Symptoms
and Signs
Injury usually results from an activity that
increases the compressive load on the spine (eg, lifting, bending forward, or misstepping
while walking). In the elderly, osteoporosis weakens the trabecular bone of the vertebral
bodies and leaves the posterior elements relatively unaffected. Excessive loads then
compress the vertebral bodies into a wedge-shaped configuration as the trabecular bone
impacts into itself.
Patients often present with acute pain that is
exacerbated by sitting or standing. Percussion over a specific spinal region reveals
well-localized tenderness. Associated neurologic deficits are rare.
Many vertebral-body fractures occur silently,
however. Elderly patients often have x-ray evidence of fractures without a history of
symptoms or injury.
Treatment and Prognosis
Vertebral-body compression fractures always
heal, because the trabecular bone is only impacted into itself, and the blood supply is
not impaired. These fractures are relatively stable because the intact posterior elements
prevent translational displacement. Neurologic deficits from bony impingement rarely
occur. The primary clinical sign is progressive kyphosis due to wedging and loss of height
of the vertebral bodies.
Initially, hospitalization for bed rest may be
needed to relieve pain. Analgesics, nonsteroidal anti-inflammatory drugs, and laboratory
screening tests for other causes of osteopenia may be indicated. Patients should be
encouraged to sit up and walk for short periods as soon as possible to prevent
deconditioning and accelerated bone loss. They may not be able to walk independently for a
week or so and may have considerable back pain for 6 to 12 wk. Sometimes, a month or more
later, the pain shifts from the fracture site to a higher or lower site, probably because
of altered mechanical stresses caused by the deformity.
Bracing probably does little to prevent
deformity, but it can help relieve pain and allows a quicker return to activities. Bracing
is useful only for fractures of the lumbar and lower thoracic spine because adequate
support cannot be achieved above these regions. While hyperextension braces (eg, the
Jewett) are the most effective biomechanically, they are not the most comfortable. They
apply three-point stabilization of the spine through an anterior abdominal pad, a chest
pad, and a posterior pad at the level of the fracture. Corsets or abdominal binders are
effective and better tolerated alternatives in patients with lumbar fractures. |