Osteoporotic Vertebral Fracture

Bone is living tissue that is constantly being renewed, with old bone removed and new bone laid down. In osteoporosis this balance shifts, so that bone is lost faster than it is replaced and the internal structure of the bone becomes more porous and fragile. The process is usually silent — osteoporosis causes no symptoms until a bone breaks — which is why the first sign is often a fracture. It becomes more common with age and, in women, accelerates after the menopause because of the fall in oestrogen, a hormone that helps protect bone.

The block-shaped bodies of the vertebrae are made largely of the spongy, honeycomb-like type of bone that osteoporosis affects most. As this internal scaffolding thins, the vertebra loses its ability to bear load and can collapse, most often at the front, producing a wedge shape. The junction between the chest and the lower back bears particularly high loads and is a common site. When several vertebrae are affected over time, the cumulative loss of height at the front of the spine produces the forward curvature sometimes seen in older people.

A number of factors increase the risk of osteoporosis and fragility fracture. These include increasing age, being a woman (especially after the menopause), a family history of osteoporosis or hip fracture, a previous fragility fracture, a low body weight, smoking and heavy alcohol use. Certain medical conditions and treatments also weaken bone — most notably long-term steroid (corticosteroid) tablets, but also some hormonal, inflammatory and digestive conditions. Recognising these risks allows bone health to be assessed before a fracture happens.

Some osteoporotic vertebral fractures cause sudden back pain, often in the middle or lower back, which is worse on standing or moving and eased by lying down. Others cause little or no pain and are discovered by chance on a scan. Over months and years, repeated or multiple fractures can lead to a measurable loss of height and a stooping posture, and in some people to a persistent, aching back pain related to the changed shape of the spine.

One of the most important messages about osteoporotic vertebral fractures is that a first fracture greatly increases the likelihood of further fractures — of the spine and elsewhere, including the hip. A substantial proportion of people go on to have another fracture within a year or two. This is sometimes called a "fracture cascade". The encouraging side of this is that the first fracture is also an opportunity: it identifies people who can benefit from assessment and treatment aimed at preventing the next one.

Two questions are usually being answered at the same time: is there a fracture, and are the bones weak? The fracture is confirmed with imaging — an X-ray shows the collapsed vertebra, and an MRI can tell a recent, still-painful fracture from an old, healed one. The bone weakness is assessed with a bone density (DEXA) scan, which measures how strong the bones are and expresses the result as a "T-score". Doctors also use fracture-risk calculators (such as FRAX), which combine bone density with personal risk factors to estimate the chance of a fracture over the coming years. Blood tests may be arranged to look for treatable conditions that can weaken bone.

The acute fracture is generally managed in the same way as other vertebral compression fractures: pain relief, staying as active as is comfortable, and physiotherapy, with most fractures settling over weeks to a few months. Occasionally, for severe pain that is not settling, minimally invasive cement procedures are considered, and rarely surgery is needed — these are discussed on our vertebral compression fracture page. Alongside treating the fracture, attention turns to the bones themselves.

Looking after bone health involves several everyday measures: a diet containing enough calcium, adequate vitamin D (which helps the body absorb calcium), regular weight-bearing and muscle-strengthening exercise as able, stopping smoking, and keeping alcohol within sensible limits. These steps support bone and general health, though on their own they are usually not enough to treat established osteoporosis, which is where specific medicines may be considered.

Where the risk of further fracture is high, medicines that protect bone can substantially reduce that risk, and national guidelines (such as those from NICE and the National Osteoporosis Guideline Group) set out how they are used. In broad terms there are two groups. The first slows the loss of bone: this includes the bisphosphonates (such as alendronate, risedronate and zoledronate) and denosumab. The second actively builds new bone: this includes teriparatide and romosozumab, which are generally reserved for people at very high risk, particularly those who have already had vertebral fractures. Which treatment is appropriate, and for how long, depends on the individual's risk, their other health conditions and their preferences, and is decided together with a doctor. This page describes the options and the evidence; it does not recommend a particular treatment for any individual.

