Osteoporotic Spinal Fractures

A condition guide by Mr Mohammed Madi, Consultant Orthopaedic & Spinal Surgeon.

An osteoporotic spinal fracture — also called a vertebral compression or fragility fracture — is the collapse or wedging of one of the building-block bones of the spine, caused by bone that has been weakened by osteoporosis. They are the commonest fracture caused by thin bones, and they are often missed, because many cause little or no pain at the time. Two ideas matter most in this guide. First, the great majority of these fractures are not dangerous to the nerves, and the pain settles over a few weeks. Second, and most importantly, a spinal fragility fracture is a warning sign: it means the underlying osteoporosis is typically assessed and treated, because that is what prevents the next fracture.

Each vertebra has a solid, weight-bearing block of bone at the front called the vertebral body. When bone becomes osteoporotic — thinner and more fragile — that block can give way and collapse, losing height. This is a fragility, or low-energy, fracture: it happens with little or no force that would never break a healthy bone, such as bending forward, lifting, a cough or sneeze, a heavy step or a minor stumble, and sometimes with no memorable event at all. These fractures occur most often in the middle and lower part of the mid-back and at the junction between the chest and the lower back, where the spine carries the most load. Crucially, the collapse is usually at the front of the vertebra, while the back of the bone — which surrounds the spinal cord and nerves — is usually spared, which is why most of these fractures are mechanically stable and rarely affect the nerves.

In plain terms: the front block of a spinal bone, weakened by osteoporosis, crumples a little. It is usually stable and not dangerous to the nerves, but it is a clear sign that the bones need attention.

Osteoporosis means bone that has lost both density and quality, leaving it fragile and prone to fracture. Bone naturally thins with age, and in women the fall in oestrogen at the menopause accelerates this, which is why osteoporosis and these fractures are especially common in older women — though older men are affected too. There are also important secondary causes, the commonest being long-term steroid (glucocorticoid) treatment, along with a range of hormonal, digestive, inflammatory and other conditions and medicines. The main risk factors are increasing age, being female, a previous fragility fracture, a parental history of hip fracture, steroid use, smoking, heavy alcohol intake, a low body weight, and a tendency to fall. Risk can be estimated formally with tools such as FRAX or QFracture.

The classic picture is sudden back pain coming on after some trivial activity, felt at the level of the fracture in the mid-back or thoracolumbar region, worse on moving, standing or bearing weight, and eased by lying down. But — and this is important — many of these fractures cause little or no pain and are found by chance on a scan or X-ray done for another reason. In fact, around two-thirds are clinically silent and never formally diagnosed at the time. Over the longer term, repeated fractures can cause chronic back pain, a gradual loss of height, and a progressive forward curve of the upper back, sometimes called a dowager's hump, with a stooped posture. In severe, multiple-level disease this deformity can affect breathing, balance and appetite. Pressure on the nerves is uncommon, because these fractures are usually stable.

Some features suggest the fracture may not be a simple osteoporotic one and need prompt assessment. A fracture in a younger person, or after no real trauma in someone not known to have osteoporosis, raises the question of another cause such as a cancer deposit, myeloma or infection, and the same applies to unexplained weight loss, fever, pain at rest or at night, or a history of cancer. Any new weakness or numbness in the legs, or disturbance of bladder or bowel control, is uncommon with these fractures but needs urgent assessment, because it can mean pressure on the nerves or spinal cord. An important principle is that a collapsed vertebra can occasionally be the first sign of an underlying cancer, so where there is any doubt these causes are actively excluded.

Assessment begins with the history and an examination, including measuring height against a person's recalled adult height and looking for a developing curve. A standing X-ray of the spine is the usual first test, showing the wedging and loss of height. An MRI scan is the best test to confirm that a fracture is recent and active — it shows fluid (oedema) in the bone of a fresh fracture, distinguishes a new fracture from an old healed one, and helps exclude cancer or infection. A CT scan gives fine bone detail when needed. A bone-density (DEXA) scan confirms and measures the osteoporosis and guides treatment, and blood tests are used to look for secondary causes and to exclude conditions such as myeloma. Identifying the fracture is only half the job; confirming and treating the underlying osteoporosis is the other, equally important, half.

