Vertebral Compression Fracture: Symptoms, Causes & Treatment

What Is a Vertebral Compression Fracture?

A vertebral compression fracture is a break in one of the bones (vertebrae) of the spine that causes the vertebra to collapse or become compressed. This results in loss of vertebral height and can cause sudden, severe back pain. The fractures most commonly affect the thoracolumbar junction (where the mid-back meets the lower back) and are frequently caused by osteoporosis.

The human spine consists of 33 vertebrae stacked on top of each other, providing structural support for the body while protecting the spinal cord. When a vertebra experiences a compression fracture, the front of the vertebral body typically collapses more than the back, creating a wedge-shaped deformity. This collapse occurs when the forces applied to the vertebra exceed its structural strength, which can happen with relatively minor trauma in bones weakened by osteoporosis or through significant force in healthy bones.

Vertebral compression fractures are among the most common osteoporotic fractures, affecting an estimated 1.4 million people worldwide each year. In the United States alone, approximately 750,000 vertebral fractures occur annually, though many go undiagnosed because people attribute the pain to normal aging or muscle strain. The thoracic spine (particularly vertebrae T7-T12) and the upper lumbar spine (L1-L2) are the most commonly affected regions, as they bear significant weight and stress during daily activities.

The clinical significance of vertebral compression fractures extends beyond immediate pain. Each fracture increases the risk of subsequent fractures fivefold, creating a cascade effect that can lead to progressive spinal deformity, chronic pain, reduced lung capacity, and significant decreases in quality of life. Understanding the causes, recognizing the symptoms early, and implementing appropriate treatment can help prevent these complications and maintain spinal health.

Vertebral Compression Fractures and Osteoporosis

The relationship between osteoporosis and vertebral compression fractures is fundamental to understanding this condition. Osteoporosis, meaning "porous bone," is a systemic skeletal disease characterized by low bone mass and deterioration of bone tissue microarchitecture. This leads to increased bone fragility and susceptibility to fractures, particularly in the spine, hip, and wrist.

In healthy bone, a continuous process of remodeling occurs where old bone is removed (resorption) and new bone is formed. Osteoporosis develops when bone resorption outpaces bone formation, resulting in net bone loss. This imbalance accelerates in women after menopause due to declining estrogen levels, which normally help protect bone density. By age 80, many individuals have lost 30-40% of their peak bone mass, making their vertebrae vulnerable to fracture from minimal trauma.

When osteoporosis is present, vertebral compression fractures can occur from activities that would normally be harmless, such as bending forward, lifting a moderately heavy object, coughing forcefully, or even simply getting out of bed. The weakened trabecular (spongy) bone within the vertebral body cannot withstand these everyday forces, leading to sudden collapse.

Traumatic Compression Fractures

While osteoporosis accounts for the majority of vertebral compression fractures, traumatic fractures occur when healthy vertebrae are subjected to forces that exceed their structural capacity. High-energy trauma such as motor vehicle accidents, falls from significant heights, or sports injuries can cause compression fractures in individuals with normal bone density.

Traumatic compression fractures often differ from osteoporotic fractures in several ways. They typically affect younger individuals with healthy bones, may involve multiple vertebrae simultaneously, and are more likely to be associated with other injuries to the spine or body. The fracture pattern may also differ, with traumatic fractures sometimes showing burst patterns where bone fragments may migrate into the spinal canal, potentially threatening the spinal cord.

What Are the Symptoms of a Vertebral Compression Fracture?

The primary symptom of a vertebral compression fracture is sudden, severe back pain that typically occurs immediately after the fracture. The pain worsens with standing, walking, and movement, while lying down often provides relief. Other symptoms include muscle spasms, height loss over time, and development of a hunched posture (kyphosis).

The symptoms of vertebral compression fractures can vary significantly depending on the severity of the fracture, the number of vertebrae involved, and whether the fracture is acute (recent) or chronic (old). Some individuals experience dramatic symptoms that bring them to seek immediate medical care, while others may have gradual, insidious symptoms that are attributed to normal aging or degenerative changes.

