Vertebral Compression Fracture: Recovery Time & Physical Therapy

Last update: September 2023
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What are the different types of spinal fractures?

We have three types of vertebrae along the spinal column:

• Cervical vertebrae, which are the closest to the neck.
• Thoracic vertebrae (also known as dorsal vertebrae), located below the cervical vertebrae.
• Lumbar vertebrae, situated below the thoracic vertebrae.

It is possible to fracture one or more of these vertebrae at the same time, due to a fall, an accident, or sometimes without any specific cause (especially in older individuals or those with significant osteoporosis).

In this blog post, I will discuss thoracic and lumbar fractures, as their treatment and progression are generally similar.

What does L1, L2, L5 or T12 fracture mean?

When a vertebra is fractured, the radiology report will indicate the specific vertebra affected. For example:

• Fracture of L1, L2, L3, L4, L5 refers to a fracture of the second lumbar vertebra, and so on.
• Fracture of T12, T10, T6 or D12, D10, D6, etc., indicates a fracture of the twelfth thoracic vertebra, and so on.

However, these specific details are not crucial for understanding the rest of the blog post, as the general treatment approaches are similar regardless of the specific vertebral numbers involved.

These vertebrae are bones, and like any other bones in the human body, they can fracture in various ways. Each type of fracture has different names.

Here are the main types of vertebral fractures. You may have come across these terms in your medical reports.

Vertebral compression fractures

Vertebral compression fracture (also known as osteoporotic fracture or sometimes referred to as “vertebral collapse” by patients) is by far the most common type of fracture.

It typically occurs in elderly individuals. It is caused by compression of the vertebral bodies, which can result in a reduction in spinal height and deformity of the spine.

It can be discovered incidentally, without a recent fall, often due to osteoporosis. That is why it is sometimes referred to as an osteoporotic fracture.

There are different subtypes of compression fractures, such as wedge compression fractures.

Vertebral compression fractures are the most common fractures in individuals with osteoporosis.

Vertebral compression fractures can also be associated with pelvic fractures in elderly individuals.

Other vertebral fractures

These are:

• flexion-extension fractures,
• dislocations,
• or fractures with displacement.

In addition to the bone break, there can be damage to the nerves, blood vessels, intervertebral discs, and ligaments. These fractures are more likely to occur during an accident.

We can also mention fractures of the lumbar apophysis. They mainly occur in teenagers and young adults, especially athletes.

They are often associated with:

• Rapid growth
• Overuse due to sports activities

Symptoms

Certain symptoms may suggest a vertebral fracture:

• Lower back pain
• Stiffness of the spine
• Loss of spinal height
• Gait disturbances
• Muscle weakness
• Loss of sensation in the legs, tingling
• Bladder and bowel dysfunction

In these cases, it is more likely a compression fracture. In the case of fractures of another type, there are usually other signs:

• Intense pain immediately after the accident
• Pain with movements of the spine
• Paralysis or weakness of limbs
• Urinary or fecal incontinence

Only an X-ray or an MRI can confirm the diagnosis.

However, sometimes a radiograph is not performed, even if some of these symptoms are present. Why?

Because, for example, in an elderly person with limited autonomy, there may not be any specific treatment to plan, whether or not there is a compression fracture. Additionally, X-rays expose individuals to radiation, which can damage cells, especially in elderly individuals who are more sensitive to it.

Furthermore, one-third of individuals with a vertebral compression fracture seen on an X-ray… experience no pain at all (Cochrane 2018) !

In the rest of the blog post, I will focus on compression fractures. I will write a dedicated blog post on other types of vertebral fractures soon.

What causes vertebral compression fractures?

Vertebral compression fractures can be caused by various factors, including:

1. ++++ Osteoporosis: This is the most common cause. It’s a condition characterized by low bone density and weakened bone structure, making the vertebrae more susceptible to fractures, even with minimal trauma or stress.
2. ++ Trauma: A significant impact or force on the spine, such as from a fall, car accident, or sports injury, can lead to vertebral compression fractures. Often associated with other types of spinal fractures or injuries.
3. Tumors: Cancerous tumors or metastases that affect the spine can weaken the vertebral bones and increase the risk of compression fractures. These tumors can originate from the spine itself (primary tumors) or spread from other parts of the body (secondary or metastatic tumors).
4. Spinal infections: Such as osteomyelitis or discitis. The infection weakens the bone, leading to collapse and fracture of the vertebra.
5. Genetic disorders: They can affect bone health and increase the risk of vertebral compression fractures. Examples include osteogenesis imperfecta and Marfan syndrome.

How long for vertebral compression fracture to heal?

Long bones in the body, such as the femur (thigh bone) or humerus (upper arm bone), take approximately 6 weeks to heal. However, vertebrae are not long bones. They are more complex and require a longer consolidation period because:

• They are composed of intervertebral discs and ligaments that can also be damaged.
• They bear more body weight and are subject to frequent movement, including torsion, flexion, rotation, and compression forces.
• They are surrounded by fewer powerful muscles and tendons.
• Bone density decreases with age, so consolidation may take longer in older individuals.

Vertebrae can take several months to heal, and the overall recovery time is often several months. However, this doesn’t necessarily mean you will experience pain throughout this entire period or be unable to do anything!

