Expertise · Diagnosis & treatment
Vertebral Fracture
Sudden back pain after a harmless fall, while lifting something, or even without any identifiable trigger – this can be a vertebral fracture caused by osteoporosis. These fractures are common, often underestimated, and in most cases treatable: minimally invasively, without general anaesthesia, with rapid pain relief.
What is an osteoporotic vertebral fracture?
In osteoporosis, bone loses density and stability. The vertebral bodies of the thoracic and lumbar spine are particularly at risk: they carry the entire weight of the trunk and are the first to be affected when bone quality declines. This leads to compression or collapse of the vertebral body – usually on its front (anterior) side, resulting in a wedge-shaped deformity.
Each fracture also weakens the neighbouring vertebral bodies and considerably increases the risk of further fractures. The wedge-shaped collapse of several vertebral bodies can lead to progressive kyphosis and affect breathing, the abdominal cavity and posture.
Symptoms
- Sudden, severe back pain – often after a minor trauma (stumbling, sneezing, standing up), sometimes without any identifiable event
- Pain worsens on standing and movement, relief when lying down
- Tenderness on percussion over the affected vertebral body – a characteristic sign on clinical examination
- Progressive kyphosis and reduction in height with multiple fractures
- Possible radiation into the flank or abdomen, rarely into the legs
Causes and risk factors
- Osteoporosis – bone loss due to age, hormone deficiency (menopause), corticosteroid use or other causes
- Advanced age – particularly in postmenopausal women, but also in older men
- Fall from standing height – often minor (stumbling, standing up), sufficient to cause a fracture with poor bone quality
- Corticosteroid therapy (for example in rheumatological or pulmonary conditions)
- Tumour disease – spinal metastases can cause fractures without an adequate trauma (pathological fracture)
- Previous vertebral fracture – increases the risk of further fractures fivefold
Diagnosis
- Clinical examination – tenderness on percussion, neurological status, assessment of posture
- Spine X-ray – initial assessment of fracture type, height loss and alignment
- Spine MRI – decisive for assessing fracture age (oedema = recent fracture), excluding a tumour cause and spinal cord involvement
- Spine CT – detailed bone analysis for complex fractures, surgical planning
- Bone density measurement (DXA) – to detect and quantify osteoporosis
- Laboratory tests – bone markers, tumour screening, calcium and vitamin D levels
Distinguishing between a recent, painful fracture, an already-consolidated old fracture, and a tumour-related cause is decisive for the treatment decision. MRI is the most important tool in this respect.
Treatment
Conservative therapy
Stable fractures without neurological involvement and with manageable pain are initially treated conservatively:
- Pain management – depending on intensity, opioids may also be used short-term
- Brief immobilisation, then rapid mobilisation – bed rest does not shorten healing time and increases the risk of thrombosis
- Physiotherapy – strengthening the trunk musculature, posture training, fall prevention
- Osteoporosis treatment – baseline therapy with calcium and vitamin D; depending on findings, bone-forming medication (bisphosphonates, teriparatide, denosumab)
Minimally invasive vertebral body augmentation with bone cement
In cases of persistent severe pain despite conservative treatment, or an impending further collapse of the vertebral body, minimally invasive stabilisation can be highly effective. Bone cement is introduced into the fractured vertebral body under image-intensifier control, stabilising it from within.
Percutaneous vertebroplasty
Direct injection of bone cement into the fractured vertebral body through a thin needle. A very rapid procedure, high rate of pain relief, immediate mobilisation. Suitable for recent, painful fractures without significant height loss.
Balloon-assisted augmentation
A cavity is first created using a balloon and then filled with bone cement. The aim is a partial restoration of vertebral body height and reduced cement leakage. Both procedures are performed under image-intensifier guidance, frequently under local anaesthesia.
Both procedures show significant and rapid pain reduction in clinical studies. The indication is determined individually: signs of recency on MRI, pain level, bone quality and the patient's overall condition are decisive.
When is more extensive surgery necessary?
In unstable fractures, severe deformity, neurological involvement or a tumour-related cause, surgical stabilisation with screws and rods may be required – alone or in combination with cement augmentation.
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 the clinical picture – are prerequisites for a sound treatment decision. Not every fracture requires intervention; but in cases of persistent pain and recent fractures with clear MRI oedema, cement augmentation is a convincingly effective, gentle procedure.
A particular concern of mine is the feasibility of the procedure without general anaesthesia: in suitable patients, I can perform augmentation under local anaesthesia with image-intensifier guidance – an important option for older, multimorbid patients who tolerate general anaesthesia poorly or wish to avoid it.
The scientific foundation of my work: within an ongoing AO Spine International Project, I focus on the systematic classification and quality of care of thoracolumbar fractures. My academic focus lies in improving classification systems and evaluating treatment outcomes.
More on my research into vertebral fractures →What does the research say?
Vertebroplasty vs conservative therapy for painful fracture (Lancet 2010)
Klazen et al. (VERTOS II) compared vertebroplasty with optimised conservative therapy in a randomised controlled trial of 202 patients with a recent, painful osteoporotic fracture. Vertebroplasty showed significantly stronger and faster pain reduction throughout the entire one-year observation period. The authors conclude that vertebroplasty is effective with adequate patient selection. Klazen CA et al., Lancet 2010, PMID 20951450 →
Balloon augmentation vs conservative therapy – RCT (Lancet 2009)
Wardlaw et al. (FREE Trial) showed in a multicentre randomised study that balloon augmentation, compared with conservative therapy for osteoporotic fractures, leads to significantly better quality of life, less pain and improved function – with a sustained effect over 24 months. Wardlaw D et al., Lancet 2009, PMID 19781751 →
AO Spine classification of osteoporotic fractures
Precise classification of osteoporotic vertebral fractures is the foundation of every treatment decision. The AO Spine International Project, in which I participate, works on evidence-based classification systems and guidelines for the management of these common injuries. My own publications on this topic can be found on my PubMed profile. Publication list of Sebastian Bigdon, MD, on PubMed →
Questions about your fracture?
I take the time to review your imaging and provide a clear, written assessment – also for patients with existing findings who would like a second opinion.