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Compression Fractures

    Compression Fractures

    The building blocks of the spinal column are cylindrically-shaped bones called vertebrae. Each vertebra has an arch attached behind it, and taken together, these arches form the spinal canal. A compression fracture involves the cylindrically-shaped portion of the vertebra, or vertebral body, fractures. According to the National Osteoporosis Foundation, one-in-two women and one-in-four men over age 50 will have an osteoporosis-related fracture in their lifetime; over 700,000 new spinal fractures occur in the spine each year.
    What Is It?
    When either the top, bottom, or both top and bottom of the vertebra collapses, similar to stepping on an aluminum can, a vertebral compression fracture (VCF) occurs. Most VCF’s occur in the context of osteoporosis, a slowly progressive loss of bone volume that occurs typically beyond age 50, and more likely in women than men, due to the loss of the protective effect of estrogen in women after menopause. Osteoporosis gives no warning signs until fracture occurs. VCF’s also are very common in cancer patients, whether due to malignancies arising in the bone marrow (e.g. multiple myeloma, lymphoma, and leukemia), or due to spread of a malignancy to bone, called metastatic cancer. In either case, the tumor cells replace normal bone, resulting in loss of bone volume. Demineralization of bone can occur in patients with metabolic bone disease, due to a large array of abnormalities ranging from calcium and vitamin D deficiency; testosterone deficiency; thyroid, kidney or liver disease; hyperparathyroidism; and malabsorption syndromes. When metabolic bone disease is the underlying cause, it is termed osteomalacia. Lastly, compression fractures can occur in patients with normal bone density due to trauma or injury. In the case of VCF’s in patients with less than normal bone density, fractures can occur as a result of normal activities of daily living and even spontaneously. Patients can thus develop a compression fracture while simply bending over to pick up something, reaching for an object, or carrying a bag of groceries.
    The onset of a VCF is heralded by the experience of sudden pain, often severe, but sometimes mild and persistent. The fact that symptoms of a VCF can be easily confused with other causes of back pain underscores the importance of paying attention to back pain and seeing a physician for diagnosis. Both x-rays and an MRI are required to accurately diagnose VCF’s. This is because x-ray cannot distinguish reliably between an old, healed fracture and a new one; with MRI the hemorrhage and edema that occurs within the vertebra of a new fracture can be seen.
    Because VCF’s involve a greater degree of collapse of the front of the vertebral body than the at the back of the vertebra, each fracture causes roundness or a stooped posture termed kyphosis. Multiple fractures can cause one’s spine to shorten and bend forward. This kyphosis can make it difficult to walk, reach for things, and conduct normal activities of daily living. Associated problems include height loss, a decrease in abdominal volume resulting in loss of appetite, difficulty sleeping, and a decrease in lung volume with increased risk of cardiopulmonary complications.
    Treatment Options
    Most VCF’s will heal within a period of 6-12 weeks, even without specific treatment, although VCF’s can further collapse during the healing phase, potentially giving rise to even more serious problems. Traditional treatment of VCF’s in the past was limited to rest, bracing and management of pain. For patients under 50 with traumatically-induced fractures, this treatment still pertains. 

    For VCF’s due to osteoporosis, osteomalacia, and secondary to malignancy, an FDA-approved, minimally-invasive option is available. Called “balloon kyphoplasty”, the procedure is performed percutaneously (i.e. through small incisions) under fluoroscopic-guidance. The procedure involves placing a pair of small tubes into the back of the vertebra through which two small thick-walled balloons are inserted side-by-side into the vertebral body. The balloons are then inflated, often allowing for some restoration of lost vertebral height and correction of kyphosis, and also creating two cavities within the vertebra. After the balloons are removed, a bone cement is injected into the vertebra which hardens quickly, forming an internal splint that prevents further collapse and reduces/relieves spinal pain. The procedure can be done under either general anesthesia or local anesthesia with IV sedation, and typically takes less than one hour for the treatment of up to four fractures. Most patients are discharged from the hospital within 24 hours. Patients are requested to limit bending, twisting and lifting for four weeks, but encouraged to walk and otherwise be normally active. Most patients are very satisfied with the procedure, and after four weeks are able to resume activity with appropriate precautions