What's Up Doc? Compression fractures subtle but common
Q: My aunt is 80 and was having low back pain, so she went to see her doctor. Her doctor did X-rays and told my aunt her spine was broken and squished. My aunt said she did not fall and has had no accidents or anything. She said her doctor told her that her spine had just collapsed on its own. How can this happen?
A: It sounds like your aunt has compression fractures of her spine, and that is what I will discuss in today's column.
The lumbar spine, in the lower part of the back, consists of five vertebrae that are the largest and strongest of all the vertebrae of the spine. The strong muscles of the back anchor into these vertebrae, and not only help stabilize the back but also help us walk and do many other activities. The 12 thoracic vertebrae are smaller than the lumbar vertebrae, but they are stabilized by the ribs and are still quite strong. In young people it takes severe trauma to break these very strong bones.
Many things can weaken our bones, including cancer and even some rare infections, but by far the most common thing that does this as we get older is osteoporosis (thinning and weakening of the bones, usually in older people and most common in post-menopausal women). If this becomes severe enough, the vertebrae can become so weakened they collapse into themselves, either from minor trauma or "under their own weight" from the normal stresses placed on them from the muscles that attach to them or from the normal stresses they are put under doing daily activities. This results in a shorter height of the bones (calling them squished or compressed is a good description) and can lead to other potential complications. This is what is meant by vertebral compression fractures.
Although many people with vertebral compression fractures have no symptoms (although they may note they have gotten shorter - the shrinking some people make light of as they get older), possible symptoms include back pain (the most common problem), bowel problems (such as constipation and even blockage), decreased mobility and independence, breathing problems (especially if the thoracic vertebrae become involved) and others.
Vertebral compression fractures are very common. In fact, over 50 percent of all fractures from osteoporosis occur in the spine, with one-third involving the lumbar spine, one-third the thoracic spine and one-third the lumbar-thoracic spine. It is estimated that 25 percent of post-menopausal women in the country have compression fractures. This rises to as many as 40 percent of women over age 80. This condition is also a major health issue for men, although at a much lower rate. There is some evidence that this condition is under-diagnosed since many older people assume their back pain or other symptoms may be due to arthritis or other conditions, and hence do not discuss this issue with their health care provider.
The risk factors for vertebral compression fractures mirror those of osteoporosis. These include advancing age, female sex, history of other fractures, family history of osteoporosis and/or fractures, tobacco and/or alcohol abuse, certain kidney diseases or kidney failure, certain liver diseases or liver failure, insufficient physical activity, certain medications (including steroid medications) and many others.
The evaluation of vertebral compression fractures (usually confirmed by X-rays) includes a history and physical exam to determine what symptoms exist and what limitations and concerns they are causing the patient. The treating health care provider will determine if the fractures are stable (are not displaced by ordinary physiological forces or movement). Fortunately, an overwhelming majority of vertebral compression fractures are stable.
The initial treatment of stable vertebral compression fractures is the same as for most other causes of back pain: conservative (that is, non-surgical) treatments. This includes pain medication, possibly a couple of days of bed rest (more prolonged bed rest is usually not recommended since it can cause many other problems in the elderly), as well as treatments for other symptoms as needed. Physical and/or occupational therapy are also helpful for many people. Since osteoporosis is the main cause of compression fractures, it is crucial to treat this underlying condition when it exists.
The vertebrae that have had compression fractures will not return to their normal prefracture state, however most people who suffer symptoms from stable vertebral compression fractures will improve with conservative treatments in six to 12 weeks. For those people with severe symptoms that do not respond to conservative therapies, interventional treatments such as percutaneous vertebroplasty (where acrylic cement is injected into the collapsed vertebrae to stabilize and strengthen them, with a success rate of 70 percent to 90 percent), kyphoplasty (where a balloon is used to create a cavity in the vertebrae so it can be filled with acrylic cement with restoration of the vertebral height, also with a high success rate of 70 percent to 90 percent) or other treatments may be considered.
If you have severe back pain you should see your health care provider. They can evaluate the possible causes of your pain. If vertebral compression fractures are the cause, the good news is that most people improve with conservative therapy. However, vertebral compression fractures are one of the hallmarks of osteoporosis, so treatment for this underlying condition, when it exists, is crucial to prevent other fractures.
Jeff Hersh, Ph.D., M.D., F.A.A.P., F.A.C.P., F.A.A.E.P., can be reached at DrHersh@juno.com.