Vertebral Compression Fractures

Content by Andrew McGrath, Interventional Radiology Consultant
Guy's and St. Thomas's NHS Foundation Trust.

 

Contents

  1. What are vertebral compression fractures?
  2. What are the causes of VCF?
  3. Types of VCF
  4. How is a VCF diagnosed?
  5. Symptoms of VCF
  6. Prevention and treatment of VCF
  7. Prevention and treatment of osteoporosis
  8. Treatment of tumours
  9. Pain relief for VCF

What are vertebral compression fractures?

A vertebra is one of the bones of the spine. The part at the front of each bone is called the body of the vertebra.

In a healthy person this ‘body’ is composed of dense bone and is very strong. However it can become damaged by injury or weakened by disease. If it breaks or collapses (gets squashed) this is called a vertebral compression fracture (VCF).

Symptoms of VCF include:

  • Back pain
  • Curvature of the spine
  • Difficulties with balance, mobility and even breathing
  • Bowel and bladder problems

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What are the causes of VCF?

There are several possible causes of vertebral compression fractures:

  • Osteoporosis
  • Cancerous and non-cancerous tumours
  • Physical injury

Osteoporosis

This is the most common cause. Osteoporosis is a disorder of the bones causing them to lose their strength and to become more likely to break. A break that happens in a bone weakened by osteoporosis is called a ‘fragility fracture’.  Approximately 3 million people in the UK are thought to have osteoporosis, and there are over 230,000 fragility fractures in the UK each year as a result. (NHS choices http://www.nhs.uk/Conditions/Osteoporosis/Pages/Introduction.aspx)

Like most fractures, osteoporotic VCFs can be very painful in the short term.  If the fracture heals fully, the pain will usually go away; if not there may be continued pain. If many vertebrae in the spine are affected by VCF this can result in a gradual forward curvature of the spine.

Tumours

A tumour in a bone may be malignant (cancerous) or benign (non-cancerous). Malignant tumours in the spine have most commonly spread through the blood from another part of the body; tumours that start in the bones of the spine are relatively rare.  There are also benign tumours of vertebrae that can cause pain.  Tumours often cause pain without a fracture.

Macmillan Cancer Support’s information on cancer in bones:

Macmillan Secondary Bone Cancer information

http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Bone/Bonecancer.aspx

Physical injury

A physical injury in which there is a very large force, for example as a result of a car accident, can cause a fracture of one or more vertebrae.

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Types of VCF

The specific part of the vertebra that is fractured is important.

Osteoporosis

Most osteoporotic fractures are a crush or collapse starting at the front (anterior) part of the body of the bone (diagram) but can then involve the rest of the bone as well.

Tumours

A tumour in the vertebra may break or disrupt any part of the bone; if the posterior (rear) wall of the body of the vertebra is broken or weakened, (diagram) treatment of this can be technically more difficult with a higher chance of complications.

Physical injury

In injuries with large forces, all of the body of the vertebra can be crushed. The rear (posterior) parts of the vertebra can also be disrupted or broken. In either case, an open surgical operation may be required to stabilise the spine, sometimes with a vertebroplasty procedure as well.

Multiple VCF

It is very common, especially in osteoporosis, for more than one vertebra to be involved.

Most people have 7 vertebrae in the neck (cervical spine)  (diagram), 12 vertebrae in the chest part of the spine (thoracic spine)  (diagram), and 5 vertebrae in the lower back (Lumbar spine) (diagram).  If a vertebroplasty procedure is being considered it is very important to try to be certain which of the vertebrae are causing the pain.

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How is a VCF diagnosed?

Diagnosis:                       

  • During an examination of your back by your doctor
  • X-ray of the spine
  • MRI scan
  • CT scan
  • By chance (“incidentally”) during a test that was done for other reasons

If you attend your GP or hospital doctor with pain or other symptoms in your back or legs, she or he may well suspect that you have a vertebral fracture, especially if you are someone who is likely to have osteoporosis. Sometimes just by looking at the shape of the spine, it can be seen that it is very likely that there is one or more VCFs. (image)

Osteoporosis is diagnosed by a test of bone mineral density using X-rays- Dual Energy X-ray Absorbimetry (DEXA). This is quite quick and painless and uses a very small dose of X-rays. Ultrasound tests and CT scans (also using X-rays) can also be done.

VCF is usually diagnosed first with an X-ray of the spine. An MRI scan and/or a CT scan are also often carried out. (images)

There are other problems that can affect the spine such as disorders of the discs between the bones and the other smaller joints between the bones. It can sometimes be difficult to be certain which of the problems is causing pain. Problems outside of the spine can sometimes cause pain that is sensed in a different area and confused with pain from spinal disorders. A detailed discussion between you and your doctor, a physical examination and an MRI scan are usually the best ways to work out the cause of your pain.