The hallmark symptom of an acute vertebral compression fracture is sudden onset of localized back pain. This pain typically develops immediately or within hours of the causative event, which may be as obvious as a fall or as subtle as bending to pick something up. The pain is characteristically severe during the acute phase, often described as sharp, stabbing, or knife-like. Patients frequently can identify the exact level of their spine where the fracture occurred because pressing on that area elicits significant tenderness.

Movement exacerbates the pain of vertebral compression fractures. Standing, walking, bending, and twisting all increase the load on the fractured vertebra and intensify discomfort. Conversely, lying flat typically provides substantial relief as it removes the compressive forces from the spine. This pattern of mechanical pain that worsens with activity and improves with rest is characteristic of vertebral compression fractures and helps distinguish them from other causes of back pain.

Progressive Symptoms and Height Loss

Beyond the acute pain phase, vertebral compression fractures lead to structural changes that develop over weeks to months. Each fractured vertebra loses height as it collapses, and this height loss is permanent even after the fracture heals. A single fracture typically results in 1-2 centimeters of height loss, but individuals with multiple fractures may lose several inches over years.

As vertebrae in the thoracic spine collapse, particularly when multiple levels are affected, a characteristic forward curvature called kyphosis develops. This "dowager's hump" or "hunchback" appearance results from the cumulative wedging of multiple vertebrae and becomes increasingly pronounced with each additional fracture. Kyphosis not only affects appearance but also has functional consequences, including difficulty looking forward while walking, reduced lung capacity, and altered center of gravity that increases fall risk.

When Symptoms Are Absent

Remarkably, approximately two-thirds of vertebral compression fractures cause minimal symptoms and go undiagnosed. These "silent" fractures are often discovered incidentally when spinal X-rays or CT scans are performed for other reasons. The lack of symptoms may occur because the fracture develops gradually, allowing the body to adapt, or because the individual has a high pain tolerance or attributes their discomfort to other causes.

However, even asymptomatic fractures have significant implications. They indicate underlying bone weakness, dramatically increase the risk of future fractures, and contribute to progressive height loss and postural changes. Recognition of these silent fractures is an important opportunity to diagnose osteoporosis and initiate treatment to prevent more severe symptomatic fractures in the future.

When Should You Seek Medical Care?

Seek medical care promptly if you experience sudden, severe back pain, especially after a fall or minor trauma. Seek emergency care immediately if back pain is accompanied by numbness or tingling around the buttocks or genitals, weakness or numbness in both legs, or loss of bladder or bowel control, as these symptoms may indicate spinal cord compression requiring urgent treatment.

Determining when to seek medical care for back pain can be challenging, as back pain is extremely common and most episodes resolve without medical intervention. However, certain features of the pain and accompanying symptoms should prompt evaluation for possible vertebral compression fracture.

You should contact a healthcare provider if you experience back pain that began suddenly after a fall, injury, or even minor activity, particularly if you are over age 50 or have risk factors for osteoporosis. Pain that is severe enough to limit your daily activities, pain that does not improve with rest and over-the-counter medications, or pain associated with noticeable changes in posture or height all warrant medical evaluation.

The urgency of seeking care depends largely on the presence of neurological symptoms. While compression fractures themselves rarely cause spinal cord injury (because they typically affect the front of the vertebra while the spinal cord travels through the back), severe fractures or fractures associated with tumors can occasionally compromise the spinal canal and affect nerve function.

What Causes Vertebral Compression Fractures?

Osteoporosis is the most common cause of vertebral compression fractures, accounting for approximately 70% of cases. Other causes include trauma (falls, accidents), cancer that has spread to the spine (metastatic disease), and conditions that weaken bones such as long-term corticosteroid use. In osteoporotic bone, fractures can occur from minimal trauma like bending, coughing, or lifting.

Understanding the underlying causes of vertebral compression fractures is essential for both treatment and prevention. While the immediate mechanism is always excessive force applied to the vertebra relative to its structural strength, the factors that create this vulnerability vary considerably and have important implications for management.

