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Vertebral compression fractures: How to
manage pain, avoid disability. (cover story)
Lukert, Barbara P.
Geriatrics; Feb94, Vol. 49 Issue 2, p22, 5p, 1 color, 3
bw
Article
OSTEOPOROSIS -- Treatment
FRACTURES -- Treatment
MEDICAL AND CLINICAL ISSUES
SPINAL COLUMN
Discusses a primary care approach to patients with
vertebral compression fractures related to
osteoporosis. Diagnosis; Types of fracture; Acute and
long term complications; Pain relief and bracing as
short-term treatments; Exercise and preservation of
bone mass as long-term treatments. INSET: How to
give an ice massage for back pain..
2705
0016-867X
9503102243
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EBSCOhost: Vertebral compression fractures: How to manage pain, avoid disability
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Biomedical Reference Collection: Comprehensive
VERTEBRAL COMPRESSION FRACTURES: HOW TO MANAGE PAIN, AVOID DISABILITY
Contents
Compression
fractures:
Making
the diagnosis
Complications: Acute
and long-term
Acute
treatment:
Pain relief, bracing
Long-term
treatment:
Preserving
mass
Summary
REFERENCES
bone
About 25% of U.S. women over age 50 will suffer one or more vertebral
compression fractures related to osteoporosis. Vertebral fractures may be
biconcave, anterior wedge, or crush deformities. A fracture is most often
precipitated by putting a load on outstretched arms (eg, while raising a
window). Back pain is usually incapacitating for a few weeks, then diminishes in
severity but remains intense for 2 to 3 months. Acute complications include
transient ileus, urinary retention, or (rarely) cord compression. Long-term
effects include kyphosis, deconditioning, insomnia, and depression. Initial
treatment includes bed rest, pain management with local and systemic
analgesia, bracing to improve comfort, and patient reassurance. Long-term
management includes spinal stretching exercises, walking, and treatment of
underlying osteoporosis with calcitonin or estrogen in selected patients.
Lukert, BP. Vertebral compression fractures: How to mange pain, avoid
disability. Geriatrics 1994; 49(Feb):22-26.
A simple cough may be all it takes to break a patient's back when osteoporosis
is severe. Brittle bones can be crushed by such everyday activities as opening a
window or lifting a grandchild.
Unlike most hip fracture patients, who are hospitalized immediately, most patients with vertebral fractures
are treated as outpatients by primary care physicians. For vertebral fractures, pain management is the
short-term goal, whereas prevention of subsequent fractures becomes your long-term priority.
In this article, we discuss a primary care approach to patients with vertebral compression fractures, from
the initial diagnosis and relief of acute pain to follow up measures.
Compression fractures: Making the diagnosis
Osteoporosis-related hip fractures receive far more publicity than vertebral compression fractures, but
vertebral fractures also result in a significant loss of general health, decreased mobility, and a progressive
decline in quality of life.[ 1] Many cases go unreported, but it is estimated that about 25% of U.S. women
over age 50 will suffer one or more vertebral fractures.[ 2] In men, the prevalence is higher than in
women up to the age of 60, presumably because of men's more traumatic lifestyle. After age 60, the
prevalence in men increases with age but at about one-half the rate observed in women.
A vertebral compression fracture can be defined either as a radiographic event or as a symptomatic clinical
event. A commonly accepted radiologic definition is a 15 to 20% reduction of anterior, posterior, or central
height.[ 3] As for symptoms, approximately 80% of vertebral compression fractures are associated with
acute back pain.[ 4] Fractures are easiest to identify in the patient who presents with acute pain and an
identifiable deformity of a vertebra corresponding to the area of pain.
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When a fracture is suspected, anterior-posterior and lateral x-rays of the involved area of the spine are
indicated. If there is a question of whether the fracture is new or represents a previous event, a bone scan
is helpful. There is increased uptake of bone-seek-ing isotopes (hence, a positive bone scan) at the site of
a recent fracture.
Types of fracture. Vertebral fractures may be biconcave, anterior wedge, or crush deformities (see
figure, page 24). Anterior wedge fractures occur most commonly in the mid-thoracic region and about the
thoracolumbar junction, whereas central compression fractures are more common from the first to the
fourth lumbar vertebrae.[ 5] Solitary wedge fractures seldom occur above the seventh thoracic vertebra,
and a cause other than osteoporosis (metastatic or infectious) must be suspected when you see them
above this level.
