Osteoporotic Fractures of the Thoracic and Lumbar Vertebrae
A systematic review
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Background: The prevalence of osteoporotic vertebral body fractures in Europe is 18–26%. Although most of these injuries can be treated conservatively, the underlying concepts have not been defined clearly or uniformly. In this article, we present the current state of the evidence on the diagnosis and conservative treatment of osteoporotic fractures of the thoracic and lumbar vertebrae.
Methods: A systematic review of the literature up to May 2020 was carried out in the PubMed and Web of Science Core Collection databases. 549 articles were identified, of which 36 were suitable for inclusion in the review. Articles were sought in the areas of diagnosis, provision of physical aids, pharmacotherapy, physiotherapy, and treatments from the realm of alternative medicine.
Results: The primary diagnostic technique was conventional x-ray in two planes (with the patient standing, if possible), which had 51.3% sensitivity and 75% specificity. If a fracture was suspected, magnetic resonance imaging (MRI) of the entire spine and regional computed tomography (CT) were carried out. The overall state of the evidence on treatment is poor; the best available evidence is for exercise therapy and physiotherapy, which are supported by three level I and four level II studies. Improvements were seen mainly in mobility and a reduced fear of falling. The use of an active orthosis can be useful as well. No evidence was found on the use of drugs or alternative medicine exclusively in the conservative treatment of osteoporotic vertebral body fractures.
Conclusion: It is reasonable to evaluate instability with imaging repeatedly, at regular intervals, over a period of six months. There is still a lack of reliable data on the optimal intensity and duration of physiotherapy, and on the use of orthoses.
The conservative treatment of vertebral body fractures of the thoracic and lumbar spine is inadequately defined. This is true for both traumatic fractures of normal vertebrae (1) and osteoporotic vertebral fractures. The prevalence of osteoporotic vertebral fractures is disproportionately higher—in Europe, prevalence rates vary between 18% and 26%, depending on the region; in Germany, women account for the majority of cases (factor 2.4) (2, 3). Given the high prevalence of osteoporosis and the aging of the population, this type of fracture is expected to increase significantly (5).
The guideline of the German Osteology Society (DVO, Dachverband Osteologie) uses the Genant classification to categorize the various types of vertebral fractures; however, in recent years the osteoporotic fracture (OF) classification has widely been adopted in the field of orthopedic and trauma surgery (6, 7). The OF classification system comprises five groups and is based on x-ray, computed tomography (CT) and magnetic resonance imaging (MRI) findings (Box). The OF classification describes fracture morphology. It spans from OF 1 fracture—intravertebral edema in MRI— to OF 5 fracture which is characterized by failure of the anterior and/or posterior tension band which corresponds to distraction/rotation injuries in patients with normal bone density. A study on 146 consecutively sampled fractures as well as six analysis demonstrated substantial reliability for the OF classification system (Kappa 0.63) (6). Designed to offer guidance for selecting treatment strategies, the OF score (eTable 1) takes, in addition to the OF classification, the clinical course and risk factors into account and recommends, based on the score obtained, either conservative treatment (<6 points) or surgical treatment (>6 points). The score could be used as a basis for uniform conservative treatment decisions. However, the content of conservative treatment is insufficiently clarified.
The aim of this review was to conduct a systematic search of the literature to identify studies on the conservative treatment of osteoporotic vertebral body fractures and to describe the current state of the evidence on the conservative treatment of osteoporotic fractures of the thoracolumbar spine and create recommendations for standardized conservative treatment of these fractures. Our medium-term goal is to initiate prospective studies based on these results to expand the body of evidence in this field and to scientifically strengthen the treatment strategy.
Material and methods
The literature was searched for acute vertebral body fractures without history of adequate trauma. The inclusion and exclusion criteria are listed in eTable 2.
A systematic independent review of the literature up to 3 May 2020 was performed by two of the authors (UJS, KJS) in the PubMed and Web of Science Core Collection databases. PROSPERO registration was obtained (registration no. CRD42020168694). Using the PICO scheme (8), the following review question was defined: In patients with osteoporotic thoracolumbar fractures treated conservatively, are certain diagnostic and therapeutic measures more appropriate to recommend than others? The search terms used are listed in the eBox. Subsequently, all original articles were reviewed (level of evidence , conclusions). The following subject areas were defined:
- Provision of physical aids/orthoses
- Physiotherapy and physical treatment strategies (physiotherapy, occupational therapy, physical therapy, exercise therapy/medical sports therapy)
- Alternative medicine treatments.
