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Vertebral compression fractures: a review of current management and multimodal therapy

Vertebral compression fractures: a review of current management and multimodal therapy Journal of Multidisciplinary Healthcare Dovepress open access to scientific and medical research Open Access Full Text Article R EV i EW Vertebral compression fractures: a review of current management and multimodal therapy Cyrus C Wong Abstract: Vertebral compression fractures are a prevalent disease affecting osteoporotic patients. When symptomatic, they cause significant pain and loss of function and have a high Matthew J McGirt public health impact. In this paper we outline the diagnosis and management of these patients, Vanderbilt University Medical Center, with evidence-based review of treatment outcomes for the various therapeutic options. Diagnosis Nashville, TN, USA involves a clinical history focusing on the nature of the patient’s pain as well as various imaging studies. Management is multimodal in nature and starts with conservative therapy consisting of analgesic medication, medication for osteoporosis, physical therapy, and bracing. Patients who are refractory to conservative management may be candidates for vertebral augmentation through either vertebroplasty or kyphoplasty. Keywords: ver tebral compression fractures, osteoporosis, bracing, ver tebroplasty, kyphoplasty Epidemiology and public health impact Epidemiology and risk factors Vertebral compression fractures are the most common sequelae of osteoporosis, comprising approximately 700,000 out of a total 1.5 million osteoporotic fractures annually in the USA. The actual incidence of vertebral fractures is likely much greater given the large number of vertebral fractures that go undetected, with only a third of 1–4 vertebral fractures clinically diagnosed. Vertebral fractures are directly correlated with increasing age and incidence of osteoporosis. They most commonly occur among Caucasian women and are less 1,5,6 common among men and women of African-American or Asian ethnicity. Bone density of the vertebral column decreases steadily with age, with elderly women having 7–9 lost almost half their axial bone mass by the time they reach their eighties. The rate of vertebral fractures increases from an annual incidence of 0.9% and prevalence of 5%–10% among middle-aged women in their 50s to 60s, to an incidence of 1.7% 1,10,11 and prevalence of greater than 30% among those 80 years and older. These age- correlated prevalence rates in the USA are very similar to those in Europe as published 3,12 by the European Vertebral Osteoporosis Study. Correspondence: Cyrus C Wong Department of Neurological Surgery, The risk of developing a vertebral fracture is strongly associated with decreasing Vanderbilt University Medical Center, bone density, with the risk increasing roughly two times for every standard deviation 1161 21st Avenue South, T4224 MCN, 1,3 Nashville, TN 37232-2380, USA below average vertebral bone mineral density. Bone density begins to decrease Tel +1 615 343 2452 after age 40 for both men and women, and the process is rapidly accelerated in Fax +1 615 343 8104 Email cyrus.c.wong@vanderbilt.edu postmenopausal women. Though genetic predisposition and age of puberty onset play submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 205–214 Dovepress © 2013 Wong and McGirt, publisher and licensee Dove Medical Press Ltd. This is an Open Access http://dx.doi.org./10.2147/JMDH.S31659 article which permits unrestricted noncommercial use, provided the original work is properly cited. Wong and McGirt Dovepress a significant role, a multitude of lifestyle and environmental anteriorly and be confused with a cardiac or pulmonary factors increase the risk of developing osteoporosis. These process. The vertebral bodies support 80% of the body’s include lack of exercise and low body mass index, insufc fi ient weight, so that the pain is typically worse when sitting up, dietary calcium, low vitamin D production, glucocorticoid standing, or ambulating, and improved when lying down. 1,3,13 medication, smoking, and excessive alcohol intake. This is described as mechanical axial back pain, and can be Occasionally, vertebral compression fractures may be the distinguished through history taking from other etiologies presenting finding for an underlying medical condition such of back pain such as osteoarthritic pain, pathologic pain as metastatic disease or hyperparathyroidism. associated with tumor, and lumbar strain. Though most commonly found among osteoporotic Vertebral compression fractures usually occur in the patients (T score # −2.5 on dual-energy x-ray absorptiometry mid-thoracic or thoracolumbar transition zone of the spine. [DEXA]), vertebral fractures may also occur in up to 18% of Though exceedingly rare, occasionally retropulsion of women . 60 years old with low bone mass but not meeting fracture fragments may result in compression of the spinal 1,14 the criteria for osteoporosis (T score . −2.5 but ,−1.4). cord or cauda equina and result in weakness and loss of It is estimated that more than a third of postmenopausal sensation of the lower extremities or even bowel or bladder vertebral compression fractures occur in women who do not incontinence. Depending on the severity and rapidity of 1,15 24 meet the criteria for osteoporosis. deficit onset, this may constitute a surgical emergency. Furthermore, the risk of developing a vertebral fracture The loss of height that results from a compression fracture is roughly five times greater if the patient has had a prior may lead to kyphotic deformity of the spine, especially for fracture, and 20% of osteoporotic postmenopausal women multiple compression fractures with significant height loss. who present with an initial vertebral fracture develop a This may result in focal or global sagittal imbalance, which 16,17 subsequent vertebral fracture within the year. These may lead to chronic back pain even after the fracture has patients are also at high risk of developing other significant healed and accelerate the degeneration of adjacent spinal osteoporotic fractures, such as hip fractures, highlighting the segments. The back pain and associated fatigue can severely need for early detection, treatment, and medical optimization limit a patient’s quality of life and ability to perform activities of a patient’s bone quality and health. of daily living. In addition, severe kyphoscoliotic deformity can even lead to a restricted abdominal space, limiting Socioeconomic costs pulmonary vital capacity as well as decreasing nutritional Vertebral fracture, when symptomatic through either back intake, thus compounding patient immobility. pain or occasionally neurologic compromise, is a high impact disease with significant societal and economic costs. The imaging annual US medical cost for vertebral fracture management Many imaging studies may be used in the workup of vertebral 18,19 was estimated at $13.8 billion in 2001 and has likely compression fractures. The most widely available and cost- since increased with the growing elderly population. The effective initial imaging study is a lateral X-ray of the thoracic total economic cost is also far greater than the cost for or lumbar spine (Figure 1). This allows for quick screening acute management given that vertebral fractures can lead and identification of fractures, estimation of loss of height to significant long-term morbidity. In the first year alone and, when taken upright, assessment of spinal alignment. after a painful vertebral fracture, patients have been found Certain characteristics on plain radiograph are suggestive of to require primary care services at a rate 14 times greater osteopenia: increased lucency, loss