Osteoporotic Vertebral Fractures: Difference between revisions

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== Definition / Description  ==
== Definition / Description  ==


[[Image:Vertebral Fracture.png|right|250x350px|Vertebral Fracture]]
Osteoporotic (fragility) vertebral fractures (VFs) are fractures that result from mechanical forces that would not ordinarily result in a fracture. <ref name=":1">Yoo JH, Moon SH, Ha YC, Lee DY, Gong HS, Park SY, Yang KH. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4691591/ Osteoporotic Fracture: 2015 Position Statement of the Korean Society for Bone and Mineral Research.]J Bone Metab. 2015 Nov;22(4):175-81. 30. '''Level of Evidence: 2B.''' </ref> These types of fractures are [https://www.physio-pedia.com/Insufficiency_Fracture insufficiency fractures], caused by normal stresses on abnormal bone, often indicating [[Introduction to Frailty|frailty]].   
 
Osteoporotic (fragility) fractures are fractures that result from mechanical forces that would not ordinarily result in a fracture, known as low-level (or low-energy) trauma according to National Institute for Health and Care Excellence (NICE) clinical guidelines<ref>Yoo JH, Moon SH, Ha YC, Lee DY, Gong HS, Park SY, Yang KH.Osteoporotic Fracture: 2015 Position Statement of the Korean Society for Bone and Mineral Research.J Bone Metab. 2015 Nov;22(4):175-81. 30. '''Level of Evidence: 2B.''' </ref>.
 
[[Osteoporosis]] is a disease that is characterised by low bone mass<ref name="NICE (2012)">NICE. Osteoporosis: assessing the risk of fragility fracture: NICE Guidelines CG146. Manchester: National Institute for Health and Care Excellence, 2012.</ref>,&nbsp;causing bones to be more fragile and likely to fracture<ref name="NOS (2014)">NOS. What is Osteoporosis? National Osteoporosis Society. https://www.nos.org.uk/about-osteoporosis (accessed 03/02/15)</ref>.&nbsp;The word osteoporosis means porous bone<ref name="Strom et al (2011)">Ström O, Borgström F, Kanis JA, Compston J, Cooper C, McCloskey EV, Jönsson B. Osteoporosis: burden, health care provision and opportunities in the EU: A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos 2011 6:59–155 DOI 10.1007/s11657-011-0060-1</ref>.&nbsp;One of the significant consequences of osteoporosis is fractures. Common types of fracture include wrist fractures, hip fractures and vertebral fractures<ref name="NICE (2012)" /><ref name="NHS (2014)">NHS. Osteoporosis. National Health Service.  http://www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx (accessed 03/02/15)</ref>.
 
Osteoporosis in older adults is caused by an imbalance of bone resorption in excess of bone formation. The dominant factor leading to bone loss in older adults appears to be gonadal sex steroid deficiency, with multiple genetic and biochemical factors, such as [[Vitamin D Deficiency]] or hyperparathyroidism, that may accelerate bone loss.
 
Conditions that adversely affect growth and development may limit development of peak bone mass and accelerate subsequent bone loss. Studies of bone microarchitecture have shown that trabecular bone loss begins in the third decade of life, before gonadal sex steroid deficiency develops, whereas cortical loss typically begins in the sixth decade, about the time of menopause in women and about the same age in men.  
 
Antiresorptive agents for the treatment of osteoporosis act primarily by limiting osteoclast activity, whereas osteoanabolic agents, such as teriparatide, act primarily by stimulating osteoblastic bone formation. Clinical investigation of new compounds for the treatment of osteoporosis is mainly directed to those that stimulate bone formation or differentially decrease bone resorption more than bone formation. Therapies for osteoporosis are associated with adverse effects, but in patients at high risk of fracture, the benefits generally far outweigh the risks.
 
Important: Bone mass alone does not explain the risk of fractures in at least 50% of osteoporosis cases; bone quality also plays a role<ref name="p3">Buchbinder R, Golmohammadi K, Johnston RV, Owen RJ, Homik J, Jones A, Dhillon SS, Kallmes DF, Lambert RG.Percutaneous vertebroplasty for osteoporotic vertebral compression fracture.Cochrane Database Syst Rev. 2015 Apr 30;4:CD006349. '''Level of Evidence: 1A.''' </ref>.
 
 
== Clinically Relevant Anatomy ==


Due to the osteoporosis that made the bone density low and made the bone weak (higher activity of osteoclasts and lower activity of osteoblasts), the vertebra can ‘collapse’. This is called a vertebral body fracture. The fracture can lead to hyperkyphosis or hyperlordosis depending on the vertebral level.&nbsp;People with osteoporosis break down bone faster than it can regenerate. Trabecular bone is more active and because of this, trabecular bone is more likely to be affected. When people stand up causing pressure on the spine, the weak trabecular bone of the spine body’s can start to collapse, leading to an osteoporotic vertebral fracture.&nbsp;<span style="line-height: 1.5em;">This fracture occur on the posterior part of the vertebra or the vertebral body. Because of the decrease of height of the vertebra, the anterior longitudinal ligament and posterior longitudinal ligament lose tension. This can cause vertebral instability.</span>
== Classification of Vertebral Fractures ==
Classification of VFs has been described by '''<u>type of deformity</u>''' (wedge, biconcavity, or crush compression) and further by the <u>'''degree of deformity'''</u> (grades I, II). <ref name=":3">Eastell R, Cedel SL, Wahner HW, Riggs BL, Melton LJ III. [https://asbmr.onlinelibrary.wiley.com/doi/epdf/10.1002/jbmr.5650060302 Classification of vertebral fractures.] JBMR 1991; 6(3):207-15.</ref> <ref name=":2">Alexandru D, So W. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3523935/ Evaluation and Management of Vertebral Compression Fractures.] Perm J. 2012 Fall; 16(4): 46–51. </ref>
[[File:Anterior-wedge-fracture-l1.jpg|thumb|X-Ray of an anterior wedge fracture. ]]
* '''Wedge VFs''' are the most common, occuring in the midthoracic region with compression of the anterior segment of the vertebral body (VB) and the anterior longitudinal ligament (ALL), and reports of more than 50% of all VFs. <ref>Black DM, Arden NK, Palermo L, Pearson J, Cummings SR. [https://pubmed.ncbi.nlm.nih.gov/10320531/ Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures.] Study of Osteoporotic Fractures Research Group. J Bone Miner Res. 1999 May;14(5):821–8. </ref> Wedge fractures do not involve the posterior half of the VB and do not involve the posterior osseous ligamentous complex. The former distinguishes a compression fracture from a burst fracture.  
* '''Biconcave compression VFs''' are the second-most common (approximately 17% of all VFs); here, only the middle portion of the vertebral body is collapsed, with no compromise of the anterior and posterior walls. <ref name=":2" />
* '''Crush compression VFs''' are the least common (13%), and are characterised by the collaplse of the entire anterior column, including anterior and posterior margins. <ref name=":2" />
* The remaining 20% of VFs may involve '''complex''' fractures of the spine. <ref name=":2" />
* Grade I refers to 3 SD < deformity < 4 SD and grade 2 deformity > 4 SD from the normal range for each vertebra. <ref name=":3" />


{{#ev:youtube|https://www.youtube.com/watch?v=LILgFAEMAbg|width}}<ref>Spine live. Spinal compression fractures reasons. Available from: https://www.youtube.com/watch?v=LILgFAEMAbg (last accessed 12.4.2019)</ref>  
== Etiology  ==
* The most common etiology of VFs is [[osteoporosis]], making these fractures the most common fragility fracture. <ref>Ettinger B, Black DM, Nevitt MC, Rundle AC, Cauley JA, Cummings SR, Genant HK. [https://pubmed.ncbi.nlm.nih.gov/1535172/ Contribution of vertebral deformities to chronic back pain and disability. The Study of Osteoporotic Fractures Research Group.] J Bone Miner Res. 1992 Apr;7(4):449-56.</ref><ref name="Griffith" />
* In contrast, vertebral compression fractures (VCFs) demonstrate a bimodal distribution with younger patients sustaining these injuries secondary to high energy mechanisms (fall from a height, MVA, etc.).
* VFs occur secondary to an axial/compressive (and to a lesser extent, flexion) load with a resultant biomechanical failure of the bone resulting in a fracture.


== Epidemiology / Etiology  ==
Watch this video analysing causes of VFs (including osteoporotic):{{#ev:youtube|https://www.youtube.com/watch?v=LILgFAEMAbg|width}}<ref>Spine live. Spinal compression fractures reasons. Available from: https://www.youtube.com/watch?v=LILgFAEMAbg [accessed 26/10/2023]</ref>


Osteoporotic vertebral fractures are a significant problem. The number of vertebral fractures in the UK in 2010 was estimated to be 30,994, this number is expected to increase by 17.9% by 2020<ref name="p5">Gauthier A, Kanis JA, Jiang Y, Martin M, Compston JE, Borgström F, Cooper C, McCloskey EV. Epidemiological burden of postmenopausal osteoporosis in the UK from 2010 to 2021: estimations from a disease model. Arch Osteoporos 2011 6:179–188. </ref>. In America 700,000 vertebral fractures occur within the population who have osteoporosis<ref name="p6">Kim DH, Vaccaro AR. Contemporary Concepts in Spine Care: Osteoporotic compression fractures of the spine; current options and considerations for treatment. The Spine Journal. 2006 6 479–487. </ref>. In addition to this once a vertebral fracture has been sustained the risk of subsequent vertebral, hip or wrist fractures increase<ref name="p7">NICE. Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women (amended): NICE technology appraisal guidance 160. Manchester: National Institute for Health and Care Excellence, 2011. </ref>.  
== Epidemiology  ==
European population studies have shown that the annual incidence of VCFs is 10.7 per 1000 women and 5.7 per 1000 men. <ref>European Prospective Osteoporosis Study (EPOS) Group; Felsenberg D, Silman AJ, Lunt M, Armbrecht G, Ismail AA, Finn JD, Cockerill WC, Banzer D, Benevolenskaya LI, Bhalla A, Bruges Armas J, Cannata JB, Cooper C, Dequeker J, Eastell R, Felsch B, Gowin W, Havelka S, Hoszowski K, Jajic I, Janott J, Johnell O, Kanis JA, Kragl G, Lopes Vaz A, Lorenc R, Lyritis G, Masaryk P, Matthis C, Miazgowski T, Parisi G, Pols HA, Poor G, Raspe HH, Reid DM, Reisinger W, Schedit-Nave C, Stepan JJ, Todd CJ, Weber K, Woolf AD, Yershova OB, Reeve J, O'Neill TW. [https://pubmed.ncbi.nlm.nih.gov/11918229/ Incidence of vertebral fracture in europe: results from the European Prospective Osteoporosis Study (EPOS).] J Bone Miner Res. 2002 Apr;17(4):716-24. </ref>
* VCFs are the most common fragility fractures reported in the literature. <ref>Kutsal FY, Ergin Ergani GO. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8203169/ Vertebral compression fractures: Still an unpredictable aspect of osteoporosis.] Turk J Med Sci. 2021; 51(2): 393–399.  


