Vertebral Compression Fracture
A vertebral compression fracture is a collapse or crush injury of the vertebral body—the large, cylindrical front portion of the spinal bone. These fractures occur when the vertebra is compressed beyond its ability to support normal loads, causing the front of the bone to collapse while the back portion typically remains intact, creating a wedge-shaped deformity. Compression fractures are most commonly caused by osteoporosis in older adults, occurring from minimal trauma such as bending or lifting, but can also result from high-energy trauma, cancer, or infection affecting the spine.
What is it?
Vertebral compression fractures occur when the vertebral body cannot withstand compressive forces, causing it to collapse. In healthy bone, the vertebral body maintains its rectangular shape and height. When a compression fracture occurs, the front portion of the vertebra collapses more than the back, creating a characteristic wedge shape with anterior height loss. The degree of collapse determines fracture severity—mild fractures involve less than 25% height loss, moderate fractures 25-40%, and severe fractures more than 40%. Multiple compression fractures lead to progressive loss of height and increased forward curvature of the spine (kyphosis), creating the “dowager’s hump” appearance commonly seen in older adults with osteoporosis.
Compression fractures are classified by etiology: osteoporotic fractures (most common, accounting for approximately 700,000 cases annually in the US) occur in weakened bones from minimal trauma such as bending, lifting, coughing, or even spontaneously; traumatic fractures result from high-energy injuries like falls from height or motor vehicle accidents in individuals with normal bone density; pathologic fractures occur in bones weakened by cancer metastases, multiple myeloma, or lymphoma; and infectious fractures result from osteomyelitis or discitis destroying vertebral bone. The thoracic spine (mid-back), particularly T11-L1, and lumbar spine are most commonly affected, as these are transition zones bearing significant mechanical stress. Risk factors for osteoporotic compression fractures include advanced age (especially over 70), female gender (postmenopausal women), low bone mineral density, previous compression fractures (which increase risk of future fractures 5-fold), long-term corticosteroid use, smoking, excessive alcohol consumption, vitamin D deficiency, low body weight, and sedentary lifestyle.
Important to Know
Osteoporotic compression fractures typically cause sudden onset of severe, localized back pain at the fracture site that worsens with standing, walking, or any movement and improves with lying down. The pain is usually most intense in the first few weeks and gradually improves over 2-3 months as the fracture heals. Some fractures are silent, causing minimal or no pain, and are discovered incidentally on imaging. Other symptoms include progressive height loss (individuals may lose several inches over time with multiple fractures), increasing spinal curvature or stooped posture (kyphosis), limited spinal flexibility and mobility, difficulty performing daily activities, and in severe cases with multiple fractures, reduced lung capacity due to chest cavity compression. Neurological symptoms such as leg weakness or bowel/bladder dysfunction are uncommon with simple compression fractures but indicate more serious injuries requiring urgent evaluation. Diagnosis begins with spine X-rays showing vertebral collapse and wedge deformity. MRI is essential to determine fracture age (acute versus chronic), identify bone marrow edema indicating recent fracture, distinguish osteoporotic from pathologic fractures, and assess for spinal cord compression. CT scan provides detailed bone anatomy useful for surgical planning. Bone density testing (DEXA scan) should be performed in all patients to assess osteoporosis severity. Treatment depends on fracture severity, pain level, and underlying cause. Conservative management includes pain control with analgesics and NSAIDs, activity modification with gradual return to normal activities as tolerated, bracing for stabilization (though evidence for benefit is mixed), and physical therapy once acute pain subsides. Vertebroplasty or kyphoplasty are minimally invasive procedures where bone cement is injected into the fractured vertebra to stabilize it and provide pain relief—these are considered for patients with persistent severe pain not responding to conservative treatment within 2-3 weeks. Treatment of underlying osteoporosis with calcium, vitamin D, and anti-resorptive medications (bisphosphonates, denosumab) or anabolic agents (teriparatide) is critical to prevent future fractures. Prognosis for individual fractures is generally good, with most pain resolving within 3 months. However, having one compression fracture significantly increases the risk of subsequent fractures, making prevention strategies essential. Multiple compression fractures can lead to chronic pain, disability, reduced quality of life, and increased mortality risk.