Causes. Fractures occur when a compression force is applied to the spine. The most common activity
resulting in fracture is putting a load on outstretched arms during such activities as raising a window,
picking up a sack of groceries, or lifting a small child. Other causes include a fall in the sitting position or
high-impact activities that apply a sudden force to the spine (such as horseback riding or riding in a boat
that bounces across the water). Patients with severe osteoporosis can fracture vertebrae by simply
coughing or sneezing.
Pain. Acute vertebral fractures produce intense, severe pain at the fracture site. The pain is incapacitating
for a few weeks, then usually diminishes in severity but remains intense for 2 to 3 months. Acute pain is
due to irritation of the periosteum, local bleeding causing release of cytokines, and muscle spasm. Chronic
pain persists because deformity of the vertebrae alters joint articulation and accelerates degenerative joint
changes. Radicular pain is common due to nerve root pressure.
Complications: Acute and long-term
Immediately following the fracture, patients frequently develop an ileus or urinary retention that is
transient. Cord compression is extremely rare but should always be suspected. Look for signs of cord
compression due to retropulsion of bone fragments, which include bilateral leg pain, paresthesias,
incontinence, and motor weakness. The appearance of these symptoms may be delayed and occur for the
first time weeks after the initial injury.
Loss of height and changes in postural alignment cause far-reaching problems, ranging from inability to
find clothing to fit the changing body contours to respiratory impairment. Shortening of the spine results
in a reduction in the size of the abdominal and thoracic cavities.
Patients develop a protuberant abdomen and a feeling of abdominal distention. Early satiety is a common
complaint and may contribute to weight loss. With time, the ribs begin to overlap the iliac crests and
cause discomfort. Spinal extenser muscles become weak and promote worsening of kyphosis. As a result,
patients tend to tire easily and become limited in their activities. The volume of the thoracic cage
decreases, resulting in diminishing lung volume and restrictive pulmonary disease.
Sleep disturbances are common because of the difficulty in finding a comfortable position. This frequently
leads to the development of fibromyalgia and depression.
Spinal stenosis can be a late complication and should be suspected when pain in the buttock and/or lower
extremities occurs with walking in a patient with normal vascular studies. The history will suggest
claudication, but the pain of spinal stenosis requires several minutes to hours before it remits as opposed
to the 2 to 5 minutes required for relief of pain due to exercise-induced vascular insufficiency.
Acute treatment: Pain relief, bracing
Taking the time to reassure the patient that the pain is not permanent is one of the most frequently
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overlooked aspects of vertebral compression fracture management. Patients frequently assume that a
"broken back" will never improve. You can help to alleviate their depression and despair by explaining
that the pain will diminish as the vertebra heals.
Pain management. Most patients who have suffered an acute compression fracture can be managed at
home, unless they have ileus, acute urinary retention, or neurologic complications.
The severity of the pain usually requires bed rest, local analgesia, systemic analgesia, and even narcotics
for 1 to 2 weeks. Positioning is important for comfort, and patients often find it impossible to sleep lying
flat. A hospital bed or sleeping in a lounge chair may provide better comfort during the acute phase.
Ice massage is frequently useful as a local anesthetic during the acute phase of injury (see "How to give
an ice massage for back pain"). Ice applied to the point of numbness may have an effect similar to a
regional nerve block and may give pain relief for a few hours. Later, moist heat applied for 20 minutes
every few hours may be helpful in relieving muscle spasm.
Giving a daily maintenance dose of an NSAID can often reduce the need for narcotics. When narcotics are
given, careful dosing and observation is required. Narcotics have significant potential side effects in older
patients, including reduced respiratory drive, reduced bowel motility, urinary retention, sedation, altered
mental status, and hypotension. Use narcotics for short periods of time and taper doses as soon as
possible to avoid addiction. We have had success with:
hydrocodone bitartrate, 7.5 mg, with acetaminophen, 750 mg (Vicodin ES)
codeine phosphate, 30 mg, with acetaminophen, (eg, Phenaphen w/Codeine No. 3, Tylenol w/Codeine No. 3, et al)
every 4 to 6 hours as needed for pain.