Osteoporosis affects up to 30% of women and 12% of men at some point in their lives. Two of the most important risk factors are increasing age and female gender, although other common and potentially modifiable risk factors include long-term corticosteroid therapy, chronic inflammatory disease, malabsorption and untreated premature menopause<ref name="Ralston" />.<br>  
</ref>
 
* VCFs are common in Asian and Caucasian women, and less common in African-American women. <ref name=":2" />  
There is a higher prevalence for osteoporotic vertebral fractures for elderly and females with equal frequency in both Caucasian and Asian women. One out of four postmenopausal women suffer osteoporotic vertebral fractures. Osteoporotic vertebral fractures are multiple in up to 20% of patients and affect more than 20% of those older than 50 years with slight female prevalence that markedly increases when they age above 80 years<ref name="El-Fiki" />.  
* Approximately 1.5 million VCFs occur annually in the United States (US) alone in the general population. <ref>Barr JD, Barr MS, Lemley TJ, McCann RM. [https://pubmed.ncbi.nlm.nih.gov/10767803/ Percutaneous vertebroplasty for pain relief and spinal stabilization.] Spine (Phila Pa 1976). 2000 Apr 15;25(8):923-8.</ref>
 
* Prevalence increases with age, and it is estimated that 40% to 50% of patients over age 80 years have sustained a VCF either acutely, or recognised incidentally during clinical workup for a separate condition.<ref>Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, Bauer DC, Genant HK, Haskell WL, Marcus R, Ott SM, Torner JC, Quandt SA, Reiss TF, Ensrud KE. [https://pubmed.ncbi.nlm.nih.gov/8950879/ Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures.] Fracture Intervention Trial Research Group. Lancet. 1996 Dec 7;348(9041):1535-41. </ref>
Symptomatic osteoporotic vertebral fractures affect 1 in 6 women and 1 in 12 men during their lifetime. In Europe the annual incidence of osteoporotic vertebral fractures is 10.7 per thousand for women and 5.7 per thousand for men. Statistically, men got less osteoporotic fractures then women because men lose less bone density when they age. These figures may underestimate the actual size of the problem as most osteoporotic vertebral fractures go unreported and undiagnosed. With the prevalence of osteoporosis predicted to increase by 2021, a rise in associated fractures is also likely. The main causes and risk factors of fractures and vertebral fractures are a decay in bone density and previous fractures<ref name="Steven">Steven R. Cummings et al. Epidemiology and outcomes of osteoporotic fractures. The Lancet. 2002</ref><ref name="Goodwin">Goodwin VA et al. Orthotics and taping in the management of vertebral fractures in people with osteoporosis: a systematic review. British Medical Journal.2016 (Level of Evidence 2A)</ref>.
* Thoracolumbar junction (i.e., the segment from T12 to L2) location most often affected and the second most common site is the L2 to L5 region. <ref name=":2" />
 
* Estimated annual cost of VCFs in the US is $746 million. <ref>Lad SP, Patil CG, Lad EM, Boakye M. [https://pubmed.ncbi.nlm.nih.gov/17877264/ Trends in pathological vertebral fractures in the United States: 1993 to 2004.] J Neurosurg Spine. 2007 Sep;7(3):305-10.</ref>
Looking more closely to the specific regions of the spine and the prevalence of osteoporotic fractures, we can conclude that osteoporotic fractures in the thoracic spine are mostly affected. There is a prevalence of 2,4/1000 (age 35-44), 5,1/1000 (age 44-75), 29/1000 (age &gt; 75) in the thoracic spine. (Corresponding figures for men: 5,2/1000, 15/1000, 28/1000)<ref name="Seppo">Seppo Santavirta', Yrjo T. Konttinen*, Markku Heliovaara3, Paul Knekt3, Peter Luthje4 and Arpo Aromaa. Determinants of osteoporotic thoracic vertebral fracture, Acta Oflhop Scand 1992; 63 (2): 198-202 (LoE 2B)</ref>.
In the elderly patients,
 
* 30% of VCFs in severe cases of osteoporosis occur while the patient is in bed <ref name=":2" /><ref>Kim HJ, Park S, Park SH, Park J, Chang BS, Lee CK, Yeom JS. [https://pubmed.ncbi.nlm.nih.gov/29436202/ Prevalence of Frailty in Patients with Osteoporotic Vertebral Compression Fracture and Its Association with Numbers of Fractures.] Yonsei Med J. 2018;59(2):317.</ref>
The below short video gives a brief overview of compression fractures
* As the population continues to age, the population at risk of sustaining low energy fragility fractures will continue to increase as well.
{{#ev:youtube|https://www.youtube.com/watch?v=dLiOQfr4e_A&t=20s|width}}<ref>Pain doctor Nevada. Spinal compression fracture. Available from: https://www.youtube.com/watch?v=dLiOQfr4e_A&t=20s (last accessed 12.4.2019)</ref>  
* Largely unreported and are probably more common radiographically (present up to 14% of women older than 60 years in one study)<ref name=":0">Radiopedia. Spinal compression fracture. Available from:https://radiopaedia.org/articles/osteoporotic-spinal-compression-fracture [accessed 26/10/2023]</ref>
* Currently, 10 million Americans are already diagnosed with osteoporosis, and another 34 million have [[osteopenia]].


== Clinical Presentation  ==
== Clinical Presentation  ==
[[File:Low Back Pain Guy.jpg|thumb]]
VFs present with pain and loss of mobility.<ref name=":0" />


Symptoms of vertebral fracture can include pain, curvature of the spine, height loss, difficulties with ADLs, loss of self-esteem related to changes in body shape, and in cases of severe kyphosis respiratory and gastrointestinal problems<ref name="p3" /><ref name="p8">NOF. Osteoporosis and your spine. National Osteoporosis Foundation. http://nof.org/articles/18 (accessed 03/02/15. </ref> in addition to vertebral fractures being linked to mortality<ref name="p9">Puisto V, Rissanen H, Heliövaara M, Impivaara O, Jalanko T, Kröger H, Knekt P, Aromaa A, Helenius I. Vertebral fracture and cause-specific mortality: a prospective population study of 3,210 men and 3,730 women with 30 years of follow-up. Eur Spine J 2011 20:2181–2186 DOI 10.1007/s00586-011-1852-0. </ref>.
Symptoms of VFs can include: 
 
* '''Back pain''' is common in elderly patients. Decreases when lying on the back (reduced weight baring conditions). <ref name="p3">Buchbinder R, Johnston RV, Rischin KJ, Homik J, Jones CA, Golmohammadi K, Kallmes DF. [https://pubmed.ncbi.nlm.nih.gov/29618171/ Percutaneous vertebroplasty for osteoporotic vertebral compression fracture.] Cochrane Database Syst Rev. 2018 Apr 4;4(4):CD006349. '''Level of Evidence: 1A.''' </ref><ref name="p8">NOF. Osteoporosis and your spine. National Osteoporosis Foundation. http://nof.org/articles/18 (accessed 03/02/15. </ref>
Back pain is common in elderly patients. Most vertebral fractures go unrecognized, with symptoms attributed to degenerative change. This is particularly so as osteoporotic vertebral fractures classically occur during normal day-to-day activities such as bending, walking or lifting relatively light objects. Three quarters of patients with vertebral fracture do not seek medical attention and even up to 2/3 of vertebral fractures may not result in notably severe symptoms&nbsp;<ref name="Griffith" />.<br>Vertebral compression fractures (VCF) are characterised by loss of height and acute pain. Height loss of the osteoporotic fractured vertebra may be mild (20-25%), moderate (25-40%) or severe (&gt; 40%). It commonly affects the thoracolumbar region, though any vertebra may be disturbed.
* Most patients with vertebral fractures do not seek medical attention and up to 70% of vertebral fractures may not result in notably severe symptoms.<ref name="Griffith">Griffith JF. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4559972/ Identifying osteoporotic vertebral fracture.] Quant Imaging Med Surg. 2015 Aug;5(4):592-602. </ref>
 
* '''Loss of height'''. Height loss of the osteoporotic fractured vertebra may be mild (20-25%), moderate (25-40%) or severe (&gt; 40%). It commonly affects the thoracolumbar region, though any vertebra may be disturbed.
The pain of acute fracture usually lasts 4 to 6 weeks with intense pain at the site of fracture. The pain resolves over a period of six to 12 weeks. Chronic pain may also occur in patients with multiple compression fractures, height loss and low bone density. Although this is probably due to structural changes or osteoarthritis.  
* The pain of acute fracture usually lasts 4 to 6 weeks with intense pain at the site of fracture.
 
* The pain resolves over a period of six to 12 weeks.
Osteoporotic vertebral fractures are mostly wedged with anterior or mid-body shortening, and minimal posterior vertebral body curbing. However discoid biconcave or crush-like fractures may also be seen.
* '''Chronic pain''' may also occur in patients with multiple compression fractures, height loss and low bone density (also due to structural changes or osteoarthritis).<ref name=":2" />
 
* Radiographic VCF may not be symptomatic. The greater the deformity, the greater the likelihood of pain and disability.  
Radiographic VCF may not be symptomatic. The greater the deformity, the greater the likelihood of pain and disability. As height is lost, patients experience discomfort from the rib cage pressing downward on the pelvis. Patients develop an exaggerated thoracic kyphosis and/or an exaggerated lumbar lordosis<ref name="Griffith" />. The reduced thoracic space may result in decreased exercise tolerance and reduced abdominal space may give rise to early satiety and weight loss.  
* As height is lost, patients experience discomfort from the rib cage pressing downward on the pelvis.  
 
* Patients develop an exaggerated thoracic kyphosis and/or an exaggerated lumbar lordosis<ref name="Griffith" /> - due to multiple adjacent VCFs - <ref name=":2" />which may result in decreased exercise tolerance and reduced abdominal space giving rise to early satiety and '''weight loss'''.
Sleep disorders may also occur. Patients lose self esteem. Self care may become difficult. They are often depressed. They become fearful of further fracture. They have distorted body image and poor health perception. Patients with one vertebral fracture are at increased risk of peripheral fracture and further vertebral fracture. The aims of acute management are to reduce symptoms and mobilise the patient as quickly as possible. Long-term goals are to maintain or increase skeletal mass and improve mobility and function<ref name="El-Fiki">El-Fiki M. Vertebroplasty, Kyphoplasty, Lordoplasty, expandable devices and current treatment of painful osteoporoticvertebral fractures.World Neurosurg. 2016 Apr 9</ref><ref name="Longo">Longo UG, Loppini M, Denaro L, Maffulli N, Denaro V. Conservative management of patients with an osteoporotic vertebral fracture: a review of the literature. J Bone Joint Surg Br. 2012 Feb;94(2):152-7. (Level of Evidence: 2A)</ref><ref name="Silverman">Silverman SL. The Clinical Consequences of Vertebral Compression Fracture. Bone 13, S27-S31. 1992. (Level of Evidence: 3B)</ref>.
* '''Sleep disorders''' may occur and decreased self esteem +/- depression.  
* Self care may become difficult. <ref name="El-Fiki">El-Fiki M. [https://pubmed.ncbi.nlm.nih.gov/27072339/ Vertebroplasty, Kyphoplasty, Lordoplasty, Expandable devices and Current treatment of painful osteoporoticvertebral fractures.]World Neurosurg. 2016 Jul;91:628-32.</ref><ref name="Longo">Longo UG, Loppini M, Denaro L, Maffulli N, Denaro V. [https://pubmed.ncbi.nlm.nih.gov/22323677/ Conservative management of patients with an osteoporotic vertebral fracture: a review of the literature.] J Bone Joint Surg Br. 2012 Feb;94(2):152-7. </ref><ref name="Silverman">Silverman SL. [https://pubmed.ncbi.nlm.nih.gov/1627411/ The Clinical Consequences of Vertebral Compression Fracture.] Bone 13, S27-S31. 1992. (Level of Evidence: 3B)</ref>
* Associated with an increased morbidity and '''increased mortality''' <ref name="Griffith" /><ref name="p9">Puisto V, Rissanen H, Heliövaara M, Impivaara O, Jalanko T, Kröger H, Knekt P, Aromaa A, Helenius I. [https://pubmed.ncbi.nlm.nih.gov/21611851/ Vertebral fracture and cause-specific mortality: a prospective population study of 3,210 men and 3,730 women with 30 years of follow-up.] Eur Spine J 2011 20:2181–86. </ref>


Together with an increased morbidity, vertebral fractures are also associated with increased mortality<ref name="Griffith" />.
== Fracture Risk Assessment Tool ==
A Fracture Risk Assessment Tool (FRAX) has been developed with the aim to predict osteoporotic fractures in general. It is based on cohort data generated from European, North American, Australian and Asian men and women. Although it does not refer to vertebral fractures exclusively, the FRAX algorithm indicates the 10-year chance of a major osteoporotic fracture taking place. <ref>Centre for Metabolic Bone Diseases, University of Sheffield. UK. Welcome to FRAX. Available from: https://frax.shef.ac.uk/FRAX/ [accessed 17-11-2023]</ref> Clinicians may use of the FRAX tool in combination with indications for assessment of osteoporotic vertebral fractures.


