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Current Concepts Review

Painful Osteoporotic
Vertebral Fracture
PATHOGENESIS, EVALUATION, AND ROLES OF
VERTEBROPLASTY AND KYPHOPLASTY IN ITS MANAGEMENT
BY RAJ D. RAO, MD, AND MANOJ D. SINGRAKHIA, MD
Investigation performed at the Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin

➤ Osteoporotic vertebral fractures may be a sentinel sign of failing health in elderly patients and are likely to be-
come an increasing health-care concern as the population continues to age.

➤ A reduction in the number, thickness, and interconnectivity of vertebral trabeculae in combination with altered
load transmission across the degenerated disc predisposes a vertebral body to fracture from minor trauma.

➤ The clinical course of these fractures is variable; some patients are asymptomatic, many respond to medica-
tions and activity modification, and a small subset have debilitating symptoms.

➤ Good short-term results have been reported following both vertebroplasty and kyphoplasty for the treatment of
osteoporotic and metastatic vertebral fractures. The long-term consequences of polymethylmethacrylate injec-
tion into the vertebral body are unclear, and discretion must be exercised in the use of these procedures.

➤ Vertebral body height can be partially restored in some of these fractures by extension positioning of the patient
on the table or by inflation of the vertebral body with a bone balloon.

Osteoporotic vertebral compression fractures are a frequently
encountered clinical problem, and they are becoming more
important as the median age of the population continues to
increase. Notwithstanding the potentially devastating conse-
quences, many of these fractures are initially asymptomatic
and appear to cause little morbidity other than decreased
height and a more forward stooped posture. Only 23%1 to
33%2 of these fractures become clinically evident. When such
a fracture does cause pain, the patient usually can be managed
successfully with a combination of medications, activity mod-
ification, and occasionally bracing.
Managing a patient who does not respond to this ini-
tial treatment regimen is challenging. The risks of anesthe-
sia and the poor quality of bone in this elderly group make
operative intervention such as fusion and application of in-
strumentation less attractive. Internal splinting of the ver-
tebral body by percutaneously injected methylmethacrylate
may provide adequate pain relief that allows the patient to
return to his or her previous level of functioning. The aim
of this article is to review features of osteoporosis that are
pertinent to the pathogenesis of vertebral compression
fractures and to discuss the evaluation, natural history, and
consequences of these fractures. Two new operative proce-
dures, vertebroplasty and kyphoplasty, will be reviewed,
and their role in the management of this condition will be
discussed.
Pathogenesis of Osteoporotic
Vertebral Fractures
Bone is composed of a compact cortical compartment and a
metabolically active trabecular compartment. The osteoblasts
and osteoclasts in trabecular bone participate together in a bone
formation/resorption process, which is responsible for the con-
tinuous remodeling of bone. Uncoupling of bone remodeling
begins when an individual is approximately thirty years old, con-
tinues with a steady 3% to 5% loss of bone per decade3, and can
eventually result in osteoporosis. This manifests as a reduction in
the number, thickness, and interconnectivity of the trabeculae4,5.
Osteoporotic bone becomes more fragile, which predisposes it to
eventual fracture with relatively minor trauma6.
Trabecular thinning contributes to bone loss with age in
both sexes, but trabecular loss occurs to a greater extent in
women7. In women, the loss of bone nearly triples in the ten
years following menopause, after which it returns to the pre-
menopausal state of approximately 0.4% per year8. Alter-
ations in the physiologic turnover of bone occur with age and
may be influenced by many hormonal, hereditary, medical,
and lifestyle factors (Fig. 1).
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and all three combined (4%; thirty-four of 875)10.

Physiologic conditions The prevalence of all fracture patterns increases with
x Lack of estrogen (postmenopausal osteoporosis) age, and there is no correlation between age and type of frac-
x Advanced age (senile osteoporosis) ture deformity. Height loss occurs in association with all frac-
ture types, but it is most pronounced in association with crush
Pathologic conditions
Immobility/disuse
deformities. Back pain is equally likely with each of these types
x Paralysis of deformities10. The prevalence of certain fracture types in
x Postoperative specific areas of the spine may be related to sagittal alignment
Genetic of the spine and to regional loading patterns10. In a cadaver
x Osteogenesis imperfecta study, Oda et al. noted that selective trabecular atrophy and
x Homocystinuria increased trabecular spacing in the anterosuperior portion of
Hormonal
x Hyperparathyroidism
x Hypo/hyperthyroidism
x Hypogonadism
x Hypercortisolism
x Insulin-dependent diabetes mellitus
Diseases
x Rheumatoid arthritis
x Cirrhosis
x Renal tubular acidosis
Nutritional
x Malnutrition
x Malabsorption
x Anorexia nervosa
x Vitamin-C, D deficiency
Pharmacological
x Anticoagulants
x Antineoplastics
x Anticonvulsants
x Alcohol
Neoplastic
x Multiple myeloma
x Lymphoma/leukemia
x Metastatic disease
Idiopathic
Fig. 1
Conditions affecting bone turnorver.

