A vertebral fracture sounds like an accident and paraplegia. In fact most vertebral fractures arise in later life without any accident worth mentioning — through osteoporosis, under everyday loads — and the great majority heal without an operation. This page explains the three kinds of vertebral fracture, how we tell whether a fracture is recent and stable, how it is treated without an operation, and when stabilisation with cement or with screws genuinely helps.
Three questions decide the treatment: is the fracture recent? Is it stable? And can the pain be eased far enough for you to stay on your feet? Only when one of these questions gets the wrong answer does a procedure come closer.
What is it?
The vertebral body is the load-bearing front part of a vertebra. It almost always breaks by being compressed: the endplate gives way, the front edge collapses, and the rectangular vertebra becomes a wedge or — when both plates sink in — a “fish vertebra”. Three causes are to be distinguished, because they are treated differently. The osteoporotic fracture is the most common form: the bone is so porous that it gives way on lifting, coughing or stumbling, usually at the junction between the thoracic and the lumbar spine. The traumatic fracture arises through great force — a fall from a height, a road accident — at any age, and can also tear the posterior parts of the vertebra and the ligaments. The pathological fracture occurs because a tumour, a metastasis or a disease of the bone marrow has hollowed the vertebra out from within.
In Germany, osteoporotic fractures are classified according to the OF classification: OF 1 is a fracture without visible deformity, recognisable only on MRI as bone marrow oedema; OF 2 a deformity with no or only slight involvement of the back edge; OF 3 a clear involvement of the back edge; OF 4 a loss of the vertebral frame or a collapse of the vertebra; OF 5 an injury with tearing or twisting. Accident-related fractures are classified according to the AO Spine classification into type A (compression), B (tearing of the ligaments or of the arch) and C (displacement). What both systems have in common is the central question: is the back edge of the vertebral body involved? It borders on the spinal canal, in which the spinal cord and the nerve roots run.
What symptoms occur?
Typical is a sudden, precisely localisable pain in the middle of the back, which grows worse on standing, walking, straightening up from lying down and sitting without a backrest, and eases when lying down. The spot is tender to tapping. The pain can run forwards like a belt along the ribs or — with fractures of the lumbar spine — into the buttock and the groin; that is a radiation out of the bone, not nerve pain. Tingling, numbness or weakness in the legs do not belong to an ordinary vertebral fracture: according to the DGOU/DWG guideline, fracture-related neurological deficits occur in about 2.5 in 100 of those affected.
With osteoporotic fractures the pain is often absent altogether or is put down to “the back” — about two thirds go unnoticed and come to light only through loss of height, an increasing rounded back or an X-ray taken for another reason. At the other end of the scale, according to figures from the IQWiG, about 10 in 100 of those affected have pain so severe that treatment in hospital is necessary. After an accident the rule is: any severe back pain belongs in an emergency department before anyone gets up.
Causes
Behind the osteoporotic fracture stands osteoporosis — and with it age, the menopause, cortisone treatment, smoking, lack of exercise, being underweight and a number of underlying conditions. A first vertebral fracture is at the same time the strongest pointer to further ones: bone that has given way once gives way again without treatment, and a collapsed vertebra shifts the load onto its neighbours. Accident-related fractures arise through force from above or through bending under load; in young people that takes a great deal of energy, in older people with osteoporosis a fall from standing is enough. Pathological fractures arise from a cancer, a metastasis or a multiple myeloma — which is why, with every vertebral fracture without an accident, the question of a tumour must be asked and answered with an MRI scan.
How is it diagnosed?
At the examination we look for the painful spot by tapping over the spinous processes and test strength, sensation and reflexes in the legs as well as the walking pattern. The first image is an X-ray of the thoracic and lumbar spine in two planes, standing where possible: it shows the deformity and the height of the vertebra under load. What it does not show is the age of the fracture — that takes an MRI scan. In particular sequences a recent fracture lights up as bone marrow oedema, while an old, healed fracture stays dark. The MRI scan is also the only method by which a fracture of type OF 1 is recognised at all, it uncovers further, unnoticed fractures, and it distinguishes the osteoporotic fracture from tumour involvement. The CT scan shows the back edge, the fragments and the shape of the fracture most precisely and is the basis of the classification and of any planning for an operation.