Despite the clear undisputed clinical relevance of vertebral fractures, these remain underdiagnosed in everyday clinical practice<ref>Delmas PD, van de Langerijt L, Watts NB, Eastell R, Genant H, Grauer A, Cahal DL. [https://onlinelibrary.wiley.com/doi/full/10.1359/JBMR.041214 Underdiagnosis of Vertebral Fractures Is a Worldwide Problem: The IMPACT Study]. J Bone Miner Res. 2009. Accessed 31 January 2019.
== Indications for Vertebral Fracture Assessment ==
</ref>. Two main reasons account for this inadequacy. First, as mentioned, vertebral fractures frequently do not present as a clinically recognizable event. Second, many radiologically apparent vertebral fractures go unreported. Of patients aged more than 60 years attending emergency departments, about 1/6 had a moderate to severe vertebral fracture evident on lateral chest radiographs of which only about 1/2 were noted on radiology reports and fewer still received specific medical attention<ref name="Gehlbach">Gehlbach SH, Bigelow C, Heimisdottir M, May S, Walker M, Kirkwood JR.Recognition of vertebral fracture in a clinical setting.Osteoporos Int. 2000;11(7):577-82. (Level of Evidence: 4)</ref>.
A Vertebral Fracture Assessment (VFA) is indicated: <ref>Gregson CL, Armstrong DJ, Bowden J, Cooper C, Edwards J, Gittoes NJL, Harvey N, Kanis J, Leyland S, Low R, McCloskey E, Moss K, Parker J, Paskins Z, Poole K, Reid DM, Stone M, Thomson J, Vine N, Compston J. [https://pubmed.ncbi.nlm.nih.gov/35378630/ UK clinical guideline for the prevention and treatment of osteoporosis]. Arch Osteoporos. 2022 Apr 5;17(1):58. </ref>


* In postmenopausal women, and men aged ≥ 50 years,
* In the presence of a history of ≥ 4 cm height loss, or [[kyphosis]],
* If there is a history of recent or current long-term oral glucocorticoid therapy, or other therapy that compromises the bone
* In BMD T-scores ≤ − 2.5 at either the spine or hip
* If an acute onset of [[Low Back Pain|back pain]] with risk factors for [[osteoporosis]] at an older age is reported. An updated Cochrane review assessing the [[Test Diagnostics|diagnostic accuracy]] of red flags for vertebral fracture in patients complaining for low back pain <ref>Han CS, Hancock MJ, Downie A, Jarvik JG, Koes BW, Machado GC, Verhagen AP, Williams CM, Chen Q, Maher CG. [https://pubmed.ncbi.nlm.nih.gov/37615643/ Red flags to screen for vertebral fracture in people presenting with low back pain.] Cochrane Database Syst Rev. 2023 Aug 24;8(8):CD014461.</ref> concluded that appropriate sets of vertebral fracture indicators of various aetiologies are still lacking, so this finding may be interpreted with caution. 


== Differential Diagnosis  ==
Vertebral fractures aren’t only due to osteoporosis. It’s possible that a vertebral fracture is caused due to<ref name="Medscape">Medscape. Osteoporosis Differential Diagnoses. http://emedicine.medscape.com/article/330598-differential (accessed 10 May 2016) (Level of Evidence: 5)</ref>:
● [[Osteomalacia]]/ Rickets: softening of the bones due to a Vitamin D deficiency in adults. In time it can result in decalcification of the bone, fractures, skeletal deformities, bone pain and muscle weakness. Rickets is a similar condition in children. <br>● [[Paget's Disease|Paget's]] Disease: Bone is resorbed and formed at an increased rate, which may lead to pain, fractures, deformity, headaches, dizziness, osteoarthritis, spinal stenosis, and increased size of clavicle are a few common presentation.<br>● Bone Infection<br>● Pediatric osteogenesis imperfecta<br>● Cancer: Low-energy fractures may also be result of bone cancer or metastatic cancer.<br>● [[Multiple Myeloma]]<br>● Renal osteodystrophy<br>● Scurvy: Vitamin C deficiency
== Diagnostic Procedures ==
== Diagnostic Procedures ==
[[File:Compressionfracture.jpg|thumb|435x435px|[[X-Rays|compression fracture of 3rd lumbar vertebra]]]]Diagnosed on [[X-Rays|Xrays]] when there is a loss of height in the anterior, middle, or posterior dimension of the vertebral body that exceeds 20%.


The diagnosis of osteoporosis can be confirmed by Dual Energy X-ray Absorptiometry (DXA). DXA should only be performed in patients who have an increased risk of fracture on the basis of clinical risk factors. DXA should be considered if the 10-year risk of major osteoporotic fracture is &gt; 10%. If the Bone Mineral Density (BMD) T-score valued by DXA at the lumbar spine, femoral neck or total hip are at or below -2.5 then the diagnosis of osteoporosis is confirmed. Vertebral fractures are generally taken as diagnostic of [[Osteoporosis|osteoporosis,]] even if spine BMD values are not in the osteoporotic range<ref name="Ralston">Ralston SH, Fraser J.Diagnosis and management of osteoporosis.Practitioner. 2015 Dec;259(1788):15-9, 2. (Level of Evidence: 3A)</ref>.
Osteoporotic spine fractures can be graded based on vertebral height loss as:
* '''Mild''': up to 20-25%
* '''Moderate''': 25-40%
* '''Severe''': >40%
Chronicity of the fracture indicates its temporal relationship with symptoms and hence is an important determination when deciding on conservative or surgical treatment. <ref>Garnon J, Doré B, Auloge P, Caudrelier J, Dalili D, Ramamurthy N, Koch G, Cazzato RL, Gangi A. [https://link.springer.com/article/10.1007/s00270-019-02265-y Efficacy of the vertebral body stenting system for the restoration of vertebral height in acute traumatic compression fractures in a non-osteoporotic population.] Cardiovasc Intervent Radiol. 2019;42(11):1579–87. </ref>


There is evidence that fractures occur in glucocorticoid-induced osteoporosis at higher levels of bone mineral density (BMD) than in postmenopausal osteoporosis so therapy should be considered in patients with a BMD T-score of &lt;-1.5. Although it is useful to have a DXA scan before starting treatment to provide a baseline value to assess response, DXA is not absolutely necessary to initiate bone protective therapy, especially in those aged above 65. Since the vast majority of these patients will have a T-score of -1.5 or below. In younger individuals where BMD is likely to be higher DXA is useful in determining if bone protective treatment is needed immediately or if it could be delayed until the T score falls below -1.5<ref name="Ralston" />.  
On conventional imaging, acute fracture signs include cortical breaking or impaction of trabeculae; in the absence of these signs fractures are chronic.


<span style="line-height: 1.5em; font-size: 13.28px;">A patient with presence of a prevalent fragility fracture despite T-score &gt;-2.5 is also diagnosed with osteoporosis. The presence of an low-energy, insufficiency  vertebral fracture overrides bone densitometry and is an indication to treat for osteoporosis<ref name="Griffith">Griffith JF. Identifying osteoporotic vertebral fracture. Quant Imaging Med Surg. 2015 Aug;5(4):592-602. (Level of Evidence: 2C)</ref></span>.
In uncertain cases, [[MRI Scans|MRI]] signs of oedema (acute) and presence of radiotracer uptake on bone scintigraphy (acute) help decide the age of the fracture.  


'''Category &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; T-score'''<br>Normal &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&gt; -1.0 <br>Osteopenia &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;-1.0 &gt; x &gt; -2.5<br>Osteoporosis &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; -2.5 &gt;<br>Severe Osteoporosis &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;-2.5 &gt; + insufficiency fractures
Radiography is quick, widely available and of low cost and is a good imaging modality to diagnose vertebral fracture. Lateral spinal radiography will usually suffice and should include a high quality standardized image of the C7-S1 vertebrae<ref name="Griffith" />.
Preferentially, conventional X-rays are crucial for diagnosing and grading osteoporotic vertebral deformities and for differential diagnosis during assessment for osteoporotic deformity. However, more advanced imaging techniques such as Computed Tomography (CT), Bone Scintigraphy (BS), and Magnetic Resonance Imaging (MRI) may be required to further investigate the etiology in some of these deformities as well as to differentiate chronic from acute fractures, to assess compromise of the spinal canal, and for follow-up after specific treatments such as vertebroplasty<ref name="Yoo">Yoo JH, Moon SH, Ha YC, Lee DY, Gong HS, Park SY, Yang KH.Osteoporotic Fracture: 2015 Position Statement of the Korean Society for Bone and Mineral Research.J Bone Metab. 2015 Nov;22(4):175-81. 30. (Level of Evidence: 2B)</ref>.
Deleskog L et al concluded that vertebral fracture assessment (VFA) by DXA is inferior relative to X-ray in visualizing vertebrae properly in the upper spine. This resluts in vertebrae not being assessable for analysis and reduced diagnostic performance in detecting fractures<ref name="Deleskog">Deleskog L, Laursen NØ, Nielsen BR, Schwarz P.Vertebral fracture assessment by DXA is inferior to X-ray in clinical severe osteoporosis.Osteoporos Int. 2016 Feb 18. (Level of Evidence: 3B</ref>.
Torres and Hammond concluded that Computed Tomography (CT) or Magnetic Resonance (MR) are needed to differentiate between a low-intensity vertebral fracture caused by osteoporosis or a low-intensity vertebral fracture caused by neoplastic metastasis. This is crucial for a population of elderly with a history of cancer<ref name="Torres">Torres C, Hammond I.Computed Tomography and Magnetic Resonance Imaging in the Differentiation of Osteoporotic Fractures From Neoplastic Metastatic Fractures.J Clin Densitom. 2016 Jan-Mar;19(1):63-9. (Level of Evidence: 4)</ref>.
== Outcome Measures  ==
== Outcome Measures  ==
 
# Visual analogue scale for overall pain [[Visual Analogue Scale|(VAS]]).
R. Buchbinder et al. used the following outcome measures to evaluate the progression of a patient who suffers from an osteoporotic vertebral fracture<ref name="Diamond">Diamond TH. et al. Management of Acute Osteoporotic Vertebral Fractures: A Nonrandomized Trial Comparing Percutaneous Vertebroplasty with Conservative Therapy. Am J Med. 2003;114:257–265. (Level of Evidence: 2B)</ref>:<br>
# Visual analogue scale for overall pain (VAS).
# Quality of Life questionnaire: this can be measured with the use of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). An other possibility is to use the Assessment of Quality of Life (AQoL) questionnaire or the European Quality of Life–5 Dimensions (EQ–5D) scale.
# Quality of Life questionnaire: this can be measured with the use of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). An other possibility is to use the Assessment of Quality of Life (AQoL) questionnaire or the European Quality of Life–5 Dimensions (EQ–5D) scale.
# Physical functioning: measured bij a modified 23-item version of the Roland–Morris Disability Questionnaire.
# Physical functioning: measured by a modified 23-item version of the [[Roland‐Morris Disability Questionnaire|Roland–Morris]] Disability Questionnaire.
# Pain at night and at rest (VAS score)
# Pain at night and at rest (VAS score) <ref name="Diamond">Diamond TH, Champion B, Clark WA. [https://pubmed.ncbi.nlm.nih.gov/12681451/ Management of acute osteoporotic vertebral fractures: a nonrandomized trial comparing percutaneous vertebroplasty with conservative therapy.] Am J Med. 2003 Mar;114(4):257-65.</ref>
# According to Lavelle EA, Cheney and Lavelle WF <ref name="Lavelle">Lavelle EA, Cheney R, Lavelle WF.Mortality Prediction in a Vertebral Compression Fracture Population: the ASA Physical Status Score versus the Charlson Comorbidity Index.Int J Spine Surg. 2015 Nov 12;9:63. (Level of Evidence: 3B)</ref>&nbsp;the American Society of Anesthesiologists Physical Status score (ASA) is a predictive outcome measure of mortality in a surgical population of vertebral compression fractures. The same study also concluded that the Charlson Comorbidity Index (CCI) was highly predictive of mortality in a non-surgical population of vertebral compression fractures.  
#Research suggests that the four-factor Mini-BESTest model can be effective in evaluating multiple dynamic balance aspects in older adults with femoral or vertebral fractures and may help therapists in making clinical decisions, considering factors that indicated a decline in function. <ref>Miyata K, Hasegawa S, Iwamoto H, Otani T, Kaizu Y, Shinohara T, Usuda S. [https://pubmed.ncbi.nlm.nih.gov/32623475/ Comparison of the structural validity of three Balance Evaluation Systems Test in older adults with femoral or vertebral fracture]. J Rehabil Med. 2020 Jul 30;52(7):jrm00079.</ref>


== Examination  ==
== Examination  ==


Clinical assessment of vertebral fractures is generally poor and reliance is made on imaging studies for diagnosis<ref name="Longo" />.
Clinical assessment of vertebral fractures is generally poor and reliance is made on imaging studies for diagnosis. <ref name="Longo" />  
 
However in a study of James Langdon et al. they validated 2 tests that ensure and enable the practioner to predict more accurately wich patients have an acute vertebral fracture<ref name="James Langdon">James Langdon et al. Vertebral compression fractures - new clinical signs to aid diagnosis. Ann R Coll Surg Engl 2010; 92: 163–166 (Level of evidence: 2C)</ref>.
# Closed-fist percussion sign<ref name="James Langdon" /><br>This test has a sensitivity of 87,5% and a specificity of 90%, which is good. The examinator stands behind the patiënt and the patiënt stand in front of a mirror so the examinator can see the reaction of the patiënt. Firm closed-fist percussion is used to examine the entire lenght of the spine. The clinical sign is positive when the patiënt complains of a sharp, sudden,<br>fracture pain.
 
