Osteoporotic vertebral compression fractures (VCFs) are among the most common fragility fractures in older adults, particularly postmenopausal women and elderly men with osteoporosis. They occur when weakened vertebral bodies collapse under normal physiological loads or after minimal trauma. Although osteoporosis is the leading cause, vertebral compression fractures may also result from metastatic malignancy, multiple myeloma, infection, or prolonged corticosteroid therapy.

Most fractures involve the thoracolumbar junction (T11–L2). Untreated VCFs may result in chronic pain, progressive kyphosis, reduced pulmonary function, impaired mobility, recurrent falls, and increased mortality.

Epidemiology

• Most common osteoporotic fracture after distal radius fractures

• Incidence increases significantly after 50 years of age

• More common in postmenopausal women

• Risk increases with advancing age

• Previous vertebral fracture markedly increases the risk of subsequent fractures

Etiology

Primary causes

• Osteoporosis (most common)

• Osteopenia with low-energy trauma

Secondary causes

• Long-term corticosteroid therapy

• Primary vertebral tumors

• Metastatic spinal tumors

• Multiple myeloma

• Hyperparathyroidism

• Osteomalacia

• Severe vitamin D deficiency

Pathophysiology

In osteoporosis, reduced bone mineral density and deterioration of trabecular bone architecture progressively weaken the vertebral bodies. Minor trauma, bending, lifting, coughing, or even normal daily activities may generate sufficient compressive force to cause vertebral collapse. Most fractures involve the anterior vertebral body, producing wedge deformities and progressive thoracic kyphosis.

Multiple compression fractures shift the body's centre of gravity anteriorly, increasing mechanical stress on adjacent vertebrae and predisposing patients to further fractures. Vertebral collapse may also narrow the spinal canal or neural foramina, resulting in nerve root or spinal cord compression with neurological symptoms. Chronic deformity contributes to reduced pulmonary function, impaired mobility, persistent pain, and loss of independence.

Risk factors

• Advanced age

• Female sex

• Postmenopausal state

• Previous fragility fracture

• Low bone mineral density

• Chronic glucocorticoid therapy

• Vitamin D deficiency

• Calcium deficiency

• Smoking

• Excessive alcohol intake

• Low body mass index

• Physical inactivity

• Family history of osteoporosis

Clinical presentation

Symptoms

• Sudden severe back pain

• Pain worsened by standing or walking

• Pain relieved by lying down

• Difficulty walking

• Reduced mobility

• Height loss

• Progressive spinal deformity

• Muscle spasms

Neurological symptoms

These occur when there is spinal canal compromise.

• Extremity weakness

• Numbness

• Paresthesia

• Radicular pain

• Bladder or bowel dysfunction (rare but urgent)

Physical examination

• Localized spinal tenderness

• Thoracic kyphosis ("dowager's hump")

• Loss of height

• Reduced spinal range of motion

• Pain on percussion over affected vertebra

• Neurological deficits in complicated fractures

Diagnostic criteria

Diagnosis is based on clinical presentation together with imaging evidence of vertebral collapse.

Diagnosis is established by:

• Acute or subacute back pain in a patient with osteoporosis or risk factors

• Vertebral height loss of at least 20% or at least 4 mm on spinal imaging

• Imaging consistent with acute or chronic compression fracture

• Exclusion of alternative causes such as malignancy or infection when clinically suspected

Investigations

Laboratory investigations

• Complete blood count (CBC)

• Erythrocyte sedimentation rate (ESR)

• C-reactive protein (CRP)

• Serum calcium

• Serum phosphate

• Serum alkaline phosphatase

• Serum creatinine

• Serum 25-hydroxyvitamin D

• Thyroid-stimulating hormone when indicated

• Serum protein electrophoresis if multiple myeloma is suspected

Imaging

Plain spinal radiographs

Usually demonstrate:

• Loss of vertebral body height

• Wedge fracture

• Biconcave deformity

• Crush fracture

• Kyphosis

CT scan

Useful for:

• Complex fracture morphology

• Posterior wall involvement

• Surgical planning

MRI (preferred if neurological deficit or malignancy suspected)

Identifies:

• Acute fracture oedema

• Neural compression

• Ligament injury

• Occult fractures

• Infection or malignancy

Radionuclide bone scan

Useful when:

• MRI is unavailable

• Multiple fractures are suspected

• Occult fractures require localization

Bone mineral density assessment

Dual-energy X-ray absorptiometry (DEXA) is recommended to confirm osteoporosis and assess fracture risk.

Differential diagnosis

• Metastatic vertebral disease

• Multiple myeloma

• Pyogenic spondylodiscitis

• Tuberculous spondylodiscitis

• Degenerative spine disease

• Traumatic vertebral fracture

Treatment

Management aims to relieve pain, restore mobility, prevent further fractures, and preserve spinal stability.

Non-pharmacological treatment

Conservative measures

• Short period of bed rest

• External spinal immobilization using spinal braces

• Early mobilization as pain improves

• Activity modification

• Nutritional optimisation

• Adequate calcium and vitamin D intake

Vertebral augmentation procedures

Consider referral for image-guided vertebral cement augmentation in patients with persistent severe pain despite optimal conservative therapy.

