Osteoporotic Vertebral Fractures

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Search Strategy

Databases: Pubmed, Web of Science, Pedro.

As subject headings varied between the databases, various combinations of the key words were used. These were the most productive: Osteoporotic Vertebral Fractures, Osteoporotic Vertebrae Fractures, Insufficiency Fractures, Vertebral Compression Fractures, Osteoporosis AND physical therapy, Osteoporosis AND diagnosis, Osteoporotic Vertebral Fractures AND treatment.

Definition / Description

<img src="/images/thumb/5/56/Vertebral_Fracture.png/235px-Vertebral_Fracture.png" _fck_mw_filename="Vertebral Fracture.png" _fck_mw_location="right" _fck_mw_width="250" _fck_mw_height="350" alt="Vertebral Fracture" class="fck_mw_right" />

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. 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.

<a _fcknotitle="true" href="Osteoporosis">Osteoporosis</a> is a disease that is characterised by low bone mass,NICE. Osteoporosis: assessing the risk of fragility fracture: NICE Guidelines CG146. Manchester: National Institute for Health and Care Excellence, 2012. causing bones to be more fragile and likely to fracture.NOS. What is Osteoporosis? National Osteoporosis Society. https://www.nos.org.uk/about-osteoporosis (accessed 03/02/15) The word osteoporosis literally means porous bone.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 One of the significant consequences of osteoporosis is fractures. Common types of fracture include wrist fractures, hip fractures and vertebral fractures.NHS. Osteoporosis. National Health Service. http://www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx (accessed 03/02/15)

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 <a _fcknotitle="true" href="Vitamin D Deficiency">Vitamin D Deficiency</a> 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. 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.

<img src="/images/thumb/5/56/Vertebral_Fracture.png/235px-Vertebral_Fracture.png" _fck_mw_filename="Vertebral Fracture.png" _fck_mw_location="right" _fck_mw_width="250" _fck_mw_height="350" alt="Vertebral Fracture" class="fck_mw_right" />

Epidemiology / Etiology

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.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. In America 700,000 vertebral fractures occur within the population who have osteoporosis. 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. In addition to this once a vertebral fracture has been sustained the risk of subsequent vertebral, hip or wrist fractures increase. 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.

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. Ralston SH, Fraser J.Diagnosis and management of osteoporosis.Practitioner. 2015 Dec;259(1788):15-9, 2. (Level of Evidence: 3A)

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.El-Fiki M. Vertebroplasty, Kyphoplasty, Lordoplasty, expandable devices and current treatment of painful osteoporoticvertebral fractures.World Neurosurg. 2016 Apr 9

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. Steven R. Cummings et al. Epidemiology and outcomes of osteoporotic fractures. The Lancet. 2002Goodwin 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)

Looking more closely to the specific regions of the spine and the prevalence of osteoporotic fractures, we can conclude that osteoporotic fractures in the toracic spine are mostly affected.
There is a prevalence of 2,4/1000 (age 35-44), 5,1/1000 (age 44-75), 29/1000 (age > 75) in the thoracic spine. (Corresponding figures for men: 5,2/1000, 15/1000, 28/1000)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)

Characteristics / Clinical Presentation

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, 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. NOF. Osteoporosis and your spine. National Osteoporosis Foundation. http://nof.org/articles/18 (accessed 03/02/15. in addition to vertebral fractures being linked to mortality. 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.

Medical Management

Good quality evidence supports that several medications (e.g. bisphosphonates) for bone density reduce fracture risk. Never the less side effects vary among drugs. (Crandall CJ, 2014: LoE 1A) 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.

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.Gerdhem P. Osteoporosis and fragility fractures: Vertebral fractures. Best Practice Research Clinical Rheumatology 2013 27: 743–755. 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.Dionyssiotis Y. Management of osteoporotic vertebral fractures. Int J Gen Med. 2010 3: 167–171. 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. 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. (Itshayek E et al., 2012. LoE 2A)27. Itshayek E et al. Vertebral augmentation in the treatment of vertebral compression fractures: review and new insights from recent studies.J Clin Neurosci. 2012 Jun;19(6):786-91. Level of Evidence: 2A.

Treatment after vertebral fracture should include appropriate pain management and possibly bracing.Gerdhem P. Osteoporosis and fragility fractures: Vertebral fractures. Best Practice &amp;amp;amp;amp;amp;amp;amp;amp;amp; Research Clinical Rheumatology 2013 27: 743–755 

Vertebral fractures can also be treated surgically using vertebroplasty and kyphoplasty.Dionyssiotis Y. Management of osteoporotic vertebral fractures. Int J Gen Med. 2010 3: 167–171.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 

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.

Physical Therapy Management

Regarding Physiotherapy management, there are a number of treatment approaches, including strengthening exercise, stabilisation exercise, balance training, stretching, relaxation techniques, manual therapy and taping.Pratelli E, Cinotti I, Pasquetti P. Rehabilitation in osteoporotic vertebral fractures. Clin Cases Miner Bone Metab. 2010 7(1): 45–47.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 Currently a large RCT is comparing exercise based and ‘hands on’ manual therapy based physiotherapy against a control.

Key Research

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. 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.
• A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: a randomized, controlled trial. 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.
• Positive effects of exercise on falls and fracture risk in osteopenic women. 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.
• Reducing the risk of falls through proprioceptive dynamic posture training in osteoporotic women with kyphotic posturing: a randomized pilot study
• Identifying osteoporotic vertebral fracture. Griffith JF. Identifying osteoporotic vertebral fracture. Quant Imaging Med Surg. 2015 Aug;5(4):592-602. Level of Evidence: 2C.
• Position Statement of the Korean Society for Bone and Mineral Research.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.

Resources

<a href="http://www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx">www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx</a>

<a href="https://www.nos.org.uk/about-osteoporosis">www.nos.org.uk/about-osteoporosis</a>

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.