Lumbar Compression Fracture: Practice Essentials, Pathophysiology, Epidemiology

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Drugs & Diseases > Physical Medicine and Rehabilitation
Lumbar Compression Fracture

Updated: Oct 12, 2018
Author: Andrew L Sherman, MD, MS; Chief Editor: Stephen Kishner, MD, MHA more...
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Lumbar Compression Fracture
Sections Lumbar Compression Fracture

Overview
Practice Essentials
Pathophysiology
Epidemiology
Show All
Presentation
History
Physical
Causes
Show All
DDx
Workup
Laboratory Studies
Imaging Studies
Procedures
Show All
Treatment
Rehabilitation Program
Medical Issues/Complications
Surgical Intervention
Consultations
Other Treatment
Show All
Medication
Medication Summary
Analgesics
Parathyroid hormones, recombinant
Antiosteoporotic agents
Bisphosphonates
Selective estrogen modulators
Show All
Follow-up
Further Outpatient Care
Further Inpatient Care
Inpatient & Outpatient Medications
Transfer
Deterrence
Complications
Prognosis
Patient Education
Show All
Questions & Answers
Media Gallery
References
Overview
Practice Essentials
The lumbar vertebrae are the 5 largest and strongest of all vertebrae in the spine. These vertebrae make
up the lower back. They begin at the start of the lumbar curve (ie, the thoracolumbar junction) and extend
to the sacrum. The strongest stabilizing muscles of the spine attach to the lumbar vertebrae. Fractures of
lumbar vertebrae, therefore, occur in the setting of either severe trauma or pathologic weakening of the
bone. Osteoporosis is the underlying cause of many lumbar fractures, especially in postmenopausal
women. Osteoporotic spinal fractures are unique in that they may occur without apparent trauma.
However, a thorough diagnostic workup is always required to rule out spinal malignancy. The image
below reveals a wedge compression fracture. (See Pathophysiology.)
Anteroposterior and lateral radiographs of an L1

