OrthoDx: Chronic Lower Back Pain - Clinical Advisor

OrthoDx: Chronic Lower Back Pain

Slideshow

  • Figure 1. MRI scan taken 3 months after injury.

  • Figure 2. Lateral radiograph taken 4 months after injury.

A 70-year-old woman presents to the office with a 5-month history of lower back pain from L3 and L4 compression fractures. The lower back pain started when she tried to lift a mattress off a bed. She was diagnosed with lumbar compression fractures based on initial radiographs taken 1 week after the injury.

She continued to have pain 2 months later and magnetic resonance imaging (MRI) performed 3 months after the injury showed subacute superior endplate compression fractures of the L3 and L4 vertebral bodies (Figure 1). Lateral radiographs taken 4 months after the initial visit (Figure 2) showed no change in vertebral height from the initial radiographs. She has tried rest, oral analgesics, and a short period of lumbar corset bracing but continues to have severe back pain that is worse with activities.

The patient has sustained osteoporotic lumbar vertebral compression fractures resulting in chronic lower back pain. Given her age and low-energy mechanism, the resulting fractures can be assumed to be a result of poor bone quality. The initial treatment for lumbar...

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The patient has sustained osteoporotic lumbar vertebral compression fractures resulting in chronic lower back pain. Given her age and low-energy mechanism, the resulting fractures can be assumed to be a result of poor bone quality. The initial treatment for lumbar compression fractures takes a nonoperative approach such as medical management with analgesics and activity modification to avoid bending and lifting.1 Treatment of osteoporosis is also essential to prevent future vertebral compression fractures.

Lumbar corset bracing was universally recommended in the past, although a recent study suggests it has no benefit for pain relief and does not prevent further anterior vertebral body compression.1 Furthermore, lumbar corset braces are expensive and poorly tolerated by many older adults. A period of limited bed rest followed by a gradual increase in activities for 6 to 8 weeks with avoidance of bending or lifting is a reasonable treatment approach for most patients with minimal or mild pain.1

Minimally invasive vertebral augmentation with kyphoplasty is a surgical option used when conservative treatments fail and the patient continues to have severe pain 6 to 8 weeks after injury.2 Kyphoplasty involves the use of a balloon to create a cavity in the affected vertebrae into which bone cement is injected.3 Patients with chronic pain from vertebral compression fractures lasting more than 4 months are also good candidates for kyphoplasty; studies show benefits of pain relief and improved function.4

Patients with osteoporotic compression fractures treated with kyphoplasty have fewer days of limited activity and less back disability compared with patients managed with conservative treatment. Kyphoplasty may help restore vertebral height, which is reduced with chronic fractures, although the best results are achieved when kyphoplasty is performed in the acute stage of vertebral compression fractures.4

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. Kim HJ, Yi JM, Cho HG, et al. Comparative study of the treatment outcomes of osteoporotic compression fractures without neurologic injury using a rigid brace, a soft brace, and no brace: a prospective randomized controlled non-inferiority trial. J Bone Joint Surg Am. 2014;96(23):1959-1966. doi:10.2106/JBJS.N.00187
  2. Bridwell KH, Anderson PA, Boden SD, Vaccaro AR, Wang JC. What’s new in spine surgeryJ Bone Joint Surg Am. 2010;92(10):2017-2028. doi:10.2106/JBJS.J.00434
  3. Chandra RV, Maingard J, Asadi H, et al. Vertebroplasty and kyphoplasty for osteroporotic vertebral fractures: what are the latest data? AJNR Am J Neuroradiol. 2018;39(5):798-806. doi:10.3174/ajnr.A5458
  4. Crandall D, Slaughter D, Hankins PJ, Moore C, Jerman J. Acute versus chronic vertebral compression fractures treated with kyphoplasty: early resultsSpine J. 2004;4(4):418-424. doi:10.1016/j.spinee.2004.01.003
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