Lumbar Compression Fracture

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Original Editors - Sam Verhelpen

Top Contributors - Andreas de Feyter, Remko De Smedt, Ivakhnov Sergei, Andreas De Feyter, Lucinda hampton, Kim Jackson, Lien Hennebel, Lauren Lopez, 127.0.0.1, Rachael Lowe, Sam Verhelpen, WikiSysop, Aminat Abolade, Alexander Ghyssels and Joshua Samuel  

Search Strategy

- Databases searched: Pubmed, Web of science, Pedro, Google scholar, Prometheus Atlas

- Keywords: compression, fracture, osteoporotic, lumbar, vertebral, vertebrae

- Combination of keyword: lumbar compression fracture, thoracolumbar compression fracture, vertebral fracture, osteoporotic spine fracture, vertebral compression fracture, osteoporotic compression fracture

Definition/Description

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. [14]

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. To make it easier to define the type of an osteoporosis vertebral compression fracture, a specific classification has been made and can be found in the “Clinical presentation”[2]

Clinically Relevant Anatomy

          • Anterior Longitudinal ligament
          • Posterior longitudinal ligament
          • Intervertebral disc
                       Annulus fibrosus
                       Nucleus pulposus
          • Lumbar vertebrae (L1-L5)
          • Cauda equina
          • Vertebral endplates
          • Dura

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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.[15] Because of the increased mobility, the lumbar spine is more susceptible to injury. The lumbar disk works as a cushion for the mechanical loads.[5]

Epidemiology /Etiology

Most of the time the compression fractures are caused by trauma, osteoporosis, infection and neoplasm.[14][16][17]
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. The prevalence increases by age. There above at the age of 80 years, 40% of the women have received at least one compression fracture.[14][17]

Postmenopausal middle-aged (55-65) women go through hormonal changes which give them a higher change of developing osteoporosis.[6][16] One-fourth of the postmenopausal women will be affected with vertebral compression fractures.[3][7] 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.[45]

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.[3][7]

In 80% of the situations the vertebral body is invaded by the tumor cells coming from the breast or prostate cancer.[22] This cancer metastasis on the vertebrae, is the most common skeletal complication in vertebral compression fractures.[3]
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. [16]

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.[2][14] A lumbar compression fracture is a serious injury, both when caused by osteoporosis or by trauma. There is a severe risk of neurological damage. When this is the case, surgery is recommended,[3] But the risc to get neurologic deficits is quite uncommon. [14]

The patient will most likely experience pain when the longitudinal ligaments in the spine are damaged. When these structures aren’t damaged, the pain can be overlooked and the compression fracture will be labeled as ‘asymptomatic’. [48] In general is ‘pain’ one of the main symptoms for this pathology. The less common symptoms are described below.[14]

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The pathology is also related to some risk factors developing compression fractures over time which are shown below.[14]

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There are several typical types of fractures: (Figure 5)

          1) Wedge fracture [1][4]
          2) Burst/crush fracture [1][4]
          3) Biconcave fracture:
                  → meaning the walls of the vertebrae stays intact but the center portion is compressed.[19]

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In some books the types of vertebral compression fractures are categorised by the applied forces of impact: [49]

1.  Flexion compression with damage in posterior ligamentous structures.
2. Lateral compressions that can be the cause of scoliotic deformation.
3. 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. [51]

          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).[2] 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. [21]

Patients with osteoporosis vertebral compression fractures might be asymptomatic at the time of diagnosis. Also the age of the fracture is impossible to determine.[7] However, there are several characteristics developing over time:

1) Pain:
            • Impact on pain doesn’t depend on the type of fracture.[18]
            • Not localized to the side of the compression fracture.
                     → Thoracolumbar fractures = lumbosacral/low back pain[7]
            • Pain associated with atraumatic activities[7] :
                     1) Bending forward
                     2) Vigorous sneezing and coughing
                     3) standing from being seated,
                     4) …

2) Risks:

           • Patients who had an osteoporosis vertebral compression fracture (20% of the cases):
                     → Risk to get a second fracture within a year. [3][7]
                     → Decreased pulmonary function[3]
                     → Decreased mobility and balance impairment[3]
                     → Multiple compression fractures [3][7]
                     → loss of height [3],[7]

                   Test: When the patient’s fingertips can hit the knee or lower thigh during standing, then can we speak about a spinal
                            shortening.[7]

           • A fracture has influence on:
                     → Quality of life and disability: can last at least 5 years [18]
                     → Pain: 2-4 years [18]

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 Osteoporosis
            • Secondary 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.(LoE 1A)[20]
It is important to ask the patient about his length. 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. [31]
The definitive diagnosis of vertebral compression frac¬ture 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. (LoE 1A) [20].

