Knowledge · Osteoporotic Fractures
Osteoporotic Vertebral Fracture
Sudden back pain after a minor fall, while lifting, or even without an obvious event — this can be a vertebral fracture caused by osteoporosis. These fractures are common, often underestimated, and in most cases treatable without major surgery.
What is an osteoporotic vertebral fracture?
In osteoporosis, bone loses density and structural integrity. The vertebral bodies of the thoracic and lumbar spine are particularly vulnerable: they bear the full weight of the trunk and are the first to be affected when bone quality deteriorates. The result is a compression or collapse of the vertebral body — most often on the anterior side — leading to a wedge-shaped deformity.
Each fracture also weakens adjacent vertebrae and substantially increases the risk of subsequent fractures (approximately five-fold relative risk). Wedge collapse of multiple vertebrae can lead to progressive kyphosis and may affect breathing, abdominal capacity, and posture.
Symptoms
- Sudden, severe back pain — often after a minor trauma (stumbling, sneezing, getting up), sometimes without an identifiable event
- Pain that worsens with movement and upright positioning, relief when lying down
- Point tenderness over the affected vertebra — a characteristic finding on examination
- Progressive kyphosis and height loss with multiple fractures
- Radiation into the flanks or abdomen is possible; radiation into the legs is rare
Causes and risk factors
- Osteoporosis — bone loss due to ageing, hormonal deficiency (menopause), corticosteroid use, or other causes
- Advanced age — particularly postmenopausal women, but also older men
- Low-energy falls — often trivial (stumbling, standing up), sufficient to fracture bone of poor quality
- Corticosteroid therapy (e.g. for rheumatic or pulmonary conditions)
- Malignancy — spinal metastases can cause fractures without adequate trauma (pathological fracture)
- Prior vertebral fracture — increases the risk of further fractures approximately five-fold (relative risk)
Diagnosis
- Clinical examination — percussion tenderness, neurological status, posture assessment
- Spinal X-ray — preferably weight-bearing / standing; initial assessment of fracture type, height loss, and alignment
- Spinal MRI — particularly useful to distinguish a fresh from an old fracture (bone marrow oedema = fresh fracture) and to exclude other causes
- Spinal CT — detailed bone analysis in complex fractures, surgical planning
- Bone densitometry (DXA) — to confirm and quantify osteoporosis
- Laboratory — bone markers, tumour screening, calcium and vitamin D levels
Diagnosis rests on clinical examination, weight-bearing X-rays, and — depending on the clinical question — CT or MRI. Distinguishing a fresh, painful fracture from a previously consolidated old fracture is critical for treatment planning.
Classification and treatment decision
Whether a fracture is managed conservatively or surgically depends not on a single parameter but on a comprehensive assessment. Two structured tools guide decision-making:
- OF Classification (Schnake 2018) — grades the fracture morphology and extent of vertebral body damage on imaging (OF1–OF5). The foundation of the treatment decision.
- OF Score (Blattert 2018) — supplements the classification with clinical factors (pain, mobility, general condition) to produce a composite score guiding conservative vs. surgical management.
- DGOU S2k Guideline (2025) — current evidence-based recommendation for the management of osteoporotic vertebral fractures.
Both instruments help structure the decision transparently — but they do not replace individualised clinical judgement taking into account bone quality, general health, and patient preferences.
Treatment
Conservative management
Stable fractures without neurological involvement and with manageable pain are initially treated conservatively:
- Pain management — adapted to severity; short-term opioids may be appropriate
- Brief rest, then early mobilisation — prolonged bed rest does not accelerate healing and increases the risk of thrombosis
- Physiotherapy — core strengthening, postural training, fall prevention
- Osteoporosis treatment — antiresorptive medications (e.g. bisphosphonates, denosumab) or osteoanabolic therapy (e.g. teriparatide), supplemented by adequate calcium and vitamin D, exercise therapy; often coordinated with the GP, rheumatology, or endocrinology
Minimally invasive vertebral augmentation with bone cement
In selected, primarily stable fractures with persistent severe pain, percutaneous augmentation of the vertebral body with bone cement may be considered. The procedure is performed through small skin incisions and can be performed under local anaesthesia in suitable patients.
Percutaneous vertebroplasty
Bone cement is injected directly into the fractured vertebral body through a thin needle. Suitable for fresh, painful fractures. Randomised trials show variable results depending on patient selection, fracture age, and technique — the benefit depends critically on correct case selection.
Balloon augmentation
A balloon is first inflated to create a cavity, which is then filled with bone cement. The aim is partial vertebral body height restoration and reduced cement leakage. Both procedures are performed under fluoroscopic guidance, frequently under local anaesthesia.
The indication is made on an individual basis: MRI evidence of bone marrow oedema (fresh fracture), pain severity, bone quality, fracture type (OF grade), and the patient's overall condition are decisive. Like any procedure, cement augmentation carries possible risks; benefits and risks are weighed according to imaging findings and individual circumstances.
Instrumented stabilisation
In unstable fractures (OF3–OF5), pronounced deformity, posterior element involvement, neurological deficit, or tumour-related aetiology, operative stabilisation with screws and rods is the appropriate procedure — guided by the principle: as limited as possible, as stable as necessary. Combination with cement augmentation is feasible.
My approach
Osteoporotic vertebral fractures are a clinical and scientific focus of my work. Precise classification and assessment of fracture instability — based on MRI, CT, and clinical findings as well as the OF Classification — is the prerequisite for sound treatment decisions. Not every fracture requires intervention; but with persistent pain and a fresh fracture showing clear MRI oedema, cement augmentation is an effective, minimally invasive option — in appropriately selected patients.
A particular priority for me is the feasibility of the procedure without general anaesthesia: augmentation can be performed under local anaesthesia and fluoroscopic guidance in suitable patients — an important option for older, multimorbid patients.
Within an ongoing AO Spine International Project, I am working on systematic classification and quality of care for osteoporotic thoracolumbar fractures. Learn more about my research →
What does the evidence say?
Vertebroplasty vs. conservative treatment for painful fractures
Klazen et al. (VERTOS II, Lancet 2010) compared vertebroplasty with optimised conservative treatment in a randomised trial of fresh, painful osteoporotic fractures and found significantly greater and faster pain reduction with vertebroplasty. In contrast, Buchbinder et al. (NEJM 2009) and Kallmes et al. (INVEST, NEJM 2009) in double-blind, sham-controlled trials found no significant difference over placebo. The discrepancy is partly explained by differences in patient selection and study design. The consensus: with careful selection (fresh fracture, MRI oedema, adequate pain), vertebroplasty can be effective. Klazen CA et al., Lancet 2010, PMID 20951450 →
Balloon augmentation vs. conservative treatment (FREE Trial, Lancet 2009)
Wardlaw et al. showed in a multicentre randomised trial that balloon augmentation significantly improved quality of life, reduced pain, and improved function compared with conservative treatment in osteoporotic fractures — with a sustained effect over 24 months. Wardlaw D et al., Lancet 2009, PMID 19781751 →
OF Classification and OF Score
The OF Classification (Schnake et al., Global Spine J 2018, PMID 30210960) and the OF Score (Blattert et al., Global Spine J 2018, PMID 30210962) form the structured decision framework of the DGOU for osteoporotic vertebral fractures. Both underpin the current S2k Guideline. Schnake KJ et al., Global Spine J 2018, PMID 30210960 →
Questions about your fracture?
I take time to review your imaging and provide a clear, written assessment — including for patients with existing reports who are seeking a second opinion.