In total, 549 abstracts were retrieved. Of these, 452 articles were excluded based on the abstract or title. Most of the excluded articles were concerned with other pathologies or evaluated only surgical treatments. Altogether, 97 articles were read completely. Of these, further 61 articles had to be excluded after reading the entire manuscript. Based on the PRISMA flowchart, 514 articles were excluded, leaving 36 articles suitable for inclusion in the review (10) (eFigure). The 36 remaining original articles are summarized in Table 1 (11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, e1, e2, e3, e4, e5, e6). eTable 3 shows a quality assessment of the comparative studies and the cohort study. Details of the seven original articles with levels of evidence I and II from the area “Therapeutic measures“ are provided in Table 2. The Physiotherapy Evidence Database (PEDro) scale was used to assess the quality of the included randomized studies (e7). In the light of the low level of evidence of the included studies, it was decided to carry out a narrative review and discussion of the results; consequently, confounding factors were not systematically considered.
Primary diagnostic assessment
The primary diagnostic technique is conventional x-ray in two planes (with the patient standing, if possible). This approach achieved 51.3% sensitivity and 75.0% specificity; fractures were correctly diagnosed with a rate of 24.8% (11, 12). Thus, if a fracture was suspected, magnetic resonance imaging (MRI) was recommended to avoid under-treatment (11, 13, 14, 15, 16). In the conclusion of their registry study, Lenski et al. (14) recommended an MRI scan of the entire thoracic and lumbar spine with short-tau inversion recovery (STIR) sequences. Several studies used MRI-based prognostic estimates to establish the indication for conservative treatment (17, 18, 19, 20). Dual-energy x-ray absorptiometry (DXA) appears to be an alternative to MRI. However, a retrospective case series showed that the level of diagnostic quality came with a diagnostic accuracy of 95% only close to that of MRI if the images were interpreted by experienced radiologists (21). If MRI is contraindicated, skeletal scintigraphy can be performed; a retrospective case series found that acute osteoporotic vertebral body fractures were correctly diagnosed using this diagnostic technique in 96% of cases (22).
With regard to the timing and frequency of clinical and radiographic follow-up examinations, Abe et al. (23) showed in a prospective longitudinal study that at the 3-week, 6–8 week and 24-week follow-up assessments persistent instabilities of 4.9°, 2.9 and 1.8°, respectively, were identified in the comparative x-rays obtained in supine and standing positions.
The diagnosis of osteoporosis
In addition to DXA, volumetric bone density assessment with quantitative computed tomography (QCT) as well as abdominal CT allows to categorize bone density and to determine the risk of fracture (24, 25, 26, 27, 28, 29, 30). Large studies clearly showed that low T-score values in DXA were associated with osteoporotic singular or multiple vertebral body fractures and the extent of subsequent sintering (24). In a retrospective study, Yu et al. compared DXA values (lateral and anteroposterior views) and QCT values of 240 postmenopausal patients with regard to fracture manifestation (25). The results of each of the three methods were statistically significantly associated with the occurrence of osteoporotic fractures (25).
In addition, two studies evaluated whether lumbar CT scans obtained during fracture diagnosis were suitable as a method of detecting osteoporosis (29, 30). Here, a study on a cohort demonstrated a specificity of >90% in case of low Hounsfield units (HU) of <110 (29).
In a study comparing the efficacy of a dynamic orthosis versus a soft lumbar orthosis, Li et al. (31) demonstrated a comparable, statistically significant pain reduction and improvement in function without increase in kyphosis; however, the study did not include a patient group without orthosis. In a prospective case-control study, Meccariello et al. (32) compared conservative treatment with a dynamic orthosis versus a three-point brace. At the 3– and 6-month follow-ups, patients treated with a dynamic orthosis showed a statistically significant improvement in pain (mean pain at 6-month follow-up measured using a visual analog scale [VAS] was by 1.7 lower in the dynamic orthosis group; p<0.05) and in quality of life (difference in OLBPDQ score [OLBPDQ, Oswestry Low Back Pain Disability Questionnaire] of 6.1 at six-month follow-up) without statistically significant differences in radiographic outcome.
Only one study with a prospective longitudinal design was concerned with a precise analgesic treatment algorithm, based on the WHO analgesic ladder, in patients receiving conservative treatment (33).
In a large, prospective case-control study, Spechbach et al. (34) demonstrated advantages of initiating anti-osteoporotic diagnosis and treatment already in the hospital. One of these benefits was a significantly higher percentage of drug prescriptions after six months (69% versus 27%).
Physiotherapy and physical treatment strategies
Seven level I/II studies evaluated physiotherapy and physical treatment strategies (Table 2; 35–40, e1). Moderate quality evidence supported that physical exercise can improve physical performance (balance, strength and endurance of the extensor muscles of the spine) and can reduce pain and fear of falling; however, these studies had limitations (35, 36, 37, 38, 39).