Whether a fracture that looks stable stays stable is shown only by its course: a follow-up image taken standing after about a week makes it visible whether the vertebra is collapsing further. Every osteoporotic fracture also calls for a bone density measurement and blood tests that rule out other causes. What the terms in your report mean is explained on the page Understanding your MRI report.
Warning signs
Belonging in an emergency department on the same day are back pain after a serious fall or accident, a new weakness in the legs, numbness in the area of the buttocks and the perineum, and a new problem passing water or opening the bowels. You should have the following assessed within a few days: a new, severe back pain with known osteoporosis or cancer, back pain with fever, and pain that does not ease even when lying down and at night. More on the page Warning signs.
Conservative treatment
For osteoporotic fractures of types OF 1 and OF 2 — and, where the deformity is slight, OF 3 as well — treatment without an operation is the first choice according to the DGOU/DWG guideline: loss of height under a quarter, angulation under 25 degrees, no nerve deficits. Its aim is not to repair the vertebra — no treatment can do that — but to reduce the pain far enough for you to stay moving, and to keep track that the fracture does not sink further.
- Painkillers, in steps — for milder pain anti-inflammatory medicines or metamizole, for stronger pain opioids too for a limited time; the aim is getting up early. The dose is lowered as soon as possible.
- Get up early, lie down briefly — bed rest should, according to the guideline, be prescribed very sparingly, because it breaks down muscle mass and bone and weakens the circulation and independence. Walking is encouraged; jerky bending, lifting and twisting are to be avoided in the first weeks.
- Physiotherapy — straightening up, strengthening of the back extensors and the trunk muscles, lifting technique, balance. It begins as soon as the pain allows, and later passes into your own training.
- A brace only in individual cases — a supporting corset cannot, according to the guideline, be recommended generally, because studies show no difference from treatment without one. Anyone who feels safer with it and has less pain can wear an active brace for a few weeks, one that does not immobilise the muscles.
- Follow-up images taken standing — after about a week and thereafter at intervals of weeks, to detect further collapse for as long as the fracture has not yet healed.
- Treat the osteoporosis — bone density measurement, calcium, vitamin D, exercise and, depending on the risk, treatment with medicines, prescribed by your GP practice or a practice specialising in osteology. The fracture is the symptom, the osteoporosis is the disease.
The usual course: according to figures from the IQWiG the pain mostly improves within four to six weeks, and the bony healing takes about three months. If the pain lasts longer than three months, one speaks of chronic symptoms — then it has to be clarified whether the vertebra has collapsed further, whether another vertebra has broken, or whether the pain now comes from muscles and joints that are compensating for the altered mechanics.
When an operation is considered
An urgent operation is performed for nerve deficits caused by fragments in the spinal canal and for unstable fractures with tearing of the ligaments or displacement — in accident-related fractures of types B and C and in osteoporotic fractures of types OF 4 and OF 5. A planned procedure is considered if the pain prevents getting up despite stepped painkillers, if the vertebra sinks further on follow-up images, or if an increasing rounded back develops. The DGOU/DWG guideline gathers these considerations into the OF score: points for the shape of the fracture, a markedly reduced bone density, further collapse, persisting pain despite medication, nerve deficits and the inability to get up; deductions for a poor general condition. Under 6 points treatment is without an operation, at 6 points both are possible, above 6 points the score recommends a procedure. The score is a decision aid that does not replace the conversation — the professional association of general practitioners has recorded in the guideline that a recommendation for an operation must not be tied firmly to a number of points.
On the question of whether cement in the vertebra helps against the pain there are contradictory studies that are worth knowing. In the FREE study with 300 patients, balloon kyphoplasty improved physical quality of life after one month considerably more than treatment without a procedure (7.2 versus 2.0 points on the SF-36 scale). In the VERTOS II study with 202 participants, vertebroplasty — cement without a balloon — reduced the pain after one month by 5.2 versus 2.7 points on a ten-point scale, an advantage that lasted a year. Both studies, however, compared with a treatment without any procedure at all. Studies that compared the cement with a sham procedure — most recently VERTOS IV — found a similar improvement in both groups; a Cochrane review of 2018 therefore sees no clinically meaningful benefit of vertebroplasty over the sham procedure. For balloon kyphoplasty no study with a sham procedure exists so far. The IQWiG sums up that, with very severe pain, the treatment can help some people somewhat, especially when the fracture is only a few weeks old; the DGOU/DWG guideline sees the best pain-relieving and mobilising effect at a fracture age of two to four weeks and points out that the evidence for an early procedure is limited.