osteoporotic wedge compression fracture.
View Media Gallery
Diagnosis and management
Perform a complete blood cell count with differential, prostate-specific antigen testing (in middle-aged
and older men), and erythrocyte sedimentation rate determination. The urine can be sampled for markers
of increased bone turnover, which occur in persons with osteoporosis.
Radiography is the standard imaging study for spine fractures. Anteroposterior and lateral views of the
lumbar and thoracic spines are usually the minimum studies needed. Computed tomography (CT)
scanning is an invaluable tool to evaluate the complexity of fractures seen on radiographs and to spot
subtler fractures not readily seen on radiographs. Magnetic resonance imaging (MRI) is required when the
patient describes lower extremity motor or sensory loss. Radicular pain is another indication for MRI.
Also, when canal compromise is suspected, MRI is required. Dual energy radiographic absorptiometry
(DRA) scanning is currently the most widely used method to measure bone mineral density.
When malignancy is strongly suspected, a vertebral biopsy is indicated. These biopsies are usually carried
out under CT-scan guidance. However, vertebral biopsy should not be performed when the suspected
tumor is a chordoma or other aggressive primary spine tumor that spreads via direct extension.
In the past, treatment options for lumbar fractures were quite limited, with bracing and rest prescribed
most often. While many patients improved with this regimen, some did not and were left with chronic,
disabling pain. Suh and Lyles found that vertebral compression fractures were associated with significant
performance impairments in physical, functional, and psychosocial domains in older women. [1] However,
medical and surgical options are now available that can relieve the severe pain and disability from these
fractures.
Traumatic injuries with neurologic compromise usually require comprehensive inpatient rehabilitation.
Mobility and strength rehabilitation programs are individualized to each patient's capabilities. All therapy
disciplines making up the multidisciplinary team participate in the comprehensive program. In most cases,
rehabilitation begins with the patient in a thoracic-lumbar-sacral orthosis (TLSO).
Surgical intervention is required when neurologic dysfunction and/or instability occurs as a result of the
lumbar fracture. The surgical procedure used for correction of a lumbar fracture depends on certain
factors. These critical factors include the degree of bony canal compromise seen on axial images, the
angulation on sagittal views, the level of fracture, neurologic examination findings, and the patient's
premorbid health status.
Two related procedures, vertebroplasty and kyphoplasty, are available for the patient with a lumbar wedge
fracture who continues to experience pain despite aggressive conservative treatment. Vertebroplasty
involves injecting a form of cement polymer into the fractured vertebral body. Kyphoplasty is similar to
vertebroplasty, except a balloon is used to expand the volume of the fractured segment prior to introducing
the cement polymer. [2, 3, 4]
Next:
Pathophysiology
The lumbar spine provides both stability and support, allowing humans to walk upright. Proper function
of the lumbar spine requires that it have a normal posture (ie, a normal lumbar curve). Any injury that
changes the shape of a lumbar vertebra will alter the lumbar posture, increasing or decreasing the lumbar
curve. As the body attempts to compensate for the alteration in the lumbar spine in order to maintain an
upright posture, this will tend to distort the curves of the thoracic and cervical spine.
Lumbar compression fractures can be a devastating injury, therefore, for 2 reasons. First, the fracture itself
can cause significant pain, and this pain sometimes does not resolve. Second, the fracture can alter the
mechanics of the posture. Most often, the result is an increase in thoracic kyphosis, sometimes to the point
that the patient cannot stand upright. In trying to maintain their ability to walk, patients with kyphosis
report secondary pain in their hips, sacroiliac joints, and spinal joints. These patients are also at risk for
falls and accidents, increasing the risk of secondary fractures in the spine and elsewhere.
Fractures in the lumbar spine occur for a number of reasons. [5] In younger patients, fractures are usually
due to violent trauma. Car accidents frequently cause flexion and flexion distraction injuries. Jumps or
falls from heights cause burst fractures. These fractures can also result in serious neurological injury. In
older patients, lumbar compression fractures usually occur in the absence of trauma, or in the context of
minor trauma, such as a fall. [6] The most common underlying reason for these fractures in geriatric
patients, especially women, is osteoporosis. Other disorders that can contribute to the occurrence of
compression fractures include malignancy, infections, and renal disease.
Traumatic fractures
Different types of fractures can occur in the lumbar (or thoracic) spine. Classification of these fractures is
based on the 3-column anatomic theory of Denis, which describes anterior, middle, and posterior spinal
columns consisting of aspects of the spine and their corresponding ligaments and other soft-tissue
elements. The Denis system, however, was created to classify traumatic fractures. A similar classification
system does not exist for compression fractures. The main reason to use such a classification is to help
determine whether a fracture is stable. Instability in the Denis system implies that damage has occurred to
at least 2 of the columns of the lumbar spine.
Wedge fractures are the most common type of lumbar fracture and are the typical compression
fracture of malignancy or osteoporosis. They occur as a result of an axially directed central
compressive force combined with an eccentric compressive force. In pure flexion-compression
injuries, the middle column remains intact and acts as a hinge. Although wedge fractures are usually
symmetric, 8-14% are asymmetric and are termed lateral wedge fractures.
Fractures involving flexion and distraction forces are often due to lap belts in motor vehicle
accidents. Commonly, the posterior columns are compromised in these injuries because the
ligaments of the posterior elements are disrupted. This type of injury is quite common in young
children. Most patients with flexion-distraction injuries remain neurologically intact.
Burst fractures result from high-energy axial loads to the spine. Multiple classification systems exist
for these fractures. The severity of the deformity, the severity of canal compromise, the extent of
loss of vertebral body height, and the degree of neurologic deficit affect the determination of
whether these injuries are unstable.
When any of the above injuries occurs with a severe rotational force, the degree of injury and of instability
increases.
Nontraumatic fractures
In osteoporosis, osteoclastic activity exceeds osteoblastic activity, resulting in a generalized decrease in