Osteoporosis remains the predominant cause of vertebral compression fractures, particularly in postmenopausal women and older adults of both sexes. The insidious nature of osteoporosis means that significant bone loss often occurs without symptoms until a fracture occurs. Risk factors for osteoporosis include advancing age, female sex, Caucasian or Asian ethnicity, family history of osteoporosis, low body weight, smoking, excessive alcohol consumption, sedentary lifestyle, and low calcium and vitamin D intake.

Secondary osteoporosis refers to bone loss caused by underlying medical conditions or medications. Long-term use of corticosteroids (prednisone, prednisolone) for conditions like asthma, rheumatoid arthritis, or inflammatory bowel disease significantly increases fracture risk, sometimes even at relatively low doses. Other conditions associated with secondary osteoporosis include hyperthyroidism, hyperparathyroidism, celiac disease, inflammatory bowel disease, chronic kidney disease, and certain cancer treatments.

Traumatic Causes

In individuals with normal bone density, vertebral compression fractures typically require significant force to occur. Motor vehicle accidents, particularly those involving rapid deceleration, can transmit tremendous axial (top-to-bottom) forces through the spine. Falls from height, especially landing on the feet or buttocks, concentrate force through the vertebral column. Sports injuries, particularly those involving axial loading such as diving into shallow water, football collisions, or skiing accidents, can cause compression fractures in young, healthy individuals.

The mechanism of injury often determines the fracture pattern. Pure axial compression tends to cause wedge-shaped deformities where the front of the vertebra collapses. Higher-energy injuries may cause burst fractures where the entire vertebral body shatters, potentially sending bone fragments into the spinal canal. Understanding the mechanism helps physicians assess the stability of the fracture and the need for surgical intervention.

Pathological Causes

Vertebral compression fractures can also occur when bones are weakened by diseases other than osteoporosis. Cancer that has spread (metastasized) to the spine is a particularly important cause to consider, especially in individuals with known cancer history or those with fractures without obvious trauma. The spine is one of the most common sites for cancer metastases, with breast, prostate, lung, kidney, and thyroid cancers frequently spreading to vertebrae.

Primary bone tumors, multiple myeloma, and certain infections (vertebral osteomyelitis) can also weaken vertebrae sufficiently to cause pathological fractures. These causes require specific investigation and treatment beyond standard osteoporosis management, highlighting the importance of thorough medical evaluation after any vertebral fracture.

How Is a Vertebral Compression Fracture Diagnosed?

Diagnosis begins with physical examination showing point tenderness over the affected vertebra and restricted spinal movement. Spinal X-rays confirm the fracture and show vertebral height loss. MRI distinguishes acute from chronic fractures and rules out tumors. Bone density testing (DEXA scan) is performed to diagnose osteoporosis and guide treatment decisions.

Accurate diagnosis of vertebral compression fractures involves correlating clinical symptoms with appropriate imaging studies. The diagnostic process aims not only to confirm the presence of a fracture but also to determine its age, identify the underlying cause, assess stability, and guide treatment decisions.

The physical examination begins with observation of posture and gait. Patients with acute fractures often move cautiously and may hold their back stiffly to minimize pain. Visible kyphosis may indicate previous fractures. Palpation of the spine typically reveals point tenderness directly over the fractured vertebra, and gentle percussion may elicit pain. Range of motion testing usually shows restriction, particularly in forward flexion. Neurological examination assessing strength, sensation, and reflexes in the legs is essential to rule out spinal cord or nerve root involvement.

Imaging Studies

Plain X-rays of the spine are typically the first imaging study obtained and are often sufficient to diagnose vertebral compression fractures. Lateral (side) views show the characteristic loss of vertebral height and wedge-shaped deformity. The degree of compression can be quantified by comparing the height of the fractured vertebra to adjacent normal vertebrae. X-rays also reveal features suggesting specific causes, such as the "punched out" lesions of multiple myeloma or the irregular destruction pattern of metastatic disease.