Although, in general, older people do not tolerate muscle relax-ants well, we have found that
meprobamate, 200 mg, with aspirin, 325 mg (eg, Equagesic) may be helpful. We start with one tablet 3
to 4 times daily, and if the patient does not experience drowsiness the dose can be increased to 2 tablets
if necessary.
Bracing. Bracing is underutilized in the management of vertebral fractures. The object of bracing in
patients with osteoporosis-related vertebral fractures is not to prevent neurologic complications (which are
rare), but to provide comfort.
Stabilization of the spine to prevent movements that precipitate pain is useful acutely and allows the
patient to become mobilized more quickly as healing occurs. Braces help relieve back fatigue and give the
patient more confidence that she has the strength to stand erect, until she can become rehabilitated.
For lower lumbar fractures, a wide lumbar support with Velcro closures is frequently adequate. For
fractures of lower thoracic vertebrae, the cruciform brace that has pressure points on the symphysis pubis
and the sternum or each side of the sternum is useful.
For thoracic fractures, a modified Taylor brace is indicated. Lightweight paraspinous plastic or metal
supports extending to the upper thoracic region and straps going up over the shoulder maintain extension
of the thoracic spine.
More elaborate extension braces such as the Jewitt hyperextension brace are not usually necessary,
unless neurologic complications are feared. Form-fitted braces may be useful in patients with multiple
fractures but are frequently uncomfortable because they are hot to wear.
Braces must be light-weight, easy to put on, and properly adjusted to assure comfort and patient
compliance. Be cautious that any brace used does not further compromise respiratory status.
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Long-term treatment: Preserving bone mass
Treatment of the underlying osteoporosis is an obvious part of management of vertebral compression
fractures. It is important to thoroughly evaluate the patient to be certain that bone loss is not being
accelerated by an ancillary disease process.[ 6]
Basic laboratory work should include a CBC, chemistry profile (electrolytes, calcium, phosphorus, liver and
kidney function tests, alkaline phosphatase, proteins). If the patient is anemic or serum proteins are
abnormal, a serum protein electrophoresis should be ordered. All of the parameters should be normal,
except for elevations of the alkaline phosphatase for 2 to 3 months following the fracture. If there is
reason to suspect vitamin deficiency, measurement of serum 25-OH vitamin D is indicated.
Review the patient's dietary habits to determine whether the calcium intake is in the recommended range
of 1,000 to 1,500 mg/d. If not, encourage the patient to eat more high-calcium foods. Dietary intake of
calcium can be estimated by knowing the intake of dairy products (ie, 8 oz. milk, 1 oz. cheese, or 8 oz.
yogurt equals 250 to 300 mg calcium). Calcium carbonate or citrate supplements should be given with
meals to bring the total intake to the desired level.
Relief of pain is usually indicative of fracture healing. Follow-up by x-ray is not helpful, because the
appearance of the vertebra may not change with healing. If progression of the fracture is suspected
because of increasing pain, then repeating radiographic examination may be helpful.
Exercise. As soon as the fracture has healed, begin a program of mobilization, walking, and extension
exercises. Our research shows that extension exercises may retard the progression of kyphosis, relieve
pain, and ease the sensation of muscle fatigue.[ 7] The patient should be carefully instructed by a
physical therapist before doing these exercises.
Calcitonin. Injections of the polypeptide calcitonin inhibit bone resorption and may therefore slow the
progressive loss of bone mass. Calcitonin-salmon (Calcimar, Miacalcin) also has an analgesic effect,[ 8]
which we have found to be very useful in patients with acute compression fractures.
Calcitonin is given subcutaneously, and we teach patients to self-administer this drug just asdiabetics
inject themselves with insulin. We find that an elderly patient is less likely to develop nausea if calcitonin
is given at bedtime, starting with 25 units for a few days then gradually increasing the dose to 50 to 100
MRC units daily for 2 months and then every other day.
Treatment with calcitonin is usually continued for I year. Many patients become resistant to its effect after
18 to 24 months.
Estrogen. Estrogen is known to reduce the incidence of fractures and is indicated for the long-term
management of osteoporosis in postmenopausal women who do not have a contraindication. The major
contraindications include a history of endometrial or breast cancer, acute thrombotic episode, and
estrogen-dependent neoplasia.
In the elderly, estrogen should be started with very small doses. We usually begin with oral conjugated
estrogens (Premarin), 0.3 mg every other day for 1 month, then 0.3 mg daily for one month, and then
0.625 mg daily. If the patient has an intact uterus, a progestational agent is added in the form of
medroxyprogesterone acetate (Provera), 2.5 mg daily or 5 mg 10 days of the month.