This is the reassuring part. Most acute osteoporotic fractures heal, and the acute pain settles, over roughly six to twelve weeks, with steady improvement as the bone heals. A minority go on to develop more persistent pain — from residual deformity, the curve of the spine, and the muscles working to compensate — or a progressive deformity, and some people fracture again during recovery. But for the great majority, the fracture itself heals. What it leaves behind is the most important message of all: it is a flag that the bones are fragile, and treating that fragility is where the greatest benefit lies, because it markedly reduces the chance of the next fracture.

For most people, an osteoporotic fracture is managed without any operation. Pain is controlled with sensible, stepped pain relief, starting with paracetamol and using anti-inflammatories cautiously and short courses of stronger painkillers only if needed. Just as important is keeping moving: early, gentle mobilisation and physiotherapy, working on posture and on strengthening the back, are encouraged, because prolonged bed rest worsens bone loss and stiffness. A back brace is sometimes used for short-term comfort in selected people, though the evidence for braces is limited. Attention to preventing falls is part of the plan.

Running alongside pain relief, and arguably more important than it, is treatment of the underlying osteoporosis to prevent future fractures. This means ensuring enough calcium and vitamin D, and starting a bone-protecting medicine — usually a bisphosphonate, with alternatives such as denosumab, or bone-building drugs like teriparatide or romosozumab for those at the highest risk, such as people with multiple or severe vertebral fractures. Referral to a fracture liaison or bone-health service is valuable, as these services systematically identify people who have had a fragility fracture, assess them, and start treatment, which reduces the risk of further fractures. This secondary-prevention step is the single most beneficial part of the whole process.

For a minority with severe, persistent pain from a recent fracture that has not responded to non-surgical care, a procedure called vertebral augmentation — vertebroplasty or balloon kyphoplasty — may be considered. These involve injecting bone cement into the fractured vertebra to stabilise it and reduce pain, kyphoplasty first using a balloon to create a cavity. I always discuss these honestly, because the evidence is genuinely mixed: two well-known placebo-controlled trials found no benefit over a dummy procedure, while another trial focused on very recent, severely painful fractures did show benefit, suggesting that careful patient selection matters. In the UK, these procedures are reserved for carefully selected people with severe ongoing pain from a recent, unhealed fracture despite good pain management. Risks include leakage of cement. Major instrumented surgery is reserved for the rare cases with instability, significant deformity, or pressure on the nerves, and is technically demanding in soft, osteoporotic bone.

For most people the outlook is good: the fracture heals and the pain improves over weeks to a few months. The greater risk is the next fracture, and that risk is very treatable — modern osteoporosis treatment substantially reduces it. The aim throughout is to relieve the immediate pain, keep the person moving, and, above all, to treat the underlying bone fragility so that this fracture is the last rather than the first of several.

"A spine fracture means I'll be paralysed." Almost never — these fractures are usually stable and do not affect the spinal cord; nerve injury is rare and the exception.

"Nothing can be done." Far from it — the underlying osteoporosis is very treatable, and treating it strongly reduces the chance of further fractures.

"It's just a bad back, or just old age." A risky assumption — silent fractures are routinely missed, yet each one is a warning sign of high future fracture risk.

"If it didn't hurt much, it can't matter." Many of the most important fractures are nearly painless; what matters is that they signal fragile bones.

"Cement (vertebroplasty) always fixes the pain." Not reliably — the evidence is mixed, and it is reserved for carefully selected cases.

An osteoporotic spinal fracture is the collapse of a vertebra weakened by thin bone, usually after little or no trauma. Most are stable, do not threaten the nerves, and the pain settles over six to twelve weeks; many are even painless and found by chance. But every fragility fracture is a warning that the bones are fragile, and the single most important step is to assess and treat the underlying osteoporosis — with calcium and vitamin D, bone-protecting medicines, and a fracture liaison service — because that is what prevents the next fracture. Procedures to inject cement help only carefully selected people and are an area of genuine debate. The warning signs to act on are any leg weakness or numbness, or bladder or bowel changes, and features that might point to a cause other than osteoporosis.

This page is for general education only and is not a substitute for individual medical advice. Seek prompt review if a patient develop new or progressing weakness or numbness in the legs, or any disturbance of bladder or bowel control, and discuss any new or unexplained spinal fracture with the treating clinician so the cause and the bone health can be assessed.

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This information is for general patient education and is not a substitute for an individual consultation. Always seek personalised advice from a qualified spinal specialist.