Vertebral compression fracture

In one minute

A vertebral compression fracture is a collapse of the front part of a vertebra, one of the bones of the spine. In people over 50 the usual cause is osteoporosis (bone that has become porous and weak), and the trigger can be as small as a cough or a lift. It feels like sudden back pain that is worse standing and eases lying down. An X-ray shows the collapse; an MRI (magnetic resonance imaging) tells whether it is fresh. Most fractures heal within about three months with pain control and early movement. Cement procedures (vertebroplasty and kyphoplasty) are an option for the minority whose pain stays severe, and the evidence for them is mixed. The most important step afterwards is treating the osteoporosis, because the next fracture is common and largely preventable.

What it is

The body of each vertebra is a block of spongy bone inside a thin shell. When the bone loses density, the front of the block can crush under a load that healthy bone would absorb, leaving a wedge shape. That is a compression fracture. The back wall of the vertebra and the canal behind it are usually intact, which is why most of these fractures do not threaten the spinal cord. A fracture that involves the back wall is a burst fracture, described on the spinal fractures page.

Osteoporosis is a disease of low bone mass and worn-out internal bone structure; on a bone density scan (DXA, dual-energy X-ray absorptiometry) it is defined by a T-score of 2.5 standard deviations or more below the young female adult average. The European guidance from the International Osteoporosis Foundation and ESCEO (the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis) estimated about 520,000 vertebral fractures in the European Union in 2010, and notes that vertebral fractures may cause acute pain and loss of function but may also occur without serious symptoms.

Causes and risk factors

The fracture happens when the load on a vertebra exceeds the strength of its bone: a fall or road accident in younger people, an everyday load in older people whose bone has weakened.

The risk factors the European guidance lists for fragility fractures are age, female sex, low body weight, a previous fragility fracture, a parent who broke a hip, treatment with glucocorticoids (steroid tablets), current smoking, three or more units of alcohol a day, and the medical conditions that cause secondary osteoporosis. Height loss of more than 4 cm and a rounded upper back are signs that fractures may already have happened. A tumour in the bone (myeloma or a metastasis from a cancer elsewhere) and infection are the other causes of a collapsed vertebra, and they change the treatment.

How it develops

Bone is constantly being removed and rebuilt. After the menopause, and with age in both sexes, removal outpaces rebuilding. The internal struts of the vertebra thin and disconnect, so the block loses strength faster than it loses size, until one day a load crushes the front of it. The fractured bone hurts on standing and eases when lying flat because load is what moves the broken surfaces.

Over the following weeks the bone knits in its new shape. Pain settles, but the wedge remains. Each wedge tips the spine a little further forward, and after several fractures the result is the stooped posture and height loss that people associate with old age.

Symptoms

The typical story is sudden back pain at one level, often after a minor event or no event at all, that is sharp on standing, walking, bending and coughing and eases lying down. The spine is tender over the fractured bone. Pain usually improves week by week. Some fractures are painless and come to light only through height loss, a change in posture or an X-ray for something else. Leg symptoms are unusual, because the back wall of the vertebra is intact and the nerves are not pressed; new leg weakness, numbness or bladder trouble means something else is going on.

Diagnosis

The surgeon asks how the pain started, about height loss, steroid tablets and any history of cancer, fever or weight loss, and examines the spine and the strength, sensation and reflexes of the legs.

A standing X-ray shows the collapse and how many vertebrae are involved. An MRI tells whether a fracture is fresh, because a healing bone shows fluid within it, and looks for a tumour or infection behind the fracture. The report may use bone marrow oedema (the fluid signal of a fresh fracture), retropulsion (bone pushed backward into the canal, which makes it a burst fracture) and kyphosis (forward angulation).

Every fragility fracture should prompt an assessment of bone health. The European guidance recommends a DXA scan in most cases, blood tests for the causes of secondary osteoporosis, and a fracture risk calculation such as FRAX. For our opinion, send a photograph of the X-ray, the side-view MRI images that show the fracture, the written reports and any bone density result you already have.

Treatment without surgery

The American Academy of Orthopaedic Surgeons (AAOS) tells patients that most feel better within three months without surgery. Pain control uses simple analgesics, anti-inflammatory drugs if the kidneys and stomach allow, and a short course of a stronger painkiller if needed; the doctor chooses the drug and the dose. The AAOS guideline made a moderate recommendation for a four-week course of calcitonin, a hormone-based drug, but only for a fracture that is 0 to 5 days old when the patient presents, and found the evidence for bed rest, bracing and exercise inconclusive; walking is encouraged from the first days as pain allows. A brace is a matter of comfort: a 2023 meta-analysis of three randomised trials with 447 patients found that a rigid brace reduced pain for up to six months but made no difference to the shape of the healed spine, painkiller use, function or quality of life, and that a soft brace did as well.