Fracture Patterns
Reduction of individual vertebral body height by 20% or 4
mm is considered to be indicative of a vertebral compression
fracture9. Three fracture patternswedge, crush, and bicon-
cavehave been described in the osteoporotic spine10,11 (Fig.
2). A vertebra with a wedge deformity has a collapsed anterior
border with an almost intact posterior border. Wedge defor-
mities occur mostly in the midthoracic and thoracolumbar re-
gions in both sexes. In crush fractures, the entire vertebral
body is collapsed, and these too are clustered in the midtho-
racic and thoracolumbar regions. Biconcave fractures show
collapse of the central portion of the vertebral body, and they
are more prevalent in the lumbar region. The European Verte-
bral Osteoporotic Study reported wedge compression frac-
tures to be the most common (prevalence, 51%; 444 of 875), Fig. 2
followed by biconcave fractures (17%; 147 of 875), crush frac- Classification of osteoporotic vertebral structure and defor-
tures (13%; 114 of 875), wedge and crush fractures (7%; sixty- mity. a: A normal vertebral body. b: A wedge fracture. c: A bi-
four of 875), wedge and biconcave fractures (6%; fifty-five of concave fracture. d: A crush fracture.
875), crush and biconcave fractures (2%; seventeen of 875),
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the vertebral body was prevalent with the wedge pattern12.
Lyritis et al. attempted to determine clinical outcomes
on the basis of the initial radiographic appearance of vertebral
fractures13. Patients with an obvious wedge fracture had se-
vere, sharp pain, which gradually decreased within four to
eight weeks. Patients with minimal superior end-plate discon-
tinuity tended to have gradual progression to complete col-
lapse of the vertebral body and had dull, less severe, although
recurring pain. The authors suggested that patients who have
more severe pain initially and a well-defined wedge fracture
may do well with acute pain management and early mobiliza-
tion. Patients who present with an ill-defined fracture pattern
initially may require continuing treatment for an eighteen to
twenty-four-month period.
Decreased Bone Density
Bone mineral density is perhaps the best indicator currently
available for assessment of the risk of osteoporotic fractures.
Decreased trabecular bone mass in the vertebrae, hip, wrist, and
ribs makes these bones prone to fractures. Lindsay et al. found
that, with each standard deviation of decrease in bone mineral
density compared with that of a young healthy population,
there was a 60% increase in the risk of vertebral fracture1.
In their meta-analysis of eleven separate prospective
population cohort studies involving a total of more than 2000
fractures, Marshall et al. reported that every standard devia-
tion of decrease in bone density increases the relative risk of all
fractures by 1.5 times and the relative risk of spine and hip
fractures by 2.3 and 2.6 times, respectively14. However, even
though a decrease in bone density determines fracture risk,
the authors pointed out that they could not identify which in-
dividuals would actually sustain a fracture. Ross et al. found
that a decrease in spinal bone density by two standard devia-
tions was associated with a 5.8-fold increase in vertebral frac-
ture rate15. They reported that prediction of vertebral fractures
could be improved by using two factors: bone density and
prevalent fractures (fractures that existed at the time of the
study), or two bone density measurements. Black et al. found
that decreased bone density measurements in the hip, spine,
and extremities were equally predictive of increased fracture
risk in older women16.
Prevalent Fractures
In a study of postmenopausal Japanese-American women,
Ross et al. found a fivefold increase in the risk of a new verte-
bral fracture when a single vertebral fracture was present at
baseline17. This risk increased to twelvefold when there were
two or more fractures at baseline. Lindsay et al., in a multi-
center study involving 2725 postmenopausal women with a
mean age of seventy-four years, found a cumulative incidence
of 6.6% new fractures in the first year1. Overall, 19.2% of the
women with a confirmed incidental fracture had a second
fracture within one year; 11.5% of the women with one previ-
ous fracture sustained a second fracture, whereas 24% of the
women with two or more prevalent fractures at baseline had a
new fracture within a year following the first observed frac-
P A I N F U L O S T E O P O RO T I C VE R T E B R A L F R A C T U RE
ture. Age, weight, baseline vitamin-D status, and hormonal
therapy had no effect on the risk of new fractures in patients
with a prevalent fracture. Bedrest or inactivity as a result of
pain from vertebral compression fractures accelerates bone
loss, which may increase the risk of additional fractures6,18.
Increased kyphosis from previous fractures also predis-
poses a patient to recurrent fractures. Black et al. found that
prevalent vertebral deformities from previous fractures were as-
sociated with a fivefold increase in the risk of new fractures19.
The risk was higher as the number of preexisting fractures and
the severity of the deformity increased. Prior vertebral compres-
sion fractures also increase the risk of sustaining nonspinal
fractures19,20, and the presence of multiple and severe vertebral
compression fractures was found to be a specific risk factor for
sustaining femoral neck fractures21.
Altered Loading Patterns with Age
Compressive loading of the spinal motion segments helps to
maintain the integrity of the trabecular pattern of bone. The
reductions in body weight and activity that accompany aging
result in decreased loads on the spine and secondarily result in
decreased bone mass. In young individuals with healthy discs
and uniform trabecular thicknesses and spacing, load trans-
mission at the disc-end plate interface takes place evenly
across a large portion of the end plate22. As the disc becomes
degenerated, loads are transmitted unevenly to the end plates,
resulting in possible load concentrations on parts of the end
plate23. A fracture results when this load overcomes the resis-
tance of the fragile end plate.
Keller et al. developed a biomechanical model to investi-
gate the height loss and spinal deformity associated with ver-
tebral osteoporosis in older individuals24. The bone loss and
disc degeneration associated with aging were found to weaken
the spinal column, to the extent that postural stresses and
gravity alone led to spinal deformity. Forward translation of
the cephalad part of the spinal column resulted, causing in-
creased compressive loads at the thoracolumbar junction and
making this region more susceptible to compression fractures.
Other Independent Risk Factors
A number of other factors have been reported to contribute to
the pathogenesis of vertebral compression fractures. Lack of
hormonal replacement therapy, three or more chronic illnesses
such as tuberculosis and/or peptic ulcer disease25, and smoking26
are some of these independent factors. Increased vertebral
depth, measured from the anterior to the posterior vertebral
cortex27, in combination with low bone density has also been
reported to increase the risk of fracture.
Wilkin suggested that bone density does not contribute
greatly to an individual’s risk of sustaining a fracture28. He
noted that antiresorptive agents, which decrease bone turn-
over, do not greatly increase bone mass but nevertheless sub-
stantially decrease fracture incidence. He postulated that it is a
state of high bone turnover, combined with the predisposition
of elderly individuals for falling, that increases the likelihood
of fractures.
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not visible on initial radiographs but becomes evident on radio-