{{#ev:youtube|kkD8o5vlV8I}}<ref>Physiotutors. The Closed Fist Percussion Sign | Osteoporotic Vertebral Fractures . Available from: https://www.youtube.com/watch?v=kkD8o5vlV8I</ref>
 
 <br>2. The supine sign<ref name="James Langdon" /><br>This test has a sensitivity of 81,25% and a specificity of 93,33%, wich is also pretty good. The patiënt is asked to lie supine with only one pillow for the head. The clinical sign is positive when the patiënt is unable to lie supine due to severe pain.<br>
 
{{#ev:youtube|5OQUYTuQrlM}}<ref>Physiotutors. The Supine Sign for Osteoporotic Vertebral Fractures. Available from: https://www.youtube.com/watch?v=5OQUYTuQrlM</ref>


Two tests that help the practitioner to predict more accurately which patients have an acute vertebral fracture: <ref name="James Langdon">Langdon J, Way A, Heaton S, Bernard J, Molloy S. [https://pubmed.ncbi.nlm.nih.gov/19995486/ Vertebral compression fractures--new clinical signs to aid diagnosis.] Ann R Coll Surg Engl. 2010 Mar;92(2):163-6.</ref>
# '''Closed-fist percussion sign:''' <ref name="James Langdon" />This test has a sensitivity of 87,5% and a specificity of 90%, which is good. Stand behind the patiënt and the patiënt stand in front of a mirror allowing you to see the reaction of the patiënt. Firm closed-fist percussion is used to examine the entire length of the spine. The clinical sign is positive when the patiënt complains of a sharp, sudden pain.
# '''The supine sign:''' <ref name="James Langdon" /> This test has a sensitivity of 81,25% and a specificity of 93,33%, which is also pretty good. The patiënt is asked to lie supine with only one pillow for the head. The clinical sign is positive when the patiënt is unable to lie supine due to severe pain.
== Medical Management ==
== Medical Management ==


Good quality evidence supports that several medications (e.g. bisphosphonates) for bone density reduce fracture risk. Nevertheless side effects vary among drugs. (Crandall CJ, 2014: LoE 1A) <ref name="p1">Crandall CJ, Newberry SJ, Diamant A, Lim YW, Gellad WF, Booth MJ, Motala A, Shekelle PG.Comparative effectiveness of pharmacologic treatments to prevent fractures: an updated systematic review. Ann Intern Med. 2014 Nov 18;161(10):711-23. '''Level of Evidence: 1A.''' </ref>.
VFs are usually considered stable and do not require surgical instrumentation.<ref>Donnally C, Varacallo M. Fracture, Compression. 2018. Available from:https://www.researchgate.net/publication/329717392_Fracture_Compression [accessed 26/10/2023)</ref>


At first, conservative treatment still is the method of choice. In case of resulting deformity, sintering and persistent pain vertebral cement augmentation techniques today are widely used.Treatment after vertebral fracture should include appropriate pain management and possibly bracing<ref name="p0">Gerdhem P. Osteoporosis and fragility fractures: Vertebral fractures. Best Practice Research Clinical Rheumatology 2013 27: 743–755. </ref>. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing. Vertebral fractures can also be treated surgically using vertebroplasty and kyphoplasty<ref name="p1" /><ref name="p2">NICE. Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for treating osteoporotic vertebral compression fractures: NICE technology appraisal guidance TA279. Manchester: National Institute for Health and Care Excellence, 2013. </ref>. Percutaneous vertebroplasty (VP) began as a simple, low-cost procedure that aimed to provide pain relief for patients with  vertebral compression fractures (VCF). Balloon [[Kyphoplasty]] (KP) was introduced later, and was presented not only as a ‘‘pain killer,’’ but also as a deformity correction procedure<ref name="p2" />.
Conservative management of acute osteoporotic compression fractures may involve the following goals: reducing pain and improving functional status. This can be accomplished with the following:<ref name=":4">Ponzano M, Tibert N, Brien S, Funnell L, Gibbs JC, Keller H, Laprade J, Morin SN, Papaioannou A, Weston Z, Wideman TH, Giangregorio LM. [https://pubmed.ncbi.nlm.nih.gov/36799981/ International consensus on the non-pharmacological and non-surgical management of osteoporotic vertebral fractures.] Osteoporos Int. 2023 Jun;34(6):1065-74. </ref>
The vidoe clip below tells of an elderly lady with an osteoporotic insufficiency fracture and an animated version of a vertebroplasty.
* Acetaminophen, ibuprofen, opioids
{{#ev:youtube|https://www.youtube.com/watch?v=QjvKkYehpUI|width}}<ref>Lee Health. Fixing a fractured spine. Available from: https://www.youtube.com/watch?v=QjvKkYehpUI (last accessed 12.4.2019)</ref>
* Nutritional support
Frequently used analgesia are paracetamol or salicylates and non-steroidal anti-inflammatory drugs (NSAIDs). The risk of gastrointestinal bleeding and insufficiency should be taken into account when prescribing NSAIDs<ref name="p2" />
* Bed rest (but not continuous or prolonged)
* Modifications in daily activities
There is only low or very low-quality evidence on the efficacy of non-surgical treatment of symptoms of acute osteoporotic VCFs. Immediate- and short-term effects of opioids on pain were found inconsistent across trials with different comparators. Low-quality evidence supports immediate- and short-term effects of an NSAID on reducing pain intensity. There is low-quality evidence indicating the value of spinal orthoses for pain relief and disability at medium term. At present, there is insufficient evidence to inform conservative care for acute pain related to VCF. This was concluded by Rzewuska M. and colleaguesafter a 2015 systematic review with meta-analysis<ref name="p0" />.
* Pacing or graded activity
 
* Physiotherapy e.g. exercises after 12 weeks post fracture
The primary goal of bracing is to reduce pain by stabilising the spine and limiting progression of the deformity. A spinal orthosis should reduce gross spinal movement and segmental movement at the injured segment. Bracing allows a reduction in the period of bed rest, facilitating earlier mobilisation according to Kim DH and colleagues<ref>Kim DH, Vaccaro AR. Osteoporotic compression fractures of the spine; current options and considerations for treatment.Spine J. 2006 Sep-Oct;6(5):479-87. '''Level of Evidence: 3A.''' </ref>. An ideal brace should be light-weight and easy to put on. It should be comfortable to obtain patient compliance and it has to avoid respiratory impairments. Examples of braces are the Jewett brace, Taylor brace and cruciform anterior spinal hyperextension (CASH) orthosis, they keep the spine in hyperextension.  Even though bracing is widely used in these patients, its use is still opinion-based. Important: the evidence for a conservative spinal orthosis in patients with osteoporotic vertebral fractures is based on evidence from studies in patients with non-osteoporotic vertebral burst fractures<ref name="p2" />.
* Rehabilitation programmes
 
* Taping and bracing for compression fractures is often done for patient comfort and is unlikely to influence spinal stability. A small study did support the use of semirigid thoracolumbar orthosis for gait improvement.<ref>Jacobs E, Senden R, McCrum C, van Rhijn LW, Meijer K, Willems PC. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6469477/ Effect of a semirigid thoracolumbar orthosis on gait and sagittal alignment in patients with an osteoporotic vertebral compression fracture]. Clin Interv Aging. 2019 Apr 11;14:671-680.</ref>
We could only find one study evaluating spinal orthoses in the treatment of osteoporotic VCFs. Pfeifer, Begerow and Minne<ref name="p5" /> performed a prospective randomised trial using a thoracolumbar orthosis (TLO) to manage VCFs in women with postmenopausal osteoporosis. They reported increased trunk muscle strength and improvement of posture and body height in patients treated with an orthosis. They noted that patients had less pain, a better quality of life and restoration of their ability to perform daily living tasks.
* Treatment of the underlying disease (osteoporosis) is the recommended approach.
 
In 2023, an international consensus was reached on the non-pharmacological and non-surgical management of osteoporotic vertebral fractures. <ref name=":4" /> Multidisciplinary biopsychosocial recommendations were made on pain, nutrition, safe movement, and exercise for individuals with acute and chronic vertebral fractures.<ref name=":4" />
In a vertebroplasty bone cement, usually polymethylmethacrylate (PMMA), is injected into the vertebral bone. In a kyphoplasty a balloon is inserted into the vertebral body, the balloon is inflated to attempt to re-establish normal height and posture, the balloon is remove and cement injected. It permits kyphosis correction if performed within 3 months post-fracture. Height restoration is not a perquisite for pain control<ref name="p8" />.
 
Indications for surgery are: failed medical treatment for pain control, patients with co-morbidities that make prolonged bed rest dangerous, patients with fractures that fail to heal, resulting deformity, an unstable fracture (pattern) and involvement of spinal cord<ref name="p7" />. This was proved in both retrospective and prospective studies as well as in meta-analysis<ref name="p3" /><ref name="p5" /><ref name="p4">Liu JT et al. Balloon kyphoplasty versus vertebroplasty for treatment of osteoporotic vertebral compression fracture: a prospective, comparative, and randomized clinical study. Osteoporos Int. 2010 Feb;21(2):359-64. '''Level of Evidence: 1B.''' </ref>. The procedures are proved to be cost effective<ref name="p6" />.
 
Buchbinder R. et al (2009) performed a randomized controlled trial in which they compared a vertebroplasty surgery with a sham treatment in patients who suffer from an osteoporotic vertebral fracture. There were significant improvements at all follow-up measurements for several outcome measures: overall pain, pain at night, pain at rest, physical functioning and quality of life. They concluded that there is no beneficial effect of vertebroplasty as compared with a sham procedure in patients with painful osteoporotic vertebral fractures<ref name="p6" />. This has been confirmed by a Cochrane review<ref name="p3" />.
 
Diamond TH. et al (2003) compared a conservative and percutaneous vertebroplasty treatment for patients with an osteoporotic vertebral fracture. As outcome measures they used physical functioning and pain scores. They concluded that the operatively treated group scored significantly higher on the outcome measures than the conservatively treated group. This was the case for the short-term as well as the long-term measurements<ref name="p0" />.
 
Alvarez L. et al.<ref name="p2" /> compared a conservative and operative treatment (percutaneous vertebroplasty). Similar to the results of Diamond TH. et al<ref name="p0" />, they found that treatment with percutaneous vertebroplasty gives a rapid and significant relief of pain and improvement in quality of life.
 
Anderson, Froyshteter and Tontz<ref name="p6" /> conducted a meta-analysis on vertebral augmentation (kyphoplasty). They compared vertebral augmentation with conservative treatment for osteoporotic spinal fractures. The meta-analysis showed greater pain relief, functional recovery and helath-related quality of life with cement augmentation compared with controls. Cement augmentation results were significant in the early (<12 weeks) and the late time points (six to 12 months). This meta-analysis provides strong evidence in favor of cement agmentation in the treatment of sympotmatic VCF fractures.  
 
Chang X et al (2015) compared vertebroplasty to kyphoplasty in a meta-analysis of prospective comparative studies. They concluded that percutaneous vertebroplasty takes less time in the operation, has a greater risk of cement leakage, was inferior in reducing cobb angle in the long term and results in lower anterior vertebral body height after surgery. For pain relief (main desire of patients) both procedures still remain effective<ref name="p9" />.
 