bone density. The osteoporosis weakens the bone to the point that even a minor fall on the tailbone,
causing an axial load or flexion, results in one or more compression fractures. The fracture is usually
wedge shaped. Without correction, a wedge fracture invariably increases the degree of kyphosis.
Malignancies that result in spinal fractures are most commonly metastases rather than primary bone
cancers. Primary cancers that often spread to the spine via hematologic dissemination include cancers of
the prostate, kidneys, breasts, and lungs. Melanoma is a less common but more aggressive cause of spinal
metastasis. The most common primary cancer of the spine is multiple myeloma, but others, including a
variety of sarcomas, [7] can also manifest as a spinal fracture. Nonmalignant lesions that can cause
fractures include aneurysmal bone cyst and hemangioma.
Spinal infections usually start in the lumbar intervertebral disk. From the disk, the infection spreads to
bone, resulting in osteomyelitis. Severe pain is the hallmark symptom. The exception is spinal
tuberculosis or Pott disease. In this case, the disk spaces are typically spared and a compression fracture
may be the initial manifestation that leads to its discovery.
Previous
Next:
Epidemiology
Frequency
United States
Most fractures of the lumbar spine that require operative treatment occur at the thoracolumbar junction.
These injuries are primarily traumatic in origin. Most nontraumatic lumbar fractures are osteoporotic in
origin. These are almost invariably wedge-type compression fractures. The National Osteoporosis
Foundation (NOF) estimates that currently, 10 million individuals in the United States have osteoporosis,
and 34 million more have low bone mass. [8] In 2005, osteoporosis was responsible for more than 2
million fractures; approximately 547,000 of those were vertebral fractures. Approximately one third of
osteoporotic vertebral injuries are lumbar, one third are thoracolumbar, and one third are thoracic in
origin. Additionally, 75% of women older than 65 years who have scoliosis have at least 1 osteoporotic
wedge fracture.
Mortality/Morbidity
Mortality from a lumbar fracture is rare; however, morbidity can be significant. In elderly patients with
acute osteoporotic fractures, pain and prolonged bed rest can lead to multiple secondary medical
complications.
In younger persons, neurologic damage from traumatic spine injuries can result in problems such as loss
of lower extremity strength and sensation and loss of bowel and bladder control.
A study by Imai et al indicated that in patients with an osteoporotic hip fracture, the coexistence of a
vertebral compression fracture significantly increases mortality risk. The study involved 182 patients with
osteoporotic hip fracture (average age 85 years at the time of fracture), with lumbar spine radiographs
revealing vertebral compression fracture in approximately 78% of these individuals. At 1-year following
hip fracture, the investigators found the mortality rate to be significantly higher in patients with a
coexistent vertebral compression fracture. [9]
Sex
Osteoporosis occurs primarily in postmenopausal women. Type 1 osteoporosis occurs in women aged 51-
65 years and is associated with wrist and vertebral fractures. Estrogen deficiency is the main etiologic
factor. Type 2 osteoporosis (senile type) is observed in women and men older than 75 years, in a 2:1 ratio
of women to men.
Age
In young and middle-aged adults, most lumbar fractures are traumatic in origin. High-velocity falls can
cause burst fractures, and seat-belt injuries can cause wedge fractures. As stated above, women 51-65
years old develop type 1 osteoporosis. After age 75 years, men also begin to develop type 2 osteoporosis.
Previous
Clinical Presentation
References
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http://www.nof.org/osteoporosis/diseasefacts.htm. Accessed: May 26. 2009.
9. Imai N, Endo N, Hoshino T, et al. Mortality after hip fracture with vertebral compression fracture is
poor. J Bone Miner Metab. 2014 Dec 14. [Medline].
10. Gibson JE, Pilgram TK, Gilula LA. Response of nonmidline pain to percutaneous vertebroplasty.
AJR Am J Roentgenol. 2006 Oct. 187(4):869-72. [Medline]. [Full Text].
11. Kim DE, Kim HS, Kim SW, Kim HS. Clinical analysis of acute radiculopathy after osteoporotic
lumbar compression fracture. J Korean Neurosurg Soc. 2015 Jan. 57 (1):32-5. [Medline].
12. Karaca L, Yuceler Z, Kantarci M, et al. The feasibility of dual-energy CT in differentiation of

