Slideshow
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Figure 1. Lateral view radiograph shows an L4 lumbar compression fracture.
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Figure 2. Sagittal STIR magnetic resonance imaging confirms an acute or subacute L4 compression fracture.
A 62-year-old woman presents with a 2- to 3-week history of severe lower back pain. She denies a known injury or precipitating event that may have caused the pain. She reports no radiation of pain down her legs and no bowel or bladder changes. On physical examination, the patient has severe pain to palpation over the L4 vertebral body with surrounding paraspinous muscle spasm. Her lower extremity motor coordination and sensation are intact. Lateral view radiograph (Figure 1) shows an L4 lumbar compression fracture. Sagittal STIR magnetic resonance imaging (Figure 2) shows an acute or subacute L4 compression fracture with 30% loss of vertebral height. Mild retropulsion of the fracture fragment into the spinal canal is found causing moderate stenosis. The patient is interested in pain relief options including kyphoplasty.
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Osteoporosis-related lumbar compression fractures are a common injury in the aging population. Patients can often be treated conservatively with a corset brace, nonsteroidal anti-inflammatory drugs (NSAIDs), and if necessary, opioid medication. Pain associated with lumbar compression fractures can last much longer than other fracture types, in some cases lasting up to 4 to 6 months.1,2 Cement augmentation with kyphoplasty is another treatment option that can help relieve lower back pain and preserve vertebral height in patients who have failed at least 2 to 3 weeks of conservative treatment.1,2 Before surgery, MRI should be performed if kyphoplasty is considered. Imaging is critical in determining the age of fracture, with bony edema signaling an acute or subacute process. The absence of bony edema on MRI indicates a chronic fracture, which is not amenable to kyphoplasty.1,2
Time to perform kyphoplasty is controversial with most experts agreeing that nonoperative treatment should be trialed for 2 to 3 weeks after onset of symptoms. The average time to kyphoplasty after onset of symptoms in a large meta-analysis was 10 weeks.1 The study also found improved outcomes with surgery over conservative care. Kyphoplasty has not been shown to increase the risk of adjacent, or secondary, vertebral fractures.1 Relative contraindications for kyphoplasty include bone retropulsion, the presence of radiculopathy, and greater than 70% vertebral height loss. 1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
References
1. Halvachizadeh S, Stalder AL, Bellut D, et al. Systematic review and meta-analysis of 3 treatment arms for vertebral compression fractures. a comparison of improvement in pain, adjacent-level fractures, and quality of life between vertebroplasty, kyphoplasty, and nonoperative management. JBJS Rev. 2021;9(10). doi:10.2106/JBJS.RVW.21.00045
2. Savage JW, Schroeder GD, Anderson PA. Vertebroplasty and kyphoplasty for the treatment of osteoporotic vertebral compression fractures. J Am Acad Orthop Surg. 2014;22(10):653-664. doi:10.5435/JAAOS-22-10-653
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