Low bone mineral densitiy, presence of multiple treated vertebrae and a history of steroid usage were associated with new VCFs after vertebroplasty according to a meta-analysis from Cao J et al. (2016). Patients with these factors should be informed of the potential increased risk<ref name="p8" />.
 
Song D and colleagues (2015) found no differences in the incidence of secondary fractures between vertebral augmentation techniques and conservative treatment for patients with osteoporotic vertebral compression fractures. They conducted a systematic review and meta-analysis of randomized controlled trials and prospective non-randomized controlled trials<ref name="p1" />.


For persistent pain and the failure of conservative treatments, surgical intervention may be indicated.<ref>Gutierrez-Gonzalez R, Royuela A, Zamarron A. [https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-023-07041-1 Vertebral compression fractures: pain relief, progression and new fracture rate comparing vertebral augmentation with brace]. BMC Musculoskel Dis. 2023; 24: 898. </ref>
* Vertebroplasty is usually an outpatient procedure that takes one to two hours where under guided imaging, a needle get inserted into the vertebral body and medical-grade cement is injected.  This cement hardens quickly and stabilises the fracture. <ref>Buchbinder R, Johnston RV, Rischin KJ, Homik J, Jones C, Golmohammadi K, Kallmes DF. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006349.pub4/full Vertebroplasty for treating spinal fractures due to osteoporosis.] Cochrane Library of Systematic Reviews 2018; 11:1465-1858.</ref>
* Kyphoplasty is a very similar procedure, but in this case, a balloon is used to expand the vertebral body before injecting the cement. <ref>Whitney E, Alastra AJ. [https://www.ncbi.nlm.nih.gov/books/NBK547673/ Vertebral Fracture.] Available from:https://www.ncbi.nlm.nih.gov/books/NBK547673/ [accessed 26/10/2023]</ref>
{{#ev:youtube|https://www.youtube.com/watch?v=QjvKkYehpUI|width}}<ref>Lee Health. Fixing a Fractured Spine. Available from: https://www.youtube.com/watch?v=QjvKkYehpUI&feature=emb_logo [accessed 26/10/2023]</ref>
== Physical Therapy Management  ==
== Physical Therapy Management  ==
[[File:Exercise_older_person.jpg|right|frameless|400x400px]]


[[File:Exercise older person.jpg|frameless]]
After a short period of bed rest, patients begin with a rehabilitation exercise programme. A "how-to" language is preferred rather than only suggesting activity restrictions. <ref name=":4" /> The goals of rehabilitation are the prevention of [[Falls in elderly|falls]], providing correct spine alignment (reduction of the [[Thoracic Hyperkyphosis]]), improving respiratory function in severe cases, and enhancing axial muscle strength. <ref name=":1" />  
 
After a short period of bed rest patients should begin mobilisation with a rehabilitation and exercise program. The goals of rehabilitation are the prevention of [[Falls in elderly|falls]], reduction of the [[kyphosis]], enhancing axial muscle strength and providing correct spine alignment<ref name="yoo">Yoo JH, Moon SH, Ha YC, Lee DY, Gong HS, Park SY, Yang KH.Osteoporotic Fracture: 2015 Position Statement of the Korean Society for Bone and Mineral Research.J Bone Metab. 2015 Nov;22(4):175-81. 30. (Level of Evidence: 2B)</ref>.
 
Regarding Physiotherapy management, there are a number of treatment approaches, including strengthening exercise, stabilisation exercise, [[Balance Boards|balance training]], stretching, relaxation techniques, manual therapy and taping<ref name="Pratelli et al (2010)">Pratelli E, Cinotti I, Pasquetti P. Rehabilitation in osteoporotic vertebral fractures. Clin Cases Miner Bone Metab. 2010 7(1): 45–47.</ref><ref name="Barker et al (2014)">Barker K, Javaid MK, Newman M, Minns Lowe C, Stallard N, Campbell H, Gandhi V, Lamb S. Physiotherapy Rehabilitation for Osteoporotic Vertebral Fracture (PROVE): study protocol for a randomised controlled trial. Trials 2014 15:22</ref>.&nbsp;Currently a large RCT is comparing exercise based and ‘hands on’ manual therapy based physiotherapy against a control<ref name="Barker et al (2014)" />.
 
Zehnacker and Bemis‐Dougherty conducted a systematic review to study the effect of weighted exercises on bone mineral density in post menopausal women<ref name="zehnacker">Zehnacker CH, Bemis‐Dougherty A. Effect of Weighted Exercises on Bone Mineral Density in Post Menopausal Women A Systematic Review. Journal of Geriatric Physical Therapy. 2007; 30(2):79-88. (Level of Evidence: 1A)</ref>.&nbsp;Exercises such as walking has been shown to maintain or improve bone density in an osteoporotic population. Strengthening exercises, using weights or resistance bands, has also been shown to maintain or improve bone density at the location of the targeted muscle attachments. Maintaining bone health is extremely important, especially in the elderly as there typically is a decline in bone mass with age.
 
Strengthening and flexability exercises improve overall physical function and postural control. Improving postural control is important to reduce risk for falls. Falls often result in fractures in an osteoporotic population. Balance exercises are also important to further reduce the risk of falls<ref name="burke">Burke TN, Franca FJR, Ferreira de Meneses SR, Pereira RMR, Marques AP. Postural control in elderly women with osteoporosis: comparison of balance, strengthening and stretching exercises. A randomized controlled trial. Clinical Rehabilitation; 26 (11): 1021-1031. 2012. (Level of Evidence: 1B)</ref>.&nbsp;
 
Studies from De Kam et al. (2009, LoE:1A), Karinkanta et al. (2007, LoE:1B) and Hourigan SR et al. (2008, LoE:1B) all found that a combined balance and progressive strength training programme produced the best results in terms of maintaining leg strength, balance, bone mineral density and physical function compared to balance or strength training alone<ref name="de kam">De Kam D, Smulders E, Weerdesteyn V, Smits-Engelsman BCM. Exercise interventions to reduce fall-related fractures and their risk factors in individuals with low bone density: a systematic review of randomized controlled trials. Osteoporos Int. 2009;20:2111–2125 (Level of evidence: 1A)</ref><ref name="karinkanta">Karinkanta S, Heinonen A, Sievänen H, Uusi-Rasi K, Pasanen M, Ojala K. A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: a randomized, controlled trial. Osteoporos Int. 2007;18:453–462. (Level of evidence: 1B)</ref><ref name="hourigan">Hourigan SR, Nitz JC, Brauer SG, O'Neill S, Wong J, Richardson CA. Positive effects of exercise on falls and fracture risk in osteopenic women. Osteoporos Int. 2008;19:1077–1086. (Level of evidence: 1B)</ref>.
 
Sinaki et al demonstrated that a spinal extensor strengthening programme and a dynamic proprioceptive programme increased bone density and reduced the risk of VCFs. Moreover the incidence of new fractures associated with back extension exercises is lower than the incidence related to abdominal flexion exercises (16% versus 89%)<ref name="sinaki 1">Sinaki M, Lynn SG. Reducing the risk of falls through proprioceptive dynamic posture training in osteoporotic women with kyphotic posturing: a randomized pilot study.Am J Phys Med Rehabil. 2002 Apr;81(4):241-6. (Level of Evidence: 3B)</ref>.


Exercise and exercise technique that focuses on spinal extension play an important role in reducing the risk of osteoporosis-related fractures. In addition, reports have shown that strenuous spinal flexion exercise, whether therapeutic, recreational, or job related, may induce compression fracture if beyond the biomechanical competence of the vertebral bodies. In other words, extreme flexion is contra-indicated<ref name="sinaki 2">Sinaki M. Exercise for patients with osteoporosis: management of vertebral compression fractures and trunk strengthening for fall prevention.PM R. 2012 Nov;4(11):882-8. (Level of Evidence: 3A)</ref>.  
Treatment approaches include:
 
* Diaphragmatic breathing exercises <ref name=":4" />and pelvic floor exercises
Back extensor exercises improve muscle strength, providing a better dynamic-static posture and reduction of the kyphotic deformity. Correction of the kyphosis also results in pain relief, increased mobility and an improvement in the quality of life<ref name="itoi">Itoi E, Sinaki M.Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age.Mayo Clin Proc. 1994 Nov;69(11):1054-9. (Level of Evidence: 3B)</ref>.
* Strengthening exercises, stabilisation exercise, [[Balance Boards|balance training]], stretching, relaxation techniques, taping.<ref name="Pratelli et al (2010)">Pratelli E, Cinotti I, Pasquetti P. [https://pubmed.ncbi.nlm.nih.gov/22461291/ Rehabilitation in osteoporotic vertebral fractures.] Clin Cases Miner Bone Metab. 2010 7(1): 45–47.</ref><ref name="Barker et al (2014)">Barker KL, Newman M, Stallard N, Leal J, Lowe CM, Javaid MK, Noufaily A, Hughes T, Smith D, Gandhi V, Cooper C, Lamb SE; PROVE trial group. [https://pubmed.ncbi.nlm.nih.gov/31720722/ Physiotherapy rehabilitation for osteoporotic vertebral fracture-a randomised controlled trial and economic evaluation (PROVE trial).] Osteoporos Int. 2020 Feb;31(2):277-89. </ref>
 
* Exercises such as walking help to maintain or improve bone density in an osteoporotic population.
It has been previously hypothesized that horizontal nonloading back extension exercises from a prone position can decrease the incidence of vertebral fractures<ref name="sinaki 3">Sinaki M.The role of physical activity in bone health: a new hypothesis to reduce risk of vertebral fracture.Phys Med Rehabil Clin N Am. 2007 Aug;18(3):593-608, xi-xii. (Level of Evidence: 5)</ref>. Back extension exercises performed from the prone position load vertebral horizontal trabeculae without the risk of vertebral compression fracture that can occur with vertical loading<ref name="sinaki 2" />.
* Strengthening exercises, using weights or resistance bands help maintain or improve bone density at the location of the targeted muscle attachments. <ref>Hong AR, Kim SW. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279907/ Effects of resistance exercise on bone health.] Endocrinol Metab. 2018 Dec 1;33(4):435-44.</ref> Maintaining bone health is extremely important, especially in the elderly as there typically is a decline in bone mass with age.
* Strengthening and flexibility exercises improve overall physical function and postural control (important to reduce risk for falls).<ref name="burke">Burke TN, Franca FJR, Ferreira de Meneses SR, Pereira RMR, Marques AP. [https://pubmed.ncbi.nlm.nih.gov/22498664/ Postural control in elderly women with osteoporosis: comparison of balance, strengthening and stretching exercises. A randomized controlled trial.] Clinical Rehabilitation 2012; 26 (11): 1021-1031. </ref>
* Combined balance and progressive strength training programme produced the best results in terms of maintaining leg strength, balance, bone mineral density and physical function compared to balance or strength training alone. <ref name="de kam">De Kam D, Smulders E, Weerdesteyn V, Smits-Engelsman BCM. [https://pubmed.ncbi.nlm.nih.gov/19421702/ Exercise interventions to reduce fall-related fractures and their risk factors in individuals with low bone density: a systematic review of randomized controlled trials.] Osteoporos Int. 2009;20:2111–25.</ref><ref name="karinkanta">Karinkanta S, Heinonen A, Sievänen H, Uusi-Rasi K, Pasanen M, Ojala K. [https://pubmed.ncbi.nlm.nih.gov/17103296/ A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: a randomized, controlled trial.] Osteoporos Int. 2007;18:453–462. </ref><ref name="hourigan">Hourigan SR, Nitz JC, Brauer SG, O'Neill S, Wong J, Richardson CA. [https://pubmed.ncbi.nlm.nih.gov/18188658/ Positive effects of exercise on falls and fracture risk in osteopenic women.] Osteoporos Int. 2008;19:1077–86.</ref>
* Spinal extensor strengthening programme and a dynamic proprioceptive programme increase bone density and reduced the risk of VCFs.<ref name="sinaki 1">Sinaki M, Lynn SG. [https://pubmed.ncbi.nlm.nih.gov/11953540/ Reducing the risk of falls through proprioceptive dynamic posture training in osteoporotic women with kyphotic posturing: a randomized pilot study].Am J Phys Med Rehabil. 2002 Apr;81(4):241-6. </ref>
* Back extensor exercises improve muscle strength, providing a better dynamic-static posture and reduction of the kyphotic deformity. Correction of the kyphosis also results in pain relief, increased mobility and an improvement in the quality of life.<ref name="itoi">Itoi E, Sinaki M.[https://pubmed.ncbi.nlm.nih.gov/7967758/ Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age].Mayo Clin Proc. 1994 Nov;69(11):1054-9. (Level of Evidence: 3B)</ref>


[[Image:Oefeningen osteo.png|1000x1000px]]  
[[Image:Oefeningen osteo.png|1000x1000px]]  


<br>  
<br>Postural [[taping]] can help in postural alignment. Tape is applied to the skin to provide increased proprioceptive feedback about postural alignment, improve thoracic extension, reduce pain and facilitate postural muscle activity and balance. <ref name="bautmans">Bautmans I, Van Arken J, Van Mackelenberg M, Mets T. [https://pubmed.ncbi.nlm.nih.gov/20140408/ Rehabilitation using manual mobilization for thoraic kyphosis in elderly postmenopauzal patients with osteoporosis.] J Rehabil Med 2010, 42: 129-135. (Level of Evidence: 3B)</ref> For example;{{#ev:youtube|996cC3ovLEQ|300}}<ref>John Gibbons. Try this Kinesiology Taping technique for poor posture - its incredible. Available from: http://www.youtube.com/watch?v=996cC3ovLEQ[last accessed 21/4/2020]</ref>
 
== Clinical Bottom Line ==
<br>
* Osteoporotic vertebral fractures are fractures of one or more of the vertebrae due to osteoporosis.[[File:Strengthing exercise for old people .jpg|right|frameless|400x400px]]Osteoporosis causes the  bones to be more fragile and more likely to fracture. Osteoporotic vertebral fractures classically occur during normal day-to-day activities such as bending, twisting, walking or lifting relatively light objects.
 
