Research Review By Dr. Rob Rodine©

Date Posted:

March 2009

Study Title:

The prognosis for pain, disability, activities of daily living and quality of life after an acute osteoporotic vertebral body fracture: Its relation to fracture level, type of fracture and grade of fracture deformation.

Authors:

Suzuki N, Ogikubo O & Hansson T

Author's Affiliations:

Department of Orthopedic Surgery, Nagoya City University, Nagoya, Japan; Department of Orthopedics, Gothenberg University, Goteborg, Sweden.

Publication Information:

European Spine Journal 2009; 18: 77-88.

Background Information:

An earlier article by the same authors was recently reviewed on Research Review Service by Dr. Thistle (see link below). To draw from the Dr. Thistle’s conclusions from that study: ‘[There is] some evidence that the prognosis for acute VCFs [vertebral compression fractures] may not be as favorable as is commonly thought. Patients in this study demonstrated that a VCF can be the beginning of long-lasting, potentially severe declines in function and quality of life that can be associated with sustained high pain levels…in this study, ¾ of patients still had severe pain one year after the injury.’

In the article discussed here, the authors allude to the heavily retrospective nature of current evidence assessing disability and pain following vertebral compression fractures. In addition the authors note a complete absence of prospective literature assessing location, type and deformation characteristics of vertebral compression fractures. These shortfalls in the literature make it difficult to assess prognosis of VCF with confidence. As such, the authors chose to examine these factors in this study in an effort to better predict those likely to suffer greater pain and disability over time.

Pertinent Results:

Data from 107 patients with compression fracture was analyzed:
  • 67.3% of patients presented to the hospital within one week of fracture onset
  • 14.9% waited for 1-3 weeks, while 17.8% could not clarify fracture onset
  • 58 vertebral compression fractures were located in the thoracic spine and 49 were in the lumbar spine
  • The majority of fractures were located at T12 (30%) and L1 (32%)
  • 69% of fractures were wedge, 19% were concave and 12% were crush fractures
  • The lumbar spine displayed more concave fractures than the thoracic and thoracolumbar spines, whereas the thoracic and thoracolumbar spines displayed more wedge fractures
  • Fracture deformation was 20.6% mild, 46.7% moderate and 32.7% severe – grading of deformation was not related to age, gender or fracture location (however, crush fractures tended to demonstrate more severe deformation than wedge or concave fractures)
  • All outcome measures showed improvement between 3 weeks and 3 months, however for fractures in the lumbar spine – early improvement at 3 weeks was only significant for pain and disability
  • There was no difference between thoracic and lumbar fractures at 1 year, indicating the fracture location was not a prognostic indicator – however, despite differences between 3 weeks and 12 months showing statistical significance, slight deterioration was found in pain and disability scores between 6 and 12 months for thoracic fractures (this trend was not observed for lumbar fractures)
  • When assessing the Hannover ADL scores, significant improvement compared to 3 weeks was seen in mild fracture deformation patients at 12 months only, in moderate deformations at 3 months and 6 months only with regression at 12 months, and in severe deformation groups at all time points
  • When assessing Hannover ADL scores along with pain and disability scores compared to fracture deformation, three patterns of severity continued to be apparent. Mild deformation demonstrated the lowest scores in all outcome measures throughout while severe deformation the highest. This demonstrated that fracture deformation was a prognostic indicator for pain, disability and quality of life up to one year post fracture.

Clinical Application & Conclusions:

As it was previously noted, the majority of patients suffering from vertebral compression fractures suffer from long lasting pain and disability that, while demonstrating steady improvement over time, considerably impacts quality of life. The greatest prognostic indicator for deterioration was severity of fracture deformation. Reasons for this have been speculated to include circulatory impairment with severe deformation that leads to continued collapse and deterioration. Mild and moderate deformations may impact pain and disability through the development of instability, pseudoarthrosis and altered functional loading associated with postural changes.

Also, patients with crush fractures demonstrated worse outcomes than those with wedge or concave fractures, however this group included a greater proportion of patients with severe deformation. In addition, results show that patients with thoracic fractures should expect to experience deterioration between 6 and 12 months in pain and disability scores compared to patients with lumbar fractures.

Study Methods:

Patients were included who presented to the emergency room with back pain, had radiographic evidence of a vertebral compression fracture caused by low energy trauma, and were over the age of 40 years. Data was collected over a three time period. Patients were excluded if they had evidence of another form of fracture or were suffering from serious illness such as malignancy or infection. All patients meeting these criteria were invited to participate within 10 days of their hospital visit.

Out of the 341 patients invited, data was collected and analyzed at all time points for 107 patients. Of these, 67.3% were female. Of those presenting with thoracic compression fractures, 72.4% were female, versus 61.2% in the lumbar spine. Mean age was 75.5 years with an SD of 11.9 years (ranging 42-96). There was no statistically significant difference in age between genders.

Patients completed a self-administered questionnaire at a maximum of 3 weeks following the onset of fracture and were followed up at 3, 6 and 12 months. The questionnaires used included:
  1. von Korff Pain Intensity and Disability Questionnaires
  2. Hanover ADL Score – assesses ADLs
  3. EQ-5D – is a generic health-related QoL measure
Fracture characteristics were assessed via radiographs by two independent spinal surgeons. Fractures were classified as either wedge, crush or concave fractures. Fractures were considered as acute if there was evidence of a step defect without visible callus formation. Fracture deformation was graded as: normal, mild (20-25% height reduction), moderate (25-40% height reduction) and severely deformed (40% or more height reduction).

Treatment for patients consisted of early mobilization and the use of a brace only when pain limited mobilization. Analgesics were used as needed. Patients were all told that pain would disappear within weeks to months.

Study Strengths/Weaknesses:

Please refer to the earlier review, "Clinical Course of Vertebral Body Compression Fractures" (linked below), for strengths and limitations of this study.

Related Reviews on RRS: