ePainBook: Vertebral Body Fractures - Presented by Arizona Pain Specialists

Anatomy

The bony spine is positioned so that individual vertebrae provide a flexible support structure while also protecting the
spinal cord. Certain conditions that can produce chronic pain affecting the vertebrae include spinal stenosis, vertebral
body fractures, Osteoporosis, Osteoarthritis, spondylolisthesis, neoplasms (Primary vs. metastatic lesions), and
infections. Vertebroplasty and Kyphoplasty are extremely effective treatment for many of these conditions.

Pathology

Healthy bones are able to withstand the normal amount of pressure exerted on them. They are designed to provide
strength, flexibility, and support to the spinal canal. However, if the force put on the vertebrae exceed the threshold they
can tolerate, or the threshold is lowered due to pathology to the vertebrae, then they will fracture and collapse.

Most commonly seen in patients with vertebral compression fractures is preexisting osteoporosis. Osteoporosis is a
disease frequently seen in postmenopausal women, as well as some men that affects the density of the bones. The
bones become thin and weak and are more prone to fractures. Spinal compression fractures are the most common
fracture seen in these patients and by the age of 80, 40% of these patients will have a compression fracture (Old 2004).

Metastatic cancer that spreads to the vertebrae can also cause a compression fracture. The boney spine is a common
place for certain cancers to spread to. The lytic lesions in the spine cause weakness and may eventually cause collapse
of the vertebrae. Any cancer patient who has a sudden onset of back pain or lower extremity neurological change
should be immediately evaluated for metastatic disease.

Another cause of vertebral compression fractures is trauma to the vertebrae such as blunt trauma, a fall, or motor
vehicle accident. Any force that surpasses the ability the spine is able to support can cause collapse of the vertebrae.

Diagnosis

All patients over the age of 50 who present with the acute onset of lower back pain should be evaluated for vertebral
body fractures. The pain may be relieved by laying down and is exacerbated with activity.

Your physician will perform a physical exam and may find tenderness over the vertebrae as well as kyphosis (curving of
the spine). Other manifestations of nerve involvement include constipation, loss of lower extremity reflexes, and the
sensory function.

The physician may also order radiological imaging. The plain x-ray may be diagnostic enough because commonly seen
is the classic wedge-shaped vertebral body with narrowing of the anterior portion in most compression fractures.
However, depending on the clinical suspicion and history obtained the physician may want to order additional studies
such as MRI, CT scan, or a bone scan.

Treatment

Pharmacologic treatments such as NSAID’s and analgesics are used in the acute management of pain and although
these may help relieve discomfort, they do not correct the underlying problem causing the pain. Also, an unfortunate
side effect to NSAID’s is that they have been shown to increase gastrointestinal bleeding in the elderly. Patients can also
be treated with a short time of bed rest, however, prolonged inactivity is contraindicated.

In the past few years there has been a lot of research surrounding non-surgical procedures and their effectiveness in
treating back pain associated with vertebral body fractures. Patients that do not respond to the more conservative
management described above may be good candidates for minimally invasive procedures by your pain physician that
have been proven effective, including Vertebroplasty and Kyphoplasty (Old 2004). Results of a clinical research trial
concluded that both Vertebroplasty and Kyphoplasty significantly reduce pain and improve mobility in patients with
vertebral fracture (De Negri 2007).

Vertebroplasty - This procedure involves injecting acrylic cement into the fractured vertebra to stabilize and strengthen
the vertebrae.

Kyphoplasty - This method is a newer method that involves placing an inflatable balloon into the vertebral body. When
the balloon is inflated, it makes a space in the center of the vertebrae where an acrylic is injected.

There is good evidence that diagnosing and treating Osteoporosis reduces the incidence of compression fractures of the
spine (Kim 2006). Consistent exercise and activity to help with muscle strengthening and flexibility should also be done to
help decrease vertebral fractures and back pain associated with Osteoporosis. Certain treatments aiming to reduce the
effects of Osteoporosis are bisphosphonates, hormone replacement therapy, selective estrogen receptor modulators,
calcitonin, the 1-34 fragment of parathyroid hormone, calcium and vitamin D supplements, and Clairol (Christodoulou
2003).