* The pain of acute fracture usually lasts 4 to 6 weeks with intense pain at the site of fracture. Chronic pain may also occur in patients with multiple compression fractures, height loss and low bone density. Although this is probably due to structural changes or osteoarthritis.
Chen BL and colleagues studied the effectiveness of systematic back muscle exercises after vertebroplasty for spinal osteoporotic compression fractures. They found that systematic back muscle exercises resulted in a significant better outcome on the Oswestry Disability Index and pain level (VAS) compared to the control group. Control group only received general postoperation therapy without systematic back exercises<ref name="chen">Chen BL, Zhong Y, Huang YL, Zeng LW, Li YQ, Yang XX, Jiang Q, Wang CH. Systematic back muscle exercise after percutaneous vertebroplasty for spinal osteoporotic compression fracture patients: a randomized controlled trial.Clin Rehabil. 2012 Jun;26(6):483-92. (Level of Evidence: 1B)</ref>.
* Vertebral fractures don't only occur due to osteoporosis. Also a trauma or metastasis can cause a vertebral fracture. The diagnosis of osteoporosis can be confirmed by Dual Energy X-ray Absorptiometry (DXA).
 
* Often used outcome measures to evaluate the progression of a patient are: Visual analogue scale for overall pain and pain during day and night (VAS), a Quality of Life questionnaire and a Physical functioning questionaire ( modified 23-item version of the Roland–Morris Disability Questionnaire).
Wendlova J. concluded that after a biomechanical analysis that carrying a backpack on the back is recommended to patients with osteoporotic vertebral fractures. This is based upon removing the muscular dysbalance of the trunk muscles and upon increasing the bone strength by compressive force acting upon the vertebrae. Compressive forces activate osteoblasts to enhance osteoformation.<span style="line-height: 1.5em;">The backpack load is differentiated: patients with vertebral fractures put a weight up to 1 kg into their backpacks, patients without vertebral fractures but diagnosed with osteoporosis increase the load up to 2kg. Further research is needed</span><ref name="wendlova">Wendlova J. The importance of carrying a backpack in the rehabilitation of osteoporotic patients (biomechanical analysis).Bratisl Lek Listy. 2011;112(1):41-3. (Level of Evidence: 4)</ref>.
* Conservative treatment (bed rest, analgesic medication, physiotherapy and bracing) still is the method of choice as medical treatment. Vertebral fractures can also be treated surgically using vertebroplasty and kyphoplasty.
 
* As physical therapy management there are a number of treatment approaches, including strengthening exercise, stabilisation exercise, balance training, stretching, relaxation techniques, manual therapy and taping.
To prevent falls and fractures, an exercise program should include balance and lower extremity strength training combined with a coordinated approach<ref name="sinaki 2" />.
 
Postural taping can help in maintaining postural alignment. Tape is applied to the skin to provide increased proprioceptive feedback about postural alignment, improve thoracic extension, reduce pain and facilitate postural muscle activity and balance<ref name="bautmans">Bautmans I, Van Arken J, Van Mackelenberg M, Mets T. Rehabilitation using manual mobilization for thoraic kyphosis in elderly postmenopauzal patients with osteoporosis. J Rehabil Med 2010, 42: 129-135. (Level of Evidence: 3B)</ref>.
 


== Key Research ==
== Key Research ==
The following articles are key evidence pieces for physical therapy interventions:
The following articles are key evidence pieces for physical therapy interventions:
* Exercise interventions to reduce fall-related fractures and their risk factors in individuals with low bone density: a systematic review of randomized controlled trials<ref name="p4" />
* International consensus on the non-pharmacological and non-surgical management of osteoporotic vertebral fractures. <ref name=":4" />
* A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: a randomized, controlled trial <ref name="p5" />
* Exercise interventions to reduce fall-related fractures and their risk factors in individuals with low bone density: a systematic review of randomized controlled trials <ref name="p4">Liu JT et al. Balloon kyphoplasty versus vertebroplasty for treatment of osteoporotic vertebral compression fracture: a prospective, comparative, and randomized clinical study. Osteoporos Int. 2010 Feb;21(2):359-64. '''Level of Evidence: 1B.''' </ref>
* Positive effects of exercise on falls and fracture risk in osteopenic women<ref name="p6" />
* A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: a randomized, controlled trial <ref name="p5">Gauthier A, Kanis JA, Jiang Y, Martin M, Compston JE, Borgström F, Cooper C, McCloskey EV. Epidemiological burden of postmenopausal osteoporosis in the UK from 2010 to 2021: estimations from a disease model. Arch Osteoporos 2011 6:179–188. </ref>
* Positive effects of exercise on falls and fracture risk in osteopenic women <ref name="p6">Kim DH, Vaccaro AR. Contemporary Concepts in Spine Care: Osteoporotic compression fractures of the spine; current options and considerations for treatment. The Spine Journal. 2006 6 479–487. </ref>
* Reducing the risk of falls through proprioceptive dynamic posture training in osteoporotic women with kyphotic posturing: a randomized pilot study
* Reducing the risk of falls through proprioceptive dynamic posture training in osteoporotic women with kyphotic posturing: a randomized pilot study
* Identifying osteoporotic vertebral fracture<ref name="p7" />
* Identifying osteoporotic vertebral fracture <ref name="p7">NICE. Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women (amended): NICE technology appraisal guidance 160. Manchester: National Institute for Health and Care Excellence, 2011. </ref>
* Position Statement of the Korean Society for Bone and Mineral Research<ref name="p7" />
* Position Statement of the Korean Society for Bone and Mineral Research <ref name="p7" />
 
 
== Resources  ==


== Resources ==
[http://www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx]<br>  
[http://www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx]<br>  


[https://www.nos.org.uk/about-osteoporosis www.nos.org.uk/about-osteoporosis]
[https://www.nos.org.uk/about-osteoporosis www.nos.org.uk/about-osteoporosis]
== Clinical Bottom Line ==
Osteoporotic vertebral fractures are fractures of one ore more of the vertebrae due to osteoporosis. Osteoporosis causes the  bones to be more fragile and more likely to fracture. Osteoporotic vertebral fractures classically occur during normal day-to-day activities such as bending, walking or lifting relatively light objects.
The pain of acute fracture usually lasts 4 to 6 weeks with intense pain at the site of fracture. Chronic pain may also occur in patients with multiple compression fractures, height loss and low bone density. Although this is probably due to structural changes or osteoarthritis.
Vertebral fractures doesn’t only occur due to osteoporosis. Also a trauma or metastasis can cause a vertebral fracture. The diagnosis of osteoporosis can be confirmed by Dual Energy X-ray Absorptiometry (DXA).
Often used  outcome measures to evaluate the progression of a patiënt are: Visual analogue scale for overall pain and pain during day and night (VAS), a Quality of Life questionnaire and a Physical functioning questionaire ( modified 23-item version of the Roland–Morris Disability Questionnaire).
Conservative treatment (bed rest, analgesic medication, physiotherapy and bracing) still is the method of choice as medical treatment. Vertebral fractures can also be treated surgically using vertebroplasty and kyphoplasty.
As physical therapy management there are a number of treatment approaches, including strengthening exercise, stabilisation exercise, balance training, stretching, relaxation techniques, manual therapy and taping.
== Recent Related Research ==
* Rzewuska M. The efficacy of conservative treatment of osteoporotic compression fractures on acute pain relief: a systematic review with meta-analysis.Eur Spine J. 2015 Apr;24(4):702-14. '''Level of Evidence: 1A'''.
* Buchbinder R, Golmohammadi K, Johnston RV, Owen RJ, Homik J, Jones A, Dhillon SS, Kallmes DF, Lambert RG.Percutaneous vertebroplasty for osteoporotic vertebral compression fracture.Cochrane Database Syst Rev. 2015 Apr 30;4:CD006349. '''Level of Evidence: 1A.'''


== References  ==  
== References  ==  
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[[Category:Older People/Geriatrics]]
[[Category:Bone Conditions]]
[[Category:Bone - Conditions]]
[[Category:Bone Fractures]]
[[Category:Fractures]]
[[Category:Conditions]]
[[Category:Older People/Geriatrics - Conditions]]

Latest revision as of 19:40, 11 February 2024

Original Editor - Mathieu Vanderroost

Top Contributors - Mathieu Vanderroost, Angeliki Chorti, Lucinda hampton, Jasper Vermeersch, Jon Room, Kim Jackson, Jelle Van Hemelryck, Khloud Shreif, Laura Ritchie, Lauren Lopez, Vidya Acharya, Claire Knott, 127.0.0.1, Admin, Rachael Lowe, Kai A. Sigel and WikiSysop

Definition / Description[edit | edit source]

Osteoporotic (fragility) vertebral fractures (VFs) are fractures that result from mechanical forces that would not ordinarily result in a fracture. [1] These types of fractures are insufficiency fractures, caused by normal stresses on abnormal bone, often indicating frailty.

Classification of Vertebral Fractures[edit | edit source]

Classification of VFs has been described by type of deformity (wedge, biconcavity, or crush compression) and further by the degree of deformity (grades I, II). [2] [3]

X-Ray of an anterior wedge fracture.
  • Wedge VFs are the most common, occuring in the midthoracic region with compression of the anterior segment of the vertebral body (VB) and the anterior longitudinal ligament (ALL), and reports of more than 50% of all VFs. [4] Wedge fractures do not involve the posterior half of the VB and do not involve the posterior osseous ligamentous complex. The former distinguishes a compression fracture from a burst fracture.
  • Biconcave compression VFs are the second-most common (approximately 17% of all VFs); here, only the middle portion of the vertebral body is collapsed, with no compromise of the anterior and posterior walls. [3]
  • Crush compression VFs are the least common (13%), and are characterised by the collaplse of the entire anterior column, including anterior and posterior margins. [3]
  • The remaining 20% of VFs may involve complex fractures of the spine. [3]
  • Grade I refers to 3 SD < deformity < 4 SD and grade 2 deformity > 4 SD from the normal range for each vertebra. [2]

Etiology[edit | edit source]

  • The most common etiology of VFs is osteoporosis, making these fractures the most common fragility fracture. [5][6]
  • In contrast, vertebral compression fractures (VCFs) demonstrate a bimodal distribution with younger patients sustaining these injuries secondary to high energy mechanisms (fall from a height, MVA, etc.).
  • VFs occur secondary to an axial/compressive (and to a lesser extent, flexion) load with a resultant biomechanical failure of the bone resulting in a fracture.

