Thursday, August 1, 2013

Spinal Compression Fractures

Almost a million osteoporosis-related spinal compression fractures occur each year in the United
States. To put that number into perspective, that's approximately one out of every 80 people over the age of 55... EACH year. This is not just a fracture in their lifetime, but THIS year. And, once a person has sustained one compression fracture, the chances of them sustaining another within a year increases 4- to 6-fold! This phenomena is referred to as "vertebral fracture cascade." With so many fractures, it is easy to understand why osteoporosis has become the most common metabolic bone disorder in America. The loss of mineral density (bone thinning) and microarchitectural quality from bone is what makes them susceptible to breaking. Although the hips, ribs and spine are the most commonly fractured bones due to osteoporosis, every bone is at increased risk for fracture.

Compression fractures of the spine can result from major trauma such as falling backwards onto the buttocks, or from minor traumas such as bending, lifting, coughing, or twisting. When bone is EXTREMELY fragile, fractures can result from simply walking around or changing positions such as bending forward to sit down. When the spine structure is severely weakened, it doesn't take much strain at all for the vertebrae to simply collapse.

When I fractured one of my thoracic vertebra while running many years ago, the pain lasted for about a year. While this is not unusual, nearly 50% of vertebral compression fractures cause minimal or no pain and may go undetected. In fact, many of these fractures are discovered as secondary findings when radiological procedures are being performed for other medical reasons. (Tip: if you have had radiographs taken and read at a medical facility, it is a VERY good idea to have your chiropractor double check them.)

So how do you know if you have sustained a vertebral compression fracture? Typically your chiropractor or medical physician will be able to find a localized area of tenderness when they are examining your spine. He or she may also notice an increased kyphotic or forward angulation in your spine if there is a fracture in the thoracic area. Thoracic and lumbar spine fractures are the most common areas to sustain compression fractures although they can occur in the cervical spine also. If your doctor suspects a fracture, x-rays will be ordered. A bone scan, CT (computed tomography), and/or MRI (magnetic resonance imaging) may also be indicated to determine if the fracture has occurred recently or if it is old. These tests can also help your doctor evaluate any neurological involvement and also to rule out any suspicion of cancer.

Treatment options? In 2010, the American Academy of Orthopaedic Surgeons approved new clinical guidelines for the treatment of osteoporotic spine compression fractures. According to Dr. Robert A McGuire, vice-chair of the work group:
 
"Treatment of these fractures has focused on relieving pain and restoring mobility and function. Although most fractures heal within a few months, some people have continuing pain and disability.

Both surgical and nonsurgical treatments are available. Surgical treatments may include minimally invasive procedures such as vertebroplasty (an injection of cement directly into the vertebral body and kyphoplasty (use of ballon to expand the compressed space prior to the injection of bone filer.) Nonsurgical treatments include the use of pain relievers, braces, electrical stimulation, and exercise. Additionally, complementary or alternative medical treatments such as acupuncture, massage, or the use of dietary supplements have been applied."

Most vertebral compression fractures are treated through conservative, nonsurgical care. They typically heal on their own within eight to ten weeks but I am often asked about vertebroplasty and kyphoplasty. Both of these procedures have come under considerable scrutiny, not only due to the significant risk of adverse effects such as bleeding, infection allergic reactions, and leakage of bone cement into the surrounding tissues, but also regarding questions concerning their long-term benefit. In fact, many believe that these procedures may increase the risk of the fracture cascade by placing undue mechanical stress on adjacent vertebrae. The 2010 guidelines address these concerns. Dr. McGuire continues:

"The recommendations also consider two surgical procedures often used to treat vertebral compression fractures: vertebroplasty and kyphoplasty. The single strong recommendation in the guidelines is based on two Level I studies comparing vertebroplasty to a sham procedure, and three Level II studies comparing vertebroplasty to conservative treatment:

We recommend against vertebroplasty for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms and who are neurologically intact. By making a strong recommendation against the use of vertebroplasty, the group is expressing its confidence that future evidence is unlikely to overturn the results of these trials.

The guidelines consider kyphoplasty to be an option (weak recommendation). Although the two Level II studies that compared kyphoplasty to conservative treatment did find clinically important pain relief at various points, both were flawed. The three studies comparing kyphoplasty to vertebroplasty had inconsistent results. 

Although kyphoplasty and vertebroplasty are similar procedures, the evidence supports treating them differently within the recommendations. In a comparison of kyphoplasty to conservative treatment, for example, possibly clinically important differences for critical outcomes were seen for up to 12 months; comparing vertebroplasty to conservative treatment showed possibly clinically important differences for these outcomes only on the first day after surgery. Additionally, a direct comparison between the two procedures showed a possibly clinically important advantage in critical outcomes for kyphoplasty at up to 2 years. The fact that these results were not consistent among all studies, however, lowered the confidence level that future research will confirm the results of current evidence and resulted in the "weak" recommendation."

