Osteoporosis and Spine Fractures

  Osteoporosis is a skeletal disorder in which bones become fragile and are more likely to break. If not prevented or treated, osteoporosis can progress painlessly until a bone breaks. These broken bones, called fractures, are most likely to occur in the hip, spine or wrist. Possible causes include hormonal imbalances, pregnancy, metabolic diseases or cancer in otherwise healthy people over age 60 to 65.

   Twenty-eight million Americans are at risk for developing osteoporosis. Every year, there are 1.5 million new fractures in people who have soft bone secondary to osteoporosis. Of these, annually, 700,000 people annually sustain spine fractures, 300,000 hip fractures 250,000 wrist fractures and 250,000 fractures of other bones, all as a result of osteoporosis. With 700,000 spine fractures a year, this translates to one compression fracture every 45 seconds. After a patient sustains their first compression fracture, the risk of an additional fracture goes up more than five fold (Annals of Internal Medicine).

Problems Associated with Compression Fractures

   When soft osteoporotic bone breaks, patients describe onset of significant back pain. Pain can be in the upper or lower back. When the fracture occurs, severe pain can cause a patient to be bedridden for a few weeks. If the vertebra collapses, a deformity forms in the back and the patient begins to hunch forward. This posture can lead to difficulty with breathing and digestion, problems standing up straight, increasing back pain, decreased ability to walk even medium distances, and an overall decrease in the quality of life. When the fracture settles and the patient begins to slouch forward, additional vertebra are much more likely to fracture, increasing the problem and the hunching forward even further.

The Human Cost of Compression Fractures

   The pain from a fractured vertebra causes a decrease in the level of activity. Patients describe the inability to be up and walking and performing daily activities. Often, depression sets in. Patients develop a lower self esteem as they become more reliant on others for their daily care. There is often anxiety as patients are concerned about their increasing dependence on others.

   According to a 1998 study there is a significant decrease in the lung function in patients with thoracic or lumbar fractures. Each thoracic or upper back fracture causes a 9% loss of vital capacity of the lungs (Journal of American Respiratory Disease).

   In a retrospective analysis of five-year survival rates done at the Mayo Clinic, patients with osteoporotic compression fractures of the vertebra were found to have a worse survival rate over the next five years compared to what would be expected. This decrease in survival rate was found to be similar to those patients who sustained a hip fracture. For these patients, the most common cause of premature death was pulmonary disease, emphysema and pneumonia.

Non Operative Treatment of Spinal Fractures

   The usual treatment for compression fractures has been management with pain medication. Narcotic pain medicines are used for a few months until the pain decreases. Pain from fractured bone can last from three months to more than a year, depending on the circumstances and the severity of the broken bone.

   After the pain from the fracture improves, patients need to build up bone strength. There are a few medications which are available to increase bone density. This treatment is slow and continues for years. It is the only treatment we have at this point to increase bone mass and therefore should be used by patients who are at risk for osteoporotic compression fractures, and those who have had fractures in the past. By building the bone density, we hope to prevent future fractures.

   Immobilization of the spine with a brace can help decrease pain from broken vertebra. The most appropriate brace is a soft elastic waistband with Velcro straps. Sometimes metal strips or a plastic insert in used in the back of the brace for added support. The brace is only helpful for fractures of the lower back.

Kyphoplasty

   With the development of kyphoplasty, treatment of compression fractures is changing. Patients no longer need to put up with fracture pain and progressive hunching of the spine thanks to this new technique. The kyphoplasty technique involves a new technology whereby an osteoporotic compression fracture can be treated, pain relieved, the lost bone height restored, and the fracture immediately stabilized with the injection of bone cement. This is all done through two ½" incisions on each side of the effected vertebra. The technique involves the use of x-ray equipment to insert working tools into the collapsed vertebra. An inflatable bone tamp or expander is then placed into the fractured vertebra on each side and very slowly, the balloons are inflated, lifting up the fractured portion of the vertebra to a more normal height. The balloons are deflated and cement is slowly injected.

