Compression fractures may occur in the vertebrae and cause lower back pain. They most commonly occur in patients with osteoporosis. Osteoporosis weakens the bone leading that bone vulnerable to fracture from everyday activities of daily living (e.g., lifting, twisting, coughing) that under normal circumstances would not cause a fracture. Tumors originating from within the spine, or metastases to the spine, may also weaken the bone and result in compression fractures. Significant trauma of course can also result in compression fractures in the spine.

An important fact about compression fractures in the spine is that they can be asymptomatic. Indeed, sometimes, the patient has a compression fracture and no recollection of any back pain. Consider that it has been estimated that a quarter of postmenopausal females have had at least one vertebral compression fracture. Sometimes a patient may remember an episode of lower back pain but that pain subsequently resolved. When lower back pain occurs and a compression fracture is found on an imaging test, it is important to take the fracture seriously, consider why it is there, and consider that it is a potential source of the lower back pain, but it is also important to recognize that the pain may be originating from another source within the spine and that the compression fracture may be incidental to the pain.

Consider the following patient. Eleanor is an 82-year-old female who presents with 2 weeks of severe lower back pain. She has a history of hypertension and osteoporosis but was otherwise doing okay until she lifted her granddaughter 2 weeks ago and immediately felt a sharp pain in the upper part of her lower back. The pain has been so intense that she has been mostly bedbound for the last 2 weeks. She went to her primary care doctor who ordered an X-ray that revealed an L1 compression fracture, multilevel facet joint arthropathy, and degenerative disc disease. On physical examination she is neurologically intact and has severe point tenderness over the anatomic location consistent with her L1 spinal segment. Trunk movement of any kind while standing intensifies the pain.

Most spine specialists would agree that Eleanor is suffering from an acute L1 compression fracture. An MRI is often obtained in order to evaluate the extent of the fracture as well as to evaluate the nerves. A CT may be obtained if there is not a concern for neurologic damage and if an invasive procedure such as kyphoplasty of vertebroplasty to address the pain is being considered. When a compression fracture is identified, it is important to treat the pain from the fracture as well as to make sure that the underlying cause of the fracture (e.g., osteoporosis in Eleanor’s case) is being optimally managed. If a compression fracture is found in an older patient who has not had a recent DEXA scan then it is important to obtain one. If a compression fracture is found in a younger patient with no other obvious cause for the fracture (e.g., tumor), then a DEXA scan should be included as part of the work-up as to why the fracture occurred.

Initial treatment of a compression fracture is nonsurgical and involves relative rest and pain medications. Physical therapy is often started in order to maximize the movement that can be tolerated. Especially in patients with underlying osteoporosis, bed rest can lead to worsening of that osteoporosis as well as put the patient at risk for a thromboembolic event so mobilization is important. Physical therapy will often incorporate heat and gentle massage for pain relief. The exercises in physical therapy should target flexibility and lumbar stabilization exercises with an extension bias used for the exercises [1, 2]. In years past, extension bracing was commonly used, but this has become controversial because of the extra stress that bracing places on the posterior elements of the spine. As such, it is no longer considered the standard of care but can be used in select cases.

Most cases of compression fractures will improve with noninterventional care. However, if the pain is intolerable or does not improve over 6–8 weeks, then vertebroplasty and kyphoplasty are two interventional treatments that may be considered for painful compression fractures [3]. In both of these procedures, a needle or surgical device is inserted into the compression fracture. In vertebroplasty, cement is injected under high pressure to stabilize the fracture. The advantage of vertebroplasty is that it is relatively quicker than kyphoplasty. The disadvantage is that high pressure is used and this can lead to complications such as cement emboli. Additionally, as opposed to kyphoplasty, the height of the bone is not restored. In kyphoplasty, surgical instrumentation is placed into the fracture and a balloon is inflated that creates a vacuum into which cement is injected. The two advantages of kyphoplasty are that the procedure is done under relatively low pressure, minimizing cement emboli, and also height is restored to the fractured vertebral body. Both vertebroplasty and kyphoplasty are effective at quickly reducing the pain from an osteoporotic compression fracture; however, both suffer from the criticism that they may potentially increase the risk of adjacent-level compression fractures [4]. This remains a point of ongoing research and some contention. In the meantime, vertebroplasty and kyphoplasty are appropriate surgical options for patients with severe pain who are not responding to more conservative measures.