Approach

The possibility of a spinal compression fracture should be considered in patients at risk of osteoporotic bone disease, particularly older people and those taking long-term corticosteroid therapy.[50]​ In the setting of “red flags” (e.g., history of significant trauma, minor fall or heavy lift in a potentially osteoporotic or elderly person, prolonged use of corticosteroids), the initial evaluation of a painful vertebral compression fracture includes assessing any neurologic deficits and evaluating mechanical versus radicular pain.[9]

Presentation

Most osteoporotic spinal compression fractures are identified as an incidental finding on chest and abdominal x-rays taken for other indications, and these patients are frequently asymptomatic at the time of diagnosis.[11][51] However, some patients may report an acute onset of back pain with relatively atraumatic activities, such as standing from a seated position, picking up a suitcase, bending forward, or even coughing or sneezing.[51]​ 

Patients may variably describe the pain as dull or sharp, and often as being aggravated by movement. Patients may report disturbance of sleep. The pain may radiate bilaterally to the abdomen, although, unlike pain from a herniated intervertebral disk, it rarely radiates to the legs. Local pain originating from vertebral fractures may last for 3 years or more; but many vertebral fractures do not cause any pain.[52][53][54]​​​

Patients with multiple fractures and a marked kyphosis may report weight gain and difficulty fitting into clothes, although their weight remains stable. This is due to loss of height, and the kyphosis compressing abdominal contents and causing the abdomen to bulge forward. Progressive kyphosis of the thoracic spine with compensatory lumbar lordosis can result in decreased appetite.[51] Severe kyphosis or multiple vertebral fractures can affect pulmonary function and may lead to dyspnea.[11][55] These patients may also report neck pain resulting from the need for continuous neck extension to look forward or upward.

Lumbar fractures can alter abdominal anatomy, leading to constipation, abdominal pain, early satiety, and weight loss.[11]​ Loss of sagittal balance occurs when the patient is no longer able to compensate for progressive kyphosis by rotating the pelvis backward.[56]​ This causes intolerance of standing still or walking slowly. Sometimes this can be compensated for by walking fast, or by using impromptu walking aids, such as a grocery cart or child's stroller.

Clinical exam

Patients with multiple wedge fractures of the thoracic spine may have a notable kyphosis, although this can also occur in the absence of vertebral fractures. Conversely, wedge fractures of the lumbar spine can lead to lessening of the lumbar lordosis. Loss of height also occurs with these fractures, particularly if there are multiple fractures.[1][51]​ In combination with a kyphosis, this loss of height can result in bulging of the abdomen as the contents are compressed and pushed forward. As a consequence of these factors, the patient may not be able to stand upright with the head balanced over the hips without bending the knees (loss of sagittal balance).[56]​ In an acute injury, there will be tenderness locally over the spine at the level involved. A full neurologic exam is indicated in these patients. Neurologic exam is also indicated after a minor fall or heavy lift in a potentially osteoporotic or elderly person or in patients with a history of prolonged use of corticosteroids.[9]​ Although osteoporotic spinal compression fractures do not generally cause neurologic problems, the presence of neurologic signs indicates a need for urgent computed tomography (CT) or magnetic resonance imaging (MRI).

Diagnostic workup

Where there are concerns about the occurrence of a vertebral fracture(s), recent imaging that includes the spine should be reviewed. If no recent imaging is available or the patient’s symptoms began after the previous imaging, patients should be referred for spine imaging. The referral should highlight the concern about the presence of fracture.[57]

Plain x-ray

Initial investigation for all patients involves radiographic evaluation with anteroposterior (AP) and lateral spine x-rays.[11]​ These often reveal the classic wedge fracture with loss of anterior vertebral height and relative preservation of posterior body height. In osteoporotic patients, fractures usually occur around the midthoracic level (T7-T8) or thoracolumbar junction level (T12-L1). The AP x-ray may show interpedicular widening or malalignment of the spinous processes, which would suggest posterior column injury. Other radiographic features of concern include loss of vertebral height >50% or segmental kyphosis >20° (both suggest posterior ligamentous injury), or multiple adjacent compression fractures that may require surgical treatment to reduce the development of kyphotic deformity.