   Results from this technique have shown excellent restoration of fractures which are less than four to six months old, and better than 90% success at reducing pain associated with the broken vertebra.

   Complications from this procedure have been very few and have been primarily related to patients who have been on blood thinner medications. Potential complications could include cement leaking out of the vertebra and into inappropriate areas. To date, these have not been reported with kyphoplasty.

Who Would Benefit From Kyphoplasty?

   Patients who have experienced a recent vertebral compression fracture due to osteoporosis can benefit from kyphoplasty. Fractures are best treated and have the best chance at being restored to their original height when the fractures are less than four months old. For patients who are on chronic Prednisone or steroids, even older fractures can be treated and restored to full height.

Case History

   An 82-year-old woman presented to my office with recent onset of severe back pain. X-rays showed a fractured vertebra in the mid back. Examination of the patient showed she was beginning to stoop forward. Pushing along the spine revealed one area of maximum tenderness, which correlated, with the x-ray findings of the fracture. She was sent for an MRI scan, which confirmed the new fracture. No other significant abnormalities were found.

   This patient was a very active woman who had been married more than 50 years to the same man. The two of them enjoyed walking, traveling, shopping and socializing with friends. The patient was not able to perform any of her daily activities because of the pain.

   The patient elected to proceed with kyphoplasty. After this one-hour surgery, the patient noted immediate relief of pain and was "able to roll over in bed now without yelling out in pain". She returned to the office two weeks later for a check up and reported being back to full activity. She was very happy with her results. The x-rays showed excellent restoration of the fractured vertebra and immediate stability of the broken bone.

Other Surgical Options for Spinal Fractures

   Vertebroplasty is a procedure where cement is injected into the fractured vertebra without any attempt at correction of the collapsed bone. The pain relief is similar to kyphoplasty, though vertebroplasty has a higher complication rate from extruded cement going in places it was not meant to go. This is due to vertebroplasty requiring high pressures to inject very liquid cement into the bone. In stark contrast, kyphoplasty uses thickened cement injected slowly to fill the void created by the balloon and the cement technique is therefore much safer than vertebroplasty. Because of problems with cement filling, and inability to reduce the fracture deformity, vertebroplasty is clearly a second choice to kyphoplasty.

   When there is a severe collapse of several vertebra in a row causing the patient to be stooped forward, kyphoplasty will not help. These fractures are often too old or too severe to inject with cement. The only other option is to consider major surgery to straighten the spine and hold it in place with spinal instrumentation (screws, hooks and rods). Such an undertaking is only advisable after all other options have been exhausted and when there is significant pain and functional disability.

The Future

   I predict that kyphoplasty will become the standard treatment for patients who experience new osteoporosis related fractures in their spine. This technique has been shown to eliminate both the deformity and the pain from the fracture. It is all done through a small ½" incision on each side of the vertebra. Following surgery, these incisions are covered with Band-Aids and the patient is able to get up and walk immediately. There is no down time. This exciting procedure has changed the way we care for patients with osteoporotic compression fractures.

About the Author:
   Dr. Dennis Crandall received his medical degree from St. Louis University School of Medicine and completed his orthopaedic residency at St. Louis University Hospitals in St. Louis, Missouri. He completed a fellowship in spinal reconstructive surgery, adult and pediatric spinal deformity and spinal trauma from the University of Maryland, Section of Spinal Surgery, Division of Orthopaedic Surgery at the University of Maryland Hospital and Maryland Institute for Emergency Medical Services in Baltimore, Maryland. Dr. Crandall is board certified by the National Board of Medical Examiners and the American Board of Orthopaedic Surgery. He is a member of the American Academy of Orthopaedic Surgeons, American College of Surgeons, the Scoliosis Research Society, North American Spinal Society and the Spinal Fixation Study Group to name a few of his affiliations. Dr. Crandall is chief of spinal surgery, Phoenix Orthopaedic Residency Program and the medical director of the Sonoran Spine Center in Phoenix, Arizona. Dr. Crandall has published numerous papers, book chapters and provided many presentations on spine treatment and surgery.

For more information, visit Sonoran Spine Center

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