In a randomized, controlled level II trial, Stanghelle et al. (36) found positive effects of a strength and balance exercise program on secondary endpoints, such as balance, but not on gait speed, the primary endpoint of the study. In a randomized, controlled level II trial, Evstigneeva et al. (37) reported statistically significant improvements in quality of life, mobility and balance (at 12-month follow-up: QUALLEFO-41 score: 44.6 ± 7.8 in the exercise group versus 56.6 ± 9.4 in the control group; p<0.0001 [QUALEFFO, Quality-of-Life Questionnaire]); the study included patients with fractures sustained within the past 6 months and did not document details of the activities of daily living in the control group.
In a randomized, controlled level II trial of 12 months of daily home exercise, Giangregorio et al. (40) found no statistically significant differences with regard to the number of falls and further fractures between the intervention group and the control group; the study population consisted primarily of high-risk patients and with 66% the adherence level was low. In a level I trial of a 12-week home exercise program, Barker et al. (e1) observed improvements in endurance and mobility at four months, especially among patients ≤= 70 years. These benefits were no longer detectable at twelve months; in addition, most participants did not reach the exercise intensity target and treatment adherence was poor.
In a prospective study on 106 patients, Weerink et al. (e2) evaluated the initial treatment after osteoporotic vertebral body fractures. Especially patients under 80 years of age were found to predominantly have good functional results after conservative treatment. A retrospective analysis did not find a functional difference between early mobilization and primary immobilization. However, an increased complication rate was observed after immobilization.
A limitation was that all of the discussed studies with a high level of evidence included patients with unknown fracture age or subacute fractures (>3 months) and thus did not reflect the primary phase of conservative treatment. Overall, effects shown for early initiated exercise therapy/physiotherapy were mainly positive; however, the strength of evidence with regard to optimum treatment density, length of treatment and specific treatment units is insufficient.
Alternative medicine interventions
No pertinent studies were found in the current literature.
From the perspective of orthopedic and trauma surgery, the OF classification has generally been shown to be an easier to apply and more surgically relevant system to classify osteoporotic fractures (5). On the basis of the OF classification, the Spine Section of the German Society for Orthopedics and Trauma Surgery (DGOU) also developed a score for the therapeutic indication and the subsequent surgical interventions (e8). This score provides clear indications for the surgical treatment of patients with relevant fracture instability or neurological deficits. A CT scan should be obtained to assess fracture morphology and fracture stability (6).
If conservative treatment is initiated, regular follow-up examinations are required. The authors of this study recommend to obtain standing follow-up radiographs after mobilization and at weeks one, three and six as well as later in the course, if symptoms persist.
At the time an osteoporotic fracture is diagnosed, neither a bone density scan nor a specific treatment of osteoporosis has been undertaken in up to 80% of the affected patients (e9). For the diagnosis of osteoporosis, the German Osteology Society (DVO) recommends a basic assessment after multiple minor fractures or after singular moderate or severe fractures (e10). The DVO uses the Genant classification to classify these fractures (7). The probability to have osteoporosis is increased 2 to >10 times after two or more grade 1 vertebral fractures (20%–25% vertebral height loss) or after one or more grade 2 or 3 vertebral body fractures (vertebral height loss >25 or 40%). For example, the odds ratio for the presence of osteoporosis in patients with a history of three vertebral body fractures is 21.2 (95% confidence interval: [7.1; 63.6]; 47.6% of those affected) and with a history of one grade 4 vertebral body fracture the odds ratio is 22.2 [8.3; 58.8] (24). The relative risk for occurrence of a fracture is shown in eTable 4.
The overall risk is determined based on a special medical history, taking into account risk factors, clinical examination, laboratory tests to rule out secondary osteoporosis, x-rays, and DXA bone density measurement. Since the risk of subsequent fractures is greatly increased in patients with a history of grade 2 or higher fractures, it is sufficient in these cases to rule out secondary osteoporosis and contraindication to pharmacotherapy to be able to start the initial therapy.
There is a lack of uniform strategies for the treatment of osteoporotic vertebral fractures due to the inadequacy of the available data. A systematic Cochrane review by Gibbs et al. (e11) showed that the effects of physical exercise after osteoporotic vertebral fracture have not been adequately studied.
Similarly, the optimum daily period of use of a dynamic orthosis has not been conclusively established. However, wearing a dynamic orthosis daily for 2–4 hours over a period of 3–6 months appears to be the most effective regimen (e12). Overall, there is evidence that chronification of pain after osteoporotic vertebral body fracture may occur in every second patient (e13). Specific analgesia as part of the conservative treatment of osteoporotic vertebral body fractures is in general inadequately defined; however, the DVO guideline mentions basic measures of pain therapy in patients with osteoporosis (e10).