of horizontal trabeculae, 3,21 than the general population. Furthermore, osteoporotic and decreased cortical thickness but increased relative opacity compression fractures have been associated with a 15% of the end-plates and vertical trabeculae. Comparison to pre- higher mortality rate. existing spine X-rays allows the clinician to diagnose and judge the age of the vertebral fracture. In patients without Diagnosis and symptoms prior spinal imaging, certain radiographic criteria may aid Clinical presentation in diagnosis. Compression fractures may be classified based Many fractures may develop insidiously and chronic on the portion of the vertebral body that is affected: either compression fractures are commonly detected incidentally wedge-shaped (anterior), biconcave (middle), or crush on chest X-rays. When symptomatic, patients complain (posterior), with a minimum of 20% height loss relative to of sudden-onset severe, focal, back pain that may radiate the unaffected portion of the vertebral body. In cases of submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Dovepress Vertebral compression fractures Figure 1 Lateral radiograph demonstrates biconcave-appearing compression fractures at L2 and L3, showing progression in loss of height in these X-rays taken a year apart. complete compression fractures there is a reduction in both for osteoporosis. After the diagnosis of a compression fracture posterior and anterior height. A plain radiograph may be on initial imaging, bone density should be assessed by DEXA all that is necessary for a majority of compression fractures, scan. Bone density on DEXA is reported as a T score and is especially if one proceeds with conservative, medical typically measured at several sites including the spine, hip, management. and femoral neck to avoid being thrown off by local variations When there is need for further characterization, a computed secondary to osteoarthritis. Roughly half of patients with tomography (CT) scan allows for the best imaging of bony vertebral fractures have osteoporosis (T score , −2.5) and anatomy and improved assessment of loss of height, fragment another 40% have osteopenia (T score −1 to −2.5), and retropulsion, and canal compromise. However, this comes medical treatment aimed at improving bone quality should with greater expense and irradiation for the patient. CT scan be initiated in these patients. may also reveal a chronic fracture through the presence of cortication. However, magnetic resonance imaging (MRI) is Medical management the best study for judging fracture age, as it will show bony Pain control edema for an acute fracture. In addition, MRI allows for the Following initial evaluation and diagnosis of a vertebral evaluation of neural compromise secondary to compression compression fracture, therapy should be aimed at pain control of the spinal cord or nerve roots (Figure 2). MRI short TI in a manner that avoids prolonged bed-rest and allows for inversion recovery (STIR) sequence will also reveal integrity early mobilization of the patient. Acute pain control may of the spinal ligamentous complex, which can be important include nonsteroidal anti-inflammatory drugs (NSAIDs), during surgical evaluation of fracture stability. Finally, a post- muscle relaxants, narcotic pain medication, neuropathic contrast MRI study will detect a pathologic fracture secondary pain agents (ie, tricyclic antidepressants), local analgesic to an oncologic process. Other, less commonly used imaging patch, intercostal nerve blocks, and transcutaneous nerve 1,3 studies include bone scan (Figure 3), which will show increased stimulation units. NSAIDs are often r fi st-line drugs for back uptake in a fracture, or vertebral fracture assessment, which pain as they do not have sedating effects. However, they do allows for a quick fracture evaluation from T4 to L4 and may have gastric toxicity and an increased risk of cardiac events be done in conjunction with a DEXA scan. for patients with hypertension and coronary artery disease. There is also a theoretical inhibitory effect of NSAIDs on Bone density assessment bony healing, though this has not been the case in actual 29,30 Without a histor y of trauma, spontaneous ver tebral studies. Opioids and muscle relaxants may provide strong compression fractures are typically pathognomonic relief when NSAIDs are inadequate but have significant submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Wong and McGirt Dovepress Figure 2 Sagittal T2 magnetic resonance imaging demonstrating a traumatic burst fracture at L4 with bony retropulsion and canal compromise requiring open surgical decompression and fixation. Note: A concomitant acute compression fracture at L1 (note the bony edema) was treated with kyphoplasty in the same surgery. sedative effects as well as the risk of dependency. As such medication given its favorable safety profile and efficacy in their use needs to be carefully balanced in the geriatric reducing fracture risk. Hormone replacement therapy may 3 3 patient. be an option for younger postmenopausal women. Finally, while calcium and vitamin D are insufficient alone in Preventative medicine reducing fracture risk, supplementation may be necessary Other than acute pain control, medical therapy should be for deficient patients. Follow up of treatment efficacy may aimed at improving bone quality and thus reducing the risk be done with subsequent DEXA scan, though typically a of future fracture. Agents for treating osteoporosis include 2-year treatment period is needed before improvement of bisphosphonates, selective estrogen receptor modulators, bone mineral density is detected. recombinant parathyroid hormone, and calcitonin. These Interestingly, several medications for osteoporosis agents act through either antiresportive or osteogenic treatment also play a role in acute pain relief. Calcitonin mechanisms. The bisphosphonate alendronate is a first-line has been found in multiple randomized controlled trials submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Dovepress Vertebral compression fractures long term. As such, the exercises prescribed should have two purposes: (1) strengthening the patient’s supportive axial musculature, in particular the spinal extensors, and (2) training the patient’s proprioceptive reflexes to improve posture and ambulation and decrease the likelihood of future falls. The erector spinae play a crucial role in the posterior tension band that maintains normal posture, by balancing the biomechanical tendency of the spine to fall forward. This function coincidentally reduces mechanical stress on the vertebral bodies. As such, strengthening the spinal extensor muscles will improve lumbar lordosis and posture, thus reducing acute fracture pain as well as chronic back pain associated with kyphotic deformity. This reinforcement is especially important since axial musculature decreases in strength with age, particularly among women, who are most at risk for vertebral fracture. Studies have shown that back extension strength and lumbar mobility are the most important factors for quality of life among postmenopausal osteoporotic women, compared to other relevant factors such as lumbar kyphosis angle and bone mineral density. While repetitive mechanical loading will stimulate osteogenesis (Wolff ’s law) and improve patient bone quality, such loading parameters need to be within the physiologic capacity of the compromised bone. To that end, both exercise selection and intensity should be tailored towards the individual patient to avoid over-stressing the spine and causing new injury. Intense spinal flexion exercise in any form transmits significant force to the intervertebral discs which, when the discs are degenerated, is largely passed on to the vertebral bodies. In