graphs made two or three weeks later as the osteoporotic bone
settles. There is little correlation between the degree of collapse
of the vertebral body and the level of pain.
Magnetic resonance imaging of the spine is probably the
single most useful test for determining fracture age, ruling out a
malignant tumor, and selecting the appropriate treatment. In the
acute period following a vertebral fracture, magnetic resonance
imaging shows a geographic pattern of low-intensity-signal
changes on T1-weighted images and high-intensity-signal
changes on T2-weighted images33 (Figs. 3-A and 3-B). As the
fracture becomes chronic, a linear area of low-intensity-
signal change replaces the geographic area on T1-weighted im-
ages. As healing continues, the linear pattern is replaced by
restoration of fatty marrow33. Sagittal short tau inversion re-
covery (STIR) sequences are helpful; they show high-intensity-
signal changes in areas of edema from acute or healing fractures.
Distinguishing osteoporotic and metastatic spine frac-
tures can be very difficult, even with magnetic resonance imag-
ing. The typical findings of both osteoporotic and metastatic
fractures are decreased signal intensity on T1-weighted images
and increased signal intensity on T2-weighted images. Osseous
involvement of the pedicles or other posterior elements and the
Fig. 3-A presence of soft-tissue lesions in the epidural space or paraspi-
Figs. 3-A and 3-B An eighty-one-year-old man with an osteoporotic nal regions favor the diagnosis of a malignant tumor (Figs. 4-A
vertebral compression fracture. Fig. 3-A T1-weighted sagittal im- and 4-B). T1-weighted images of bone typically do not show
age showing decreased signal in the vertebral body of T12. normal signal intensity with tumors. Diffusion-weighted
magnetic resonance imaging is a recently described tool that
Evaluation may help to distinguish metastatic from osteoporotic verte-
Patients with a symptomatic vertebral fracture typically present
with severe back pain following minor injury. Sometimes,
sneezing or vigorous coughing precipitates a fracture in os-
teoporotic bone. The pain is made worse by standing erect and
occasionally even by lying flat. On examination, the patient is
often limited to a wheelchair or may stoop forward when stand-
ing. The spine shows exaggerated thoracic kyphosis, and the
pain is typically reproduced by deep pressure over the spinous
process at the involved level. Neurologic deficits are rarely asso-
ciated with these fractures, but they always must be ruled out29.
Radiographs show the osteopenia characteristic in these
patients. The vertebral body shows a fracture with loss of height
and wedging and occasionally with retropulsion of osseous
fragments into the spinal canal. Fractures commonly occur in
the thoracolumbar region, but they may be present anywhere in
the spine10,30. Osteoporotic fractures in the upper thoracic spine
may be indicative of an underlying malignant tumor, and a
thorough search for a possible primary lesion should always be
carried out31,32. A white blood-cell count, measurement of the
erythrocyte sedimentation rate, and serum protein electro-
phoresis help to rule out an underlying infectious or malignant
etiology.
The age of the fracture cannot be accurately determined
from radiographs. Dense sclerotic osteophytes or cortical mar-
gins may suggest that the fracture is chronic. A review of any Fig. 3-B
available previous spine or chest radiographs can determine Inversion recovery magnetic resonance image showing increased
whether the fracture is a new event. Occasionally, the fracture is signal through the same region, suggesting a recent fracture.
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is the technique of choice for determining bone density. Ac-

cording to World Health Organization criteria, osteoporosis is
diagnosed when bone density on a dual-energy x-ray absorp-
tiometry scan measures <2.5 standard deviations below that
of young, healthy individuals of the same sex. Individuals with
low bone mass and a resultant fracture are diagnosed as hav-
ing severe osteoporosis (Table I)3.

Consequences of Osteoporotic Fractures

Vertebral fractures are the most common skeletal injury result-
ing from osteoporosis, with an estimated incidence of 700,000
per year in the United States37. These fractures occur earlier in
the natural history of osteoporosis than do other fractures, but
they are frequently unrecognized. Melton et al. estimated the
incidence of vertebral fractures on the basis of an age-stratified
analysis of 762 women in Rochester, Minnesota38. The overall
incidence in women who were fifty years of age or older was
17.8 per 1000 person-years; the incidence increased from 5.8
per 1000 person-years in women between the ages of fifty and
fifty-four years to 26.1 per 1000 person-years in those between
seventy-five and seventy-nine years. The prevalence of any ver-
tebral deformity in women who were fifty years of age or older
was estimated to be 25.3%. Many elderly patients with os-

Fig. 4-A
Figs. 4-A and 4-B A seventy-two-year-old man with metastatic
colon carcinoma involving the T6 vertebral body. Fig. 4-A T1-
weighted sagittal magnetic resonance image showing decreased
signal within the vertebral body and posterior elements of T6.

