Answer
The fractures may be as a result of bone weakened by osteoporosis, trauma, or tumors such as metastases, multiple myeloma, and hemangioma. Osteoporosis, however, accounts for most fractures. The disease accounts for an estimated annual incidence of 700,000 fractures per year; of these, approximately 260,000 are vertebral compression fractures. Once a vertebral compression fracture occurs, the risk of additional fractures in adjacent vertebrae increases 5-fold.
Fractures are identified in 26% of women aged 50 years or older and are radiographically present at a rate of 500 cases per 100,000 persons in patients aged 50-54 years and 2,960 cases per 100,000 persons in patients older than 85 years. [3] Vertebral compression fractures are twice as common in females, [4] occurring in 153 females per 100,000 compared with 81 males per 100,000. Prevalence rates in North America for White women ≥ 50 years are 20–24%, with a White/Black ratio of 1.6. [5] For reasons not clearly understood, only one third of spinal compression fractures are painful; most of these are refractory to medical management. The remaining patients report a history of significant spinal pain in the past or do not have pain at the time of diagnosis.
Dozens of diseases and conditions predispose individuals to osteoporosis and secondary vertebral compression fracture. Examples include the following:
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Advanced age
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Oophorectomy, bilateral
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Renal disease, chronic
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Transplants
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Tumors, parathyroid-related peptide
In addition, certain drugs are also associated with osteoporosis, as follows: [6]
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Glucocorticoids
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Proton pump inhibitors
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Antiepileptic drugs
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Medroxyprogesterone acetate
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Aromatase inhibitors
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GnRH agonists
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Serotonin selective reuptake inhibitors
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Thiazolidinediones
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Calcineurininhibitors
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Heparin
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Warfarin
Patients with compression fractures typically present with a sudden onset of intense back pain, often after a relatively benign activity. Many patients refer to intractable pain after a sneeze or a cough. The pain tends to be debilitating. Patients find it difficult to find a comfortable position, and therefore, they have difficulty sleeping. Many patients refer to sleep in a seated or semireclining position.
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Anterior wedge compression fracture with intact posterior vertebral cortex.
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Transpedicular placement of a trocar in the anterior third of the fractured vertebral body.
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Anterior wedge compression fracture after fusion of the fracture fragments with methylmethacrylate.
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Lateral radiograph of fractured vertebra shows the initial placement of the trocar.
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Injection of methylmethacrylate through the trocar in anterior one third of the vertebral body.
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Compression fracture after vertebroplasty.
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In a vertebral hemangioma, the fine trabeculae are replaced by venous channels, which predispose the patient to painful microfractures.
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In a vertebral hemangioma after vertebroplasty, the venous channels are now filled with acrylic.
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Two adjacent vertebral hemangiomas causing continuous back pain as seen by MRI (A) and CT (B, C, D). Fluoroscopic appearance prevertebroplasty (E, F) and postvertebroplasty (G, H). The patient's pain had abated by the end of the procedure.
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A vertebral burst fracture is a fracture that cannot be treated safely by using vertebroplasty.
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Once an anterior wedge compression fracture has occurred, the physics of load bearing distribution are altered, creating abnormal stress points on the adjacent vertebra that can lead to a second fracture. This, however, is not the result of the vertebroplasty procedure; rather, it is a consequence of the wedge deformity of the original fracture exerting additional stresses on the adjacent weakened osteoporotic vertebra. A second fracture is likely to occur from this deformity, regardless of whether a vertebroplasty procedure is performed on the first fracture. Some authorities believe vertebroplasty stops the progression of a compression fracture, preventing further wedge deformity and likely reducing the chance of a second fracture.
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In kyphoplasty, a KyphX inflatable bone tamp is percutaneously advanced into the collapsed vertebral body (A). It is then inflated, (B) elevating the depressed endplate, creating a central cavity, and compacting the remaining trabeculae to the periphery. Once the balloon tamp is deflated and withdrawn, the cavity (C) is filled under low pressure with a viscous preparation of methylmethacrylate (D).
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Reduction in kyphotic angulation after kyphoplasty.
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This image was obtained in an 80-year-old man with a steroid-induced osteoporosis and a painful acute midthoracic vertebral compression fracture. Several additional chronic fractures are also present.
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After inflation of balloon tamp, the depressed superior endplate is elevated, and some height is restored. The cavity is then filled with methylmethacrylate. Pain is reduced, and the patient's posture is improved.
