Compression Fractures

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Compression Fractures

Eleanor Adams Eleanor Adams

Harvard Medical School Year IV Harvard Medical School Year IV

Gillian Lieberman, MD Gillian Lieberman, MD

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Overview

•

• Spine Anatomy

Spine Anatomy

•

• Thoracolumbar

Thoracolumbar

Fractures

•

• Cases

Cases

•

• Compression Fractures,

Compression Fractures,

Ddx

•

• Radiologic Tests of Choice

Radiologic Tests of Choice

•

• Treatment Options

Treatment Options

Cedars

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Vertebral Anatomy:

Overview of Thoracic Vertebrae

http://www.spineuniverse.com/dis http://www.spineuniverse.com/dis playarticle.php/article1286.html playarticle.php/article1286.html Vertebral Body Vertebral Body Lamina Spinous Process Spinous Process Pedicle Pedicle Transverse Process

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Vertebral Anatomy:

Overview of Facets

Superior Articular Facet Superior Articular Facet Transverse Costal Facet Transverse Costal Facet

Inferior Costal Facet

Superior Costal Facet

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playarticle.php/article1286.html

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For Comparison…

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Normal

Frontal

Radiograph

PACS, BIDMC PACS, BIDMC Spinous Processes Pedicles Intervertebral Disc Space •

• Need to Assess: Need to Assess: •

• Quality ControlQuality Control •

• Soft TissuesSoft Tissues • • AlignmentAlignment • • BonesBones • • CartilageCartilage

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Normal Lateral

Radiograph

Vertebral Body Pedicle Spinous Process Intervertebral Disc Space PACS, BIDMC PACS, BIDMC

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Spinal Columns

1.)

Anterior column

–

– Anterior longitudinal ligament, anterior half of the Anterior longitudinal ligament, anterior half of the vertebral body, disc, and annulus

vertebral body, disc, and annulus

2.)

Middle column

–

– Posterior half of the vertebral body, disc, and Posterior half of the vertebral body, disc, and annulus, and the posterior longitudinal ligament annulus, and the posterior longitudinal ligament

3.)

Posterior column

–

– Facet joints, Facet joints, ligamentum ligamentum flavumflavum, the posterior , the posterior elements and the interconnecting ligaments.

elements and the interconnecting ligaments.

Panjabi et al. 1995 Panjabi et al. 1995

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Spinal Columns

Anterior Column Middle Column Posterior Column PACS, BIDMC PACS, BIDMC

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Spinal Columns

•

• The spinal canal and cord are located in the

The spinal canal and cord are located in the

Posterior Column, adjacent to the Middle

Column

•

• Therefore, fractures in elements in the Middle

Therefore, fractures in elements in the Middle

or Posterior Columns have the potential to

impinge on the spinal canal and cord

•

• For this reason, Middle and Posterior Column

For this reason, Middle and Posterior Column

fractures are considered unstable.

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Types of Fractures

Type of Fracture

Type of Fracture Column Affected Column Affected Stable vs. UnstableStable vs. Unstable

Compression/Wedge

Compression/Wedge Anterior Only Anterior Only StableStable Fracture

Fracture

Burst fractures

Burst fractures Anterior and Middle Anterior and Middle UnstableUnstable Fracture/Dislocation

Fracture/Dislocation Anterior, Middle, Anterior, Middle, UnstableUnstable Injury

Injury PosteriorPosterior Seat belt fractures

Seat belt fractures Anterior, Middle, Anterior, Middle, UnstableUnstable Posterior

Posterior

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Patient LI

•

• Patient LI, an 82 year old female with

Patient LI, an 82 year old female with

osteoporosis and mild dementia, presented to

her physician with lower back pain and

posterior leg pain

•

• Back pain present for 1

Back pain present for 1

-

2 months

•

• Difficulty getting out of bed in morning due to

Difficulty getting out of bed in morning due to

pain

•

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Patient LI

•

• Given that Patient LI had

_{Given that Patient LI had}

osteoporosis, her physician suspected

she had a compression fracture.

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Compression Fractures

•

• Osteoporosis is the leading cause of vertebral Osteoporosis is the leading cause of vertebral compression fractures in the U.S.

compression fractures in the U.S. •

• 700,000 per year in U.S.700,000 per year in U.S. •

• Affect 25% postmenopausal womenAffect 25% postmenopausal women •

• Incidence expected to increase fourfold in next 50 Incidence expected to increase fourfold in next 50 years

years •

• Why Important?Why Important?