bral compression fractures. Osteoporotic vertebral fractures

are hypointense to isointense compared with the adjacent
normal vertebrae, whereas metastatic compression fractures
are hyperintense34.
Bone scans provide useful information about bone
turnover and thereby identify any vertebral fracture that has
an ongoing healing process. Bone scans are sensitive for the
detection of fractures, but they have low specificity for the di-
agnosis of underlying disease. An additional limitation of
bone-scanning is that increased bone turnover can be detected
as long as two years following a vertebral fracture35. This limits
the ability of a bone scan to demonstrate the acuity of an os-
teoporotic vertebral fracture, and it is not helpful for deter-
mining the source of the pain or the predictability of the
response to treatment. Distinguishing among vertebral frac-
tures, neoplasms, and infections is difficult on a bone scan,
unless multiple metastatic lesions are clearly identified. Bone-
scanning plays a role in identifying osteoporotic fractures in Fig. 4-B
patients who have negative findings on plain radiographs and Contrast-medium-enhanced T1-weighted sagittal image demon-
in identifying additional fractures at other levels36. strating increased signal in the same region. Involvement of the
Dual-energy x-ray absorptiometry of the midlumbar upper thoracic spine and signal changes in the posterior body
spine and proximal part of the femur is quick and safe, and it and pedicle both raise the suspicion of metastatic involvement.
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TABLE I World Health Organization Diagnostic Criteria for
Osteoporosis
Group Diagnostic Criteria
Normal Bone mineral density within 1 standard
deviation of the mean of a young adult
reference population
Osteopenia Bone mineral density between 1.0 and
(low bone mass) 2.5 standard deviations below the mean
of a young adult reference population
Osteoporosis Bone mineral density <2.5 standard
deviations below the mean of a young
adult reference population
Severe Osteoporosis with one or more fragility
osteoporosis fractures
teoporotic vertebral fractures often presume that the back pain
and impaired mobility associated with those fractures are
changes that come with age and that little can be done about
them. Acute pain from these fractures is usually benign and
self-limiting, with the majority of patients quickly returning to
normalcy. Two-thirds of these patients are never seen by a phy-
sician when the fracture is acute2, but a loss of height or the de-
velopment of a kyphotic deformity may be discovered later.
Physiologic Consequences of Fracture
Osteoporotic vertebral fractures with wedging or collapse of
the body result in a kyphotic spinal deformity with cosmetic,
physiologic, neurologic, and functional effects. Patients with
vertebral compression fractures become shorter, both from
the vertebral compression and from a flexed posture that they
assume because an erect position exacerbates the vertebral
pain. An exaggerated thoracic kyphosis (dowager’s hump) and
a protuberant abdomen develop, and these changes may affect
normal functions of the respiratory and gastrointestinal sys-
tems. Lung function (forced vital capacity and forced vital ca-
pacity in one second) is substantially reduced in patients with
thoracic and lumbar fractures39. One chronic thoracic verte-
bral fracture causes a 9% loss of forced vital capacity40. Thora-
columbar or lumbar fractures result in localized kyphosis and
secondary mechanical compression of the abdominal viscera,
with early satiety and weight loss18.
Neurologic deficits are infrequently associated with these
low-energy injuries, even when there has been retropulsion of
osseous fragments into the canal. In one series, neurologic in-
volvement that required surgical decompression was reported
in ten of 497 patients with osteoporotic vertebral compression
fractures29.
The psychological state of the individual may also be al-
tered, with changes in self-esteem, body image, and mood. Pa-
tients become more apprehensive and fearful of activity as the
potential of more fractures lingers in their minds. Many pa-
tients experience severe depression41.
Osteoporotic vertebral fractures may be a sentinel sign of
failing health in elderly patients. In one study, a group of
P A I N F U L O S T E O P O RO T I C VE R T E B R A L F R A C T U RE
women with three or more vertebral fractures had eleven hos-
pitalizations per 100 patient-years, whereas an age and sex-
matched group without vertebral fracture had seven hospital
admissions per 100 patient-years42. There is a 35% to 40% in-
crease in cancer deaths, independent of smoking habits, among
patients with vertebral compression fractures43. Osteoporotic
vertebral fractures are associated with an increased mortality
rate. In a population-based prospective study involving 9575
women followed for more than eight years, Kado et al. found a
23% to 34% increase in the mortality rate for women with ver-
tebral compression fractures compared with that for women
without them43. The most common cause of death in that series
was pulmonary disease. The five-year survival rate for patients
with vertebral compression fractures is 61%, which is substan-
tially worse than the 76% rate for age-matched peers44. Survival
rates following vertebral compression fractures are similar to
those following hip fractures in the elderly, but they steadily
decline with time. The survival rate following hip fractures re-
turns to baseline in six months44.
Pain from Vertebral Fractures
Symptomatic vertebral fractures usually present as acute tho-
racic or lumbar back pain. Most symptomatic fractures are
adequately managed with a short period of rest or activity
modification, narcotic analgesics, and a brace. However, ap-
proximately 150,000 vertebral compression fractures every
year in the United States are refractory to these measures and
require hospitalization, with prolonged periods of bed rest
and intravenous analgesics37. The bed rest probably aggravates
the bone loss in these patients45: studies have shown a 0.25%
loss in bone mineral density per week in normal individuals
treated with bed rest for seventeen weeks46 and a 1% loss per
week in individuals with herniated intervertebral disc disease
treated with bed rest47.
The intensity and duration of pain from symptomatic
fractures varies from patient to patient. In an attempt to link
radiographic fracture types with clinical presentation, Lyritis
et al. studied 210 postmenopausal women who had acute pain
and radiographic evidence of spinal fracture13. All patients had
initial pain of >5 as indicated on a visual analogue scale rang-
ing from 0 to 10. All were followed with repeat radiographs
and dual-energy x-ray absorptiometry scans of the lumbar
spine every six months, or immediately if a second episode of
acute pain developed. At the end of eighteen months, two dif-
ferent groups of patients could be identified: the first had a
mean age of sixty-seven years, lower bone density, and radio-
graphic evidence of a completely collapsed vertebra, and the
second had a mean age of sixty years and either no obvious