Surgical options
For a recent, stable osteoporotic fracture whose pain cannot be controlled, we perform kyphoplasty: the collapsed vertebral body is stabilised from within with bone cement. For unstable fractures — accident-related fractures of types B and C, osteoporotic fractures of types OF 4 and OF 5 — we stabilise the affected segment with screws and rods (screw-and-rod spinal fusion), and in porous bone the screws can additionally be anchored with cement. If fragments press on nerves or the spinal cord, they are removed in the same procedure (decompression). The most common procedure is kyphoplasty:
- ProcedureLying face down and under X-ray guidance, a hollow needle is advanced through the vertebral arch into the vertebral body through each of two small skin incisions. A balloon raises the collapsed vertebra as far as possible and creates a cavity into which viscous bone cement is introduced; it hardens within minutes. The procedure is carried out under general anaesthetic or deep sedation; its duration, the hospital stay and the aftercare depend on your situation and are discussed with you beforehand.
- RisksThe most important complication specific to this procedure is a leakage of cement out of the vertebra. Usually this has no consequences; rarely, cement reaches the spinal canal or the veins and can then press on nerves or the spinal cord or block blood vessels, in extreme cases life-threateningly. Added to this are infection, bleeding, the risks of anaesthesia, and the possibility that the pain does not ease, or eases only partly. Whether the stiffened vertebra encourages fractures of the neighbouring vertebrae is not conclusively settled; what is certain is that the osteoporosis has to go on being treated.
- AftercareGetting up on the day of the procedure or the day after; walking is encouraged. For a few weeks no heavy lifting and no deep bending, then physiotherapy with straightening up and strengthening. An X-ray check taken standing shows whether the vertebra and its neighbours stay stable. The osteoporosis treatment begins or is continued.
With a stabilisation using screws and rods the procedure is larger, the hospital stay longer, and the risks of any fusion apply: malposition or loosening of screws — more frequent in osteoporotic bone —, injury to the membrane around the nerves, failure of the bone to heal, greater loading of the adjacent segments. Which combination of cement, screws and decompression makes sense in your situation, we discuss before the procedure.
Alternatives
The most important alternative to any procedure is continued treatment without an operation, with adjusted painkillers, physiotherapy and close follow-up images — for most fractures it is not the alternative but the standard. If you have been advised elsewhere to have a kyphoplasty or a screw fixation and you are unsure, you can obtain a second opinion from us; for planned procedures on the spine this is a right laid down in law.
What to expect
A broken vertebra heals bonily in about three months, but keeps its new shape: the deformity remains, and with every further fracture the rounded back increases. The long-term course is therefore decided less by the first fracture than by the question of whether a second one is prevented. What you can do yourself: train the back extensors for the long term, walk every day, bend your knees when lifting, avoid falls, do not smoke, keep to the osteoporosis treatment and measure your height every year. A new, suddenly starting back pain after a fracture is a reason to get in touch — it may be the neighbouring vertebra.
Frequently asked questions
Do I have to stay in bed with a vertebral fracture?
Only for as short a time as necessary. With a stable fracture you should, with adequate pain treatment, get up and walk as early as possible. Longer bed rest weakens muscles, bone and circulation and makes recovery harder.
Does the vertebra grow back into its old shape?
No. The fracture heals, but in the shape the vertebra took on as it sank in. A kyphoplasty can partly raise the vertebra when the fracture is recent; a vertebra that has been collapsed for months it no longer raises.
When does a kyphoplasty make sense?
When a recent osteoporotic fracture hurts so much despite stepped painkillers that you cannot get up, when it sinks further on follow-up images, or when you cannot tolerate the painkillers you need. For fractures older than a few weeks, and for pain that can be controlled with medicines, the benefit is not established.
Is the cement dangerous?
The cement itself is well tolerated. The risk lies in its leaking out of the vertebra: usually this has no consequences, rarely it reaches the spinal canal or the blood vessels. The balloon creates a bounded cavity and lowers this risk compared with vertebroplasty without a balloon. We discuss with you what is to the fore in your situation.
What should I bring to my first appointment?
X-ray, CT and MRI images on CD together with the reports — especially images taken standing and the MRI scan —, the report of a bone density measurement if you have one, and your list of medicines. Everything else is on the page Your first appointment.