one study of postmenopausal osteoporotic women undergoing exercise rehabilitation, there was an 89% rate of further vertebral fracture associated with abdominal flexion training compared to only 16% with back extension exercises. Likewise, exercises aimed Figure 3 Nuclear medicine bone scan demonstrating increased uptake at a T7 at increasing spinal flexibility, particularly spinal flexion, fracture. may actually reduce some of the protective mechanisms against back pain. Exercises should focus on strengthening to provide pain relief for acute compression fractures. back extension and may include weighted or unweighted Bisphosphonates have also shown similar improvements in prone position extension exercises, isometric contraction acute pain control. Finally, patients treated with teriparatide of the paraspinal muscles, and careful loading of the upper 41–43 (recombinant parathyroid hormone) show decreased back extremities. pain, when compared with patients treated with placebo, The Spinal Proprioception Extension Exercise Dynamic 33,34 9 hormone replacement therapy, or alendronate. (SPEED) program designed by Sinaki is an example of a regimen that focuses on strengthening the spinal Physical therapy extensors using a weighted kypho-orthosis and postural Physical therapy should assist with early mobilization and proprioceptive training, through twice-daily, 20-minute in the acute phase and prevent further injuries in the exercise sessions. A 4-week program was found to improve submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Wong and McGirt Dovepress back pain and back strength, reduce the risk of fall and patient (L1–3). Intervertebral motion has been shown to actually fear of falls, and increase physical activity level. The patients increase from L4–S1 with a lumbosacral orthoses brace. were also shown to have improved gait and posture using Potential downfalls of a rigid brace include patient 9,44 computerized analysis. discomfort, which may decrease compliance. These patients, Several other trials have demonstrated similar efc fi acy of typically elderly and frail, are at risk for skin breakdown if physical therapy programs in managing painful compression the brace edges are not carefully padded. In addition, a brace fractures. Malmros et al looked at a 10-week physiotherapy that is too restrictive may impede the patient’s respiratory program involving strength and balance training and found volume. Finally, with prolonged periods of bracing there is benefits in back extension strength, quality of life, and potential for deconditioning and atrophy of the trunk and reduction in pain and analgesic use. These benefits persisted paraspinal muscles. As such, many authors have moved away at follow-up 12 weeks after the patients had completed the from recommending rigid braces and towards light-weight, training program. Bennell et al similarly used a 10-week soft braces, except in cases of severe deformity. program that included manual therapy in addition to exercise Surgical management and demonstrated improved back pain, physical function, and quality of life. Papaioannou et al studied a longer, 6-month indications and contraindications home exercise program consisting of stretching, strength Though there is no standard time for appropriate conservative training, and aerobics and found that the exercise group had management, patients should have pain relief by 6 weeks. When improved Osteoporosis Quality of Life Questionnaire scores patients continue to have unremitting pain or demonstrated and improved balance at the 1-year point, though no change fracture progression on follow-up radiograph, consideration in bone mineral density was found. should then be given to a vertebral augmentation procedure. Vertebroplasty and kyphoplasty are minimally invasive, Bracing percutaneous procedures performed by spine surgeons Bracing is commonly used for symptomatic management and pain management specialists to treat osteoporotic or of vertebral fractures. However, the majority of randomized oncologic fractures. controlled trials examining bracing were based on acute, Eligible patients should have significant back pain and traumatic burst fractures. As such, there is little consensus tenderness in the fracture area that increases with mechanical on its application for osteoporotic compression fractures. axial loading. The fracture should be within the subacute One prospective randomized trial on the 6-month use of phase before it is healed. In addition, it is not possible a thoracolumbar orthoses (TLO) brace for osteoporotic to perform vertebroplasty or kyphoplasty in completely compression fractures found improvement in trunk muscle collapsed vertebral bodies, known as vertebra plana. If CT strength, posture, and body height amongst the treatment demonstrates incompetency or fracture through the posterior group, ultimately with better quality of life and ability to wall of the vertebrae, risk of cement extrusion into the spinal perform activities of daily living (ADL). canal is greatly increased. An absolute contraindication is The use of a spinal orthosis maintains neutral spinal bony retropulsion with neurologic compromise, as this may alignment and limits flexion, thus reducing axial loading worsen with the injection of cement. In these cases, an open on the fractured vertebra. In addition, the brace allows for surgical decompression and fixation may be appropriate. less fatigue of the paraspinal musculature and muscle spasm Other contraindications include active osteomyelitis of 52–54 relief. However, this finding has not consistently held up the fracture site or allergies to kyphoplasty cement. to electromyography study, with two studies showing In addition, patients need to tolerate general anesthesia in 49,50 increased activity in the spinal muscles with bracing. the prone position (though occasionally sedation and local Several brace types are available depending on the location anesthesia is used). Particular attention needs to be paid to and severity of fracture. Fractures in the thoracic spine may cardiac and pulmonary reserve, especially with treatment be treated with TLO. Examples include the Jewitt, cruciform of multiple levels, as both operative time and the risk of anterior spinal hyperextension, and Taylor brace. Braces pulmonary fat embolism increases. which extend to the sacrum are termed thoracolumbar sacral orthoses. Finally, lumbosacral orthoses are also Procedure available for lumbar fractures but are only effective in Ver tebroplasty involves the fluoroscopically-guided restricting sagittal plane motion in the upper lumbar spine transpedicular insertion of a cannulated trochar that is used to submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Dovepress Vertebral compression fractures inject radiopaque cement, typically polymethylmethacrylate sequentially injected in incremental volumes. It is necessary into the fracture. The goal is to provide structural support to to take multiple images during injection to ensure that there the compromised trabecular bone and restore lost vertebral is adequate cavity filling and no cement retropulsion into the height. Typically a bipedicular approach using two trochars spinal canal (Figure 5). is chosen for more even cement distribution. Occasionally in the upper thoracic spine, where the pedicles can be very Potential complications small, an extrapedicular approach is used with trochar Typically vertebral augmentation is performed as an insertion between the medial rib head and lateral edge of outpatient procedure and is well tolerated. Patients may the pedicle. experience relief of their back pain within 24 hours of Ideally two u fl oroscopy machines are used simultaneously the procedure. The overall reported complication rates