My mother has fractured vertebrae in her back several times. Is that common? How do I know if I fracture one of mine? How long will it take to heal?

Vertebral compression fractures (VCFs)[1] account for half of all fractures related to osteoporosis. Although VCFs can cause extreme pain, they can also be "silent." In fact, two-thirds of spinal fractures do not cause pain. Regardless of pain, VCFs can lead to major changes in your mother's life:

• VCFs can cause loss of height. Figure 14 shows an example of a spinal fracture, and Figure 6 (Question 18) shows the decrease in height as more vertebrae compress, shortening the spine.

• VCFs can bring about physiologic changes such as respiratory and gastrointestinal problems because the spine becomes compressed, which leads to pushing the body's internal organs together. Compression

Vertebral compression fracture.

Figure 14 Vertebral compression fracture.

of the organs can result in shortness of breath, pain, reflux, incontinence, and indigestion.

• VCFs can cause a decreased quality of life. Your mother may not be able to do the things she has always done for herself. If she works outside the home, she may not be able to do her job. At home, her activities may be limited due to her inability to bend, reach, lift, and go up and down stairs. It may be difficult for her to bathe and dress herself. Unfortunately, the effects on her quality of life can continue even after the fracture heals.

• There is a 12-fold increase in the risk of fracturing another vertebra within 1 year. The anticipation of new fractures can be very scary. The loss of independence can cause mental health problems and a loss of self-esteem.

• VCFs can cause both acute and chronic back pain and sleeplessness.

• VCFs can cause depression and anxiety.

• Death rates are higher among those who have vertebral fractures. There is a 5% to 10% increase in all causes of death following a vertebral fracture. Shockingly, after 5 years following a spinal fracture, death rates go up by 20% beyond the rate expected for a person's age and sex. Clearly, it is important to prevent these fractures, detect and treat them if they occur, prevent future fractures, and attend to mental and physical health following a VCF.

• The financial burden for VCFs can also be high. Being out of work following a VCF or taking time out of work to care for a loved one with a VCF contributes to the high cost of fractures. There may be expenses for required care that are not covered by Medicare, Medicaid, or other insurance. In fact, it's estimated that only 83% of the costs related to osteoporosis is paid for by any type of insurance.

Because VCFs don't always cause pain, you may have one and not know it. Sometimes VCFs are suspected when your height is measured at your physical exam. A loss of height can be the first indication that you have had a VCF. Chest x-rays can also reveal fractures that have not been previously diagnosed. In a recent study, a staggering 75% of vertebral fractures noted on chest x-rays were among older adults who were not being treated for osteoporosis! Question 12 lists the risk factors for osteoporosis, so you can request BMD testing of your spine before you get a fracture.

Because VCFs don't always cause pain, you may have one and not know it.

Although VCFs can sometimes be seen on conventional x-rays, they are often missed. Multiple fractures can be missed, too. So further evaluation is usually needed, especially if you are experiencing back pain or have unexplained height loss and a conventional x-ray doesn't show a fracture. VCFs can be managed a couple of ways. If you have not been on medications for osteoporosis, your clinician will likely suggest treatment with a bisphosphonate. Fosamax reduces the incidence of vertebral fractures by 47% after 3 years and Actonel by 41% to 49%. Fosamax, Actonel, Boniva, and Reclast all increase BMD in the spine in women who have an existing vertebral fracture. So, while your current fracture is healing, you could be preventing future fractures by taking a bisphosphonate. In addition, you may be treated with Miacalcin NS or Fortical (calcitonin nasal spray) because the calcitonin spray helps slow bone breakdown and has pain-killing effects. However, calcitonin nasal spray is not usually a first-line treatment choice. Rather, it is used when bisphosphonate therapy cannot be tolerated or when Evista or Forteo cannot be used. Menopause hormone therapy is not the best option to start when you have a vertebral fracture because MHT is used for prevention, not treatment.

A few clinicians might prescribe a back brace, which needs to be correctly fitted. The brace, usually worn during the hours you are awake, prevents your spine from twisting or bending so that the fractures can heal more easily. It also serves as an instant reminder not to bend forward, twist, or flex the spine. Figure 15 shows how a back brace is used to support the spine. A vertebral fracture can take from 6 to 8 weeks to heal. Although bed rest may be suggested initially, long stretches in bed are not recommended and do not heal fractures any faster. Your muscles can become very weak by staying in bed, which makes you less likely to tolerate activity and exercise. While back braces and bed rest were commonly used in the past, they are rarely recommended now because the risks of inactivity and the benefits of maintaining activity have been better recognized. In fact, bone loss that occurs while you are in bed is substantial. Vertebral bone loss in older adults on bed rest accelerates to 50 times the rate that occurs in young adults.

Example of a brace that provides support to the spine after a vertebral compression fracture.

Figure 15 Example of a brace that provides support to the spine after a vertebral compression fracture.

Some clinicians will x-ray the spine again to determine progress. If you are no longer in pain, it doesn't necessarily mean that the fracture has healed completely, as many vertebral fractures do not cause pain in the first place. How you are feeling is the biggest guide for activity. You should slowly resume your normal activities as soon as possible, and avoid extended periods of inactivity. Your clinician likely will also want to monitor your bone density and measure your height regularly to screen for possible additional VCFs.

  • [1] A fracture of the body of a vertebra (spine bone) that collapses it and makes it thinner and weaker. Usually results from osteoporosis but can also result from complications of cancer or some injuries.
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