Compression fracture

A compression fracture occurs when a vertebral body — the cylindrical load-bearing portion of a spinal vertebra — collapses under compressive force. Unlike fractures of the vertebral arch (which surrounds and protects the spinal cord), compression fractures primarily affect the anterior vertebral body and typically produce a wedge deformity.

**Anatomy of the vertebra**

Each vertebra has two main parts: - The *vertebral body* — the large cylindrical block at the front that bears most of the axial load of the spine. In compression fractures, this is the part that collapses - The *vertebral arch* — the ring-shaped posterior structure that forms the roof of the spinal canal and protects the spinal cord

In a wedge fracture (the most common type), the front of the vertebral body collapses while the back remains intact, creating a forward-tapered shape. When many vertebrae fracture in this way, the cumulative wedging causes the spine to bow forward, producing kyphosis.

**Causes and risk factors**

- *Osteoporosis:* the most common cause. Thin, brittle bone can fracture under loads that would not injure normal bone — sometimes from a minor fall, bending forward, or even a cough. Elderly women are most affected - *Trauma:* high-energy injuries (motor vehicle accidents, falls from height) can fracture otherwise healthy vertebrae; also common in younger men - *Spinal metastases or primary bone tumours:* pathological fractures through tumour-infiltrated bone - *Long-term corticosteroid use:* accelerates bone loss and significantly raises fracture risk

**Neurological involvement**

Most compression fractures do not compromise the spinal canal. Severe fractures, burst variants (in which fragments are driven posteriorly), or fractures at multiple levels can narrow the canal and compress the spinal cord or nerve roots, causing radicular pain, weakness, or — in severe cases — myelopathy or cauda equina syndrome requiring urgent surgical decompression.

**Non-surgical management**

- *Analgesia:* NSAIDs, paracetamol, opioids for severe acute pain; short-term calcitonin may modestly reduce pain in acute osteoporotic fractures - *Bracing:* a thoracolumbar orthosis limits spinal motion, reducing pain during the acute healing phase - *Physiotherapy:* spinal extension exercises, postural training, and core strengthening reduce load on the fractured segment and protect against future fractures - *Osteoporosis treatment:* bisphosphonates, denosumab, or teriparatide address the underlying bone disease

**Surgical options**

- *Vertebroplasty:* percutaneous injection of bone cement (polymethylmethacrylate) directly into the fractured vertebral body — stabilises the fracture and significantly reduces pain in most patients - *Kyphoplasty:* a balloon is first inflated inside the vertebral body to create a cavity and partially restore vertebral height, then cement is injected — associated with slightly better height restoration than vertebroplasty - *Spinal fusion:* internal fixation with screws and rods is reserved for spinal instability or significant neurological compromise