The fracture itself usually heals, and pain typically improves over several weeks. The longer-term outlook depends heavily on what is done about the underlying bone weakness. Left unaddressed, further fractures are common; identified and treated, the risk of future fractures can be substantially reduced. Osteoporotic fractures, particularly of the hip and spine, are also associated with a reduction in general health and, in some studies, with increased mortality — a further reason that assessing and treating bone health after a fracture is so important. With the right combination of bone-protecting treatment, exercise and fall prevention, many people remain active and independent.

Because many fragility fractures are linked to falls, reducing the risk of falling is an important part of care. Practical measures include reviewing medicines that can cause dizziness, checking eyesight, doing exercises that improve strength and balance, and making the home safer by removing trip hazards and improving lighting. These simple steps can meaningfully lower the chance of a further fracture.

Myth: "Osteoporosis is just a normal part of ageing and can't be treated." Fact: Bone loss increases with age, but osteoporosis can be assessed and effectively treated to reduce fracture risk.

Myth: "If my back doesn't hurt, my bones are fine." Fact: Osteoporosis is usually silent, and some vertebral fractures are painless; a fracture can be the first sign.

Myth: "Only women get osteoporosis." Fact: It is more common in women after the menopause, but men also develop osteoporosis and fragility fractures.

Myth: "Taking calcium is all you need." Fact: Calcium and vitamin D help, but people at high risk usually need specific bone-protecting medicines as well.

This page is for general education and does not replace an individual assessment. Treatment depends on a person's specific symptoms, examination findings, imaging findings and overall health, and should always be discussed with a suitably qualified healthcare professional.

An osteoporotic vertebral fracture is the most common type of fracture caused by osteoporosis, a condition in which the bones gradually become thinner and weaker. Because osteoporotic bone is fragile, a vertebra can collapse with very little force — sometimes during an everyday activity such as bending, lifting or even coughing. This is why such fractures are called "fragility fractures". They matter for two reasons: the fracture itself can cause pain and a gradual stooping of the spine, and, just as importantly, it is often the first clear sign that the bones are weak and at risk of breaking again. This page focuses on the bone-health side of the problem — understanding osteoporosis, diagnosing it, and reducing future risk. The fracture itself is managed much like any vertebral compression fracture, which our dedicated page covers in more detail.

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• —Kanis JA, Johansson H, Harvey NC, McCloskey EV. A brief history of FRAX. Arch Osteoporos. 2018;13(1):118. doi:10.1007/s11657-018-0510-0
• —Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet. 1996;348(9041):1535-1541. doi:10.1016/S0140-6736(96)07088-2
• —Cummings SR, San Martin J, McClung MR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med. 2009;361(8):756-765. doi:10.1056/NEJMoa0809493
• —Neer RM, Arnaud CD, Zanchetta JR, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med. 2001;344(19):1434-1441. doi:10.1056/NEJM200105103441904
• —Cosman F, Crittenden DB, Adachi JD, et al. Romosozumab Treatment in Postmenopausal Women with Osteoporosis. N Engl J Med. 2016;375(16):1532-1543. doi:10.1056/NEJMoa1607948
• —Weaver CM, Alexander DD, Boushey CJ, et al. Calcium plus vitamin D supplementation and risk of fractures: an updated meta-analysis. Osteoporos Int. 2016;27(1):367-376. doi:10.1007/s00198-015-3386-5
• —National Institute for Health and Care Excellence (NICE). Osteoporosis: assessing the risk of fragility fracture. Clinical guideline CG146. 2012 (updated 2017).
• —National Institute for Health and Care Excellence (NICE). Bisphosphonates for treating osteoporosis. Technology appraisal guidance TA464. 2017.
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• —Guideline note: NICE guidance (CG146 fragility fracture risk assessment; TA464 bisphosphonates) and the UK National Osteoporosis Guideline Group (NOGG) clinical guideline were reviewed for bone-protection strategies. No AAOS clinical practice guideline specific to osteoporotic vertebral fracture management was identified at the time of writing.

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.