fracture or mild depression of the superior end plate of the
vertebra. The women in the first group had only a single acute
episode of pain, which persisted for a short duration of 6 ± 1.8
weeks. The number of subsequent attacks of acute pain (3 ±
1.05) was higher in the second group, and it took more than
forty-nine weeks on the average for them to finally present
with a complete collapse fracture. The acute pain in the first
group was severe, whereas it was milder in the second group
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and usually those patients did not have subsequent attacks of
pain requiring follow-up visits with a physician. In the first
group, the complete deformity developed after the first epi-
sode of pain, whereas the deformity developed gradually in
the second group. The authors concluded that older patients
with acute pain and early radiographic evidence of a collapsed
vertebra should be treated promptly with early mobilization,
whereas the patients in the second group should be treated in-
tensely with hormones and calcium for a longer period to pre-
vent complete collapse fractures.
Many patients have chronic pain from these fractures18;
in some, the pain may recur after an asymptomatic period
that lasts for a variable period of time. The etiology of chronic
pain from vertebral compression fractures is unclear, but there
are probably multiple sources, including: (1) back muscle fa-
tigue from localized fracture kyphosis, (2) back muscle fatigue
from forward shift of the upper part of the trunk, (3) second-
ary facet joint arthrosis, (4) recurring trabecular microfrac-
tures, (5) neural irritation, or (6) the rib cage descending and
impinging on the pelvis. The risk of chronic pain increases
with the number of vertebral levels fractured48,49.
Economic Impact
Many patients who have osteoporotic fractures have concomi-
tant medical comorbidities common to this age-group. Im-
mobility or pain from the fractures may aggravate underlying
medical conditions. Thus, it may be difficult to assess the eco-
nomic impact of these fractures separately from that of other
problems experienced by the elderly. The Michigan Depart-
ment of Community Health nevertheless estimated the direct
expenditures resulting from osteoporotic fractures in the
United States in 1995 to be greater than $13.8 billion, or $38
million per day. These costs are likely to escalate as the popula-
tion continues to age. The projected direct costs for the year
2030 exceed $60 billion, or $164 million per day50. Indirect
costs of these fractures resulting from lost productivity and
earlier transition to residential facilities for the elderly may
add to the overall economic impact of these fractures.
General Management of the Osteoporotic Patient
Prophylaxis against osteoporosis is best carried out by obtain-
ing optimal peak bone mass before early adulthood and pre-
serving bone mass thereafter. Exercise and an active lifestyle in
combination with appropriate nutrition, including calcium
and vitamin D, are adequate prevention measures for most
individuals. Lack of exercise, poor nutrition, and tobacco or
alcohol abuse may contribute to loss of bone in adult life.
Close monitoring of bone health is necessary in individuals
with conditions associated with secondary osteoporosis. The
indications for the use of hormone replacement therapy in
menopausal women are very limited, as the benefits in terms
of bone mass are outweighed by the risks of cardiovascular
problems and breast cancer51.
Nonmedical interventions may play a role in preventing
fragility fractures in elderly patients. Fall prevention strategies
include light weight-bearing exercise and proprioceptive
P A I N F U L O S T E O P O RO T I C VE R T E B R A L F R A C T U RE
training with gentle stretching. Tai chi chuan or other balance
training programs have been associated with a 40% reduction
in the risk of falls52. Simple modifications of the environment
and appropriate use of assistive devices and footwear may
make a large difference in the overall health of elderly patients.
The bulk of pharmacologic agents used in the treat-
ment of osteoporosis work by preventing bone resorption.
The most commonly used bisphosphonates, alendronate and
risedronate, bind to the hydroxyapatite crystals on bone sur-
faces and inhibit resorption. Both are safe and generally well
tolerated, and they are now available in once-weekly doses53,54.
Raloxifene is a selective estrogen-receptor modulator that in-
hibits bone resorption and may be particularly indicated in
women at increased risk for breast cancer or coronary artery
disease. Calcitonin prevents osteoclast-mediated bone resorp-
tion and may also have an analgesic effect. It is administered as
a nasal spray and is used most commonly by patients who are
unable to tolerate the oral bisphosphonates and by those with
acute fractures because of the analgesia that it offers. The most
recently approved drug for the treatment of osteoporosis is
teriparatide, the first thirty-four amino acids of human par-
athyroid hormone. Unlike its predecessors, teriparatide works
by stimulation of bone formation. It is administered by daily
subcutaneous injection.
All of the above pharmacologic agents have been shown to
increase bone mineral density. The incidence of vertebral frac-
tures decreases by approximately 60% after one year of treat-
ment with any of these drugs55-57. It is likely that this protective
effect against fractures begins as early as six months after initia-
tion of therapy with the antiresorptive drugs and lasts for at least
the first three to four years of treatment. Additional placebo-
controlled studies may help to determine whether the decreased
incidence of vertebral fractures persists over the long term.
Surgical Treatment, Vertebroplasty, and Kyphoplasty
Operative intervention is necessary in a very small subset of
patients with vertebral compression fractures in whom a pro-
gressive neurologic deficit or intractable pain develops from
the fracture deformity. These operations are extensive, involv-
ing prolonged duration of anesthesia, blood transfusion, and
associated complications58,59. Frequently, the osteoporotic bone
results in inadequate purchase of pedicle screws, wires cutting
through bone, construct failure, and possibly even worsening
of the deformity.
A number of measures can be taken to optimize the re-
sults of conventional surgery in this challenging group of pa-
tients. Hu et al. called attention to the fact that nutritionally
depleted patients have higher mortality rates and decreased
healing potentials, and they recommended optimizing the nu-
tritional status of patients prior to any operative intervention60.
During operative treatment, longer constructs with multiple
segmental points of fixation are often necessary to preserve fixa-
tion. The lamina consists primarily of cortical bone, and sub-
laminar wires are used when possible61. The use of larger pedicle
screws and augmentation of pedicle screws with methylmeth-
acrylate or bone graft may allow for more secure purchase62,63.
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aspect of the vertebral body. Some physicians have a verte-

