Conditions · Spine surgery · Lainate
Osteoporosis and vertebral fractures: from sudden pain to vertebroplasty
Someone gets out of bed, lifts a shopping bag or coughs hard, and feels a dull, deep pain in the middle of the back, without any fall. In many cases, behind this picture lies a fragility fracture of a vertebra, the most typical consequence of osteoporosis.
What osteoporosis is
It is a skeletal disease in which bone loses mass and quality. Inside the vertebrae, bone is a dense network of thin struts, the trabeculae: with osteoporosis they become thinner and break, and the vertebra becomes like an emptied sponge. Osteoporosis itself is not painful: it is silent for years and often shows itself only when something breaks.
How a vertebra breaks without an injury
In osteoporotic bone, the loads of everyday life are enough: bending, lifting a modest weight, a cough. The vertebral body gives way and collapses, most often at the front. The pain is dull and deep, worse when standing and better when lying down; over time, a loss of height or a more rounded back may be noticed. A consultation is needed and, usually, an Magnetic resonance imaging (MRI), which shows whether the fracture is recent.
Vertebroplasty: how it works
It is a minimally invasive procedure: under local anaesthesia or sedation and X-ray guidance, a thin needle enters from the back through the pedicle and injects bone cement (PMMA), which fills the spaces between the trabeculae and, hardening within a few minutes, strengthens the vertebra from the inside.
Vertebroplasty or kyphoplasty?
In kyphoplasty a small balloon is first inflated inside the vertebra to create a cavity and restore some of its height, and then the cement is injected. In the randomised FREE trial, kyphoplasty improved quality of life at one month compared with non-surgical care alone [4]. The choice between the two techniques depends on the type and age of the fracture.
What the studies say
The evidence is not entirely consistent. The VAPOUR trial, on acute painful fractures, showed a benefit on pain compared with a sham procedure [2]; the VERTOS IV trial, with a similar design, found no significant differences [3]. This is why the procedure should be offered in selected cases, after careful assessment, and never as a substitute for treating the osteoporosis.
The DXA bone density scan: how to read it
Bone mineral densitometry (DXA scan) measures bone density at the spine and hip. According to WHO criteria [1]: T-score ≥ -1 normal; between -1 and -2.5 osteopenia; ≤ -2.5 osteoporosis. Anyone who has already had a fragility fracture has a high risk of further fractures.
Treating the bone
Repairing the vertebra is only half the job: the other half is reducing the risk of subsequent fractures. In the FREEDOM trial, denosumab significantly reduced new vertebral fractures compared with placebo [5]. It must never be stopped on your own initiative: when it is discontinued, the risk of multiple vertebral fractures increases [6]. Any change in treatment should be decided with the specialist.
Videos by Dr. Lavanga
Osteoporosis and collapsing vertebrae: vertebroplasty explained
Vertebral fracture repaired with percutaneous vertebroplasty
Vertebral fractures: the complete guide
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Related articles
Scientific references (PubMed)
- Kanis JA et al. The diagnosis of osteoporosis. J Bone Miner Res. 1994. PMID 7976495
- Clark W et al. Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet. 2016. PMID 27544377
- Firanescu CE et al. Vertebroplasty versus sham procedure for painful acute osteoporotic vertebral compression fractures (VERTOS IV): randomised sham controlled clinical trial. BMJ. 2018. PMID 29743284
- Wardlaw D et al. Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. Lancet. 2009. PMID 19246088
- Cummings SR et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med. 2009. PMID 19671655
- Cummings SR et al. Vertebral Fractures After Discontinuation of Denosumab: A Post Hoc Analysis of the Randomized Placebo-Controlled FREEDOM Trial and Its Extension. J Bone Miner Res. 2018. PMID 29105841
Information only: this does not replace a medical consultation, diagnosis or personalised treatment.