VCF caused by osteoporosis is sometimes found by chance (“incidentally”) when an X-ray or scan is done for another reason. Treatment for osteoporosis may then prevent other fractures in future. If there is no osteoporosis then other causes will be looked for.

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Symptoms of VCF

The main symptoms of vertebral compression fractures are pain and a change in shape of the spine.  Both of these can cause problems with mechanical activities.

This includes breathing.  Although we do not usually think about it, breathing requires a large number of muscles, joints, and bones, many of which are in the spine.  As the spine thoracic curves forward with VCFs, there is less and less space for the lungs to expand.

Walking is also affected. Walking requires much more energy to move the same distance when the shape of the spine is altered and balance is often worse.

Ability to exercise decreases and less exercise makes osteoporosis worse.

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Prevention and treatment of VCF

  • Prevention and treatment of osteoporosis
  • Treatment of tumours
  • Pain relief for VCF

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Prevention and treatment of osteoporosis

Osteoporosis is one of the main causes of VCF but not everyone with osteoporosis gets a VCF. One in two women and one in five men over the age of 50 will break a bone, mainly because of poor bone health. Broken wrists, hips and spinal bones are the most common fractures in people with osteoporosis.

Apart from preventing VCF or another VCF, treatment of osteoporosis also aims to prevent other fractures, particularly hip fractures.  Hip fractures can cause very serious health problems, especially in the elderly.

http://www.nhs.uk/Conditions/Osteoporosis/Pages/Introduction.aspx

Osteoporosis is more common:

  • In women; especially after the menopause and particularly after early menopause
  • With increasing age
  • In smokers and those consuming excess alcohol
  • In people who are very underweight
  • In people with problems absorbing nutrition or with some long term illnesses
  • When taking steroid medication
  • In other disorders of hormone-producing glands (thyroid, adrenal, and pituitary glands and the ovaries and testes)
  • With a history of osteoporosis in your family
  • With long periods of physical inactivity or bed rest

Ways to prevent osteoporosis, or to slow its progress, include:

  • Having a healthy diet with adequate calcium and vitamin D (vitamin D is also produced when the skin is exposed to sunlight)
  • Taking regular exercise, particularly weight-bearing exercise such as walking
  • Not smoking

Dietary supplements such as Calcium and Vitamin D can also be used. Advice on other medications can be sought from your general practitioner or a hospital specialist. The National Osteoporosis Society has lots of information on medications for osteoporosis:

http://www.nos.org.uk/NetCommunity/Page.aspx?pid=264&srcid=234

There is more information available from the National Osteoporosis Society, and NHS choices:

http://www.nos.org.uk 

http://www.nhs.uk/Conditions/Osteoporosis/Pages/Prevention.aspx

Guidance on medications (alendronate, etidronate, risedronate, strontium ranelate and raloxifene) for preventing bone fractures in postmenopausal women with osteoporosis who have not had a fracture:

http://www.nice.org.uk/nicemedia/pdf/TA160publicinfo.pdf

Guidance on medications (alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide) for preventing bone fractures in postmenopausal women with osteoporosis who have already had a fracture:

http://www.nice.org.uk/nicemedia/pdf/TA161publicinfo.pdf

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Treatment of tumours

Malignant tumours

  • Radiation treatment
  • Chemotherapy
  • Surgery
  • Vertebroplasty & kyphoplasty
  • Embolisation (see section on new advances)
  • Radiofrequency ablation (see section on new advances)

Benign tumours

  • Surgery
  • Vertebroplasty & kyphoplasty
  • Radiation treatment
  • Embolisation (see section on new advances)
  • Radiofrequency ablation (see section on new advances)

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Pain relief for VCF

Pain relief is very important - getting rid of pain can improve mobility and breathing and help better sleep.

Paracetamol

  • A very good painkiller
  • Relatively few side effects
  • Must be used with care if you have liver problems

Anti-inflammatories

  • Very useful
  • Care is needed to avoid problems with kidneys and stomach
  • Should not be taken for long periods if possible

Opiates (medications related to morphine)

  • These are very strong painkillers
  • Available only on prescription
  • Can cause drowsiness, confusion, falls, constipation

Other medications are usually only prescribed after other possibilities have all been tried.

There are other pain relief techniques that do not involve medication. See NHS choices section on treating back pain:

http://www.nhs.uk/Conditions/Back-pain/Pages/Treatment.aspx

For a painful vertebral fracture when the pain has not been adequately controlled after three weeks of treatment with painkilling medication, a procedure called vertebroplasty is considered. It is also used for painful spinal tumours and for fractures that happen in otherwise healthy vertebrae. This procedure is fully explained in the next section.

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