bral venogram made prior to a vertebroplasty, to delineate
the venous plexus and ensure that it is unlikely that large
volumes of cement will be embolized into the venous sys-
tem. If a kyphoplasty is planned, an inflatable balloon tamp
is introduced through the cannula. The balloon is inflated
under manometric control in an attempt to restore the col-
lapsed vertebra to its normal position and thus create a
space within the body for injection of cement (Fig. 6). In
both kyphoplasty and vertebroplasty, viscous cement is in-
jected into the vertebral body under fluoroscopic control,
ensuring that the cement remains within the confines of the
vertebral body and, particularly, does not flow in a retrograde
fashion into the spinal canal. Although we are not aware of any
studies addressing the viscosity of the cement injected in either
procedure, it is assumed that the cement can be injected in a
doughier state in a kyphoplasty because of the prior creation of
a void space in the bone.
The cement is mixed with barium sulfate to increase ra-
diopacity. Antibiotics can be added for prophylaxis against in-
fection. Using cold cement allows a slight increase in the
working time before the cement becomes too viscous to allow
injection through the cannula system.
Fig. 5
Restoration of vertebral height during vertebroplasty. a: A frac-
tured vertebral body with an intravertebral mobile cleft. b: Exten-
sion positioning opens the cleft within the vertebral body, allowing
some restoration of vertebral body height. c: Methylmethacrylate
injection stabilizes the fracture in this position.

