthoses. Finally, lumbosacral orthoses are also available for lumbar fractures but are only effective in restricting sagittal plane motion in the upper lumbar spine (L1–3). [1] Intervertebral motion has been shown to actually increase from L4–S1 with a lumbosacral orthoses brace. [5]

Clinical Bottom Line

Lumbar compression fractures, whether from trauma, osteoporosis, infection or neoplasm, occur often enough to be worthy of adequate research with focus on healing procedures. Most of the present information acknowledges that there is no evidence which proves that surgical intervention of a lumbar compression fracture surpasses physical therapy. However, no current research exists that effectively compares the most effective therapy. Current recommendations revolve around prevention, basic core and lumbar muscle strengthening and postural taping. We believe that more research, that focuses specifically on lumbar compression fractures and on the most effective therapy treatments, is necessary.

Guo, Jia-Bao, et al. "Surgical versus non-surgical treatment for vertebral compression fracture with osteopenia: a systematic review and meta-analysis." PloS one 10.5 (2015): e0127145.

Presentations

https://http://www.youtube.com/watch?v=9t3PwKG1mToLumbar fracture mgt ppt.PNG
Management of Lumbar Fractures

This presentation, created by Mel Kaplan, Jacob Landersm Kari Mann, and Kelsie Martin; Texas State DPT Class.

View the presentation

References

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