–

– Pain can lead to immobility and further disabilityPain can lead to immobility and further disability –

– 15% increased mortality rate15% increased mortality rate –

– Preventable in most casesPreventable in most cases

Old et al., 2004 Old et al., 2004

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Compression Fractures

•

• Most commonly occur T8Most commonly occur T8--L4L4 •

• Anterior or lateral flexion causes Anterior or lateral flexion causes failure of

failure of Anterior column Anterior column onlyonly •

• Middle column Middle column and and Posterior column Posterior column are undisrupted

are undisrupted •

• Middle column Middle column may act as hingemay act as hinge •

• Can be further classified by the Denis Can be further classified by the Denis Classification according to endplate Classification according to endplate

involvement involvement P M A PACS, BIDMC PACS, BIDMC

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Differential Diagnosis

•

• Atraumatic

Atraumatic

Compression Fracture:

–

– Osteoporosis Osteoporosis

•

• Senile/PostSenile/Post--Menopausal Menopausal •

• SteroidsSteroids

–

– OsteomalaciaOsteomalacia –

– Pagets DiseasePagets Disease –

– Multiple MyelomaMultiple Myeloma –

– HyperparathyroidismHyperparathyroidism

Cedars

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What is your initial imaging test of

choice?

•

• Plain frontal and lateral radiographs are the

Plain frontal and lateral radiographs are the

initial studies of choice

•

• In 20

In 20

-

30% cases multiple fractures are present

•

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Radiograph Findings of

Compression Fractures

•

• Anterior height of vertebral body is diminished

Anterior height of vertebral body is diminished

•

• Posterior height of vertebral body is normal

Posterior height of vertebral body is normal

•

• No anterior or posterior translation of vertebral

No anterior or posterior translation of vertebral

bodies

•

• If anterior compression is >40% when

If anterior compression is >40% when

compared to posterior vertebral body height,

suspect burst fracture

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Patient LI:

Frontal Plain

Radiograph

•

• Dextroscoliosis Dextroscoliosis centered centered around L2

around L2--33 •

• Multilevel degenerative Multilevel degenerative changes

changes

•

• Endplate sclerosisEndplate sclerosis •

• Multilevel facet Multilevel facet hypertrophy

hypertrophy

•

• Increased Increased lucency lucency in in vertebral bodies

vertebral bodies

•

• Compression fracture of Compression fracture of L1

L1

PACS, BIDMC

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Patient LI: Lateral

Radiograph

PACS, BIDMC PACS, BIDMC

• Compression

_Compression

fracture of the

L1

vertebrae causing

focal

kyphosis

•

• There is a 5 mm

There is a 5 mm

anterolisthesis

of L5 on S1

Compression Compression Fracture of L1 Fracture of L1 Normal Normal L2 L2

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Comparison A:

Lateral Radiograph

•

• 71 year old with a history of 71 year old with a history of

osteopenia

osteopenia who presented with who presented with mid

mid--lower back painlower back pain

Courtesy Dr. Yamada, BIDMC

Normal T12 Normal T12 Compression Compression Fracture of T11 Fracture of T11 •

• Compression fracture of Compression fracture of anterior of the T11 vertebral anterior of the T11 vertebral

body body • • Demineralization Demineralization present present

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Comparison B:

Lateral Radiograph

•

• 82 year old who 82 year old who

suffered a mechanical suffered a mechanical

fall at her assisted living fall at her assisted living

home home •

• There is approximately There is approximately a 15% loss of anterior a 15% loss of anterior

vertebral body height of vertebral body height of

T12 T12

Courtesy Dr. Yamada, BIDMC

Compression

Fracture of T12

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Role of Additional Imaging

•

• Role of CT:Role of CT:

•

• Use to identify fractures not well visualized on plain filmUse to identify fractures not well visualized on plain film •

• Allows for visualization of middle and posterior elementsAllows for visualization of middle and posterior elements

•

• Can distinguish between compression fracture and burst fractureCan distinguish between compression fracture and burst fracture

•

• Can also reveal spinal canal narrowingCan also reveal spinal canal narrowing •

• Disadvantage: Disadvantage:

•

• Can’t detect horizontal fractures of vertebral bodies or pedicles Can’t detect horizontal fractures of vertebral bodies or pedicles well

well

•

• Role of MRI:Role of MRI:

