Osteoporotic vertebral fractures

What is an osteoporotic vertebral fracture?

An osteoporotic vertebral fracture happens when a bone in your spine, called a vertebra, becomes compressed or squashed because osteoporosis has left it too weak to bear the usual load. You might hear it called a spinal fracture, vertebral fracture or compression fracture, and unlike most broken bones, it doesn't crack outright: it collapses in on itself.

What are the symptoms of an osteoporotic vertebral fracture?

These fractures can be surprisingly quiet. Up to two-thirds of people don't have severe symptoms, and when pain does occur, it's often mistaken for ordinary muscular back pain. Unlike a hip fracture, only around 20% happen after a fall; most are caused by everyday activities, such as lifting, bending forward or sitting down heavily, so you may not recall a specific injury at all.

Where symptoms are present, they can include:

• pain localised to the area of the fracture, which may be worse with movement
• tenderness over the spine when pressed
• muscle spasm in the muscles either side of your spine
• a noticeable loss of height, especially if you've had more than one fracture
• an outward curve developing in your upper back (kyphosis)

Even after the bone has healed, changes to the shape of your spine can cause ongoing problems. These include nerve pain, if a nerve was pinched or irritated as the bone healed or has become oversensitive; muscle spasms when lifting, pushing, pulling, bending or twisting; and strain on the joints and ligaments between your vertebrae, which can also make existing arthritis worse. If you've lost height from multiple fractures, the resulting curve can leave you short of breath or feeling bloated, since there's less room for your lungs and stomach.

What are the causes of osteoporotic vertebral fractures and who is at risk?

These fractures happen when bone weakened by osteoporosis can no longer withstand everyday loads, such as lifting an object, bending forward or sitting down heavily. You're at higher risk if you:

• are aged 50 or over
• have had a previous fragility fracture, which is the strongest predictor of a future vertebral fracture, particularly if you've already had two
• currently take, or have recently and frequently taken, steroid tablets or other systemic steroids
• have a history of falls, or a family history of hip fracture
• have another cause of secondary osteoporosis, such as rheumatoid arthritis or a condition affecting how you absorb nutrients
• have a low body mass index, under 18.5kg/m²
• smoke, or drink more than 14 units of alcohol a week

How are osteoporotic vertebral fractures diagnosed?

Because symptoms are often subtle or absent, these fractures are diagnosed in two main ways: because you've reported symptoms, or because a fracture is spotted by chance on a scan taken for another reason. There are no exam findings unique to this condition, though your doctor may find tenderness over your spine, muscle spasm nearby, or signs of height loss and curvature if you've had more than one fracture.

If a vertebral fracture is suspected, the main test is a plain X-ray of your spine; separate lumbar and thoracic X-rays are more reliable than a single combined image, which can miss individual vertebrae. A fracture typically shows as a height loss of 20% or more, or at least 4mm, in part of the vertebra.

A CT or MRI scan isn't usually needed to confirm a straightforward fracture, but may be used if the X-ray is unclear, if you have neurological symptoms in your legs, or to help tell a recent fracture from an old one, assess nearby ligaments, or check whether the fracture is due to osteoporosis rather than another cause, such as cancer that has spread to the spine. Because of this, your doctor will consider whether your fracture pattern looks atypical, for example if it's above the middle of your back, if you're younger with no history of a fall, or if you have unexplained weight loss, since these would prompt further tests to rule out other causes.

If a fracture is confirmed, you should have your future fracture risk assessed, usually with a tool such as FRAX, followed by a bone density (DXA) scan if indicated. It's worth knowing that these risk calculators tend to underestimate your risk once you've already had a vertebral fracture. Blood tests are also usually arranged to check for underlying or contributing conditions, covering vitamin D, calcium, liver and kidney function, coeliac disease, thyroid function, and markers of inflammation or myeloma.

How are osteoporotic vertebral fractures treated?

Non-surgical treatment

Most people don't need an operation. Staying as active as you comfortably can, rather than resting for a long period, is recommended: it lowers your risk of chest infections, constipation and blood clots, helps you keep your muscle strength, and reduces the chances of ongoing pain once the fracture has healed. Movement doesn't affect the healing process itself, though pain can make it difficult. If pain is severe at first, resting briefly and using pain relief to help you gradually get moving again is a reasonable approach.

Pain relief is usually taken as tablets rather than injections where possible, reviewed regularly, and adjusted to use the smallest effective dose for the shortest time. Anti-inflammatory painkillers are generally avoided in older people, and if opioid painkillers are used, a laxative is usually prescribed alongside them.

Exercise plays an important role too. Programmes that build up muscle strength, particularly in the muscles that extend your back, can help, and if movement is painful at first, starting with exercises lying down can make this more manageable. A physiotherapist can also give you clear, practical guidance on adapting everyday movements, and may be involved early on if your pain is severe enough to affect your daily activities.

Because a vertebral fracture significantly raises your risk of a further fracture, including a hip fracture, assessing and treating your underlying osteoporosis is a central part of your care. Bone-strengthening medicines, such as bisphosphonates, can reduce the chance of another fracture by 30–50%, and starting these while you're still in hospital, where relevant, makes you significantly more likely to keep taking them. Many hospitals now offer this follow-up through a Fracture Liaison Service, and you should also have your risk of falling assessed, with a referral to a falls prevention service if appropriate.

Procedures for severe, ongoing pain

If your pain remains severe and pain-relieving medicines aren't helping, your doctor may consider vertebroplasty or balloon kyphoplasty. In vertebroplasty, bone cement is injected into the fractured vertebra to stabilise it. In balloon kyphoplasty, a balloon is first inserted and inflated to create space in the bone, before cement is injected to fill it, which may also partly restore some height to the vertebra.

These procedures are only available at a small number of specialist centres in the UK, so you may need to travel. They take a couple of hours under general or local anaesthetic, and you'll need to lie on your front until the cement sets, sometimes staying in hospital overnight. Neither procedure improves bone strength or lowers your risk of future fractures, and they aren't suitable for most people with a vertebral fracture. Uncommon side effects include cement leaking, infection, a blood clot in the lungs, allergic reaction, and injury to the spinal cord or a nerve root; there's also a long-term concern that the treated, stiffer bone may put extra strain on the vertebrae next to it.

These procedures can be an option once non-surgical treatment has been tried for 4 to 6 weeks without enough improvement, however they are an option for a minority of people, not a routine step.

When should I see a doctor?

See your doctor if you develop new or worsening back pain, particularly if you're over 50 or have other risk factors for osteoporosis, since a fracture can happen without an obvious injury. It's also worth getting checked if you notice you've lost height, or that your upper back is developing a forward curve.

Seek urgent medical attention if you have any numbness, weakness, or pins and needles in your legs alongside back pain, since this can occasionally signal pressure on a nerve or the spinal cord and needs prompt assessment.