VCFs and the Impact of Spinal Deformity

Vertebral body compression fractures (VCFs) caused by osteoporosis are a significant burden on patients who sustain them. The impact of the spinal deformity, independent of acute VCF pain, is underappreciated.

Many studies document that VCFs are not stable, and that the final osteoporotic vertebral body collapse can take months to occur. (1) For example, among 210 women with acute back pain (VAS >= 5 out of 10) seen at an osteoporosis center, 58% presented with severe vertebral body collapse and the acute pain lasted approximately 6 weeks, the expected clinical course. In contrast, the remaining 42% showed no or only minor radiographic evidence of vertebral fracture, and it took up to four more subsequent radiographs to detect vertebral height loss. In this group, the mean time to final vertebral collapse was nearly 50 weeks. (2)

This variation in clinical course can explain why many VCFs are not diagnosed, and also illustrates how, unlike traumatic VCFs in younger patients, osteoporotic VCFs are not stable and thus lead to spinal deformity.

Multiple studies document that the deformity itself, independent of acute fracture pain, is associated with diminished physical and functional performance, difficulties in performing activities of daily living, declines in multiple measures of health and quality of life, excess mortality, and future fracture risk.(3)

In a longitudinal study of adults over 65, subjects with vertebral deformities (compared to those without) spent more days in bed, had lower peak expiratory flow, had lower scores on performance tests of walking, standing and self-care, and had worse scores on the Nottingham pain profile.(4) The authors concluded that, even where not clinically manifest, VCFs have a substantial impact on physical functioning and well-being.

In a cross-sectional study of women over 65 without clinically-evident VCFs, each additional radiographically-detected vertebral deformity incrementally decreased physical function and health-related quality of life in post-menopausal women (see figure above). (5)

In a large longitudinal study of adults over 65, the presence of any VCF reduced health-related quality of life to a similar degree as COPD and cardiac disease, while the presence of 3 or more VCFs was associated with a loss of health-related quality of life comparable to that of cancer or stroke. (6) Kyphotic deformity has also been shown to correlate to excess mortality. (7)

Worse yet, each additional vertebral deformity increases future fracture risk. Lindsay et al., who published in 2001 (8) that the risk of a new VCF increased 19.2% if the patient had one or more prior VCFs, reanalyzed the same data, looking at the risk for each additional VCF. (9)

The risk of future VCF increased linearly with each additional vertebral deformity up to 8, demonstrating the profound effect of increasing deformity on future fracture risk.

Thus, while treatment of the underlying osteoporosis is paramount, medical management alone of acutely painful osteoporotic VCFs can lead to spinal deformity, which profoundly impairs health, quality of life and survival, and increases the risk of future deformity, with likely further physical and functional decline.

References

1. Lyritis et al. Clin Rheum 1989 ;8(Suppl. 2):66-69, Heggeness Osteoporos Int 1993;3:215-2, Reginster et al. Osteoporos Int 2000;11:83-91, Kasperk et al. J Bone Miner Res 2005;20:604-612, Nakano et al. J Neuro-Spine 2006;4:110-117.
2. Lyritis et al. Clin Rheum 1989;8(Suppl. 2):66-69.
3. Reviewed in Gold et al. In: Marcus et al. (edas.) Osteoporosis, Academic Press, San Diego, 1996, Ch. 52, pp. 1086-1095.
4. Pluijm et al. J Bone Miner Res 2000;15:1564-1572.
5. Silverman S, et al. Arthr Rheum. 2001;44:2611-2619.
6. Van Schoor et al. Osteoporos Intl 2005;16:749-56.
7. Kado Am Geriatr Soc 2004;52:1662-1667.
8. Lindsay et al. J Am Med Assoc 2001;285:320-323 soc 2
9. Lindsay et al. Osteoporosis International 2005;16:306-12.