Watch this video analysing causes of VFs (including osteoporotic):

[7]

Epidemiology[edit | edit source]

European population studies have shown that the annual incidence of VCFs is 10.7 per 1000 women and 5.7 per 1000 men. [8]

  • VCFs are the most common fragility fractures reported in the literature. [9]
  • VCFs are common in Asian and Caucasian women, and less common in African-American women. [3]
  • Approximately 1.5 million VCFs occur annually in the United States (US) alone in the general population. [10]
  • Prevalence increases with age, and it is estimated that 40% to 50% of patients over age 80 years have sustained a VCF either acutely, or recognised incidentally during clinical workup for a separate condition.[11]
  • Thoracolumbar junction (i.e., the segment from T12 to L2) location most often affected and the second most common site is the L2 to L5 region. [3]
  • Estimated annual cost of VCFs in the US is $746 million. [12]

In the elderly patients,

  • 30% of VCFs in severe cases of osteoporosis occur while the patient is in bed [3][13]
  • As the population continues to age, the population at risk of sustaining low energy fragility fractures will continue to increase as well.
  • Largely unreported and are probably more common radiographically (present up to 14% of women older than 60 years in one study)[14]
  • Currently, 10 million Americans are already diagnosed with osteoporosis, and another 34 million have osteopenia.

Clinical Presentation[edit | edit source]

Low Back Pain Guy.jpg

VFs present with pain and loss of mobility.[14]

Symptoms of VFs can include:

  • Back pain is common in elderly patients. Decreases when lying on the back (reduced weight baring conditions). [15][16]
  • Most patients with vertebral fractures do not seek medical attention and up to 70% of vertebral fractures may not result in notably severe symptoms.[6]
  • Loss of height. Height loss of the osteoporotic fractured vertebra may be mild (20-25%), moderate (25-40%) or severe (> 40%). It commonly affects the thoracolumbar region, though any vertebra may be disturbed.
  • The pain of acute fracture usually lasts 4 to 6 weeks with intense pain at the site of fracture.
  • The pain resolves over a period of six to 12 weeks.
  • Chronic pain may also occur in patients with multiple compression fractures, height loss and low bone density (also due to structural changes or osteoarthritis).[3]
  • Radiographic VCF may not be symptomatic. The greater the deformity, the greater the likelihood of pain and disability.
  • As height is lost, patients experience discomfort from the rib cage pressing downward on the pelvis.
  • Patients develop an exaggerated thoracic kyphosis and/or an exaggerated lumbar lordosis[6] - due to multiple adjacent VCFs - [3]which may result in decreased exercise tolerance and reduced abdominal space giving rise to early satiety and weight loss.
  • Sleep disorders may occur and decreased self esteem +/- depression.
  • Self care may become difficult. [17][18][19]
  • Associated with an increased morbidity and increased mortality [6][20]

Fracture Risk Assessment Tool[edit | edit source]

A Fracture Risk Assessment Tool (FRAX) has been developed with the aim to predict osteoporotic fractures in general. It is based on cohort data generated from European, North American, Australian and Asian men and women. Although it does not refer to vertebral fractures exclusively, the FRAX algorithm indicates the 10-year chance of a major osteoporotic fracture taking place. [21] Clinicians may use of the FRAX tool in combination with indications for assessment of osteoporotic vertebral fractures.

Indications for Vertebral Fracture Assessment[edit | edit source]

A Vertebral Fracture Assessment (VFA) is indicated: [22]

  • In postmenopausal women, and men aged ≥ 50 years,
  • In the presence of a history of ≥ 4 cm height loss, or kyphosis,
  • If there is a history of recent or current long-term oral glucocorticoid therapy, or other therapy that compromises the bone
  • In BMD T-scores ≤ − 2.5 at either the spine or hip
  • If an acute onset of back pain with risk factors for osteoporosis at an older age is reported. An updated Cochrane review assessing the diagnostic accuracy of red flags for vertebral fracture in patients complaining for low back pain [23] concluded that appropriate sets of vertebral fracture indicators of various aetiologies are still lacking, so this finding may be interpreted with caution.

Diagnostic Procedures[edit | edit source]

compression fracture of 3rd lumbar vertebra

Diagnosed on Xrays when there is a loss of height in the anterior, middle, or posterior dimension of the vertebral body that exceeds 20%.

Osteoporotic spine fractures can be graded based on vertebral height loss as:

  • Mild: up to 20-25%
  • Moderate: 25-40%
  • Severe: >40%

Chronicity of the fracture indicates its temporal relationship with symptoms and hence is an important determination when deciding on conservative or surgical treatment. [24]

On conventional imaging, acute fracture signs include cortical breaking or impaction of trabeculae; in the absence of these signs fractures are chronic.

In uncertain cases, MRI signs of oedema (acute) and presence of radiotracer uptake on bone scintigraphy (acute) help decide the age of the fracture.

Outcome Measures[edit | edit source]

  1. Visual analogue scale for overall pain (VAS).
  2. Quality of Life questionnaire: this can be measured with the use of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). An other possibility is to use the Assessment of Quality of Life (AQoL) questionnaire or the European Quality of Life–5 Dimensions (EQ–5D) scale.
  3. Physical functioning: measured by a modified 23-item version of the Roland–Morris Disability Questionnaire.
  4. Pain at night and at rest (VAS score) [25]
  5. Research suggests that the four-factor Mini-BESTest model can be effective in evaluating multiple dynamic balance aspects in older adults with femoral or vertebral fractures and may help therapists in making clinical decisions, considering factors that indicated a decline in function. [26]

Examination[edit | edit source]

Clinical assessment of vertebral fractures is generally poor and reliance is made on imaging studies for diagnosis. [18]

Two tests that help the practitioner to predict more accurately which patients have an acute vertebral fracture: [27]

  1. Closed-fist percussion sign: [27]This test has a sensitivity of 87,5% and a specificity of 90%, which is good. Stand behind the patiënt and the patiënt stand in front of a mirror allowing you to see the reaction of the patiënt. Firm closed-fist percussion is used to examine the entire length of the spine. The clinical sign is positive when the patiënt complains of a sharp, sudden pain.
  2. The supine sign: [27] This test has a sensitivity of 81,25% and a specificity of 93,33%, which is also pretty good. The patiënt is asked to lie supine with only one pillow for the head. The clinical sign is positive when the patiënt is unable to lie supine due to severe pain.

Medical Management[edit | edit source]

VFs are usually considered stable and do not require surgical instrumentation.[28]

Conservative management of acute osteoporotic compression fractures may involve the following goals: reducing pain and improving functional status. This can be accomplished with the following:[29]

  • Acetaminophen, ibuprofen, opioids
  • Nutritional support
  • Bed rest (but not continuous or prolonged)
  • Modifications in daily activities
  • Pacing or graded activity
  • Physiotherapy e.g. exercises after 12 weeks post fracture
  • Rehabilitation programmes
  • Taping and bracing for compression fractures is often done for patient comfort and is unlikely to influence spinal stability. A small study did support the use of semirigid thoracolumbar orthosis for gait improvement.[30]
  • Treatment of the underlying disease (osteoporosis) is the recommended approach.

In 2023, an international consensus was reached on the non-pharmacological and non-surgical management of osteoporotic vertebral fractures. [29] Multidisciplinary biopsychosocial recommendations were made on pain, nutrition, safe movement, and exercise for individuals with acute and chronic vertebral fractures.[29]

For persistent pain and the failure of conservative treatments, surgical intervention may be indicated.[31]

  • Vertebroplasty is usually an outpatient procedure that takes one to two hours where under guided imaging, a needle get inserted into the vertebral body and medical-grade cement is injected.  This cement hardens quickly and stabilises the fracture. [32]
  • Kyphoplasty is a very similar procedure, but in this case, a balloon is used to expand the vertebral body before injecting the cement. [33]

[34]

Physical Therapy Management[edit | edit source]

Exercise older person.jpg

After a short period of bed rest, patients begin with a rehabilitation exercise programme. A "how-to" language is preferred rather than only suggesting activity restrictions. [29] The goals of rehabilitation are the prevention of falls, providing correct spine alignment (reduction of the Thoracic Hyperkyphosis), improving respiratory function in severe cases, and enhancing axial muscle strength. [1]

Treatment approaches include:

  • Diaphragmatic breathing exercises [29]and pelvic floor exercises
  • Strengthening exercises, stabilisation exercise, balance training, stretching, relaxation techniques, taping.[35][36]
  • Exercises such as walking help to maintain or improve bone density in an osteoporotic population.
  • Strengthening exercises, using weights or resistance bands help maintain or improve bone density at the location of the targeted muscle attachments. [37] Maintaining bone health is extremely important, especially in the elderly as there typically is a decline in bone mass with age.
  • Strengthening and flexibility exercises improve overall physical function and postural control (important to reduce risk for falls).[38]
  • Combined balance and progressive strength training programme produced the best results in terms of maintaining leg strength, balance, bone mineral density and physical function compared to balance or strength training alone. [39][40][41]
  • Spinal extensor strengthening programme and a dynamic proprioceptive programme increase bone density and reduced the risk of VCFs.[42]
  • Back extensor exercises improve muscle strength, providing a better dynamic-static posture and reduction of the kyphotic deformity. Correction of the kyphosis also results in pain relief, increased mobility and an improvement in the quality of life.[43]

Oefeningen osteo.png


Postural taping can help in postural alignment. Tape is applied to the skin to provide increased proprioceptive feedback about postural alignment, improve thoracic extension, reduce pain and facilitate postural muscle activity and balance. [44] For example;

[45]

Clinical Bottom Line[edit | edit source]

  • Osteoporotic vertebral fractures are fractures of one or more of the vertebrae due to osteoporosis.
    Strengthing exercise for old people .jpg
    Osteoporosis causes the bones to be more fragile and more likely to fracture. Osteoporotic vertebral fractures classically occur during normal day-to-day activities such as bending, twisting, walking or lifting relatively light objects.
  • The pain of acute fracture usually lasts 4 to 6 weeks with intense pain at the site of fracture. Chronic pain may also occur in patients with multiple compression fractures, height loss and low bone density. Although this is probably due to structural changes or osteoarthritis.
  • Vertebral fractures don't only occur due to osteoporosis. Also a trauma or metastasis can cause a vertebral fracture. The diagnosis of osteoporosis can be confirmed by Dual Energy X-ray Absorptiometry (DXA).
  • Often used outcome measures to evaluate the progression of a patient are: Visual analogue scale for overall pain and pain during day and night (VAS), a Quality of Life questionnaire and a Physical functioning questionaire ( modified 23-item version of the Roland–Morris Disability Questionnaire).
  • Conservative treatment (bed rest, analgesic medication, physiotherapy and bracing) still is the method of choice as medical treatment. Vertebral fractures can also be treated surgically using vertebroplasty and kyphoplasty.
  • As physical therapy management there are a number of treatment approaches, including strengthening exercise, stabilisation exercise, balance training, stretching, relaxation techniques, manual therapy and taping.

