Key Facts

Vertebral fractures are under-diagnosed and under-treated, yet they are a major cause of pain, disability, and further fracture risk in older adults.

Epidemiology

• ~120,000 vertebral fractures/year in the UK
• Only ~33% clinically diagnosed (most are incidental findings)
• Female:male ratio 2:1
• Prevalence increases with age: 20% of women >70, 35% of women >80

Aetiology

• Osteoporosis (primary cause in older adults)
• Minimal or no trauma (spontaneous in severe osteoporosis)
• Secondary causes: corticosteroids, malignancy (myeloma, metastases), Paget's disease
• High-energy trauma in younger patients (RTCs, falls from height)

Pathophysiology

• Vertebral body compression due to reduced bone strength
• Anterior wedge fracture (most common): anterior height loss → kyphosis
• Biconcave fracture: central height loss
• Crush fracture: uniform height loss (severe)
• Thoracolumbar junction most vulnerable (transition from fixed thoracic to mobile lumbar spine)
• One fracture increases stress on adjacent vertebrae → fracture cascade

Acute Vertebral Fracture

• Sudden onset back pain (thoracic or lumbar)
• Pain worse with movement, relieved by rest
• Localised tenderness over spinous process
• Paravertebral muscle spasm

Chronic/Incidental

• Height loss (>2cm since last measurement or >4cm from recalled height)
• Progressive thoracic kyphosis (dowager's hump)
• Reduced rib-pelvis distance
• Chronic back pain
• Protuberant abdomen
• Reduced respiratory function (multiple thoracic fractures)

Red Flags

• Neurological deficit (cord compression — rare in osteoporotic fractures but consider malignancy)
• Severe pain not controlled with standard analgesia
• Known malignancy (pathological fracture)
• Fever (infection/discitis)
• Age <50 without major trauma (consider secondary causes)

Bedside

• Height measurement (compare with previous records)
• Spinal examination (tenderness, kyphosis, range of motion)
• Neurological examination of lower limbs

Bloods

• Bone profile (calcium, phosphate, ALP)
• Vitamin D
• FBC, ESR, CRP (exclude infection, myeloma)
• Serum protein electrophoresis (myeloma screen)
• TFTs, U&Es, LFTs
• PTH (if calcium abnormal)

Imaging

• Spinal X-ray (thoracic and lumbar AP + lateral): first-line; assess vertebral body height
• VFA (vertebral fracture assessment) via DEXA: alternative screening
• MRI spine: if neurological signs, suspected malignancy, or infection; differentiates acute from chronic fractures (bone marrow oedema)
• DEXA scan: bone density assessment
• CT: if MRI contraindicated; detailed bony anatomy

Special Tests

• FRAX/QFracture: 10-year fracture risk
• Genant classification: grading vertebral fracture severity (mild 20-25%, moderate 25-40%, severe >40% height loss)

Non-pharmacological

• Analgesia: paracetamol 1g QDS, short-course opioids if needed (minimise), topical heat
• Early mobilisation: bed rest should be avoided; physiotherapy for posture, core strengthening
• Spinal extension exercises: improve kyphosis and reduce fracture risk (evidence from PROVES trial)
• Thoracolumbar orthosis (brace): short-term for comfort; not routinely recommended
• Falls prevention: as per NICE CG161

Pharmacological

• Bone protection (all patients with vertebral fragility fracture):
  • Alendronate 70mg weekly + vitamin D 800-1,000 IU daily (first-line)
  • Denosumab 60mg SC 6-monthly (if bisphosphonate contraindicated)
  • Teriparatide 20mcg SC daily: for severe osteoporosis with multiple vertebral fractures (NICE TA161)
• Pain management: paracetamol, codeine/tramadol short-term, consider calcitonin nasal spray 200 IU daily for acute fracture pain (limited evidence)

Surgical/Interventional

• Vertebroplasty: percutaneous injection of bone cement into fractured vertebral body (pain relief)
• Kyphoplasty: balloon inflation then cement injection (aims to restore height)
  • Consider for painful fractures not responding to 6 weeks of conservative treatment (NICE IPG12)
  • Evidence equivocal (VERTOS-II showed benefit vs sham; INVEST/FREE trials mixed)

Referral Criteria

• All vertebral fragility fractures: Fracture Liaison Service
• Severe pain not responding to conservative measures: spine MDT
• Neurological deficit: emergency MRI and neurosurgical/orthopaedic review
• Multiple fractures or severe osteoporosis: metabolic bone specialist
• Suspected malignancy: urgent investigation

• One vertebral fracture increases risk of further fracture by 5× (fracture cascade)
• 20-25% of patients with one vertebral fracture will have another within 1 year
• Alendronate: reduces vertebral fracture risk by 50%
• Teriparatide: reduces vertebral fracture risk by 65%
• Kyphosis and multiple fractures impair respiratory function and quality of life
• Most acute pain resolves within 6-12 weeks
• Chronic pain in 30-40% of patients
• Vertebral fractures are independently associated with increased mortality

Genant Classification of Vertebral Fracture Severity

Types of Vertebral Fracture