•

• Recommended when patient has suspected spinal cord Recommended when patient has suspected spinal cord compression or other neurologic symptoms

compression or other neurologic symptoms

Old et al., 2004 Old et al., 2004

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Patient LI

•

• Given that Patient LI reported posterior leg

Given that Patient LI reported posterior leg

pain, her physician decided to order an MRI to

assess the spinal cord and spinal canal

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Patient LI: T2 MRI

PACS, BIDMC PACS, BIDMC Sagittal Sagittal Axial Axial

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Patient LI: MRI Findings

•

• The

The

conus

terminates at L1

•

• No evidence for internal

No evidence for internal

expansile

mass

•

• Dextroscoliosis

Dextroscoliosis

of the

lumbosacral

spine with

apex at L2/3

•

• L1 compression fracture

L1 compression fracture

•

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Treatment Options

•

• Non

Non

-

operative treatment is the standard

–

– Pain medication (observe bowel motility)Pain medication (observe bowel motility) –

– Brief rest (2-Brief rest (2-3 days), encourage early ambulation3 days), encourage early ambulation –

– Avoid compression overloads for 2 monthsAvoid compression overloads for 2 months –

– Muscle relaxants, external back braces, and Muscle relaxants, external back braces, and physical therapy may also help

physical therapy may also help

•

• If patients do not respond to conservative

If patients do not respond to conservative

tx

:

–

– Percutaneous VertebroplastyPercutaneous Vertebroplasty –

– KyphoplastyKyphoplasty

Singh et al., 2006 Singh et al., 2006

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Summary

•

• Compression fractures common in elderly populationCompression fractures common in elderly population •

• Compression fractures are caused by failure of the Compression fractures are caused by failure of the anterior column only

anterior column only •

• Initial imaging modality of choice is plain filmInitial imaging modality of choice is plain film •

• Can use CT or MRI if have concern that the middle Can use CT or MRI if have concern that the middle or posterior columns are involved, and to evaluate or posterior columns are involved, and to evaluate

spinal cord spinal cord •

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References

•

• De De Smet AA, Robinson RG, Johnson BE, Smet AA, Robinson RG, Johnson BE, LukertLukert BP. Spinal Compression BP. Spinal Compression Fractures and Osteoporotic Women: Patterns and Relationship to

Fractures and Osteoporotic Women: Patterns and Relationship to HyperkyphosisHyperkyphosis. .

Radiology

Radiology 1988; 166:497-1988; 166:497-500. 500. •

• Kroth PJ, Murray MD, McDonald CJ. Kroth PJ, Murray MD, McDonald CJ. UndertreatmentUndertreatment of osteoporosis in women, of osteoporosis in women, based on detection of vertebral compression fractures on chest r

based on detection of vertebral compression fractures on chest radiography. adiography. Am J Am J Geriatr

Geriatr Pharmacother Pharmacother 2004; 2(2):112-2004; 2(2):112-118. 118. •

• Old JL, Calvert M. Vertebral Compression Fractures in the ElderlOld JL, Calvert M. Vertebral Compression Fractures in the Elderly. y. Am Am Acad Acad Fam Fam Phys

Phys 2004: 69(1):111-2004: 69(1):111-116.116. •

• Panjabi MM, Panjabi MM, Oxland TR, Oxland TR, KifuneKifune M, M, ArandArand M, M, WenWen L, Chen A. Validity of the L, Chen A. Validity of the three

three--column theory of column theory of thoracolumbarthoracolumbar fractures. fractures. Spine Spine 1995; 20(10):1122-1995; 20(10):1122-1127.1127. •

• Singh AK, Singh AK, Pilgram TK, Pilgram TK, Gilula Gilula LA. Osteoporotic Compression Fractures: Outcomes LA. Osteoporotic Compression Fractures: Outcomes after Single versus Multiple

after Single versus Multiple--Level Level PercutaneousPercutaneous VertebroplastyVertebroplasty. . Radiology Radiology 2006; 2006; 238(1):211

238(1):211--220.220. •

• Yuh Yuh WT, WT, Zacher Zacher CK, CK, Barloon Barloon TJ, Sato Y, TJ, Sato Y, Sickels Sickels WJ, Hawes DR. Vertebral WJ, Hawes DR. Vertebral Compression Fractures: Distinction between Benign and Malignant

Compression Fractures: Distinction between Benign and Malignant Causes with Causes with MR Imaging.

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Acknowledgements

•

• Special Thanks to:

Special Thanks to:

•

• Gillian Lieberman, MDGillian Lieberman, MD •

• Maryellen Sun, MDMaryellen Sun, MD •

• Kei Yamada, MDKei Yamada, MD •

• Pamela Pamela LepkowskiLepkowski •