around the patient, who is positioned in an ar ms-up are particularly low in cases of osteoporotic compression “superman” position on a Jackson table, to allow for fractures (,4%), but increase for oncologic fractures, though 18,53,56,57 concurrent anteroposterior (AP) and lateral images. This symptomatic complications remain less than 10%. The saves time and reduces the chance of contamination by incidence of cement extravasation into the spinal canal or 18,53 avoiding the need for frequent fluoroscopy repositioning. neuroforamen is rare (0.4%–4%) and often asymptomatic A good starting AP image, with the endplates lined up at the or transient, but it is important to recognize when this occurs, procedural level and pedicles clearly outlined, is crucial when as it may result in painful radiculopathy and weakness. If introducing the trochars. Subsequently both AP and lateral high enough to affect the spinal cord or conus medullaris, it images are used to guide the advancement of the trochar into may even cause paraparesis, which constitutes an emergency the collapsed vertebral body, avoid medial or lateral breaches, and requires surgical decompression. Cement may also and determine the final depth. extravasate into the paraspinal musculature, which is typically Kyphoplasty adds an additional step prior to the cement asymptomatic, but on extremely rare instances may enter 18,52 injection. After trochar insertion, an infla table balloon tamp the venous system and result in embolic phenomenon. is threaded into the fracture and expanded. The purpose Finally, fractures may develop in vertebrae adjacent to the of this step is to compact the cancellous bone and create augmented vertebral body. Some researchers, for example, an expanded cavity for cement injection. This plays a Hadley et al, have speculated that this is due to increased signic fi ant role in restoring vertebral body height. The extent loading on the adjacent levels secondary to stiffness of the of inflation is determined by monitoring pressure, inflated augmented body, but similar incidences of adjacent fracture volume, and appearance of the balloon and vertebral body with untreated patients have been reported, suggesting that on fluoroscopy. Pressure should not exceed a maximum of this is a consequence of the patient’s existing osteoporotic 53 53 300 psi and is usually kept less than 220 psi. Maximum disease as opposed to a result of the intervention. volume inflation ranges from 4–6 mL. During the inflation process sequential images are taken to monitor appropriate Treatment outcomes expansion of the balloon, ensuring adequate contact with, but Though a large number of trials have examined the efc fi acy avoiding violation of, the cortical endplates (Figure 4). Once of vertebral augmentation compared to optimal medical the inflation cavity has been created, radiopaque cement is management, there remains signif icant controversy. Figure 4 intraoperative images showing lateral and anteroposterior fluoroscopic images, after the injection of polymethylmethacrylate. submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Wong and McGirt Dovepress Figure 5 Pre- and postoperative X-rays demonstrating the restoration of vertebral body height after kyphoplasty. 63,64 Overall, there are a greater number of studies on vertebroplasty Medicine and received signic fi ant publicity. These studies, than kyphoplasty given its longer history. McGirt et al by Buchbinder et al and by Kallmes et al, involved comparisons published a review in 2009 of all studies of vertebral between vertebroplasty and sham procedure groups, rather augmentation outcomes over a 20-year period. The review than the usual comparison group of medical management. included 74 studies (including one level I) of vertebroplasty The authors of both studies reported no difference in pain for osteoporotic compression fractures, 35 kyphoplasty control or function between the groups, from 1 week to studies for osteoporotic fractures, and 18 studies for tumor- 6 months follow-up in one study and 1 month follow-up in the 63,64 related fractures, which were all level IV studies. The authors other. They suggested that the benet fi s of vertebroplasty in 65,66 found level I evidence that vertebroplasty provides superior prior trials were secondary to a procedural placebo effect. pain control over medical management in the r fi st 2 weeks, These studies have been the subject of criticism, focusing and level II–III evidence that within the r fi st 3 months there on their low enrollment numbers (78 and 131 patients), low are superior outcomes in analgesic use, disability, and general volume and infrequent rate of vertebroplasty performed at health, and n fi ally level II–III evidence that by 2 years there the centers over a long time interval, lack of clear inclusion is a similar level of pain control and physical function. With criteria specifying patients with mechanical axial back pain, 67,68 regards to kyphoplasty, there was level II–III evidence of and inadequate volume of cement injection. The debate improvement in daily activity, physical function, and pain about vertebral augmentation continues. One ongoing study control at 6 months, compared to medical management. that may shed light on the matter is the VERTOS IV trial, a Though the studies were favorable for tumor-related fractures non-industry supported, prospective randomized controlled there was insufficient evidence for comparison. trial of 180 patients that compares vertebroplasty to sham Since this review, other randomized trials have been procedure, similar to the New England Journal of Medicine performed, which have mostly shown improved pain control studies, but uses the strict inclusion criteria of the VERTOS 69,70 and physical function with vertebroplasty in the short II trial. 59,60 term, but diminished or no difference with medical 60,61 management at 1-year follow-up. A subsequent, larger, Conclusion randomized controlled trial enrolling 202 patients dubbed Vertebral fractures have signic fi ant effect on patient quality of VERTOS II did find sustained, significant differences at life and a high socioeconomic cost. Initial management begins 1-year follow-up with continued improved pain relief for the with the primary care provider. Diagnostic studies include vertebroplasty group. plain radiographs and are typically followed by bone density Notably, in 2009, two double-blind randomized controlled workup with DEXA imaging. Conservative management trials were published in the New England Journal of should be attempted for up to 6 weeks. This may involve submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Dovepress Vertebral compression fractures 13. Compston JE. Risk factors for osteoporosis. 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Vertebral compression fractures: a review of current management and multimodal therapy

Journal of Multidisciplinary Healthcare , Volume 6 – Jun 17, 2013

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Abstract

