Lumbar Compression Fracture

  Search strategy

Databases searched: Pubmed, Web of knowledge, Pedro and Google Scholar.

Keywords searched: Lumbar compression fracture, classification, epidemiology, non-operative treatment, neurological deficits, conservative treatment and physical management.

Also books were used from the medical library of the Free University of Brussels in the domain musculoskeletal.

Definition / Description

The lumbar spine provides stability and support for the whole upper body. By that a normal lumbar shape is necessary. Any injury that changes the shape of a lumbar vertebra will alter the lumbar posture, increasing or decreasing the lumbar curve. The definition of a fracture is a complete or partial interruption of the continuity of the bone. Compression fractures are either caused by osteoporosis or trauma. Most non-traumatic fractures are caused by osteoporosis (especially in the postmenopausal women), a decrease of the bone mineral density. Those are caused by pressure placed against the vertebrae due to lack of disc cushioning between the spinal bones. To make it easier to define the type of an osteoporotic vertebral compression fracture, a specific classification has been made:

• Type I: a compression fracture in which only the anterior column is involved and with the posterior vertebral body height still intact.
• Type II: a compression fracture in which both, the anterior and middle column, are involved.

Each type of compression fracture is divided into two groups: Fractures with union and fractures with non-union. It is proven that type II has a higher incidence of non-union than type I compression fractures (p < 0.05).
Even though these fractures are most common with osteoporosis, there is also a possibility they are caused by trauma.
A lumbar compression fracture is a serious injury, both when caused by osteoporosis or by trauma. There is a severe risk of neurological damage. When this is the case, surgery is recommended.

There are 2 typical types of fractures: a wedge fracture and a burst fracture (caused by a trauma).

Clinically Relevant Anatomy

The 5 lumbar vertebrae are the strongest and largest of all vertebrae in the spine. Those are included in the lower back. They start at the thoracolumbar junction in the beginning of the lumbar lordosis and extend to the sacrum. The bony lumbar spine is designed so that vertebrae “stacked” together can provide a movable support structure while also protecting the spinal cord from injury. The lower back region has a greater mobility in flexion, extension, but lateroflexion and rotation are also possible. Because of the increased mobility, the lumbar spine is more susceptible to injury. The lumbar disk works as a cushion for the mechanical loads.

Epidemiology/Etiology

Most fractures occur at the thoracolumbar junction. It is because of the load on that region. The most non-traumatic fractures are osteoporotic in origin. Osteoporosis occur in postmenopausal women and begin at the middle-age (55-65 years). One-fourth of the postmenopausal women will be affected with vertebral compression fractures. In 2005, there were near 2 million fractures causes by osteoporosis in the United States (16% by women and 6 % of the fractures by man).
There are several patient population studies who suggests an increased mortality rate in patients with osteoporotic vertebral compression fractures that correlates with the number of involved vertebrae.

Vertebral compression fractures are the most common skeletal complication of metastatic cancer.

Characteristics/Clinical presentation

Patients with osteoporotic vertebral compression fractures are asymptomatic at the time of diagnosis. Also the age of the fracture is impossible to determine. However, there are several characteristics developing over time:

• Pain is not localized to the site of the compression fracture (However thoracolumbar fractures present lumbosacral pain or low back pain).
  
• Pain associated with atraumatic activities: bending forward, vigorous sneezing and coughing, standing from being seated, …
  
• Inspection of the patient: a loss of lumbar lordosis or focal kyphosis. This kyphosis can lead to a reduction of the abdominal space and/or a decreased ventilator capacity.
  
• 20% of patients who had a osteoporotic vertebral compression fracture, will have a second fractures within one year. This several osteoporotic vertebral compression fractures result in loss of height. When the patient’s fingertips hit the knee or lower thigh during standing, then can we speak about a spinal shortening.
  
• Further fractures result also in a decreased pulmonary function, mobility and balance impairment.
  
• In the acute phase: localized tenderness over the involved level. This localized tenderness does not distinguish if the anterior or posterior column is involved. However, this is useful to identify an acute fracture.
  

Differential diagnosis

• Coccyx pain
  
• Lumbar facet arthropathy
  
• Mechanical low back pain (Clinical pain presentations)
  
• Lumbar degenerative disc disease
  
• Lumbar Spondylolysis and Spondylolisthesis
  
• Primary Osteoporosis
  
• Secondary osteoporosis
  

Medical management

A surgical management is required when neurological deficits, instability, prevention of kyphosis and pain occurs caused by the lumbar fracture. Also when several nonoperative treatments didn’t help, surgery is recommended. In most patients Kyphoplasty and vertebroplasty are good options. This two surgical procedures are percutaneous and stabilize the fracture with polymethylmethacrylate. Several studies have demonstrated that both, kyphoplasty and vertebroplasty, results in immediate and sustained pain relief in most patients.

Physical therapy management

Non-operative treatment consists of pain relief, bracing and rehabilitation. The rehabilitation program starts with a thoracic-lumbar-sacral orthosis. The physiotherapist learns the patient how to use that orthosis. It is recommended to wear the brace/orthosis for 6 to 12 weeks, followed by supervised physical therapy.

It is important that the patient overcomes his fear of movement (kinesiophobia) and continues with his/her activities. Rest is not recommended.

Supervised physical therapy:

• NSAID’s and massages are given to reduce pain at the start of the rehabilitation.
• Early mobilization is important to prevent secondary complications of immobilization.
• Weight-bearing exercises are usual part of the program and are believed to be the main type of therapy required to prevent progression of the osteoporosis and other fractures in the future.
• Pelvic stabilization.
• Strengthening-exercises: in this phase, it is important to improve the lumbar stabilization by strengthening the muscles of the lower back, but also the muscles of the trunk.
• Occupational therapy is essential to restore the normal level of function and increase the quality of life.
• Low impact exercises such as swimming, cycling and walking can be performed to optimize the endurance of the lower back and trunk musculature. High impact sport such as running, volleyball and basketball need to be avoided.

Patients who followed a back extensor-strengthening extensorprogram (like in the 6th point of the supervised physical therapy) have a smaller chance to relapse into a new lumbar fracture in the future.

When, during physical therapy session with a non-operative compression fracture patient, it shows that the patient continues to have a lot of pain, or there is no progression at all, it is advised to send the patient to a doctor or preferably an orthopedic surgeon, as surgery may be required.