Key Research[edit | edit source]

The following articles are key evidence pieces for physical therapy interventions:

  • International consensus on the non-pharmacological and non-surgical management of osteoporotic vertebral fractures. [29]
  • Exercise interventions to reduce fall-related fractures and their risk factors in individuals with low bone density: a systematic review of randomized controlled trials [46]
  • A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: a randomized, controlled trial [47]
  • Positive effects of exercise on falls and fracture risk in osteopenic women [48]
  • Reducing the risk of falls through proprioceptive dynamic posture training in osteoporotic women with kyphotic posturing: a randomized pilot study
  • Identifying osteoporotic vertebral fracture [49]
  • Position Statement of the Korean Society for Bone and Mineral Research [49]

Resources[edit | edit source]

www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx

www.nos.org.uk/about-osteoporosis

References[edit | edit source]

  1. ↑ 1.0 1.1 Yoo JH, Moon SH, Ha YC, Lee DY, Gong HS, Park SY, Yang KH. Osteoporotic Fracture: 2015 Position Statement of the Korean Society for Bone and Mineral Research.J Bone Metab. 2015 Nov;22(4):175-81. 30. Level of Evidence: 2B.
  2. ↑ 2.0 2.1 Eastell R, Cedel SL, Wahner HW, Riggs BL, Melton LJ III. Classification of vertebral fractures. JBMR 1991; 6(3):207-15.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Alexandru D, So W. Evaluation and Management of Vertebral Compression Fractures. Perm J. 2012 Fall; 16(4): 46–51.
  4. ↑ Black DM, Arden NK, Palermo L, Pearson J, Cummings SR. Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures. Study of Osteoporotic Fractures Research Group. J Bone Miner Res. 1999 May;14(5):821–8.
  5. ↑ Ettinger B, Black DM, Nevitt MC, Rundle AC, Cauley JA, Cummings SR, Genant HK. Contribution of vertebral deformities to chronic back pain and disability. The Study of Osteoporotic Fractures Research Group. J Bone Miner Res. 1992 Apr;7(4):449-56.
  6. ↑ 6.0 6.1 6.2 6.3 Griffith JF. Identifying osteoporotic vertebral fracture. Quant Imaging Med Surg. 2015 Aug;5(4):592-602.
  7. ↑ Spine live. Spinal compression fractures reasons. Available from: https://www.youtube.com/watch?v=LILgFAEMAbg [accessed 26/10/2023]
  8. ↑ European Prospective Osteoporosis Study (EPOS) Group; Felsenberg D, Silman AJ, Lunt M, Armbrecht G, Ismail AA, Finn JD, Cockerill WC, Banzer D, Benevolenskaya LI, Bhalla A, Bruges Armas J, Cannata JB, Cooper C, Dequeker J, Eastell R, Felsch B, Gowin W, Havelka S, Hoszowski K, Jajic I, Janott J, Johnell O, Kanis JA, Kragl G, Lopes Vaz A, Lorenc R, Lyritis G, Masaryk P, Matthis C, Miazgowski T, Parisi G, Pols HA, Poor G, Raspe HH, Reid DM, Reisinger W, Schedit-Nave C, Stepan JJ, Todd CJ, Weber K, Woolf AD, Yershova OB, Reeve J, O'Neill TW. Incidence of vertebral fracture in europe: results from the European Prospective Osteoporosis Study (EPOS). J Bone Miner Res. 2002 Apr;17(4):716-24.
  9. ↑ Kutsal FY, Ergin Ergani GO. Vertebral compression fractures: Still an unpredictable aspect of osteoporosis. Turk J Med Sci. 2021; 51(2): 393–399.
  10. ↑ Barr JD, Barr MS, Lemley TJ, McCann RM. Percutaneous vertebroplasty for pain relief and spinal stabilization. Spine (Phila Pa 1976). 2000 Apr 15;25(8):923-8.
  11. ↑ Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, Bauer DC, Genant HK, Haskell WL, Marcus R, Ott SM, Torner JC, Quandt SA, Reiss TF, Ensrud KE. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet. 1996 Dec 7;348(9041):1535-41.
  12. ↑ Lad SP, Patil CG, Lad EM, Boakye M. Trends in pathological vertebral fractures in the United States: 1993 to 2004. J Neurosurg Spine. 2007 Sep;7(3):305-10.
  13. ↑ Kim HJ, Park S, Park SH, Park J, Chang BS, Lee CK, Yeom JS. Prevalence of Frailty in Patients with Osteoporotic Vertebral Compression Fracture and Its Association with Numbers of Fractures. Yonsei Med J. 2018;59(2):317.
  14. ↑ 14.0 14.1 Radiopedia. Spinal compression fracture. Available from:https://radiopaedia.org/articles/osteoporotic-spinal-compression-fracture [accessed 26/10/2023]
  15. ↑ Buchbinder R, Johnston RV, Rischin KJ, Homik J, Jones CA, Golmohammadi K, Kallmes DF. Percutaneous vertebroplasty for osteoporotic vertebral compression fracture. Cochrane Database Syst Rev. 2018 Apr 4;4(4):CD006349. Level of Evidence: 1A.
  16. ↑ NOF. Osteoporosis and your spine. National Osteoporosis Foundation. http://nof.org/articles/18 (accessed 03/02/15.
  17. ↑ El-Fiki M. Vertebroplasty, Kyphoplasty, Lordoplasty, Expandable devices and Current treatment of painful osteoporoticvertebral fractures.World Neurosurg. 2016 Jul;91:628-32.
  18. ↑ 18.0 18.1 Longo UG, Loppini M, Denaro L, Maffulli N, Denaro V. Conservative management of patients with an osteoporotic vertebral fracture: a review of the literature. J Bone Joint Surg Br. 2012 Feb;94(2):152-7.
  19. ↑ Silverman SL. The Clinical Consequences of Vertebral Compression Fracture. Bone 13, S27-S31. 1992. (Level of Evidence: 3B)
  20. ↑ Puisto V, Rissanen H, Heliövaara M, Impivaara O, Jalanko T, Kröger H, Knekt P, Aromaa A, Helenius I. Vertebral fracture and cause-specific mortality: a prospective population study of 3,210 men and 3,730 women with 30 years of follow-up. Eur Spine J 2011 20:2181–86.
  21. ↑ Centre for Metabolic Bone Diseases, University of Sheffield. UK. Welcome to FRAX. Available from: https://frax.shef.ac.uk/FRAX/ [accessed 17-11-2023]
  22. ↑ Gregson CL, Armstrong DJ, Bowden J, Cooper C, Edwards J, Gittoes NJL, Harvey N, Kanis J, Leyland S, Low R, McCloskey E, Moss K, Parker J, Paskins Z, Poole K, Reid DM, Stone M, Thomson J, Vine N, Compston J. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos. 2022 Apr 5;17(1):58.
  23. ↑ Han CS, Hancock MJ, Downie A, Jarvik JG, Koes BW, Machado GC, Verhagen AP, Williams CM, Chen Q, Maher CG. Red flags to screen for vertebral fracture in people presenting with low back pain. Cochrane Database Syst Rev. 2023 Aug 24;8(8):CD014461.
  24. ↑ Garnon J, Doré B, Auloge P, Caudrelier J, Dalili D, Ramamurthy N, Koch G, Cazzato RL, Gangi A. Efficacy of the vertebral body stenting system for the restoration of vertebral height in acute traumatic compression fractures in a non-osteoporotic population. Cardiovasc Intervent Radiol. 2019;42(11):1579–87.
  25. ↑ Diamond TH, Champion B, Clark WA. Management of acute osteoporotic vertebral fractures: a nonrandomized trial comparing percutaneous vertebroplasty with conservative therapy. Am J Med. 2003 Mar;114(4):257-65.
  26. ↑ Miyata K, Hasegawa S, Iwamoto H, Otani T, Kaizu Y, Shinohara T, Usuda S. Comparison of the structural validity of three Balance Evaluation Systems Test in older adults with femoral or vertebral fracture. J Rehabil Med. 2020 Jul 30;52(7):jrm00079.
  27. ↑ 27.0 27.1 27.2 Langdon J, Way A, Heaton S, Bernard J, Molloy S. Vertebral compression fractures--new clinical signs to aid diagnosis. Ann R Coll Surg Engl. 2010 Mar;92(2):163-6.
  28. ↑ Donnally C, Varacallo M. Fracture, Compression. 2018. Available from:https://www.researchgate.net/publication/329717392_Fracture_Compression [accessed 26/10/2023)
  29. ↑ 29.0 29.1 29.2 29.3 29.4 29.5 Ponzano M, Tibert N, Brien S, Funnell L, Gibbs JC, Keller H, Laprade J, Morin SN, Papaioannou A, Weston Z, Wideman TH, Giangregorio LM. International consensus on the non-pharmacological and non-surgical management of osteoporotic vertebral fractures. Osteoporos Int. 2023 Jun;34(6):1065-74.
  30. ↑ Jacobs E, Senden R, McCrum C, van Rhijn LW, Meijer K, Willems PC. Effect of a semirigid thoracolumbar orthosis on gait and sagittal alignment in patients with an osteoporotic vertebral compression fracture. Clin Interv Aging. 2019 Apr 11;14:671-680.
  31. ↑ Gutierrez-Gonzalez R, Royuela A, Zamarron A. Vertebral compression fractures: pain relief, progression and new fracture rate comparing vertebral augmentation with brace. BMC Musculoskel Dis. 2023; 24: 898.
  32. ↑ Buchbinder R, Johnston RV, Rischin KJ, Homik J, Jones C, Golmohammadi K, Kallmes DF. Vertebroplasty for treating spinal fractures due to osteoporosis. Cochrane Library of Systematic Reviews 2018; 11:1465-1858.
  33. ↑ Whitney E, Alastra AJ. Vertebral Fracture. Available from:https://www.ncbi.nlm.nih.gov/books/NBK547673/ [accessed 26/10/2023]
  34. ↑ Lee Health. Fixing a Fractured Spine. Available from: https://www.youtube.com/watch?v=QjvKkYehpUI&feature=emb_logo [accessed 26/10/2023]
  35. ↑ Pratelli E, Cinotti I, Pasquetti P. Rehabilitation in osteoporotic vertebral fractures. Clin Cases Miner Bone Metab. 2010 7(1): 45–47.
  36. ↑ Barker KL, Newman M, Stallard N, Leal J, Lowe CM, Javaid MK, Noufaily A, Hughes T, Smith D, Gandhi V, Cooper C, Lamb SE; PROVE trial group. Physiotherapy rehabilitation for osteoporotic vertebral fracture-a randomised controlled trial and economic evaluation (PROVE trial). Osteoporos Int. 2020 Feb;31(2):277-89.
  37. ↑ Hong AR, Kim SW. Effects of resistance exercise on bone health. Endocrinol Metab. 2018 Dec 1;33(4):435-44.
  38. ↑ Burke TN, Franca FJR, Ferreira de Meneses SR, Pereira RMR, Marques AP. Postural control in elderly women with osteoporosis: comparison of balance, strengthening and stretching exercises. A randomized controlled trial. Clinical Rehabilitation 2012; 26 (11): 1021-1031.
  39. ↑ De Kam D, Smulders E, Weerdesteyn V, Smits-Engelsman BCM. Exercise interventions to reduce fall-related fractures and their risk factors in individuals with low bone density: a systematic review of randomized controlled trials. Osteoporos Int. 2009;20:2111–25.
  40. ↑ Karinkanta S, Heinonen A, Sievänen H, Uusi-Rasi K, Pasanen M, Ojala K. A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: a randomized, controlled trial. Osteoporos Int. 2007;18:453–462.
  41. ↑ Hourigan SR, Nitz JC, Brauer SG, O'Neill S, Wong J, Richardson CA. Positive effects of exercise on falls and fracture risk in osteopenic women. Osteoporos Int. 2008;19:1077–86.
  42. ↑ Sinaki M, Lynn SG. Reducing the risk of falls through proprioceptive dynamic posture training in osteoporotic women with kyphotic posturing: a randomized pilot study.Am J Phys Med Rehabil. 2002 Apr;81(4):241-6.
  43. ↑ Itoi E, Sinaki M.Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age.Mayo Clin Proc. 1994 Nov;69(11):1054-9. (Level of Evidence: 3B)
  44. ↑ Bautmans I, Van Arken J, Van Mackelenberg M, Mets T. Rehabilitation using manual mobilization for thoraic kyphosis in elderly postmenopauzal patients with osteoporosis. J Rehabil Med 2010, 42: 129-135. (Level of Evidence: 3B)
  45. ↑ John Gibbons. Try this Kinesiology Taping technique for poor posture - its incredible. Available from: http://www.youtube.com/watch?v=996cC3ovLEQ[last accessed 21/4/2020]
  46. ↑ Liu JT et al. Balloon kyphoplasty versus vertebroplasty for treatment of osteoporotic vertebral compression fracture: a prospective, comparative, and randomized clinical study. Osteoporos Int. 2010 Feb;21(2):359-64. Level of Evidence: 1B.
  47. ↑ Gauthier A, Kanis JA, Jiang Y, Martin M, Compston JE, Borgström F, Cooper C, McCloskey EV. Epidemiological burden of postmenopausal osteoporosis in the UK from 2010 to 2021: estimations from a disease model. Arch Osteoporos 2011 6:179–188.
  48. ↑ Kim DH, Vaccaro AR. Contemporary Concepts in Spine Care: Osteoporotic compression fractures of the spine; current options and considerations for treatment. The Spine Journal. 2006 6 479–487.
  49. ↑ 49.0 49.1 NICE. Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women (amended): NICE technology appraisal guidance 160. Manchester: National Institute for Health and Care Excellence, 2011.
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