More recently, the risk of developing compression fractures in vertebra located adjacent to the cemented vertebroplasty-repaired vertebra was analyzed by Martinez-Ferrer et al. from Spain and published in the August 2013 edition of the Journal of Bone and Mineral Research. These researchers found "nearly 30% of patients with osteoporotic VF [vertebral fracture] treated with VP [vertebroplasty] presented a new VF after the procedure." They found that leakage of cement into the disk beneath the vertebra being repaired contributed up to a six-fold increased risk for developing a new vertebral fracture. When hard cement leaks into the disk this places increased mechanical pressure on the vertebra below. The authors state that other comparative studies indicate a similar problem with kyphoplasty. In addition to cement leakage, which occurs in 15% of vertebroplasty procedures, vitamin D deficiency was also associated with an increased risk of vertebral fracture after vertebroplasty. "Patients with levels lower than 20 ng/ml showed a greater than 15-fold increased risk for a new VF, a finding that was not observed after conservative treatment."

My recommendations:
As a chiropractor, I find that patients with spinal fractures gain considerable relief from pain and spasms through gentle massage and, when appropriate, gentle mobilization procedures. When healing of the fracture allows, stabilization of the trunk through core and balance exercises is also extremely important. As noted earlier, sustaining a vertebral compression fracture places you at a much greater risk for a second vertebral fracture or "fracture cascade." There are several key steps you can take to help avoid this structural decline of the spine.

1) Medication.  Most likely you will be placed on an osteoporosis medication, if you are not already on one.

2) Diet and Supplements.  A diet and nutrition evaluation is vital. Not only is it important that you eat a bone-healthy, anti-inflammatory diet but also adding specific supplements to your daily regimen can be crucial. The nutrients you take in not only make your bones healthier but they also help your muscles stay strong so you can avoid falls.

3) Exercise.  One of the most important things you can do to prevent fractures of the spine is to engage in specific exercises that will help improve your core, upper back and leg strength, as well as balance. Ideally, it would be best for a person to begin strengthening and stabilizing exercises as soon as they find out they have osteoporosis. This may help prevent compression fractures from ever occurring.

Once a fracture has occurred, gentle exercises can typically begin begin four to six weeks after sustaining the fracture. This is a multi-step process. Your chiropractor can help to ensure good nerve flow from your spine to your muscles. He or she may begin doing this within a week or so of the fracture depending upon the circumstances and your level of pain. I treat many patients who have sustained spinal compression fractures and their response to chiropractic care is excellent. Chiropractors are expert at evaluating the spine and ensuring that spinal alignment is optimal for nerve energy to flow to the muscles. Without good flow of nerve energy, exercises will not be as effective. Chiropractic care using gentle techniques can help reduce the pain from surrounding muscle spasms.

Specific exercises are important for improving overall strength, especially that of the trunk, upper back and leg muscles. Core strength will help stabilize your spine and prevent abnormal mechanical strains from poor spinal motion. Upper back exercises will help maintain your erect upright posture reducing any excessive kyphotic strain in your thoracic spine that could increase your risk for further fractures. Strong leg muscles are important for balance and preventing falls.

Many chiropractors and physical therapists will be able to give you safe and effective exercises for improving posture and the strength of your muscles. Consulting a Certified Exercise Specialists using the Meek's Method can be especially helpful for a comprehensive approach that includes exercises, as well as breathing and relaxation techniques. Balance exercises are also important to incorporate into your exercise regime. Most fractures occur due to falls; balance and coordination exercises will help you avoid falls.

4) Bracing.  With acute, painful, vertebral compression fractures a Jewitt-style back brace may be helpful for stabilizing the fracture and reducing pain. After a period of healing, less restrictive braces such as the Spinomed orthosis are preferable for helping to promote safe body mechanics while doing specific back strengthening exercises. Check out my previous blog Exercises and Bracing for Fracture Prevention and Pain Relief for more info on this type of bracing.

The statistics are daunting. Almost one million fractures annually. People who have sustained one osteoporotic vertebral compression fracture are at five times the risk of sustaining a second. Frequently a spinal fracture can be present with either minor symptoms or no symptoms, but the risk still exists for additional fractures to occur. There is good news, however; no matter what your age, there are many things you can do to improve your bone health and reduce fracture risk.

The Treatment of Symptomatic Osteoporotic Spinal Compression Fractures ̴ Guideline and Evidence Report. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, September 24, 2010. http://www.aaos.org/research/guideline.pdf and http://www.aaos.org/news/aaosnow/oct10/cover1.asp

Martinez-Ferrer, A. et al. 2013. Risk factors for the development of vertebral fractures after percutaneous vertebroplasty. Journal of Bone and Mineral Research 28(8):1821-1829.
    
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