Journal of Multidisciplinary Healthcare Dovepress open access to scientific and medical research Open Access Full Text Article R EV i EW Vertebral compression fractures: a review of current management and multimodal therapy Cyrus C Wong Abstract: Vertebral compression fractures are a prevalent disease affecting osteoporotic patients. When symptomatic, they cause significant pain and loss of function and have a high Matthew J McGirt public health impact. In this paper we outline the diagnosis and management of these patients, Vanderbilt University Medical Center, with evidence-based review of treatment outcomes for the various therapeutic options. Diagnosis Nashville, TN, USA involves a clinical history focusing on the nature of the patient’s pain as well as various imaging studies. Management is multimodal in nature and starts with conservative therapy consisting of analgesic medication, medication for osteoporosis, physical therapy, and bracing. Patients who are refractory to conservative management may be candidates for vertebral augmentation through either vertebroplasty or kyphoplasty. Keywords: ver tebral compression fractures, osteoporosis, bracing, ver tebroplasty, kyphoplasty Epidemiology and public health impact Epidemiology and risk factors Vertebral compression fractures are the most common sequelae of osteoporosis, comprising approximately 700,000 out of a total 1.5 million osteoporotic fractures annually in the USA. The actual incidence of vertebral fractures is likely much greater given the large number of vertebral fractures that go undetected, with only a third of 1–4 vertebral fractures clinically diagnosed. Vertebral fractures are directly correlated with increasing age and incidence of osteoporosis. They most commonly occur among Caucasian women and are less 1,5,6 common among men and women of African-American or Asian ethnicity. Bone density of the vertebral column decreases steadily with age, with elderly women having 7–9 lost almost half their axial bone mass by the time they reach their eighties. The rate of vertebral fractures increases from an annual incidence of 0.9% and prevalence of 5%–10% among middle-aged women in their 50s to 60s, to an incidence of 1.7% 1,10,11 and prevalence of greater than 30% among those 80 years and older. These age- correlated prevalence rates in the USA are very similar to those in Europe as published 3,12 by the European Vertebral Osteoporosis Study. Correspondence: Cyrus C Wong Department of Neurological Surgery, The risk of developing a vertebral fracture is strongly associated with decreasing Vanderbilt University Medical Center, bone density, with the risk increasing roughly two times for every standard deviation 1161 21st Avenue South, T4224 MCN, 1,3 Nashville, TN 37232-2380, USA below average vertebral bone mineral density. Bone density begins to decrease Tel +1 615 343 2452 after age 40 for both men and women, and the process is rapidly accelerated in Fax +1 615 343 8104 Email cyrus.c.wong@vanderbilt.edu postmenopausal women. Though genetic predisposition and age of puberty onset play submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 205–214 Dovepress © 2013 Wong and McGirt, publisher and licensee Dove Medical Press Ltd. This is an Open Access http://dx.doi.org./10.2147/JMDH.S31659 article which permits unrestricted noncommercial use, provided the original work is properly cited. Wong and McGirt Dovepress a significant role, a multitude of lifestyle and environmental anteriorly and be confused with a cardiac or pulmonary factors increase the risk of developing osteoporosis. These process. The vertebral bodies support 80% of the body’s include lack of exercise and low body mass index, insufc fi ient weight, so that the pain is typically worse when sitting up, dietary calcium, low vitamin D production, glucocorticoid standing, or ambulating, and improved when lying down. 1,3,13 medication, smoking, and excessive alcohol intake. This is described as mechanical axial back pain, and can be Occasionally, vertebral compression fractures may be the distinguished through history taking from other etiologies presenting finding for an underlying medical condition such of back pain such as osteoarthritic pain, pathologic pain as metastatic disease or hyperparathyroidism. associated with tumor, and lumbar strain. Though most commonly found among osteoporotic Vertebral compression fractures usually occur in the patients (T score # −2.5 on dual-energy x-ray absorptiometry mid-thoracic or thoracolumbar transition zone of the spine. [DEXA]), vertebral fractures may also occur in up to 18% of Though exceedingly rare, occasionally retropulsion of women . 60 years old with low bone mass but not meeting fracture fragments may result in compression of the spinal 1,14 the criteria for osteoporosis (T score . −2.5 but ,−1.4). cord or cauda equina and result in weakness and loss of It is estimated that more than a third of postmenopausal sensation of the lower extremities or even bowel or bladder vertebral compression fractures occur in women who do not incontinence. Depending on the severity and rapidity of 1,15 24 meet the criteria for osteoporosis. deficit onset, this may constitute a surgical emergency. Furthermore, the risk of developing a vertebral fracture The loss of height that results from a compression fracture is roughly five times greater if the patient has had a prior may lead to kyphotic deformity of the spine, especially for fracture, and 20% of osteoporotic postmenopausal women multiple compression fractures with significant height loss. who present with an initial vertebral fracture develop a This may result in focal or global sagittal imbalance, which 16,17 subsequent vertebral fracture within the year. These may lead to chronic back pain even after the fracture has patients are also at high risk of developing other significant healed and accelerate the degeneration of adjacent spinal osteoporotic fractures, such as hip fractures, highlighting the segments. The back pain and associated fatigue can severely need for early detection, treatment, and medical optimization limit a patient’s quality of life and ability to perform activities of a patient’s bone quality and health. of daily living. In addition, severe kyphoscoliotic deformity can even lead to a restricted abdominal space, limiting Socioeconomic costs pulmonary vital capacity as well as decreasing nutritional Vertebral fracture, when symptomatic through either back intake, thus compounding patient immobility. pain or occasionally neurologic compromise, is a high impact disease with significant societal and economic costs. The imaging annual US medical cost for vertebral fracture management Many imaging studies may be used in the workup of vertebral 18,19 was estimated at $13.8 billion in 2001 and has likely compression fractures. The most widely available and cost- since increased with the growing elderly population. The effective initial imaging study is a lateral X-ray of the thoracic total economic cost is also far greater than the cost for or lumbar spine (Figure 1). This allows for quick screening acute management given that vertebral fractures can lead and identification of fractures, estimation of loss of height to significant long-term morbidity. In the first year alone and, when taken upright, assessment of spinal alignment. after a painful vertebral fracture, patients have been found Certain characteristics on plain radiograph are suggestive of to require primary care services at a rate 14 times greater osteopenia: increased lucency, loss of horizontal trabeculae, 3,21 than the general population. Furthermore, osteoporotic and decreased cortical thickness but increased relative opacity compression fractures have been associated with a 15% of the end-plates and vertical trabeculae. Comparison to pre- higher mortality rate. existing spine X-rays allows the clinician to diagnose and judge the age of the vertebral fracture. In patients without Diagnosis and symptoms prior spinal imaging, certain radiographic criteria may aid Clinical presentation in diagnosis. Compression fractures may be classified based Many fractures may develop insidiously and chronic on the portion of the vertebral body that is affected: either compression fractures are commonly detected incidentally wedge-shaped (anterior), biconcave (middle), or crush on chest X-rays. When symptomatic, patients complain (posterior), with a minimum of 20% height loss relative to of sudden-onset severe, focal, back pain that may radiate the unaffected portion of the