The majority of studies on drug treatments for osteoporosis included not only patients with osteoporotic vertebral body fractures but other fractures as well; consequently, these studies were not suitable for inclusion in the review, but they will still be discussed here selectively. The indications for anti-osteoporotic therapy in the absence of risk factors are listed in eTable 5. For detailed information about individual anti-osteoporotic treatment planning, please refer to the current guideline of the DVO (e10). As a general rule, the specific active agent to be used should be selected based on the individual risk of the patient. Basic therapy with calcium and vitamin D is generally recommended. The DVO guideline should be used to estimate the individual risk (e14).
Based on current high (level I) evidence showing statistically significant reduction in the risk of new vertebral fractures compared to bisphosphonate treatment, osteoanabolic therapy with teriparatide and romosozumab was incorporated in the management of postmenopausal women at very high risk of fracture (e10, e15, e16). In addition, the use of romosozumab was found to be associated with a statistically significant reduction in non-vertebral fractures compared to treatment with teriparatide (e16). However, due its side effects, romosozumab is only approved for use in women without history of cardiovascular disease, such as myocardial infarction and stroke.
A longitudinal study of 1.2 million patients, evaluating anti-osteoporotic agents, showed a statistically significant reduction in the risk of clinical vertebral fractures within a 12-month period (e17). The relative reductions in fracture risk achieved with the osteoanabolic drug teriparatide, antiresorptive bisphosphonate therapy and denosumab were 64%, 23% and 51%, respectively (e17).
In summary, swift diagnostic evaluation and initiation of pharmacotherapy are essential elements of the conservative treatment of osteoporotic vertebral body fractures and should ideally be initiated already in the acute phase. Drugs should be selected on an individual basis, considering the patient’s risks (e.g. the risk of medication-related osteonecrosis of the jaw, among others) and the various contraindications of the agents.
Conventional radiography should be used for the initial assessment. If a fracture is suspected, magnetic resonance imaging (MRI) and computed tomography (CT) are indicated. Follow-up radiography at regular intervals (weeks 1, 3, 6, 12, and 26) is advisable. Anti-osteoporotic diagnosis and treatment should be initiated. Physiotherapy should be started early. The use of dynamic orthoses may be of advantage.
Conflict of interest statement
Prof. Heyde received royalties and consulting fees from Medacta International.
Prof. Maus received consulting fees and lecture fees from UCB, Amgen, Theramex, Lilly, Alexion, und Kyowa Kirin.
PD Osterhoff received consulting fees from Medtronic.
Dr. Schnake received consultant and author fees from Ottobock.
The remaining authors declare that no conflict of interest exists.
Manuscript received on 12 February 2021, revised version accepted on 13 July 2021
Translated from the original German by Ralf Thoene, MD.
Prof. Dr. med. Ulrich Spiegl
Klinik und Poliklinik für Unfall-, Wiederherstellungs-
und Plastische Chirurgie
Liebigstr. 20, 04103 Leipzig, Germany
Cite this as:
Spiegl U, Bork H, Grüninger S, Maus U, Osterhoff G, Scheyerer MJ, Pieroh P, Schnoor J, Heyde CE, Schnake KJ: Osteoporotic fractures of the thoracic and lumbar vertebrae: diagnosis and conservative treatment—
a systematic review. Dtsch Arztebl Int 2021; 118: 670–7.
► Supplementary material
eReferences, eBox, eTables, eFigure:
Rehabilitation Center, St. Josef-Stift Sendenhorst, Sendenhorst, Germany:
Dr. Hartmut Bork
Department of Orthopedic and Trauma Surgery, University Hospital of the Paracelsus Medical University (PMU), Nuremberg site, Nürnberg, Germany:
Dr. med. Sebastian Grüninger
Department of Orthopedic and Trauma Surgery, Special Orthopedic Surgery, Osteology (DVO, German Osteology Society), University Hospital of Düsseldorf, Düsseldorf, Germany: Prof. Dr. med.
Department of Orthopedics and Trauma Surgery, University Hospital Cologne, Cologne, Germany: PD Dr. Max J. Scheyerer
Department of Anesthesiology and Intensive Care Medicine, Paul Gerhardt Stift Hospital, Lutherstadt Wittenberg, Germany: PD Dr. med. habil. Jörg Schnoor MBA
Interdisciplinary Center for Spine and Scoliosis therapy. Malteser Waldkrankenhaus St. Marien, Erlangen, Germany:
Dr. med. Klaus J. Schnake
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