Magnetic resonance imaging (MRI) provides crucial additional information that X-rays cannot offer. Most importantly, MRI can distinguish between acute (recent) and chronic (old) fractures based on the presence or absence of bone marrow edema (swelling within the bone). This distinction matters because it confirms that the visualized fracture is responsible for current symptoms and helps guide treatment decisions. MRI also excellently evaluates for tumors, infections, and spinal cord compression.

Computed tomography (CT) scanning offers detailed visualization of bone architecture and fracture patterns. CT is particularly valuable for assessing the posterior wall of the vertebral body (which faces the spinal canal) and determining fracture stability. It may also reveal fractures not visible on plain X-rays, particularly in complex spinal injuries.

Bone Density Testing

Dual-energy X-ray absorptiometry (DEXA) scanning measures bone mineral density and is the standard test for diagnosing osteoporosis. After any vertebral compression fracture, bone density testing should be performed to assess for osteoporosis and quantify fracture risk. The DEXA results, expressed as a T-score comparing the patient's bone density to that of a healthy young adult, guide decisions about osteoporosis treatment to prevent future fractures.

How Are Vertebral Compression Fractures Treated?

Treatment begins with conservative measures including pain medication, short-term rest followed by early mobilization, and physical therapy for core strengthening. Bracing may provide support during healing. Osteoporosis medications are essential to prevent future fractures. For severe, persistent pain that doesn't respond to conservative treatment, vertebroplasty or kyphoplasty may be considered.

The treatment of vertebral compression fractures has evolved significantly over the past two decades. The goals of treatment are to relieve pain, promote healing, maintain or restore function, prevent future fractures, and address the underlying cause. Most patients are managed successfully with conservative (non-surgical) treatment, though interventional procedures are available for those who do not respond adequately.

Pain management is the immediate priority for patients with acute vertebral compression fractures. Initial treatment typically includes over-the-counter analgesics such as acetaminophen (paracetamol) or non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen. For more severe pain, physicians may prescribe stronger medications including opioid analgesics for short-term use, muscle relaxants to address associated muscle spasms, or medications specifically designed for bone pain such as calcitonin nasal spray.

Activity modification is important during the acute healing phase, but prolonged bed rest should be avoided. While lying flat provides pain relief, extended immobility leads to rapid additional bone loss, muscle weakness, deconditioning, and increased risk of complications such as blood clots and pneumonia. Current recommendations suggest limiting rest to short periods as needed for pain control while encouraging progressive mobilization as tolerated.

Physical Therapy and Rehabilitation

Physical therapy plays a crucial role in recovery from vertebral compression fractures. During the acute phase, gentle movements and positioning strategies help maintain mobility while minimizing pain. As healing progresses, physical therapists guide patients through exercises designed to strengthen the core musculature (abdominal and back muscles) that supports the spine, improve posture, enhance balance, and reduce fall risk.

Specific exercise programs for individuals with vertebral fractures emphasize extension exercises (bending backward) while avoiding flexion exercises (bending forward) that increase stress on the anterior vertebral body. Exercises like prone lying, gentle back extensions, and shoulder blade squeezes help counteract the tendency toward kyphosis. Balance training is essential for fall prevention, as falls are a major cause of additional fractures in individuals with osteoporosis.

Bracing

Spinal braces or orthoses may be recommended during the healing phase of vertebral compression fractures, though their benefit remains somewhat controversial. Theoretically, braces provide external support to reduce spinal loading, remind patients to maintain good posture, and limit painful movements. Common types include thoracolumbosacral orthoses (TLSO) for thoracic and upper lumbar fractures and lumbosacral orthoses (LSO) for lower lumbar fractures.

However, prolonged brace use can lead to muscle weakness and dependency, so braces are typically recommended for limited periods (6-12 weeks) and combined with physical therapy to maintain muscle function. The decision to use bracing should be individualized based on pain severity, fracture location and stability, and patient factors.

Interventional Procedures

For patients with severe, persistent pain that does not respond adequately to conservative treatment after 4-6 weeks, minimally invasive vertebral augmentation procedures may be considered. These procedures involve injecting bone cement (polymethylmethacrylate) into the fractured vertebra to stabilize it and provide pain relief.