Estrogen is especially useful for preventing further bone loss for patients with postmenopausal
osteoporosis. However, little is known about the acute effects of estrogen on fracture pain or healing.
Regardless of the treatment used, assessment of response to therapy should be monitored by measuring
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bone density by dual energy x-ray whenever this technology is available.
Summary
Vertebral compression fractures are common in women with postmenopausal osteoporosis and often
cause severe pain. For short-term treatment, measures to relieve pain include bed rest for 1 to 2 weeks,
analgesics, ice massage, muscle relaxants, anti-inflammatory agents, heat to relieve muscle spasm, and
bracing. Patients should be reassured that the pain will remit as the vertebra heals.
Over the long term, treatment includes exercise, such as walking and spinal extension, and measures to
slow progressive bone loss, such as calcitonin or estrogen replacement therapy for selected patients.
ILLUSTRATION: Spinal fractures occur when sufficient compression force is applied to vertebrae weakened
by osteoporosis. Acute fractures usually produce severe pain at the fracture site that diminishes but
remains intense for 2 to 3 months. Illustration for GERIATRICS by Scott Thorn Barrows
PHOTO (BLACK & WHITE): Figure. On spinal x-rays, vertebral compression fractures may be seen as
biconcave (A), anterior wedge (B), or crush (C) deformities. Note that with crush fractures, the anterior
and posterior heights are similar, but the total height is decreased compared with that of adjacent
vertebrae. Radiographs provided by Barbara P. Lukert, MD
REFERENCES
1. Linnel PW, Hermansen SE, Elias MF, et al. Quality of life in osteoporotic women. J Bone Miner Res
1991; 6 (suppl 1, abs 96): S106.
2. Melton LJ, Kan SH, Frye MA, Wahner HW, O'Fallon WM, Riggs BL. Epidemiology of vertebral fractures in
women. Am J Epidemiol 1989; 129:1000-11.
3. Eastell R, Cedel SL, Wahner HW, Riggs BL, Melton LJ III. Classification of vertebral fractures. J Bone
Miner Res 1991; 6:207-15.
4. Cooper C, Atkison ES, O'Fallon WM, Melton LJ. The incidence of clinically diagnosed vertebral fractures:
A population based study in Rochester, Minnesota, 1985-1989. J Bone Miner Res 1992; 7:221-8.
5. Hedlund LR, Gallagher JC, Meeger C, Stoner S. Change in vertebral shape in spinal osteoporosis. Calcif
Tissue Int 1989; 44:168-72.
6. Johnson BE, Lukert BP, Lucasey B. Contributing diagnoses in osteoporosis: The value of a complete
medical evaluation. Arch Intern Med 1989; 149:106972.
7. Lukert BP, Ball JM, VanderVeen DK. Effect of extension exercise on posture in women ages 50-60. Proc
Am Soc Gerentol 1991; (suppl 1)44.
8. Levernieux J, Julien D, Caulin F. The effect of calcitonin on bone pain and acute resorption related to
recent osteoporotic crush fractures. Result of a double blind and an open study. In: Cecchetin M, Segre G,
Elsevier BV (eds). Calciotropic hormones and calcium metabolism. Amsterdam: Excerpta Medica,
1986:171-8.
~~~~~~~~
By BARBARA P LUKERT, MD
Dr. Lukert is professor of medicine, division of endocrinology, metabolism and genetics, department of
medicine, University of Kansas Medical Center, Kansas City.
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HOW TO GIVE AN ICE MASSAGE FOR BACK PAIN
PREPARATION
Freeze water in a paper cup
Trim paper away from one end
TECHNIQUE
Caregiver massages area of fracture with ice until area is numb
FOUR PHASES OF SENSATION
Cold!
Ache begins after a few minutes
Burning begins after 4 to 5 minutes of massage
Continue massaging to the point of numbness or to the maximum safety time. Do not apply ice for
more than 7 minutes over a small area or 10 minutes over a large area.
REPEAT
May repeat every hour, if necessary
ILLUSTRATIONS
~~~~~~~~
By BARBARA P. LUKERT, MD
Copyright of Geriatrics is the property of Advanstar Communications Inc. and its content may not be copied or emailed to
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