Percutaneous cement augmentation of the vertebral

body was introduced to treat a subset of patients with vertebral
compression fractures who do not need operative decompres-
sion of the neural elements but nevertheless have intractable
pain. Both vertebroplasty and kyphoplasty refer to an essen-
tially percutaneous injection of methylmethacrylate into the
vertebral body, which splints the fracture internally and pro-
vides pain relief. Vertebroplasty was initially described by Gali-
bert et al., in 1987, to treat symptomatic hemangiomas of the
vertebral body64, but it is now more frequently used in the
management of painful osteoporotic vertebral compression
fractures (Fig. 5). Kyphoplasty, developed by Reileyin 199865,
refers to the insertion of a balloon tamp into the vertebral
body prior to cement injection. The balloon is expanded
within the compressed vertebral fracture in an attempt to in-
crease vertebral body height and correct the kyphotic defor-
mity. Cement is injected into the void left behind after the
balloon is withdrawn (Fig. 6). Fig. 6

Many patients can tolerate either a vertebroplasty or a
kyphoplasty with a local anesthetic if injection at one or two
levels is planned. The patient is positioned prone, with bol-
sters located under the sternum and pelvis in an attempt to
reduce the kyphosis from the fracture (Fig. 5). Under fluo-
roscopic guidance, an 11-gauge trocar with a cannula is in-
serted through or adjacent to the pedicle into the posterior
Restoration of vertebral height during kyphoplasty. a: A frac-
tured vertebra displaying loss of height. b: An inflated bone bal-
loon displaces vertebral trabeculae and elevates the superior
end plate, allowing some restoration of the height of the verte-
bral body. c: Removal of the balloon is followed by injection of
methylmethacrylate into the void space.
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Pain Relief
Short-term pain relief is very good following vertebroplasty and
kyphoplasty for the treatment of osteoporotic compression
fractures. Studies of the results of vertebroplasties demonstrated
moderate or complete pain relief in 90% (twenty-six of twenty-
nine) to 95% (thirty-six of thirty-eight) of patients with os-
teoporotic compression fractures66,67 and in 72% (twenty-three
of thirty-two) to 75% (twelve of sixteen) of patients with verte-
bral metastases or multiple myeloma68,69. In a short-term follow-
up study, Garfin et al. reported that 90% of 340 patients had a
decrease in symptoms after kyphoplasty70. In a study using the
Short Form-36 questionnaire to assess outcomes, Lieberman et
al. also found substantial improvement65. Katzman compared
vertebroplasty and kyphoplasty in two dissimilar groups: verte-
broplasty was carried out for fractures that were more than
three months old, and kyphoplasty was carried out for more
acute fractures71. Results were excellent in both groups, without
a significant difference between them. Factors that may predis-
pose to a successful outcome with either procedure include (1)
localized pain over the fracture site, (2) evidence of a recent
fracture on magnetic resonance imaging or bone-scanning, and
(3) severe pain72.
The long-term outcome of cement injection into the
vertebral body is less clear. In a study of thirteen patients fol-
lowed for five years after vertebroplasty, Perez-Higueras et al.
reported that twelve patients stated that they would have the
procedure done again under similar circumstances73. Pain
scores on a visual analog scale decreased significantly (p <
0.001) from 9.07 prior to the procedure to 2.07 three days after
the procedure and remained steady at 2.15 five years later. In a
study of twenty-five patients with either primary or secondary
osteoporosis who underwent vertebroplasty, Grados et al.
found that the pain relief provided by the procedure contin-
ued through the four-year follow-up period74. Yeom et al. re-
ported on thirty-eight patients who had significant (p <
0.001) pain relief following vertebroplasty75. However, the pain
relief was less satisfactory after more than two years of follow-
up, with eleven of the thirty-eight patients having recurrent
pain that was moderate or severe. The cause of the pain was
either recollapse at the level of the injection or fracture of ad-
jacent vertebrae. We are not aware of any long-term indepen-
dent studies of the kyphoplasty procedure.
Complications
Complications are infrequent after vertebroplasty and kypho-
plasty, and those that occur are usually transient. Transient lo-
cal pain, radiculopathy, or fever that resolves in two to four
days may occur as a result of inflammation or infection at the
site of injection or as a result of exothermic effects of the
cement76. Unreacted monomer from the cement can have sys-
temic cardiopulmonary effects resulting in hypoxia and
embolism77. Rib fractures may occur from positioning or pres-
sure on the rib cage in these elderly patients66. In a group of
274 patients who underwent vertebroplasty, the complication
rate was 1.3% for those with osteoporotic vertebral fractures
and as high as 10% for those with metastatic fractures78. We
P A I N F U L O S T E O P O RO T I C VE R T E B R A L F R A C T U RE
are not aware of any reports of adverse events associated with
the use of the balloon tamp in kyphoplasty. In general, both
procedures are relatively safe, and complications from either
procedure appear to be primarily caused by improper needle
placement or inattention to fluoroscopic patterns of cement
flow during the injection process.
Leakage of cement into the epidural or paravertebral ar-
eas has been reported in 30% to 70% of vertebroplasties, but
usually it has been minor and has not resulted in adverse
events68,69,73. In a group of thirty patients who underwent kypho-
plasty, Lieberman et al. reported cement leakage into the epidu-
ral space in one patient, into a disc space on two occasions, and
into the paraspinal tissues in three patients65. The incidence of
cement leakage following either procedure may be higher than
that seen on radiographs. Yeom et al. found that computerized
tomography revealed cement leakage 1.5 times more frequently
than did radiographs79. Only 7% (two) of twenty-eight leaks
into the spinal canal were correctly diagnosed with radiographs,
and leakage of cement into the basivertebral vein or segmental
vein was commonly missed or underestimated on routine lat-
eral radiographs. Phillips et al. evaluated whether the creation
of a bone void during kyphoplasty reduced the risk of cement
leakage80. Under fluoroscopic control, they injected radiopaque
contrast material into the vertebral body prior to and following
the creation of a void within the vertebra. There was less extra-
vertebral leakage of the contrast material into the epidural
vessels, inferior vena cava, and transcortically following the cre-
ation of the cavity, suggesting that cement leakage may be less
likely following kyphoplasty.
Methylmethacrylate leakage causing neurologic injury
has been reported with both vertebroplasty and kyphoplasty.
Cement can extrude through a cortical defect into the spinal
canal or foramen and result in a neurologic deficit. In a study of
274 vertebroplasties, Chiras et al. reported post-vertebroplasty
radicular pain in 3.7% of patients and spinal cord injury in
one78. Lee et al. reported total paraplegia below T11 in a sixty-
six-year-old woman who had undergone a three-level verte-
broplasty with 7 mL of methylmethacrylate at each level81.
Computed tomography scanning showed extravasation of
methylmethacrylate into the anterior and posterior epidural
veins and longitudinal venous sinuses leading to spinal cord
compression. Harrington reported claudication symptoms
developing as a result of circumferential constriction by ex-
travasated methylmethacrylate of the thecal sac at the T10-L2
levels following vertebroplasty82. Garfin et al. reported on two
patients with spinal cord injury following kyphoplasty70. One
patient had partial motor loss in the lower extremities as a re-
sult of improper placement of the insertion tools and subse-
quent injection of cement into the spinal canal through the
tract. In another patient, with a fracture at the junction of the
body and pedicle, an anterior cord syndrome developed fol-
lowing performance of the kyphoplasty through an inferior
extrapedicular approach.
Restoration of Vertebral Height
The concept of kyphoplasty has brought to the forefront the is-
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sue of restoration of vertebral height in osteoporotic vertebral
compression fractures. Residual vertebral deformities have been
reported to be associated with a fivefold increase in the risk of
progression of the deformity, with the risk of new fractures de-
pending on the number of levels involved and the severity of the
deformity19. Restoration of vertebral body height and reduction
of postfracture kyphosis has the theoretical benefits of correct-
ing sagittal deformity, restoring lost height, improving cos-
metic appearance, improving pulmonary and gastrointestinal
function, and reducing the risk of a neurologic deficit being
caused by progression of the deformity.
Garfin et al. reported that kyphoplasty can restore height
and reduce kyphosis if it is performed within three months after
the occurrence of the fracture70. They reported that predicted
anterior vertebral body height increased from an average 83%
before treatment to 99% after kyphoplasty. Lieberman et al. re-
ported that kyphoplasties carried out at a mean of 5.9 months
after seventy vertebral fractures restored an average of 35% of
the lost height65. In another series, 34% of the lost height was re-
stored in vertebral fractures resulting from multiple myeloma83.
Katzman reported that nineteen of eighty-two patients had cor-
rection of vertebral body height after kyphoplasty and that there
was a 57.6% chance of correction if the procedure was done
