Ortho on the go
Ortho on the go
Common cause of back pain in older adults
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Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves. Today we're going to discuss back pain. So this is a common complaint that we often see patients come in for. This is a specific case that I see quite often and that I think a lot of us see quite often in our clinics. So I had a 72-year-old female who came into the clinic complaining of lower thoracic and upper lumbar back pain. She states that her husband actually has multiple vertebral compression fractures and he had fallen on down to his knees. She attempted to lift him up and felt what she describes as a cracking sensation within her back. This happened approximately five days ago. She tried to treat this conservatively with anti-inflammatory medications and rest, but continues to have quite significant pain within the back area and was concerned about possible injury to her back and presented to the orthopedic urgent care for evaluation. She states she's had no previous issues with her back. She does not describe any neurological deficits at the time of the evaluation. As with many of us, hard to walk into the orthopedic office without getting x-rays. She did have a direct trauma, so we got x-rays of the thoracic and lumbar spine based upon the location of her pain. The x-rays did show anterior wedging noted at the L1 vertebrae, consistent with concerns for a vertebral compression fracture within this area. This didn't match up to where her pain and tenderness was at. So discussed with her that it seemed to be a diagnosis of vertebral compression fracture and discussed with her regarding the treatment for this. I think vertebral compression fractures are common fractures that we see in a lot of our clinics. One of the important things to remember is that only about 25 to 30% of these fractures are patients that come in with acute back pain. A lot of these fractures are diagnosed incidentally on screening x-rays for other conditions. And so a lot of the patients can get these fragility compression fractures and not have direct pain, and or it can be a minor pain that they're able to work through their daily lives and not come in specifically for evaluation. In discussing vertebral compression fractures, so this is the most common fragility fracture that we see. Again, it's often associated with osteopenia or osteoporosis in patients. So if you have a patient that comes in that has uh symptoms and are x-rays consistent with a vertebral compression fracture, always question them about do they have a diagnosis of osteoporosis or osteopenia? If they don't, andor it's been a while since they've had testing, I always do recommend a follow-up with Bone Health andor their primary care for testing to see if this has progressed and they may be a candidate for treatment regarding this. There is a bit of a bimodal distribution with these compression fractures. We typically see this in our older population. So again, typically about 25% in the patients over 70 will have these fractures, and about 50% in the patients over 80 will have these fractures. If you do see the fractures in younger patients, this is typically related to high in in high energy mechanism, so a fall from a height or a motor vehicle accident. These could be much more significant in these patients and could be associated with neurological deficits in these patients. So again, compression fracture and otherwise a young patient that has a fall from a height or a motor vehicle accident, I would be highly more concerned about possible instability of this fracture and more likely to obtain X-rays. One of the things that I think is sometimes hard to distinguish is what is a vertebral compression compression fracture versus a burst fracture. So a vertebral compression fracture only affects the anterior column of the spine, thereby only compromising the anterior half of the vertebrae and the anterior longitudinal ligament. It'll cause this characteristic wedge shaped deformity noted within the vertebrae. If we divide the spine into three sections, which you typically do, so it'd be the anterior column, which would involve the anterior longitudinal ligaments and the anterior portion of the vertebrae, the middle column, which would be the posterior portion of the vertebrae and the posterior longitudinal ligaments, and the posterior column, which represents the ligamentum flavum, the neural arches, the facets, and the posterior ligamentous complex. Again, with a vertebral compression fracture, only this anterior column is affected. If there is damage andor concern about injury to the posterior column or the middle column, or at least two out of the three columns, this would be more considered a burst fracture. So again, a burst fracture would be a vertebral fracture that affects both the anterior and middle columns, as well as affect the posterior longitudinal ligament that we see supporting the vertebrates. These are more significant of a fractures. These are considered to be unstable fractures and typically require a further workup, MRIs, concern for neurological deficits and possible, further stabilization with surgery. If it is an isolated anterior column fracture, such as a vertebral compression fracture, these are often considered stable fractures. Now recent reports have cited that the thoracicolumbar junction is the most common place that we see these vertebral compression fractures. So over 60 to 75% of these fractures occur between this T12 and L2 area, and then another 30% will occur between the L2 and L5 area. So these are the most common locations that we're going to see patients that come in with these fractures. If we do see fractures above the T5 area, this is often associated with metastatic cancer of the spine and definitely should be worked up regarding this. A couple things to remember regarding vertebral compression fractures is that multiple compression fractures can actually lead to kyphosis, and kyphosis can affect pulmonary function. With every vertebral compression fracture, this does lead to a 9% reduction in forced volume that patients have when doing pulmonary function testing, and this can increase the risk of mortality related to pulmonary dysfunction. Most of the patients presenting with vertebral compression fractures will present with a history of some type of fall. Again, my patient presented with more of a lifting history, but did, you know, was lifting in a bent over position, which created that compression force to the spine. But oftentimes this is a ground level fall, typically right onto their sacral area. This will cause an axial load around the center of rotation of the spinal column, and this will typically cause the vertebral bodies to have this compression fracture or these fatigue fractures of failure of the bony structures of the vertebrae. A lot of these patients will present with focal tenderness around the spinous process area of the area where the compression fracture is at. They can have local kyphosis more significantly if they have multiple compression fractures