       1. A 'radiograph' provides the following diagnostic information. [31][45]:

                  • Identification of a vertebral compression fracture, including type (wedge, biconcave, or crush). In cases of complete
                    compression fractures there is a reduction in both posterior and anterior height. [38]
                  • 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. [31][45]
                  • Measurement of increased distance between the processes or pedicles, indicating vertebral disruprution. [31][45]
                  • Estimation of how much a vertebra has moved out of alignment along its anterior and posterior lines can be seen on erect
                    projections.[31][45]

The most widely available and cost-effective initial imaging study is a lateral X-ray of the thoracic or lumbar spine (Figure 6).[31] Comparison 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.

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     2. When there is need for further characterization, a computed tomography (CT) scan allows for the best imaging of bony anatomy
         and improved assessment of loss of height, fragment retropulsion, and canal compromise. [45]

     3. However, 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. (LoE 2B) [31]

     4. However Samah Al-Helo proposes a fully automated Computer-Aided Diagnosis System (CAD) for the diagnosis of vertebra
         wedge/compression fracture from CT images that integrates within the clinical routine that consist of a set of clinically motivated
         features that distinguish the fractured vertebra. (LoE 4)[41]

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). [33]

Outcome Measures

According to Lavelle EA, Cheney and Lavelle WF the American Society of Anesthesiologists Physical Status score (ASA) is a predictive outcome measure of mortality in a surgical population of vertebral compression fractures. (LoE 3B)[43]

R. Buchbinder et al. used the following outcome measures to evaluate the progression of a patiënt who suffers from an osteoporotic vertebral fracture: (LoE 2B)[44]

          • Pain: Visual analogue scale for overall pain (VAS).
                      We can use this scale for measuring pain at night, rest, daily activities,…
          • Quality of Life: this can be measured with the use of the Quality of Life Questionnaire of the European Foundation for
                      osteoporosis (QUALEFFO). Another possibility is to use the Assessment of Quality of Life (AQoL) questionnaire or the
                      European Quality of Life–5 Dimensions (EQ–5D) scale.
          • Physical functioning: measured bij a modified 23-item version of the Roland–Morris Disability Questionnaire.

Other validated questionnaires are the:

          • The Patient-Specific Functional Scale (PSFS): This useful questionnaire can be used to quantify activity limitation and
                      measure functional outcome for patients with any orthopaedic condition. The PSFS is a valid, reliable, and responsive
                      outcome measure for patients with upper extremity problems. [47]
          • Quebec Back Pain Disability Questionnaire: measures the way in which the patients back-pain influences his activities of daily
                      living by using a 20-item 6-scale questionnaire. These outcomes score within the range of 0 and 100, determines the level
                      of functional disability, with higher numbers representing greater levels of disability. The construct validity of the English,
                      French and Dutch version is good. (Grade of recommendation: B) [46]

Examination

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Medical 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. This two surgical procedures are percutaneous and stabilize the fracture with polymethylmethacrylate. Several studies have demonstrated that both, kyphoplasty and vertebroplasty, results in immediate and sustained pain relief in most patients.

Physical Therapy Management

Non-operative treatment consists of pain relief, bracing and rehabilitation. The rehabilitation program 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.

It is important that the patient overcomes his fear of movement (kinesiophobia) and continues with his/her activities. Rest is not recommended.

Supervised physical therapy:

• NSAID’s and massages are given to reduce pain at the start of the rehabilitation.
• Early mobilization is important to prevent secondary complications of immobilization.
• Weight-bearing exercises are usual part of the program and are believed to be the main type of therapy required to prevent progression of the osteoporosis and other fractures in the future.
• Pelvic stabilization.
• Strengthening-exercises: in this phase, it is important to improve the lumbar stabilization by strengthening the muscles of the lower back, but also the muscles of the trunk.
• Occupational therapy is essential to restore the normal level of function and increase the quality of life.
• Low impact exercises such as swimming, cycling and walking can be performed to optimize the endurance of the lower back and trunk musculature. High impact sport such as running, volleyball and basketball need to be avoided.

Patients who followed a back extensor-strengthening extensorprogram (like in the 6th point of the supervised physical therapy) have a smaller chance to relapse into a new lumbar fracture in the future.

When, during physical therapy session with a non-operative compression fracture patient, it shows that 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, as surgery may be required.

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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Presentations

Management of Lumbar Fractures This presentation, created by Mel Kaplan, Jacob Landersm Kari Mann, and Kelsie Martin; Texas State DPT Class. View the presentation