informal cpd learning hours continuing osteoporotic ... · 3. essentials of skeletal radiology;...

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Volume 15.5.3This Lecture Serties qualifies for 0.5 Informal CPD Learning Hours Continuing

Professional Development

Osteoporotic Compression Fractures

By Dr Kristin Grace(DACBR)

“89 year old male presented with lower lumbar spine pain after a ‘slip’ getting up off floor using a chair. All neurologic tests appear normal. 60% improvement after single treatment consisting of soft tissue therapy and gentle mobilization. Severe pain 3 days after, insidious cause. Current diagnosis prostate CA, regular check-ups but no treatment. GP not concerned.”


Image Description

AP Lumbopelvic: Significant osteoporosis, indentation of the superior endplates of T11, L2 and L3, extensive degenerative changes, postural changes.

Lateral lumbar: Significant osteoporosis, anterior compression fracture T11, impaction superior endplate fractures L2 and L3 withsubchondral zone of sclerosisindicating these are probably acute; abdominal aortic aneurysm and atherosclerotic calcification are seen anterior to L2-L4.


Osteoporotic compression fractures T11, L2 and L3

Osteoporotic vertebral compression fracture (OVCF) is estimated to occur in 26% of women over age 50 and 40% over 80 years old.

Compression fractures related to osteoporosis can take a number of different forms. It is not unusual to see multiple forms in one spine. Osteoporotic compression fractures are most common in the thoracic spine and at the thoracolumbar junction.

Spinal compression fractures may be insidious and may produce only modest back pain. Over time, multiple fractures may cause significant loss of height. Progressive loss of stature results in shortened paraspinal muscles that require prolonged active contraction to maintain posture and results in muscle fatigue and pain. Pain may continue long after the compression fracture has healed.

1/3 of vertebral compression fractures are actually diagnosed. 2/3 go unrecognised. Supine recumbent position often relieves some discomfort, standing or walking exacerbates the pain. Compression fracture should be suspected in any patient older than 50 with acute onset of sudden LBP. Many patients will remember a specific cause. 30% of compression fractures in patients with severe osteoporosis occur in bed.

About 1/3 of OVCF’s cause severe back pain of variable pain patterns. Pain patterns may range from paravertebral but mostly localised to midline, diffuse extension of paravertebral pain and low back pain or lumbosacral pain remotefrom the site of lesion. Compression fractures of the lower thoracolumbar

junction often will refer pain to the top of the iliac crest, lumbosacral junction or sacrum and can often be overlooked. This is particularly when there are degenerative changes that may account for the presenting symptoms at the lum-bosacral zygoapophyseal joints or sacro-iliac joints. This is a unique phenomenon however the T12, L1 and L2 dermatomes are localised to the low back and lumbosacral area. Fur-thermore, the referral of pain along the length of the quadratus lumborum may be related as well.

Studies have shown that having one vertebral compression fracture leads to a five-fold increase in a patient’s risk of developing another vertebral fracture and having two or more compression fractures increases the risk of having another fracture by twelve-fold.

Pancake Vertebrae

- Loss of both anterior and posterior vertebral body height- Uncommon and unusual for osteoporosis- Must be differentiated from pathologic compression fracture

Wedge

- Anterior vertebral body height loss with preserved posterior height


- Also common in traumatic compression fractures with normal mineralisation

Biconcave (Fish, Codfish, Hourglass…)

- Central endplate depression - May be at multiple contiguous levels and due to direct pressure from nucleus and due to direct pressure from nucleus on weakened bone

Isolated endplate deformities

- Peripheral or central- The central endplate depression is most frequent at L1 & L4

Acute versus Chronic/Healed

In the presence of acute compression of the thoracic spine there may be paraspinal hematoma identified by displaced paraspinal soft tissue or paraspinal stripe. Acute compression fractures are often accompanied by a subchondral zone of sclerosis due to impaction of trabeculae and/or an anterior step defect, an abrupt angular.

Chronic or healed compression fracture will no longer demonstrate a zone of sclerosis and the step defect will be healed. There may be adjacent disc narrowing and osteophytic proliferation. At times it is difficult to date a compression fracture and MRI may be useful. MRI may show active healing of a compression fracture for up to a year.

( Very observant, the case imagesdemonstrate a very substantial abdominal aortic aneurysm… for future discussion…)

References

1. Tae-Hoon, Doo et all; Clinical Relevance of Pain Patterns in Osteoporotic Vertebral Compression Fractures; J Korean Med Sci 2008 Dec; 23(6): 1005-10102. Old, J: Vertebral Compression Fractures in the Elderly; Am Fam Physician. 2004. Jan 1; 69(1):111-1163. Essentials of Skeletal Radiology; Yochum and Rowe; 3rd Ed; LWW 20054. Alexandru, D.; Evaluation and Management of Vertebral Compression Fractures; Perm J 2012 Fall; 16 (4): 46-51

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informal cpd learning hours continuing osteoporotic ... · 3. essentials of skeletal radiology;...

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