Journal Articles

Osteoporotic compression fractures of the spine; current options and considerations for treatment Kim DH, Vaccaro AR.
Spine J. 2006 Sep-Oct;6(5):479-87 PMID: 16934715

Vertebral Compression Fractures in the Elderly. Old, Jerry; Calvert, Michelle. American Family Physician. January 1,
2004

What is osteoporosis? Christodoulou C, Cooper C. Postgrad Med J. 2003 Mar;79(929):133-8. PMID: 12697910

Treatment of painful osteoporotic or traumatic vertebral compression fractures by percutaneous vertebral augmentation
procedures: a nonrandomized comparison between vertebroplasty and kyphoplasty. De Negri P, Tirri T, Paternoster G,
Modano P. Clin J Pain. 2007 Jun;23(5):425-30 PMID: 17515741

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Vertebral Body Fractures
by Nicole Berardoni M.D, Tory McJunkin M.D, and Paul Lynch M.D

A fracture of the vertebrae (bones of the spine) that eventually
cause a collapse of the vertebral body. These fractures are most
commonly located in the thoracic spine (the middle portion of the
spine) and are extremely common. This condition can cause pain
and complications in 25% of all post menopausal women. The
major risk factor for vertebral body fractures are increasing age
and occur when the upper body weight exceeds the ability of
vertebrae to support the load. Although more frequently seen in
women, men can be affected as well (Old, 2004).

Book I - Pain Syndromes

Chapter 1     Low Back Pain
Chapter 2     Neck Pain
Chapter 3     Cancer Pain
Chapter 4     Headaches
Chapter 5     Spinal Stenosis
Chapter 6     Sciatica
Chapter 7     Arthritis
Chapter 8     Fibromyalgia
Chapter 9     Motor Vehicle Injuries
Chapter 10   Complex Regional Pain
Syndrome
Chapter 11   Vertebral Body
Fractures
Chapter 12   Hip and Leg Pain
Chapter 13   Diabetic Peripheral
Neuropathy

Book II - Interventional Procedures

Chapter 14   Epidural Steroid
Injection
Chapter 15   Facet Injections/Medial
Branch Blocks
Chapter 16   Radiofrequency Ablation
Chapter 17   Spinal Cord Stimulator
Implants
Chapter 18   IntraDiscal
Electrothermal Therapy (IDET)
Chapter 19
Vertebroplasty/Kyphoplasty
Chapter 20   Discography
Chapter 21   Percutaneous
Discectomy
Chapter 22   Occipital Nerve Block
Chapter 23   Sympathetic Block
Chapter 24   Stellate Ganglion Block
Chapter 25   Intrathecal Pump
Implants
Chapter 26   Caudal Steroid Injection
Chapter 27   Adhesiolysis
Chapter 28   Cervical Steroid
Injection
Chapter 29   Sacroiliac Joint
Injections
Chapter 30   Celiac Plexus Block
Chapter 31   Head and Neck
Procedures
Chapter 32   Joint Injections
Chapter 33   Continuous Catheter
Nerve Blocks
Chapter 34   Peripheral Nerve
Stimulation/Field Stimulation
Chapter 35   Disc Denervation

Book III   Other Treatments

Chapter 36   Medication Management
Chapter 37   Acupuncture
Chapter 38   Prolotherapy
Chapter 39   Botox
Chapter 40   Massage
Chapter 41   Alternative and
Complementary Medicines
Chapter 42   Exercise and Nutrition
Counseling
Chapter 43   Prayer
Chapter 44   Cognitive Behavioral
Therapy
Chapter 45   Group Therapy
Chapter 46   Biofeedback
Chapter 47   Chiropractic
Manipulations
Chapter 48   Vitamin Supplements
Chapter 49   Customized
Pharmaceutical Formulations
Chapter 50   Hormone Therapy

Frequently Asked Questions