Vertebral compression fracture
A vertebral compression fracture is a collapse of the anterior or middle vertebral body, most often from osteoporotic fragility with minimal or no trauma, presenting as acute focal spinal tenderness or, in up to two-thirds of cases, as an asymptomatic finding on imaging. Diagnosis is by spine radiograph confirming the fracture, which alone establishes a clinical diagnosis of osteoporosis, and first-line management is analgesia (acetaminophen 650 mg PO every 6 hours) with antiresorptive or anabolic pharmacotherapy to prevent further fracture.
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What this article covers
- Overview
A collapse of the vertebral body, usually from fragility rather than major trauma: most vertebral compression fractures occur with minimal loading, such as lifting or bending, in a spine already weakened by low bone mass.
- Epidemiology
Common in older adults: vertebral compression fractures are among the most frequent osteoporotic fractures, alongside hip and distal radius fractures, with incidence rising steeply after age 65 years.
- Risk factors
Established osteoporosis or low bone mineral density: the dominant risk factor; a T-score of -2.5 or less at the spine, hip, or femoral neck is the strongest single predictor.
- Pathophysiology
Trabecular bone loss reduces vertebral body strength: the vertebral body is predominantly trabecular bone, lost earlier and more rapidly in osteoporosis than cortical bone, making the spine a preferential fracture site.
- Clinical features
Acute, focal spinal tenderness after minimal loading is the classic presentation: sudden onset of severe back pain, often described as a "crack," following lifting, bending, or coughing, with point…
- Differential diagnosis
Pathologic fracture from metastatic malignancy or myeloma: unlike osteoporotic fracture, systemic symptoms (weight loss, night sweats), other lytic lesions, or a monoclonal protein on serum protein electrophoresis are often present.
- Diagnosis
A vertebral compression fracture confirmed on imaging, without another identifiable structural cause, is itself diagnostic of osteoporosis, independent of a bone mineral density (BMD) measurement…
- Management
First, control pain. Start acetaminophen 650 mg PO every 6 hours as needed (maximum 3,000-4,000 mg/day); favored first because of its safety profile in an older, often frail population.
- Complications
Subsequent fracture (fracture cascade): a first vertebral compression fracture raises the risk of a second vertebral fracture and of hip fracture, since altered biomechanics increase load on adjacent levels.
- Prognosis
Most acute pain resolves within 4-6 weeks, though the bony deformity is permanent.
- Prevention
Screen for osteoporosis with BMD testing in women 65 years and older, and in postmenopausal women and men aged 50-69 years with risk factors, so pharmacotherapy can begin before a first fracture.
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Osteoporosis is low bone strength that raises fragility fracture risk, diagnosed by a hip or spine T-score of -2.5 or less or by a fragility fracture itself. First-line treatment is an oral bisphosphonate, alendronate or risedronate, alongside adequate calcium and vitamin D intake.
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