vertebral compression fractures. Br J Radiol. 2016. 89 (1057):20150300. [Medline].
13. American College of Radiology. ACR Appropriateness Criteria® osteoporosis and bone mineral
density. National Guideline Clearinghouse. Available at
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15. Piazzolla A, Solarino G, Lamartina C, et al. Vertebral Bone Marrow Edema (VBME) in
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32. Bischoff-Ferrari HA, Willett WC, Wong JB, Stuck AE, Staehelin HB, Orav EJ, et al. Prevention of
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33. O'Daly BJ, Morris SF, O'Rourke SK. Long-term functional outcome in pyogenic spinal infection.
Spine. 2008 Apr 15. 33(8):E246-53. [Medline].
34. Luzzati R, Giacomazzi D, Danzi MC, Tacconi L, Concia E, Vento S. Diagnosis, management and
outcome of clinically- suspected spinal infection. J Infect. 2009 Apr. 58(4):259-65. [Medline].
35. Hirakawa M, Kobayashi N, Ishiyama M, Fuwa S, Saida Y, Honda H, et al. Radiological findings as
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[Medline].
Media Gallery
Anteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture.

Fluoroscopic view of a kyphoplasty procedure.
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Contributor Information and Disclosures
Author
Andrew L Sherman, MD, MS Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman,
Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency
Programs, Department of Rehabilitation Medicine, University of Miami, Leonard A Miller School of
Medicine
Andrew L Sherman, MD, MS is a member of the following medical societies: American Academy of
Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic
Medicine, Association of Academic Physiatrists, Florida Society of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.
Coauthor(s)
Nizam Razack, MD, FACS Assistant Professor of Neurological Surgery, Orthopedics, and
Rehabilitation, University of Miami; Neurosurgeon, Spine and Brain Neurosurgery Center; Chairman,
Department of Neurosurgery, Orlando Regional Medical Center
Nizam Razack, MD, FACS is a member of the following medical societies: American Association of
Neurological Surgeons, American College of Surgeons, Florida Medical Association, Society for Neuro-
Oncology, Congress of Neurological Surgeons
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Patrick M Foye, MD Director of Coccyx Pain Center, Professor of Physical Medicine and Rehabilitation,
Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back
Pain Clinic, University Hospital
Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical
Medicine and Rehabilitation
Chief Editor
Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation
Residency Program Director, Louisiana State University School of Medicine in New Orleans
Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of
Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic
Medicine
Additional Contributors
Curtis W Slipman, MD Director, University of Pennsylvania Spine Center; Associate Professor,

Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center
Curtis W Slipman, MD is a member of the following medical societies: American Academy of Physical
Medicine and Rehabilitation, Association of Academic Physiatrists, International Association for the
Study of Pain, North American Spine Society
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Sections Lumbar Compression Fracture

Overview
Practice Essentials
Pathophysiology
Epidemiology
Show All
Presentation
History
Physical
Causes
Show All
DDx
Workup
Laboratory Studies
Imaging Studies
Procedures
Show All
Treatment
Rehabilitation Program
Medical Issues/Complications
Surgical Intervention
Consultations
Other Treatment
Show All
Medication
Medication Summary
Analgesics
Parathyroid hormones, recombinant
Antiosteoporotic agents
Bisphosphonates
Selective estrogen modulators
Show All
Follow-up
Further Outpatient Care
Further Inpatient Care
Inpatient & Outpatient Medications
Transfer
Deterrence
Complications
Prognosis
Patient Education
Show All
Questions & Answers
Media Gallery
References
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News & Perspective

Lumbar Compression Fracture

Sections Lumbar Compression Fracture

Anteroposterior and lateral radiographs of an L1

Diagnosis and management

In osteoporosis, osteoclastic activity exceeds osteoblastic activity, resulting in a generalized decrease in

8. Fast Facts on Osteoporosis. National Osteoporosis Foundation. Available at

12. Karaca L, Yuceler Z, Kantarci M, et al. The feasibility of dual-energy CT in differentiation of

Osteoporotic Vertebral Compression Fractures Following Treatment for Osteoporotic Vertebral

28. Zhang H, Xu C, Zhang T, Gao Z, Zhang T. Does Percutaneous Vertebroplasty or Balloon

Anteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture.

Contributor Information and Disclosures

Disclosure: Nothing to disclose.

Disclosure: Nothing to disclose.

Specialty Editor Board

Disclosure: Received salary from Medscape for employment. for: Medscape.

Disclosure: Nothing to disclose.

Disclosure: Nothing to disclose.

Curtis W Slipman, MD Director, University of Pennsylvania Spine Center; Associate Professor,

Disclosure: Nothing to disclose.

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