Diagnosing vertebral compression fractures

It is important to accurately diagnose vertebral fractures, as there are a number of potential adverse effects if a diagnosis is missed and there is no treatment. In general, vertebral fractures are associated with both increased morbidity (unwanted side effects) and mortality (death).

Morbidity (side effects) associated with vertebral fractures often includes continued pain, decreased physical function, deformity, and potentially social isolation, all of which negatively impact the individual’s overall quality of and enjoyment of life.
Mortality is also associated with vertebral fractures, as women diagnosed with a compression fracture of the vertebra have a 15 percent higher mortality rate than those who do not experience fractures.²

The presence of one vertebral fracture increases the risk of any subsequent vertebral fracture 5-fold. Of women who have had a recent osteoporotic vertebral fracture, it is estimated that approximately 20% will sustain a new fracture within the next 12 months.

Difficulty in diagnosing an osteoporotic fracture
Unlike many other conditions, diagnosing a vertebral compression fracture is not as straightforward as one would think. For example:

When an elderly person complains of back pain, it is often assumed to be just general back pain, arthritis, or a normal part of the aches and pains associated with aging. This assumption may be made by the patient, by his or her family or caregivers, and/or by the treating physician. When this happens, the patient is often not even checked for a vertebral fracture.
In most cases of an osteoporotic hip or wrist fracture, the fractured bone is easily identified by a standard x-ray. However, in the spine a compression fracture in the vertebral bone may be missed on an x-ray, and if this is the case it may be assumed that the patient’s pain is due to general muscle strain or just the aches and pains that accompany aging.

For these and other reasons, it is estimated that only about one-third of vertebral compression fractures that occur in the U.S. each year are diagnosed.

Diagnostic process
The diagnostic process includes a complete history of the patient’s condition, medical history and family history. A number of questions related to the patient’s pain will probably be asked, such as:

When did the pain start? Was it sudden or gradual?
Where is the pain? What is the intensity of the pain?
What activities or positions tend to make the pain feel better or worse?
Does the pain radiate down the leg, arm or to other parts of the body?

After taking the patient’s history, the physician will do a physical examination, with the objective of trying to determine the cause of the pain and ruling out other possible problems. If a vertebral compression fracture is suspected, the doctor will test for tenderness and sensitivity near specific vertebrae along the spine. Based on the patient’s history and physical exam, if a vertebral fracture is suspected an x-ray will be ordered to confirm the diagnosis.

Depending on the physician’s findings from the patient’s history, physical exam and x-ray, additional diagnostic tests may also be needed, such as:

A CAT scan, to see whether or not the fractured bone is stable and/or to see if the adjacent near the fracture are being irritated or may be affected by the fracture. Because a CAT scan can show soft tissue (e.g. nerves) as well as bone, and because it can take cross-sectional images of the spine, it provides the physician more information than an x-ray.
An MRI scan may be ordered if the doctor suspects that there may be some other cause of the patient’s pain (e.g. a herniated disc), or if there is a chance that nerves near the fracture are being affected. An MRI scan shows a high level of detail of the soft tissues (e.g. nerves, discs) surrounding the fracture that may be affected. An MRI scan can also tell if the fracture is old or new. In a new fracture the bone will be particularly dark on one sequence of films (the T1 weighted sagittal images).
A nuclear bone scan may be used to help determine when the fracture occurred. The age of the fracture is sometimes important to know to help guide treatment options.

Finally, in addition to diagnosing the fracture, it is also very important to accurately diagnose the cause of the spinal fracture. While osteoporosis is the most common cause of vertebral compression fractures, especially in women over the age of 50, other possible causes of the fracture may sometimes need to be considered, such as:

Trauma to the spinal vertebrae can also lead to minor or severe fractures. Such trauma could come from a fall, a forceful jump, a car accident, or any event that stresses the bones in the spine past its breaking point.
Some types of cancer can also cause a weakening of the vertebrae in the spine to the point where they may fracture. It is not uncommon for metastatic cancer that starts in another part of the body to spread to bones in the spine. A compression fracture of the spine that appears for little or no reason may be the first indication that an unrecognized cancer has spread to the spine. Cancer or multiple myeloma should be considered in patients who also have hypercalcemia, otherwise unexplained anemia, weight loss, or proteinuria.

If osteoporosis is the cause of the fracture, then usually a two-pronged treatment approach will be recommended, which includes treating the fracture and helping prevent future fractures.

Treatment for the vertebral fracture will typically include non-surgical care, such as rest, pain medication and slow return to mobility, and/or surgical care, such as vertebroplasty or kyphoplasty, to help the fracture heal.
Measures to help prevent more vertebral fractures from occurring will typically include one or a combination of the following: calcium supplements, increased vitamin D, weight-bearing exercises, and hormone replacement therapy for women

By: Scott Boden, MD
May 11, 2005

Reference:

2. Cooper C, Atkinson EJ, Jacobsen SJ, O'Fallon WM, Melton LJ 3d. Population-based study of survival after osteoporotic fractures. Am J Epidemioly. 1993; 137:1001-5.