within the area. They can have some nerve root deficits noted distally, and they will often present with pain around the rib cage in a more dermatomal distribution, so sometimes can be confused with zoster within the area or an outbreak of zoster within the area. Regarding treatment, non-operative treatment is typically recommended. Regarding imaging, so majority of these vertebral compression fractures can be picked up on X-rays. So usually it's this lateral radiograph that can see if there is a loss of height within the vertebrae. The X-rays can oftentimes diagnose this but not show the level of chronicity regarding the fracture. So as mentioned earlier, a lot of these fractures are old and or acute on chronic. They had a chronic fracture with an acute exacerbation. If we want to age the fracture or evaluate for the chronicity of the fracture and MRI is what will likely evaluate and/or show this most significantly, the MRI will also show if there's injury to the anterior and posterior ligamentous complex, if there's any spinal cord compression or injuries to the discs, and possible metastatic etiology versus osteoporotic etiology. So if we are concerned about any of these, uh progressing to the MRI may be beneficial. Regarding a CT scan, typically not indicated for this. Usually only if there's inadequate films with patients that present with continued pain. But again, most likely for those patients I'd obtain an MRI because we're going to get much more out of this. For most of these patients, I don't recommend an MRI if their physical exam is consistent with this. If their X-rays do show evidence of this vertebra compression fracture, and if they had a don't have any motor or strength deficits distally or ridicular symptoms concerning for neurological deficits. Because again, even if it does show that it's an old compression fracture, but they're complaining of pain within this area, it likely won't change our treatment. It may change the longevity of our treatment. So this is one reason to get it. We may only put the patient in limited activities for two weeks with just more of a low back strain or soft tissue injury versus a six weeks for more of a compression fracture type injury. So if we're concerned andor want to evaluate the patient to see how long we want uh to have the treatment, an MRI may be indicated for this as well. Some of the literature, at least some of the old literature, showed that if there was a 30% um traumatic kyphosis or forward flexion of the spine and a 50 degree loss of vertebral height, this could be considered an unstable fracture. And these are sometimes ones that we would not treat uh non-operatively, but possibly treat operatively. Some of the new literature has um disproved this, uh, and there's new evidence that are changing the beliefs regarding this. So anybody with any neurological deficits, I would definitely recommend getting further imaging on. Definitely something you want to check on all of these patients. Regarding treatment, a majority of these patients can be treated non-operatively. Um this does include modified activities, uh, trying to keep the patient in a more upright position as flexion of the trunk and or the lumbar spine tends to cause more pain. There is some literature that shows calcitonin can be used in the first four weeks to decrease pain within the area. Medical management can consist of bisphosphonates to help uh prevent future risk of fragility fractures within the area. And then extension back braces can often be used, but the compliance to these back braces is often quite poor because they are difficult to put on. Put the patient in an upright position, if not a slightly extended position, because again, pain will be exacerbated with forward flexion. Oftentimes I can just recommend to the patient not to do any forward flexion activities, especially under load, and this will typically cause exacerbation of symptoms. If this extension brace is too much for the patient, you can put them in a TLSO or an LSO type brace to just provide some support to the area, and oftentimes this can be enough for the patient. Regarding surgical intervention, there are a couple different types of surgeries, vertebal plasties and kyphoplastys that we can use for this. Both of these are used only in certain select patients as extravasation of the product can cause possible neuro deficits. If there is an unstable fracture, surgical decompression, a stabilization could be performed, but again, this is typically when we think the posterior lateral ligament or posterior middle column of the spine is effected and possibly going to create some instability within the back area. One thing to remember with these patients is that the incidence of a new fracture within the vertebral uh area is uh within that 15 to 20 percent rate within one year. Um so oftentimes uh these patients that do present with these incident-derived vertebral compression fractures can have a new fracture within one year. So again, advocating the treatment for bone health to reduce the risk of these fractures. As the patients develop more of these fractures, these increased risks of mortality and/or comorbidities can occur, and the pulmonary function risk can occur as well. It's documented that the one-year risk of mortality after vertebral compression fracture is approximately 15%, and the two-year risk of mortality is 20%. Now, if you look at these studies, most of these patients that had these higher risk of mortalities did have some sort of metabolic fragility prior to the fracture, uh, and so I think this did help to increase the risk of the mortality in these patients. Um, so if you do have a patient that has a physical frailty andor previous metabolic conditions that has these vertebral compression fractures, we do want to treat this from a multimodal perspective and make sure that their primary care is involved, that bone health is involved, and either you're following the patient closely. Again, just keep in mind that if you have a younger patient that has a vertebral compression fracture, this is typically associated with a trauma, want to make sure this gets a fully evaluation. A lot of these patients can be treated non-operatively. They do have quite a bit of pain, especially initially after the fracture um happens. Uh, treating the pain with um analgesics, bracing, um, limited activities, lifting restrictions can be quite helpful. So I thought this was a great case, you know, regarding a patient uh that came in with a um common finding with a vertebral compression fracture that we often see. Again, uh please uh follow us on um andor follow the podcast on social media, both on Instagram and on um Facebook. I also have a YouTube page. Uh the images for this patient, as well as some images associated with this uh podcast will be placed on the YouTube page. Hopefully I'll have that up shortly. Uh so maybe more of like a PowerPoint presentation. Uh if you're a visual learner, this may help you quite a bit. So look out for that YouTube page, uh on the go. Uh, and uh uh hopefully the images for this will be up there soon. Thank you.