Vertebral injuries

Vertebral compression fracture

• Etiology & Risk Factors:
  • Osteoporosis (most common cause; postmenopausal, advanced age).
  • Systemic glucocorticoid use (≥5 mg/day prednisone for ≥3 months).
  • Malignancy: Multiple myeloma (MM), metastatic disease (breast, prostate, lung).
  • Secondary causes: Low BMI (<20), celiac disease, hyperparathyroidism, smoking, alcohol use.
• Clinical Features:
  • Sudden, severe, focal back pain after minimal exertion (e.g., coughing, bending, lifting).
  • Focal point tenderness to percussion over the involved spinous process. c
  • Neurologic examination is usually normal.
  • Chronic findings: Progressive height loss (>2–4 cm) and thoracic kyphosis (“dowager’s hump”).
• Diagnosis:
  • Initial test: Spine X-ray (AP and Lateral) showing vertebral height loss (≥20%) and anterior wedge deformity.
  • Confirmatory / Advanced test: MRI spine without/with contrast.
    • Differentiates acute vs. chronic via bone marrow edema (T2/STIR hyperintensity).
    • Rules out posterior element involvement (malignancy) and spinal cord compression.
  • Workup for secondary causes: Serum Ca, PO4, ALP, 25-OH Vit D, and SPEP/UPEP/free light chains (r/o MM).
  • Bone density: DEXA scan (fragility fracture establishes clinical osteoporosis regardless of T-score).
• Differential Diagnostics:
  • Lumbar muscle strain: Paraspinal tenderness only; absent spinous process percussion tenderness; normal X-ray.
  • Metastatic disease: Unremitting nocturnal pain; AP X-ray shows loss of pedicle (“winking owl” sign).
  • Multiple myeloma: Associated with hypercalcemia, renal failure, normocytic anemia, and “punched-out” lytic lesions.
• Management:
  • First-line (Conservative):
    • Analgesia: Scheduled acetaminophen and/or short-term NSAIDs; short-term weak opioids for severe pain.
    • Short-course intranasal calcitonin (acute analgesic properties).
    • Early mobilization as tolerated (avoid prolonged bed rest).
  • Underlying Osteoporosis Treatment:
    • Oral or IV bisphosphonates (first-line).
    • Calcium (1000–1200 mg/day) + Vitamin D (800–2000 IU/day).
    • Fall prevention and physical therapy.
  • Refractory pain (≥4–6 weeks): Percutaneous kyphoplasty or vertebroplasty.
  • Surgical emergency: Urgent open decompression/stabilization if progressive neurologic deficits or spinal cord compression develop.
• Complications:
  • Acute spinal cord or cauda equina compression.
  • Severe dorsal kyphosis leading to restrictive ventilatory defect and early satiety.
  • Markedly elevated risk of subsequent vertebral and hip fragility fractures.