Vertebroplasty involves inserting a needle through the skin into the fractured vertebral body under fluoroscopic (X-ray) guidance and injecting bone cement directly into the compressed bone. The cement hardens within minutes, stabilizing the fracture. The procedure is typically performed as an outpatient under local anesthesia with sedation.

Kyphoplasty is similar to vertebroplasty but includes an additional step: before injecting cement, an inflatable balloon is inserted into the vertebral body and expanded to create a cavity and potentially restore some vertebral height. The balloon is then removed, and cement is injected into the created space. Kyphoplasty may offer theoretical advantages in reducing cement leakage and restoring spinal alignment, though it is more expensive than vertebroplasty.

How Can You Prevent Vertebral Compression Fractures?

Prevention focuses on maintaining strong bones throughout life through regular weight-bearing and resistance exercise, adequate calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) intake, avoiding smoking, and limiting alcohol consumption. Fall prevention strategies are essential, including home safety modifications and balance exercises. Osteoporosis medications significantly reduce fracture risk in those with low bone density.

Prevention of vertebral compression fractures operates on two levels: primary prevention aimed at maintaining bone health and preventing osteoporosis, and secondary prevention focused on preventing additional fractures in those who have already sustained one. Both approaches emphasize lifestyle factors, fall prevention, and appropriate medical treatment.

Building and maintaining strong bones throughout life is the foundation of primary prevention. Peak bone mass is typically achieved by age 30, and the skeleton developed during childhood, adolescence, and early adulthood represents the "bone bank" that must last a lifetime. Lifestyle factors that optimize peak bone mass and slow subsequent bone loss include regular physical activity, adequate nutrition, avoiding harmful substances, and addressing modifiable risk factors.

Exercise for Bone Health

Physical activity is one of the most effective interventions for maintaining bone health. Bones respond to mechanical loading by becoming stronger, following Wolff's law that bone adapts to the stresses placed upon it. The most beneficial exercises for bone health are weight-bearing activities (where you support your body weight through your feet and legs) and resistance exercises (where you work against an opposing force).

Weight-bearing exercises include walking, jogging, hiking, climbing stairs, tennis, and dancing. These activities transmit forces through the skeleton that stimulate bone formation. Resistance training using weights, resistance bands, or body weight exercises builds muscle mass and strength while also loading bones at muscle attachment sites. A comprehensive exercise program should include both types of activity performed at least 3-4 times weekly.

For individuals with existing osteoporosis or prior vertebral fractures, exercise selection requires more care. High-impact activities and exercises that involve forward bending of the spine should generally be avoided as they may increase fracture risk. Instead, emphasis should be placed on extension exercises, gentle strengthening, balance training, and low-impact activities like walking or swimming.

Nutrition for Bone Health

Adequate calcium and vitamin D intake are essential for bone health at all ages. Calcium is the primary mineral component of bone, while vitamin D is necessary for calcium absorption from the intestine. Insufficient intake of either nutrient leads to weakened bones and increased fracture risk.

Current recommendations suggest daily calcium intake of 1000 mg for adults aged 19-50 and men aged 51-70, increasing to 1200 mg for women over 50 and men over 70. Dietary sources of calcium include dairy products, calcium-fortified foods, leafy green vegetables, and canned fish with bones. When dietary intake is insufficient, calcium supplements can help meet requirements.

Vitamin D requirements are 600-800 IU daily for most adults, with some experts recommending 1000-2000 IU for those at risk of deficiency. Vitamin D is synthesized in the skin with sun exposure and obtained from fatty fish, fortified foods, and supplements. Many people, particularly those living at northern latitudes or spending limited time outdoors, require supplements to maintain adequate vitamin D levels.

Fall Prevention

Falls are a major cause of fractures in people with osteoporosis, making fall prevention a crucial component of fracture prevention strategy. Fall prevention involves addressing intrinsic factors (related to the individual) and extrinsic factors (related to the environment).