within two weeks after the fracture71.
McKiernan et al. reported that the wedging of the verte-
bral body in many compression fractures is not fixed84. So-
called mobile fractures show an intravertebral radiolucent cleft,
and a reversal of kyphosis may be seen on extension radio-
graphs. Substantial recovery of lost height can be achieved dur-
ing vertebroplasty with careful patient positioning alone.
McKiernan et al. reported on sixty-five vertebral compression
fractures in forty-one patients who underwent vertebroplasty at
an average of eighty-nine days following fracture; 44% of these
patients showed dynamic mobility of the fracture84. In these
mobile fractures, anterior vertebral height increased from an
average of 42% to 70% of normal, with an average increase of
106% of the diminished height of the vertebral body after the
fracture, as a result of postural height restoration followed by a
vertebroplasty. The patients with fixed fractures in that series
had no appreciable restoration of vertebral height. Another re-
cent study demonstrated an average 2.5-mm increase in ante-
rior vertebral body height following vertebroplasty in which no
attempt was made to posturally reduce the fracture85. The au-
thors postulated that the restoration of height resulted from the
injection of high-viscosity bone cement under pressure.
We are not aware of any studies providing a direct com-
parison of height restoration with vertebroplasty and kypho-
plasty. Assessment of height restoration has varied widely
among the different studies, making it difficult to draw mean-
ingful comparisons.
Secondary Vertebral Fractures
In a study that included twenty-five patients with severe primary
(mean T-score, −3.1) and secondary osteoporosis evaluated four
years after vertebroplasty, Grados et al. found that at least one
vertebral fracture developed in the vicinity of the cemented ver-
P A I N F U L O S T E O P O RO T I C VE R T E B R A L F R A C T U RE
tebra in thirteen patients (52%)74. In another study, 23% (three)
of thirteen patients who had undergone vertebroplasty sustained
additional vertebral fractures over a five-year period, with the
fractures in two of these patients being adjacent to a treated
vertebra73. In a study of 115 patients who underwent kypho-
plasty, Harrop et al. reported that 19% (twenty-two) had new
compression fractures within ten months after the index
procedure86. Within this group, 9% (seven) of eighty patients
with primary osteoporosis and 43% (fifteen) of thirty-five pa-
tients with osteoporosis secondary to long-term steroid use had
new fractures in the follow-up period. Hyde et al. reported a
30% prevalence (twenty of sixty-six) of new fractures in a nine-
month period following kyphoplasty87. New fractures were more
likely in patients who had had more than a single fracture previ-
ously. Katzman found fractures at adjacent levels in 5% (two) of
forty-two patients who had undergone vertebroplasty and 5%
(four) of eighty-two patients who had undergone kyphoplasty71.
Neither procedure had an adverse effect on the refracture rate
when compared with the rate in a control group.
The natural history of osteoporotic vertebral compres-
sion fractures suggests that 11.5% of women with a single
prevalent vertebral fracture and 24% of women with more
than two prevalent vertebral fractures are likely to sustain a
new vertebral fracture within a year1. Up to 23% of these frac-
tures may be symptomatic1. It is unclear whether the injection
of cement and the abnormal stiffness of the vertebral body re-
sulting from either vertebroplasty or kyphoplasty increase the
likelihood of fractures at adjacent levels. Because of the lack of
long-term follow-up and the small numbers of patients in
most series, it is not possible to determine whether either pro-
cedure has an advantage over the other in this regard.
Biomechanics of Vertebral Augmentation
With the recent surge in interest in osteoporotic fractures,
many authors have explored the biomechanical effects of ce-
ment augmentation in these fractures. The limiting factor in
all of these studies is insufficient knowledge about the optimal
strength and stiffness required in the clinical management of
these fractures. The long-term effects of varying cement vol-
umes or patterns of fill, in terms of both relief of pain and the
effects on the adjacent segments, are still unclear.
Early vertebral augmentation procedures focused on
maximal fill of the vertebral body, but it is now evident that
smaller volumes may more appropriately restore biomechani-
cal properties of the vertebral body. The volume of cement in-
jected into the vertebral body is directly related to the stiffness
and strength that is achieved88. A small amountapproximately
15% volume fractionmay be adequate to restore the stiffness
of the vertebral body to its prefracture level. Use of a large vol-
ume of cement in an attempt to maximally fill the vertebral
body increases the stiffness of the vertebra and potentially leads
to fractures of adjacent, nonaugmented vertebrae89. A large fill
volume also makes the vertebral body more sensitive to cement
placement. Asymmetric distribution of the cement promotes
single-sided load transfer and potential toggle88.
Ikeuchi et al. investigated cement distribution within
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the vertebral body90. They found that cement that was injected
into only the caudad half of the vertebral body provided the
same stiffness, strength, and mechanical gradient with adja-
cent vertebrae as did cement injected into the entire vertebral
body. A bipedicular approach is sometimes indicated when
the cement does not symmetrically infiltrate the collapsed ver-
tebra, as in patients with a severe long-standing osteoporotic
wedge or biconcave fracture. Liebschner et al., in their finite
element study, found that unipedicular distribution led to a
mediolateral bending movement toward the untreated side
during compressive loading88.
In an attempt to study the loading patterns on the ante-
rior column following vertebroplasty and kyphoplasty, Anan-
thakrishnan et al. recently simulated an osteoporotic fracture
in a human cadaver model91. Hydrostatic pressures in adja-
cent discs were increased following either vertebroplasty or
kyphoplasty, but there was no significant difference in these
pressures between the two procedures.
Alternative Materials for Vertebral Augmentation
Polymethylmethacrylate has been used successfully, and al-
most exclusively, for vertebroplasty and kyphoplasty. The ad-
vantages are that (1) orthopaedic surgeons are familiar with it,
(2) it is easy to handle, (3) radiopaque materials can be added
to it, (4) it provides the necessary strength and stiffness, and
(5) it is inexpensive. Its disadvantages are (1) it has no osteo-
conductive or inductive properties, (2) high polymerization
temperatures can result in damage to surrounding tissues, (3)
unreacted monomer has systemic cardiopulmonary side ef-
fects, (4) excessive inherent stiffness can have a mechanical ef-
fect on adjacent vertebrae, and (5) it is not remodeled by
creeping substitution over time.
Several investigators have reported promising results of
vertebral augmentation with the use of biodegradable products
such as calcium phosphate, hydroxyapatite, or coral granules in
vitro92-94. Injectable mineral cements harden within metaphy-
seal bone without producing much heat. It is presumed that
new bone is laid down in apposition to, and eventually replaces,
the bone cement. At this time, it is unknown whether this pro-
cess of remodeling will occur in osteoporotic vertebrae. Current
problems with mineral cements are (1) high viscosity, which
prevents interstitial diffusion within the vertebral body, (2)
handling characteristics that differ from those of polymethyl-
methacrylate, (3) the fact that the in vivo resorption properties
have not yet been defined, and (4) high cost.
Takemasa and Yamamoto reported preliminary results
in a study of thirty-eight patients who had undergone stabili-
zation of osteoporotic vertebral compression fractures with
bioactive calcium phosphate cement95. All patients had sub-
stantial pain relief, and radiographs made three months after
treatment showed no progression of vertebral collapse and no
radiolucent zone around the injected cement.
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P A I N F U L O S T E O P O RO T I C VE R T E B R A L F R A C T U RE
Overview
Osteoporotic vertebral fractures are likely to become an even
greater health-care concern as our population continues to age.
These fractures are a clinical indicator of decreased bone min-
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underlying medical problems. Fortunately, the majority of these
fractures are asymptomatic and require minimal or no treat-
ment. The management of patients who have painful fractures
can be challenging. Rest, bracing, and medications help to some
degree, and operative stabilization is generally reserved for pa-
tients with an impending or actual neurologic deficit.
Newer techniquesi.e., vertebroplasty and kyphoplas-
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strate long-term biocompatibility may be a better solution.
Raj D. Rao, MD
Manoj D. Singrakhia, MD
Department of Orthopaedic Surgery, Medical College of Wisconsin,
9200 West Wisconsin Avenue, Milwaukee, WI 53226
The authors did not receive grants or outside funding in support of their
research or preparation of this manuscript. They did not receive pay-
ments or other benefits or a commitment or agreement to provide such
benefits from a commercial entity. No commercial entity paid or
directed, or agreed to pay or direct, any benefits to any research fund,
foundation, educational institution, or other charitable or nonprofit
organization with which the authors are affiliated or associated.
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