vertebral body. In cases of submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Dovepress Vertebral compression fractures Figure 1 Lateral radiograph demonstrates biconcave-appearing compression fractures at L2 and L3, showing progression in loss of height in these X-rays taken a year apart. complete compression fractures there is a reduction in both for osteoporosis. After the diagnosis of a compression fracture posterior and anterior height. A plain radiograph may be on initial imaging, bone density should be assessed by DEXA all that is necessary for a majority of compression fractures, scan. Bone density on DEXA is reported as a T score and is especially if one proceeds with conservative, medical typically measured at several sites including the spine, hip, management. and femoral neck to avoid being thrown off by local variations When there is need for further characterization, a computed secondary to osteoarthritis. Roughly half of patients with tomography (CT) scan allows for the best imaging of bony vertebral fractures have osteoporosis (T score , −2.5) and anatomy and improved assessment of loss of height, fragment another 40% have osteopenia (T score −1 to −2.5), and retropulsion, and canal compromise. However, this comes medical treatment aimed at improving bone quality should with greater expense and irradiation for the patient. CT scan be initiated in these patients. may also reveal a chronic fracture through the presence of cortication. However, magnetic resonance imaging (MRI) is Medical management the best study for judging fracture age, as it will show bony Pain control edema for an acute fracture. In addition, MRI allows for the Following initial evaluation and diagnosis of a vertebral evaluation of neural compromise secondary to compression compression fracture, therapy should be aimed at pain control of the spinal cord or nerve roots (Figure 2). MRI short TI in a manner that avoids prolonged bed-rest and allows for inversion recovery (STIR) sequence will also reveal integrity early mobilization of the patient. Acute pain control may of the spinal ligamentous complex, which can be important include nonsteroidal anti-inflammatory drugs (NSAIDs), during surgical evaluation of fracture stability. Finally, a post- muscle relaxants, narcotic pain medication, neuropathic contrast MRI study will detect a pathologic fracture secondary pain agents (ie, tricyclic antidepressants), local analgesic to an oncologic process. Other, less commonly used imaging patch, intercostal nerve blocks, and transcutaneous nerve 1,3 studies include bone scan (Figure 3), which will show increased stimulation units. NSAIDs are often r fi st-line drugs for back uptake in a fracture, or vertebral fracture assessment, which pain as they do not have sedating effects. However, they do allows for a quick fracture evaluation from T4 to L4 and may have gastric toxicity and an increased risk of cardiac events be done in conjunction with a DEXA scan. for patients with hypertension and coronary artery disease. There is also a theoretical inhibitory effect of NSAIDs on Bone density assessment bony healing, though this has not been the case in actual 29,30 Without a histor y of trauma, spontaneous ver tebral studies. Opioids and muscle relaxants may provide strong compression fractures are typically pathognomonic relief when NSAIDs are inadequate but have significant submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Wong and McGirt Dovepress Figure 2 Sagittal T2 magnetic resonance imaging demonstrating a traumatic burst fracture at L4 with bony retropulsion and canal compromise requiring open surgical decompression and fixation. Note: A concomitant acute compression fracture at L1 (note the bony edema) was treated with kyphoplasty in the same surgery. sedative effects as well as the risk of dependency. As such medication given its favorable safety profile and efficacy in their use needs to be carefully balanced in the geriatric reducing fracture risk. Hormone replacement therapy may 3 3 patient. be an option for younger postmenopausal women. Finally, while calcium and vitamin D are insufficient alone in Preventative medicine reducing fracture risk, supplementation may be necessary Other than acute pain control, medical therapy should be for deficient patients. Follow up of treatment efficacy may aimed at improving bone quality and thus reducing the risk be done with subsequent DEXA scan, though typically a of future fracture. Agents for treating osteoporosis include 2-year treatment period is needed before improvement of bisphosphonates, selective estrogen receptor modulators, bone mineral density is detected. recombinant parathyroid hormone, and calcitonin. These Interestingly, several medications for osteoporosis agents act through either antiresportive or osteogenic treatment also play a role in acute pain relief. Calcitonin mechanisms. The bisphosphonate alendronate is a first-line has been found in multiple randomized controlled trials submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Dovepress Vertebral compression fractures long term. As such, the exercises prescribed should have two purposes: (1) strengthening the patient’s supportive axial musculature, in particular the spinal extensors, and (2) training the patient’s proprioceptive reflexes to improve posture and ambulation and decrease the likelihood of future falls. The erector spinae play a crucial role in the posterior tension band that maintains normal posture, by balancing the biomechanical tendency of the spine to fall forward. This function coincidentally reduces mechanical stress on the vertebral bodies. As such, strengthening the spinal extensor muscles will improve lumbar lordosis and posture, thus reducing acute fracture pain as well as chronic back pain associated with kyphotic deformity. This reinforcement is especially important since axial musculature decreases in strength with age, particularly among women, who are most at risk for vertebral fracture. Studies have shown that back extension strength and lumbar mobility are the most important factors for quality of life among postmenopausal osteoporotic women, compared to other relevant factors such as lumbar kyphosis angle and bone mineral density. While repetitive mechanical loading will stimulate osteogenesis (Wolff ’s law) and improve patient bone quality, such loading parameters need to be within the physiologic capacity of the compromised bone. To that end, both exercise selection and intensity should be tailored towards the individual patient to avoid over-stressing the spine and causing new injury. Intense spinal flexion exercise in any form transmits significant force to the intervertebral discs which, when the discs are degenerated, is largely passed on to the vertebral bodies. In one study of postmenopausal osteoporotic women undergoing exercise rehabilitation, there was an 89% rate of further vertebral fracture associated with abdominal flexion training compared to only 16% with back extension exercises. Likewise, exercises aimed Figure 3 Nuclear medicine bone scan demonstrating increased uptake at a T7 at increasing spinal flexibility, particularly spinal flexion, fracture. may actually reduce some of the protective mechanisms against back pain. Exercises should focus on strengthening to provide pain relief for acute compression fractures. back extension and may include weighted or unweighted Bisphosphonates have also shown similar improvements in prone position extension exercises, isometric contraction acute pain control. Finally, patients treated with teriparatide of the paraspinal muscles, and careful loading of the upper 41–43 (recombinant parathyroid hormone) show decreased back extremities. pain, when compared with patients treated with placebo, The