Distinguishing acute fractures from old fractures on plain radiographs is difficult.[1] Acute fractures typically have well-demarcated fracture lines or distinct discontinuity of the thin layer of cortical bone. Older fractures often have sclerosis of the fracture lines, a dense cortical margin, and osteophyte formation around the fracture site. In cases where there are no previous plain radiographs for comparison, MRI or bone scan may be needed to age fracture acuity.[50]

[Figure caption and citation for the preceding image starts]: Lateral radiograph showing a T12 compression fracture in osteoporotic bonePersonal collection of Nasir A. Quraishi [Citation ends].com.bmj.content.model.Caption@5cf1129a

MRI spine/CT spine

In patients with new symptomatic vertebral compression fractures identified on radiographs and no known malignancy, MRI or CT spine of the area of interest is usually appropriate for pre-procedural planning, if intervention is being considered.[9][50]​ CT or MRI spine of the area of interest are particularly useful for initial imaging if radiographs are negative.[50]​​

CT provides osseous details of axial spine fractures before vertebral augmentation and permits evaluation of vertebral body height, architecture, and integrity of the posterior cortex and pedicles before vertebral augmentation, which is critical in patients with cortical disruption, posterior cortex osseous retropulsion, and spinal canal compression.[9] MRI is particularly useful in identifying minimally compressed fractures, distinguishing acute from chronic fractures, and distinguishing fractures due to tumor or infection.[1][9][50]​ If there are neurologic signs, concerns over fracture stability, or a suspicion that fractures may be pathologic, a CT scan and/or an MRI is indicated.[19]​ MRI is more useful than CT for assessing the integrity of the soft tissue and neural structures, particularly that of the spinal canal.[50]​ MRI is the only modality for evaluating the internal structure of the spinal cord.[58]​ ​

Technetium-99m (Tc-99m) whole-body bone scan (bone scintigraphy)

Tc-99m whole-body bone scan (bone scintigraphy) may be helpful to determine the painful vertebrae, particularly the causative level.[9] Whole-body bone scans may be helpful in the setting of compression fractures to help identify fracture acuity and to appropriately select patients for intervention, particularly if MRI cannot be safely/easily obtained.[50][59]​​

Single-photon emission computed tomography (SPECT)/CT

SPECT coupled with CT may also be appropriate.[9][50]​ SPECT/CT has been shown to localize abnormalities in the vertebra more precisely compared with SPECT imaging alone, particularly in complicated cases, such as multiple collapsed vertebrae of different ages.​[9][60] SPECT/CT appears to be comparable to MRI in detecting fractures, particularly in the acute phase, and could be considered if MRI is contraindicated​​​.[61][62]

​​Other investigations

Additional investigations may be appropriate:

  • If a diagnosis of osteoporosis is suspected but unconfirmed, a nonurgent dual-energy x-ray absorptiometry bone density scan may be obtained as part of the workup.[11]

  • If there is a suspicion of malignancy, a complete blood count (CBC), serum alkaline phosphatase, and C-reactive protein are indicated.

  • If there is a suspicion of infection, a CBC and blood cultures should be obtained.

  • A bone profile may be useful to exclude a metabolic cause. This includes serum calcium, albumin, parathyroid hormone, phosphate, alkaline phosphatase, magnesium, creatinine, and serum 25-hydroxyvitamin D (25OHD).

  • Other tests such as thyroid-stimulating hormone, screening for hypercortisolism, and serum protein electrophoresis may also be considered.

  • If spinal hardware is present, CT myelography may be useful in the assessment of hardware integrity and position.[50][63]​​

Use of this content is subject to our disclaimer