Procedures include:

• Vertebroplasty

• Kyphoplasty

Physical and occupational therapy

• Back extensor muscle strengthening

• Balance training

• Postural correction

• Walking programme

• Weight-bearing exercise 3–5 sessions weekly (45–60 minutes/session)

• Low-impact aerobic exercise such as walking and cycling

• Occupational therapy for activities of daily living

Behavioural modification

• Smoking cessation

• Limit alcohol intake

• Moderate caffeine consumption

• Encourage regular physical activity

Fall prevention

• Install handrails in bathrooms and stairways

• Improve household lighting

• Remove loose rugs and obstacles

• Wear supportive low-heeled footwear

• Use walking aids where appropriate

Pharmacological treatment

Principles of conservative treatment

• External spinal immobilization

• Adequate analgesia

• Muscle relaxants when indicated

• Osteoporosis treatment

• Monitor for spinal instability and neurological deterioration

Mild pain

Ibuprofen

• 400 mg orally stat then 200 mg every 8 hours

OR

Diclofenac sodium

• 50 mg orally every 8 hours for 7–14 days

OR

Meloxicam

• 7.5–15 mg orally every 12–24 hours for 7–14 days

Severe pain

Diclofenac

• 75 mg intramuscularly every 12 hours by deep IM injection for 1–3 days

±

Tramadol

• 100 mg intramuscularly every 12 hours by deep IM injection for 1–3 days

THEN

Diclofenac

• 50 mg orally every 8 hours for 14 days

±

Tramadol

• 50 mg orally every 8 hours for up to 14 days

Topical analgesics

Diclofenac gel

• Apply every 12 hours

OR

Ketoprofen gel

• Apply every 12 hours

Gastroprotection

For patients receiving NSAIDs for two weeks or longer or those at high gastrointestinal risk:

Omeprazole

• 20 mg orally once daily for 2–4 weeks

OR

Pantoprazole

• 40 mg orally once daily for 2–4 weeks

OR

Lansoprazole

• 30 mg orally once daily for 2–4 weeks

OR

Esomeprazole

• 40 mg orally once daily for 2–4 weeks

Radicular symptoms

Pregabalin

• 75–150 mg orally once daily for 4 weeks (dose may be increased according to response)

AND

Vitamin B1 + Vitamin B6 + Vitamin B12

• One tablet orally once daily for 4 weeks

AND

Baclofen

• 5 mg orally every 8 hours initially; increase by 5 mg per dose every 3 days up to 20 mg every 8 hours for up to 2 weeks

OR

Tizanidine

• Initially 2 mg orally every 8 hours; increase gradually to 4 mg daily every 1–4 days according to response. If discontinuing, taper gradually by reducing 2–4 mg daily.

Calcium supplementation

Calcium 600 mg + Vitamin D 800 IU

• Orally once daily for 3 months, then re-evaluate

(1 microgram vitamin D = 40 IU)

Bisphosphonate therapy

Bisphosphonate therapy should be continued for five years unless contraindicated.

Ibandronate

• 3 mg intravenously every 3 months administered over 15–20 minutes for treatment

Surgical management

Surgical intervention is indicated for patients with instability, neurological compromise, or failure of conservative management.

Indications

• Progressive neurological deficits due to neural compression

• Progressive spinal deformity with disabling pain

• Mechanical instability

• Failure of conservative treatment

• Pathological fractures requiring stabilization

Surgical procedures

• Posterior spinal decompression

• Instrumented spinal stabilization

• Vertebral reconstruction where indicated

• Minimally invasive or open techniques depending on patient factors and surgical expertise

Complications

• Chronic back pain

• Progressive kyphosis

• Loss of height

• Recurrent vertebral fractures

• Respiratory compromise

• Reduced mobility

• Deep vein thrombosis

• Pressure ulcers

• Spinal cord compression

• Permanent neurological deficits

Prognosis

Most osteoporotic vertebral compression fractures improve with conservative management over several weeks to months. Early osteoporosis treatment significantly reduces the risk of subsequent fractures. Patients with multiple fractures have an increased risk of chronic pain, disability, spinal deformity, and reduced quality of life.

Prevention

• Early diagnosis and treatment of osteoporosis

• Adequate calcium and vitamin D intake

• Regular weight-bearing and resistance exercise

• Smoking cessation

• Moderate alcohol consumption

• Fall prevention strategies

• Minimise long-term corticosteroid use where possible

• Routine osteoporosis screening in high-risk individuals

Patient education

Patients should be advised to:

• Adhere to osteoporosis medications as prescribed.

• Take calcium and vitamin D supplements regularly.

• Maintain regular physical activity within their ability.

• Avoid smoking and excessive alcohol intake.

• Use walking aids if balance is impaired.

• Report new back pain or neurological symptoms immediately.

• Attend follow-up visits for reassessment and bone density monitoring.