Spinal Proprioception Extension Exercise Dynamic 33,34 9 hormone replacement therapy, or alendronate. (SPEED) program designed by Sinaki is an example of a regimen that focuses on strengthening the spinal Physical therapy extensors using a weighted kypho-orthosis and postural Physical therapy should assist with early mobilization and proprioceptive training, through twice-daily, 20-minute in the acute phase and prevent further injuries in the exercise sessions. A 4-week program was found to improve submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Wong and McGirt Dovepress back pain and back strength, reduce the risk of fall and patient (L1–3). Intervertebral motion has been shown to actually fear of falls, and increase physical activity level. The patients increase from L4–S1 with a lumbosacral orthoses brace. were also shown to have improved gait and posture using Potential downfalls of a rigid brace include patient 9,44 computerized analysis. discomfort, which may decrease compliance. These patients, Several other trials have demonstrated similar efc fi acy of typically elderly and frail, are at risk for skin breakdown if physical therapy programs in managing painful compression the brace edges are not carefully padded. In addition, a brace fractures. Malmros et al looked at a 10-week physiotherapy that is too restrictive may impede the patient’s respiratory program involving strength and balance training and found volume. Finally, with prolonged periods of bracing there is benefits in back extension strength, quality of life, and potential for deconditioning and atrophy of the trunk and reduction in pain and analgesic use. These benefits persisted paraspinal muscles. As such, many authors have moved away at follow-up 12 weeks after the patients had completed the from recommending rigid braces and towards light-weight, training program. Bennell et al similarly used a 10-week soft braces, except in cases of severe deformity. program that included manual therapy in addition to exercise Surgical management and demonstrated improved back pain, physical function, and quality of life. Papaioannou et al studied a longer, 6-month indications and contraindications home exercise program consisting of stretching, strength Though there is no standard time for appropriate conservative training, and aerobics and found that the exercise group had management, patients should have pain relief by 6 weeks. When improved Osteoporosis Quality of Life Questionnaire scores patients continue to have unremitting pain or demonstrated and improved balance at the 1-year point, though no change fracture progression on follow-up radiograph, consideration in bone mineral density was found. should then be given to a vertebral augmentation procedure. Vertebroplasty and kyphoplasty are minimally invasive, Bracing percutaneous procedures performed by spine surgeons Bracing is commonly used for symptomatic management and pain management specialists to treat osteoporotic or of vertebral fractures. However, the majority of randomized oncologic fractures. controlled trials examining bracing were based on acute, Eligible patients should have significant back pain and traumatic burst fractures. As such, there is little consensus tenderness in the fracture area that increases with mechanical on its application for osteoporotic compression fractures. axial loading. The fracture should be within the subacute One prospective randomized trial on the 6-month use of phase before it is healed. In addition, it is not possible a thoracolumbar orthoses (TLO) brace for osteoporotic to perform vertebroplasty or kyphoplasty in completely compression fractures found improvement in trunk muscle collapsed vertebral bodies, known as vertebra plana. If CT strength, posture, and body height amongst the treatment demonstrates incompetency or fracture through the posterior group, ultimately with better quality of life and ability to wall of the vertebrae, risk of cement extrusion into the spinal perform activities of daily living (ADL). canal is greatly increased. An absolute contraindication is The use of a spinal orthosis maintains neutral spinal bony retropulsion with neurologic compromise, as this may alignment and limits flexion, thus reducing axial loading worsen with the injection of cement. In these cases, an open on the fractured vertebra. In addition, the brace allows for surgical decompression and fixation may be appropriate. less fatigue of the paraspinal musculature and muscle spasm Other contraindications include active osteomyelitis of 52–54 relief. However, this finding has not consistently held up the fracture site or allergies to kyphoplasty cement. to electromyography study, with two studies showing In addition, patients need to tolerate general anesthesia in 49,50 increased activity in the spinal muscles with bracing. the prone position (though occasionally sedation and local Several brace types are available depending on the location anesthesia is used). Particular attention needs to be paid to and severity of fracture. Fractures in the thoracic spine may cardiac and pulmonary reserve, especially with treatment be treated with TLO. Examples include the Jewitt, cruciform of multiple levels, as both operative time and the risk of anterior spinal hyperextension, and Taylor brace. Braces pulmonary fat embolism increases. which extend to the sacrum are termed thoracolumbar sacral orthoses. Finally, lumbosacral orthoses are also Procedure available for lumbar fractures but are only effective in Ver tebroplasty involves the fluoroscopically-guided restricting sagittal plane motion in the upper lumbar spine transpedicular insertion of a cannulated trochar that is used to submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Dovepress Vertebral compression fractures inject radiopaque cement, typically polymethylmethacrylate sequentially injected in incremental volumes. It is necessary into the fracture. The goal is to provide structural support to to take multiple images during injection to ensure that there the compromised trabecular bone and restore lost vertebral is adequate cavity filling and no cement retropulsion into the height. Typically a bipedicular approach using two trochars spinal canal (Figure 5). is chosen for more even cement distribution. Occasionally in the upper thoracic spine, where the pedicles can be very Potential complications small, an extrapedicular approach is used with trochar Typically vertebral augmentation is performed as an insertion between the medial rib head and lateral edge of outpatient procedure and is well tolerated. Patients may the pedicle. experience relief of their back pain within 24 hours of Ideally two u fl oroscopy machines are used simultaneously the procedure. The overall reported complication rates around the patient, who is positioned in an ar ms-up are particularly low in cases of osteoporotic compression “superman” position on a Jackson table, to allow for fractures (,4%), but increase for oncologic fractures, though 18,53,56,57 concurrent anteroposterior (AP) and lateral images. This symptomatic complications remain less than 10%. The saves time and reduces the chance of contamination by incidence of cement extravasation into the spinal canal or 18,53 avoiding the need for frequent fluoroscopy repositioning. neuroforamen is rare (0.4%–4%) and often asymptomatic A good starting AP image, with the endplates lined up at the or transient, but it is important to recognize when this occurs, procedural level and pedicles clearly outlined, is crucial when as it may result in painful radiculopathy and weakness. If introducing the trochars. Subsequently both AP and lateral high enough to affect the spinal cord or conus medullaris, it images are used to guide the advancement of the trochar