Vertebral Compression Fractures: What Time Destroys, Methylmethacrylate May Mend - An Editorial

Dr. Mazanec and colleagues, in their article on vertebral compression fractures in this issue of the Cleveland Clinic Journal of Medicine,(1) should be congratulated on an excellent discussion of an increasingly important problem.

Osteoporosis vs Trauma
Mazanec et al appropriately highlight the difference between osteoporotic compression fractures and traumatic fractures of the thoracolumbar spine. This is an important distinction, as it influences management.

This distinction should be made first by history and then, by radiographic imaging.

History and Presentation

Osteoporotic compression fractures generally occur in elderly and postmenopausal women after low-energy stresses, such as picking up a baby or a bag of groceries, or sneezing. However, these injuries should not be overlooked in elderly men.(2)

Patients with osteoporotic compression fractures sometimes present with low back pain, particularly if the lesion is in the low lumbar region. However, fractures are more common in the lower thoracic and upper lumbar region, likely because it is a transition zone between the relatively stiff thoracic vertebrae and the more mobile lumbar segments. The clinical presentation, therefore, is more typically mid-to-low thoracic pain.

Furthermore, the pain is not necessarily mechanical in nature. While pain can be exacerbated by movement, fracture pain is generally constant and dull. Importantly, complaints of low back pain in an osteoporotic patient should alert the clinician to the possibility of a sacral insufficiency fracture. This can be diagnosed by a bone scan, which displays the hallmark "H-pattern" of increased uptake. These fractures respond to limited bed rest and progressive mobilization.

High-energy traumatic fractures can and do occur in patients of any age, male or female, though they are more common in younger men engaged in high-risk activities. They most commonly occur at the T12-L1 region.

Radiographic Appearance
Osteoporotic compression fractures, by definition, occur in osteoporotic bone. On plain radiographs, the vertebrae appear to be "washed out" with loss of detail of the bony contours. It is also important to examine the sacrum and iliac wings and to note any loss of the dense cortical bone that is normally present in these broad bony structures.

But compression fractures often occur in nonosteoporotic bone as well. These fractures usually appear as a simple wedge fracture, which can result in acute kyphotic deformities at that level. While some osteoporotic fractures are the simple wedge type, more often they are of two other types: biconcave (ie, both the inferior and superior vertebral end plates are pushed in) or crush (ie, uniform height loss). The latter two types rarely occur after high-energy traumatic lesions.

Treatment of Traumatic Fractures
Treatment of traumatic vertebral fractures is based on the amount of residual stability. This is influenced not only by the extent of fractured bone, but also by the integrity of the spinal ligaments, which is assessed with plain radiographs, computed tomography, and magnetic resonance imaging.

If a fracture is considered unstable, it is usually treated with open surgery that may consist of internal fixation with hardware. The goal is to protect the neurologic structures and to decrease pain and deformity.

Cleveland Clinic Journal of Medicine, Volume 70, Number 2, February 2003.

This paper discusses therapies that are experimental or that are not approved by the US Food and Drug Administration for the use under discussion.