Treating the osteoporosis is the part that changes the future. The European guidance names oral bisphosphonates as the usual initial treatment, with intravenous bisphosphonates or denosumab for people who cannot take tablets and teriparatide, a bone-building drug, for those at high risk of further fracture. Bisphosphonate treatment is reviewed after three to five years, fracture risk rises again in people who stop, and denosumab must not be stopped without a plan because vertebral fractures rebound after withdrawal. The guidance also records the gap: fewer than 20% of people with a fragility fracture receive treatment to prevent the next one within a year.

When surgery is considered

A procedure is considered when a fracture is fresh on MRI and the pain remains severe and disabling after several weeks of proper conservative care.

The evidence deserves a plain summary. The 2018 Cochrane review pooled five trials in which 541 patients were randomised to vertebroplasty or a sham procedure (needles placed, no cement). Vertebroplasty gave no clinically important benefit: pain was 0.7 points better on a 0 to 10 scale, where 1.5 points is the smallest difference patients notice, and disability 1.5 points better on a 23-point scale, with no difference between acute and subacute fractures. The largest of those trials, VERTOS IV with 180 patients, found that both groups improved substantially, with no significant difference at any point over a year.

Trials without a sham arm tell a different story. VERTOS II randomised 202 patients with persistent pain to vertebroplasty or conservative care and found pain 2.6 points lower after vertebroplasty at one month and 2.0 points lower at one year; notably, 229 of the 431 patients screened got better on their own before they could be randomised. The FREE trial randomised 300 patients to balloon kyphoplasty or non-surgical care and found the physical component of the SF-36 quality of life score 5.2 points better with kyphoplasty at one month.

The AAOS guideline made a strong recommendation against vertebroplasty for neurologically intact patients and listed kyphoplasty as a weak option. Our reading is the same: cement can help a selected patient with a fresh, severely painful fracture, and it is not a routine step. Because the Cochrane subgroups showed no advantage for early treatment, there is no reason to rush the decision.

Surgical options

Vertebroplasty places a needle through the pedicle (the bony bridge at the back of the vertebra) under X-ray guidance and injects bone cement into the fractured body to stabilise it. Kyphoplasty first inflates a balloon inside the vertebra to create a cavity and partially restore height, then fills the cavity with cement at lower pressure. Both are needle procedures through skin punctures, described on the vertebroplasty and kyphoplasty page. The risks of both are cement leaking outside the bone, a new fracture in a neighbouring vertebra, and the rare serious events the Cochrane review recorded.

Stabilisation with screws, sometimes cement-augmented in osteoporotic bone, with or without decompression of the canal, is reserved for fractures that are unstable, collapsing progressively or injuring the nerves; see the spinal fusion page. Endoscopic surgery is not a treatment for the fracture itself.

How we treat it at spine.uz

We are Tashkent's first endoscopic spine team, five surgeons operating as one, and the team treats the full range of surgical spine pathology, including vertebroplasty, kyphoplasty and stabilisation when they are indicated. Not every fracture needs any of them.

The first step is free: send your X-ray and MRI through Telegram or WhatsApp and a doctor from the team replies by voice within 48 hours, including whether a procedure is needed at all. If one is indicated, the in-person consultation and the operation are paid, and after the consultation you receive a written conclusion from the team. Across the team's 27,600+ endoscopic and spine operations, our complication rate is well below 1%.

Recovery and outcomes

With conservative care, pain usually improves steadily and most people feel better within about three months. The wedge shape and any height loss remain. After vertebroplasty or kyphoplasty, pain relief in the trials was immediate, but so was the relief in the sham groups, so the honest expectation is faster comfort in a proportion of patients rather than a certain result.

What decides the long-term outcome is whether another fracture follows. The AAOS patient information puts the chance of a further fracture within a year at more than 30%, and the European guidance stresses that fracture risk should be reassessed after any new fracture and that disability rises with the number of fractures. That is the reason to treat the bone as well as the pain.

Living with it and prevention

Keep walking. Do regular weight-bearing and strengthening exercise suited to your ability, eat enough protein, calcium and vitamin D, stop smoking and keep alcohol low. Make the home safe against falls. Take the osteoporosis medicine you are prescribed and do not stop it without a doctor's plan. Have your height measured once a year: a loss of more than 4 cm is a reason to look for new fractures.