into may even cause paraparesis, which constitutes an emergency the collapsed vertebral body, avoid medial or lateral breaches, and requires surgical decompression. Cement may also and determine the final depth. extravasate into the paraspinal musculature, which is typically Kyphoplasty adds an additional step prior to the cement asymptomatic, but on extremely rare instances may enter 18,52 injection. After trochar insertion, an infla table balloon tamp the venous system and result in embolic phenomenon. is threaded into the fracture and expanded. The purpose Finally, fractures may develop in vertebrae adjacent to the of this step is to compact the cancellous bone and create augmented vertebral body. Some researchers, for example, an expanded cavity for cement injection. This plays a Hadley et al, have speculated that this is due to increased signic fi ant role in restoring vertebral body height. The extent loading on the adjacent levels secondary to stiffness of the of inflation is determined by monitoring pressure, inflated augmented body, but similar incidences of adjacent fracture volume, and appearance of the balloon and vertebral body with untreated patients have been reported, suggesting that on fluoroscopy. Pressure should not exceed a maximum of this is a consequence of the patient’s existing osteoporotic 53 53 300 psi and is usually kept less than 220 psi. Maximum disease as opposed to a result of the intervention. volume inflation ranges from 4–6 mL. During the inflation process sequential images are taken to monitor appropriate Treatment outcomes expansion of the balloon, ensuring adequate contact with, but Though a large number of trials have examined the efc fi acy avoiding violation of, the cortical endplates (Figure 4). Once of vertebral augmentation compared to optimal medical the inflation cavity has been created, radiopaque cement is management, there remains signif icant controversy. Figure 4 intraoperative images showing lateral and anteroposterior fluoroscopic images, after the injection of polymethylmethacrylate. submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Wong and McGirt Dovepress Figure 5 Pre- and postoperative X-rays demonstrating the restoration of vertebral body height after kyphoplasty. 63,64 Overall, there are a greater number of studies on vertebroplasty Medicine and received signic fi ant publicity. These studies, than kyphoplasty given its longer history. McGirt et al by Buchbinder et al and by Kallmes et al, involved comparisons published a review in 2009 of all studies of vertebral between vertebroplasty and sham procedure groups, rather augmentation outcomes over a 20-year period. The review than the usual comparison group of medical management. included 74 studies (including one level I) of vertebroplasty The authors of both studies reported no difference in pain for osteoporotic compression fractures, 35 kyphoplasty control or function between the groups, from 1 week to studies for osteoporotic fractures, and 18 studies for tumor- 6 months follow-up in one study and 1 month follow-up in the 63,64 related fractures, which were all level IV studies. The authors other. They suggested that the benet fi s of vertebroplasty in 65,66 found level I evidence that vertebroplasty provides superior prior trials were secondary to a procedural placebo effect. pain control over medical management in the r fi st 2 weeks, These studies have been the subject of criticism, focusing and level II–III evidence that within the r fi st 3 months there on their low enrollment numbers (78 and 131 patients), low are superior outcomes in analgesic use, disability, and general volume and infrequent rate of vertebroplasty performed at health, and n fi ally level II–III evidence that by 2 years there the centers over a long time interval, lack of clear inclusion is a similar level of pain control and physical function. With criteria specifying patients with mechanical axial back pain, 67,68 regards to kyphoplasty, there was level II–III evidence of and inadequate volume of cement injection. The debate improvement in daily activity, physical function, and pain about vertebral augmentation continues. One ongoing study control at 6 months, compared to medical management. that may shed light on the matter is the VERTOS IV trial, a Though the studies were favorable for tumor-related fractures non-industry supported, prospective randomized controlled there was insufficient evidence for comparison. trial of 180 patients that compares vertebroplasty to sham Since this review, other randomized trials have been procedure, similar to the New England Journal of Medicine performed, which have mostly shown improved pain control studies, but uses the strict inclusion criteria of the VERTOS 69,70 and physical function with vertebroplasty in the short II trial. 59,60 term, but diminished or no difference with medical 60,61 management at 1-year follow-up. A subsequent, larger, Conclusion randomized controlled trial enrolling 202 patients dubbed Vertebral fractures have signic fi ant effect on patient quality of VERTOS II did find sustained, significant differences at life and a high socioeconomic cost. Initial management begins 1-year follow-up with continued improved pain relief for the with the primary care provider. Diagnostic studies include vertebroplasty group. plain radiographs and are typically followed by bone density Notably, in 2009, two double-blind randomized controlled workup with DEXA imaging. Conservative management trials were published in the New England Journal of should be attempted for up to 6 weeks. This may involve submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2013:6 Dovepress Dovepress Vertebral compression fractures 13. Compston JE. Risk factors for osteoporosis. Clin Endocrinol (Oxf). coordination with other providers including endocrinologists, 1992;36(3):223–224. physical therapists, and possibly pain specialists. Medical 14. Schousboe JT, DeBold CR, Bowles C, Glickstein S, Rubino RK. therapy should be aimed at pain control, early mobilization Prevalence of vertebral compression fracture deformity by X-ray absorptiometry of lateral thoracic and lumbar spines in a population with the assistance of bracing and rehabilitation, and improving referred for bone densitometry. J Clin Densitom. 2002;5(3):239–246. bone quality with the goal of future fracture prevention. If 15. Jergas M, Genant HK. Spinal and femoral DXA for the assessment of spinal osteoporosis. Calcif Tissue Int. 1997;61(5):351–357. patients remain refractory to conservative treatment of their 16. Ross PD, Davis JW, Epstein RS, Wasnich RD. Pre-existing fractures pain, or develop worsening of their fracture on subsequent and bone mass predict vertebral fracture incidence in women. Ann imaging, a referral to a spine surgeon or pain interventionalist Intern Med. 1991;114(11):919–923. 17. Lindsay R, Silverman SL, Cooper C, et al. Risk of new vertebral fracture may be appropriate. Vertebroplasty and kyphoplasty are in the year following a fracture. JAMA. 2001;285(3):320–323. low-risk procedures that significantly improve pain relief 18. McGir t MJ, Parker SL, Wolinsky JP, Witham TF, Bydon A, Gokaslan ZL. Vertebroplasty and kyphoplasty for the treatment of and physical function. Though evidence for their efc fi acy vertebral compression fractures: an evidenced-based review of the in oncologic fractures is limited, a large number of studies literature. Spine J. 2009;9(6):501–508. have shown at least short-term efc fi acy in improving pain 19. Truumees E. Osteoporosis. Spine (Phila Pa 1976). 2001;26(8): 930–932. and physical function for the more common osteoporotic 20. Etzioni DA, Liu JH, Maggard MA, Ko CY. The aging population and its fractures. 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