Over the past several weeks, we’ve posted a series of articles about osteoporosis, including lifestyle measures for prevention and a 3-part series on exercises to improve bone density and decrease falls and bone fractures.
As a neurosurgeon, I am asked to consult on vertebral (spinal) fractures. Osteoporosis is an important risk factor for acute compression fractures. This blog is by no means exhaustive. To avoid the yawns of my readers, I will try to be brief, but cover some of the important questions I ask myself in determining management. When a patient is having pain, and a fracture is found on Xray:
- is it acute or chronic?
- is it causing neurologic changes or not – i.e. weakness, numbness, bowel or bladder changes?
- is it pressing on the spinal cord or not? (technically, a different kind of fracture)
- Is it stable or not – could the bones potentially move and cause further damage? Are there other fractures or injuries?
- There’s a fracture and there’s pain, BUT, is the fracture actually causing the pain?
A patient is usually diagnosed with a compression fracture with an x-ray, CT, or MRI scan of the back. X-rays and CT cannot always determine whether the fracture is new or old; MRI is superior for that.
Why is this important? Because old fractures may cause pain but do not warrant a back brace or urgent treatment. New fractures need treatment, starting with non-operative treatment. When I am called for a consultation by colleagues regarding a fracture, my immediate thought is to determine unequivocally whether the fracture is old or new.
If it is a new fracture, then I want to determine whether the fracture indeed is the cause of the pain. Among other factors, I localize the pain and check whether the pain is near the fracture. Many elderly patients have pre-existing back pain that may be as low as near the buttock but their fracture is, for example, in a woman, near the bra line. In this case, I would not attribute the pain to the fracture.
In the acute fracture, I would advocate non-operative management with a brace (there are many variations to non-operative management with a large camp of spine specialists NOT advocating the brace), medication (non-narcotic and possibly narcotic), and physical therapy as the first line of management. When the patient is wearing the brace, I would allow the patient to walk with physical therapy, recheck films and see that the fracture has not worsened. If it has not worsened, and pain is manageable, I would continue bracing for 6-12 weeks with serial medical checkups and x-rays.
What if the patient fails non-operative therapy? What does failure mean? Failure can happen in a number of ways: the patient cannot tolerate the brace, cannot breathe well because the pain is too much, or cannot tolerate the pain medications either non-narcotic or narcotic due to side effects and therefore cannot manage the pain, the fracture worsens by being more compressed or by pushing fragments onto the spinal cord, the patient has new neurologic symptoms attributable to the fracture, OR the patient cannot walk due to the pain. These are just some of the indications of a failure of non-operative therapy.
Being unable to walk, having too much pain, having too much pain with breathing is a risk factor for other more dangerous conditions such as mild lung issues, and clots in the legs which can lead to clots in the lung (deep vein thrombosis leading to pulmonary embolus). Therefore, when a patient fails non-operative therapy, I weigh the risks and benefits, along with the rest of the team of doctors taking care of the patient, of a simple surgical procedure called a kyphoplasty. In complicated unstable fractures with spinal cord compression or neurologic deterioration, a more extensive procedure, a lumbar fusion with decompression maybe warranted.
Kyphoplasty is a very small surgical procedure, often not requiring general anesthesia. Cement is placed in the broken bone to add stability and decrease movement of the broken fragments, which in turn decreases pain. The NYTimes article “Spinal Fractures Can be Terribly Painful. A Common Treatment Isn’t Helping” questions kyphoplasty for painful fractures based on many medical studies. The article does not address kyphoplasty to increase stability of the fracture. Data presently supports no long-term benefit in pain reduction, but may still give short-term benefit.
I agree with the opinion of Dr. Joshua Hirsch, a back pain specialist at Massachusetts General Hospital quoted in that article. ” You have a choice,” said Dr. Hirsch. “Opiates and lying in bed with diminished activity, or a procedure that can mobilize patients and improve them.” I clarify for the patient that there may be no long term benefit with kyphoplasty, but that improved pain control in the short term can make a difference in avoiding complications such as deep venous thrombosis. Therefore, my philosophy, no doubt, cautiously and judiciously, is kyphoplasty can still be considered in short term severe pain AND when non-operative management fails.
In the end, the best medicine is prevention with a healthy lifestyle and medical treatment if osteoporosis is diagnosed. If the fracture occurs in you or your loved one, now, hopefully you will have a road map to fuel further meaningful discussions with your spine specialist and primary care doctor.
Part 3 of Osteoporosis exercises