Intrinsic factors that increase fall risk include muscle weakness, balance problems, vision impairment, medications that cause dizziness or drowsiness, and medical conditions affecting mobility. Addressing these factors through strength and balance exercises, vision correction, medication review, and treatment of underlying conditions can significantly reduce fall risk.

Environmental modifications to reduce fall risk include removing loose rugs and electrical cords from walkways, ensuring adequate lighting especially at night, installing grab bars in bathrooms, using non-slip mats in tubs and showers, and keeping frequently used items within easy reach. For individuals at high fall risk, assistive devices such as canes or walkers may be appropriate.

What Medications Treat Osteoporosis to Prevent Fractures?

Osteoporosis medications significantly reduce fracture risk. Bisphosphonates (alendronate, risedronate, zoledronic acid) are first-line treatments that slow bone loss. Denosumab is an injectable option for those who cannot take bisphosphonates. Anabolic agents (teriparatide, romosozumab) build new bone and are used for severe osteoporosis. Medication choice depends on individual factors and fracture risk.

For individuals with osteoporosis, particularly those who have already sustained a vertebral compression fracture, medication therapy is essential to reduce the risk of future fractures. Several classes of medications are available, each working through different mechanisms to improve bone strength.

Bisphosphonates are the most commonly prescribed medications for osteoporosis. They work by inhibiting bone resorption, slowing the natural breakdown of bone and allowing bone formation to gradually restore bone density. Options include oral medications taken daily (alendronate, risedronate), weekly, or monthly, as well as intravenous formulations given quarterly (ibandronate) or annually (zoledronic acid). Bisphosphonates reduce vertebral fracture risk by approximately 40-70% over 3 years of treatment.

Denosumab is a monoclonal antibody given as a subcutaneous injection every six months. It works by blocking RANKL, a protein essential for the development and activity of bone-resorbing cells. Denosumab is particularly useful for patients who cannot tolerate or have contraindications to bisphosphonates. It produces rapid improvements in bone density and significantly reduces fracture risk.

Anabolic agents represent a different approach to osteoporosis treatment. Unlike antiresorptive medications that slow bone loss, anabolic agents actively stimulate new bone formation. Teriparatide and abaloparatide are parathyroid hormone analogs given as daily injections that dramatically increase bone density. Romosozumab, a newer agent, both increases bone formation and decreases bone resorption. These medications are typically reserved for severe osteoporosis or patients who have fractured while on other treatments.

What Is the Long-Term Outlook for Vertebral Compression Fractures?

Most vertebral compression fractures heal within 8-12 weeks, with significant pain improvement in 2-4 weeks. The vertebra heals in a compressed position, resulting in permanent height loss. One compression fracture increases the risk of subsequent fractures fivefold. With appropriate treatment including osteoporosis medication and lifestyle modifications, further fractures can often be prevented.

Understanding the natural history and long-term prognosis of vertebral compression fractures helps patients set realistic expectations and emphasizes the importance of prevention and treatment. While most fractures heal successfully with conservative management, the implications extend beyond the healing of an individual fracture.

The acute pain from a vertebral compression fracture typically begins to improve within 2-4 weeks as the initial inflammatory response subsides and early healing begins. Most patients experience substantial pain relief by 6-8 weeks, though some discomfort may persist longer. The fracture itself generally heals within 8-12 weeks, though the vertebra heals in its collapsed position, resulting in permanent loss of vertebral height.

Chronic pain affects a minority of patients following vertebral compression fractures. Approximately 30% of individuals continue to experience some degree of pain beyond one year after the fracture. Risk factors for chronic pain include more severe initial pain, multiple fractures, depression, and inadequate treatment of underlying osteoporosis. Comprehensive management addressing physical, psychological, and social factors optimizes outcomes for these patients.

Perhaps the most important prognostic consideration is the risk of future fractures. Having one vertebral compression fracture increases the risk of another by approximately fivefold. This "fracture cascade" can lead to progressive spinal deformity, chronic pain, respiratory compromise from reduced lung expansion, and significant impairment in quality of life. Aggressive treatment of osteoporosis following an initial fracture is therefore essential to interrupt this cascade and preserve long-term function.