Compression Fractures and Back Pain

Compression fractures occur in the vertebrae, the bones that make up your spine. You are likely to have this type of fracture if you suffer from osteoporosis. Sudden back pain, a gradual loss of height, and a hunched posture could be signs of compression fractures.

Compression fractures may cause minor pain and heal on their own. However, they can also cause a lot of pain and require treatment. At first, your pain specialist will offer treatments such as bracing and medications. Additionally, your pain specialist can perform procedures such as kyphoplasty or vertebroplasty to relieve your pain.

What is a compression fracture?

A spinal compression fracture (a vertebral fracture) is a break in one of your backbones. The vertebrae (backbones) stack on top of each other in order to support your spine and allow movement. Vertebrae protect your spinal cord and the spinal nerves that branch off to all areas of the body.

Compression fractures can cause the vertebrae to collapse, making them shorter in height and causing bone inflammation. Fractures can also create pressure on the nerve roots or the spinal cord itself.

Two types of fractures

A spinal compression fracture usually starts in the front of the vertebra, while the back stays unchanged. This pattern results in a wedge-shaped vertebra and a decrease in height of at least 15 to 20%.

Sometimes, the entire vertebra breaks. This is called a burst fracture. Your doctor needs to be made aware if you suspect a burst fracture. It can cause shifts in your spine and injure nearby nerves or the spinal cord.

What areas of your back have pain?

Compression fractures can occur in one or several vertebrae, anywhere in your spine. They are often seen in the mid-back and lower back areas. They are unlikely in the upper back and neck.

Who is at high risk?

People with osteoporosis are at a higher risk for spinal compression fractures. Osteoporosis causes bones to lose calcium and become brittle. Since osteoporosis is more likely after menopause, women over the age of 50 have a higher risk.

However, older men can also develop these fractures. As many as 25% of men over age 50 will suffer a bone fracture (hip or spine) due to osteoporosis. A compression fracture should be suspected in any person over the age of 50 with a sudden onset of back pain.

Less common causes

Although osteoporosis is the most common cause of this type of fracture, there are other causes:

• Trauma to the back (car accidents and sports injuries)
• Tumors that start in the bones or spread to the bone from elsewhere (liver, prostate cancer)
• Tumors that start in the spine, such as multiple myeloma (cancer of the bone marrow)

Symptoms

A spinal compression fracture can cause sudden pain in a wide band pattern in your back. However, not everyone feels this. If the vertebrae collapse over time (rather than suddenly), the pain will be mild and gradual.

Some patients feel no pain at all. A spine x-ray done for some other reason may show you have a compression fracture. In time, after multiple fractures, these patients develop a bend in their back (kyphosis).

Some common symptoms:

1. A sudden onset of a “knife-like” back pain.
2. Pain that starts after a sneeze, jump, or lifting.
3. Pain that gets worse with standing or walking and improves while lying down.
4. A loss of height over time.
5. Neurologic changes (tingling, numbness, trouble walking, loss of bowel/bladder control).

Diagnosis

The first step in finding the cause for your back pain is to visit your primary care doctor or pain specialist. Your doctor will ask you about your pain pattern and will do a physical examination. Your doctor will test for tenderness in your back along specific vertebrae. Imaging studies, such as X-rays, can show the fracture.

It is important to find the cause for a fracture. It may be something common like osteoporosis or something more serious, like cancer.

Advanced imaging tests may be required:

• A CAT scan takes “slice” images of your spine. It can show whether your fracture is stable (best case scenario) or unstable (there is pressure on nearby nerves or the spinal cord). It is very specific for boney areas.
• An MRI scan shows soft tissues (e.g. nerves, discs) surrounding the fracture. It rules out other causes for your pain, such as a herniated disc. This can also be used to determine the age of the compression fracture.
• A nuclear bone scan may also be used to determine if the fracture is old or new. This will guide treatment.

Treatment

Treatment for a vertebral compression fracture often starts with conservative measures. For more serious cases, minimally invasive procedures can help. Spinal fusion surgery is the last resort.

Conservative measures

• Bed rest helps with acute pain, at first. In the long term, it causes further bone loss. Therefore, it should be limited to only a couple of days.
• A back brace provides external support to your spine. It limits movement of the fractured vertebrae and helps reduce your pain. However, braces should be used with caution since they can cause muscle weakness in your back.
• Osteoporosis treatment with medications known as bisphosphonates (Actonel, Boniva, and Fosamax) prevents further bone damage. It may even restore bones.

Minimally invasive procedures

A spinal compression fracture can heal naturally over months. Unfortunately, the fractures heal in a collapsed position that may cause a deformity (hunch) in your spine. The initial intense pain usually improves significantly in a matter of days or weeks. However, sometimes the pain continues.

Vertebroplasty or kyphoplasty is the next step at this point. They are offered by your pain specialist or a spine surgeon. They can be performed under twilight anesthesia, in a pain clinic or hospital setting. Only small incisions (entry points into your back) are required. Therefore, healing time is short.

Another benefit of these procedures is that the height of your vertebra may be maintained. This can potentially avoid significant deformity in your spine.

• Vertebroplasty – Medical-grade cement is injected into the middle of the collapsed vertebra( backbone). The cement stabilizes the fracture and relieves the back pain.
• Kyphoplasty is similar to vertebroplasty. It involves the inflation of a small balloon to create a space in your vertebra. This space is then filled with cement.

For more information on these procedures, click here.

Surgery for compression fractures

Spinal fusion permanently connects two or more vertebrae, to offer support to your spine. An orthopedic or spine surgeon places bone or a bone-like material between two of your vertebrae. Metal plates, screws, and rods are used to hold the vertebrae together. This is done under general anesthesia in an operating room.

Outcomes

It is equally important to treat osteoporosis as it is to treat the pain of an existing fracture. People who have had a compression fracture due to osteoporosis are at a higher risk for having another one. However, osteoporosis can be treated and other fractures can be prevented.

Kyphoplasty and vertebroplasty have been assessed in many scientific trials. Evidence shows that patients who are treated in the first six weeks after the fracture, do well after these procedures.

Elderly patients that are hospitalized as a result of pain after the fracture are particularly likely to improve. They have earlier hospital discharges and reduced mortality.

Vertebroplasty and kyphoplasty have good outcomes in most patients. Some patients experience immediate pain relief while others feel a significant improvement within 48 hours. Typically, patients resume normal activity within 24 hours.