According to the latest recommendations from the World Federation of Neurosurgical Societies (Zileli 2022), here are the key findings:

• With conservative treatment (non-surgical), it is likely that pain will decrease during the first 3 months of vertebral compression.
• After one year of conservative treatment, 60% of patients experience sufficient pain relief, while 40% still have pain rated at 4/10 or higher.
• It’s important to note that these data may be more pessimistic than the actual reality. This is because clinical studies often include and follow individuals with more severe conditions. Some people with vertebral compression may not even seek medical attention.

Pain from a vertebral compression fracture can diminish within a few weeks, generally within 3 months. The consolidation process may take several months, but it doesn’t necessarily prohibit activity during the recovery period.

What are the long term effects of a vertebral compression?

Due to vertebral compression, some individuals may experience:

• Pain
• Difficulty walking or even sitting and changing positions
• Challenges in performing daily activities

However, these effects are not universal, as some people may not experience any negative consequences associated with vertebral compression.

For those who are experiencing discomfort, various treatments can be recommended. The treatment approach is not solely based on radiographic findings but rather focuses on addressing the individual’s specific symptoms such as pain, loss of strength, etc.

What complications can occur?

Here are the possible (and not systematic) complications of a vertebral compression.

Pain and functional impairment?

As mentioned earlier, approximately 4 out of 10 individuals still experience back pain after a compression fracture. Vertebral compression can be a cause of chronic low back pain, which is characterized by long-lasting discomfort.

• It can also lead to spinal deformity.
• Pulmonary involvement may occur.
• Greater difficulty in performing daily activities, resulting in a diminished quality of life.

It’s important to note that these complications are possible but not universal. Some individuals may never experience pain or any complications following a compression fracture!

Rarely, compression fractures can cause nerve compression, leading to numbness, tingling, or muscle weakness in the legs, as well as urinary or fecal incontinence.

Constipation?

Many individuals wonder if experiencing constipation after a fracture is normal. Yes, it is highly likely to be related.

Due to the fracture and pain, you may move less. Even when sitting or lying down, unintentionally adopting a less mobile posture out of fear of triggering pain.

Consequently, your internal organs have reduced movement, which slows down bowel transit and increases the likelihood of constipation.

The best natural remedy for this is to move as much as possible. While there may be some apprehension about pain, gradually resuming movement can be successful.

Consuming fiber-rich foods (such as prunes) can also be helpful. Additionally, there are over-the-counter and prescription medications available to treat constipation.

How to treat a vertebral compression fracture?

There are significant differences in the treatments offered when dealing with a bothersome vertebral compression. Some medical or surgical teams may:

1. Automatically recommend surgery (vertebroplasty).
2. Others may suggest a conservative treatment approach, which may involve:
   • Wearing a brace or lumbar belt.
   • Simply recommending a “wait-and-see” approach, encouraging the continuation of activities as much as possible. They may prescribe pain medication, physical therapy sessions either at home, in a clinic, or center.

The medical team may also propose addressing the following, if not already done:

1. Osteoporosis management (if not already initiated).
2. Fall prevention if the vertebral fracture occurred due to a fall. This may include advice on adapting the living environment, physical therapy or encouragement for physical activity, identifying contributing factors, etc.

The treatment for a lumbar vertebral compression resulting from a fall is the same as if the compression occurred from other causes (accident or without any specific cause) and if one or more vertebrae are affected.

Brace?

It is usually rare for a brace to be prescribed as a first-line treatment for vertebral compression fracture. It is not among the recommended initial treatments, according to Cochrane (2018):

1. Rest (continuing daily activities while avoiding triggering excessive pain).
2. Pain management (medications or non-pharmacological methods).
3. Physical therapy.

Another meta-analysis (a synthesis of studies on a specific topic) concludes that individuals wearing rigid braces may experience slight pain relief, but it does not have an impact on quality of life, healing time, ability to move, etc. (Bolton 2022).

Custom-fitted braces can be challenging to use, especially for elderly individuals, and may cause minor injuries or significant discomfort.

In the majority of my patients who have used braces for vertebral compression, they end up being stored above a cupboard after a few days and are only worn during follow-up visits with orthopedists or physicians.

Posture correctors have no benefit. Your physical therapist may prescribe a lumbar belt, although it does not appear to significantly reduce pain, similar to rigid braces.

Surgery, vertebroplasty?

There are several studies that compare the outcomes of individuals with vertebral compression fracture:

1. Those who are not operated on.
2. Those who undergo vertebroplasty (percutaneous). Vertebroplasty is also known as cementoplasty or kyphoplasty (in this case, usually performed by an interventional radiologist). These three terms refer to the same type of procedure, where acrylic cement is injected into the vertebra. The cement hardens within the bone space to form an internal cast. The procedure is performed under local or general anesthesia.

The idea is to determine if the operated individuals fare better than the non-operated ones. Otherwise, what’s the point of performing this surgical procedure (with its potential complications), even if it seems theoretically justified?

Here is the conclusion of a recent synthesis of these studies:

We found high‐ to moderate‐quality evidence that vertebroplasty has no important benefit in terms of pain, disability, quality of life or treatment success in the treatment of acute or subacute osteoporotic vertebral fractures in routine practice when compared with a sham procedure.
Numerous serious adverse events have been observed following vertebroplasty. However due to the small number of events, we cannot be certain about whether or not vertebroplasty results in a clinically important increased risk of new symptomatic vertebral fractures and/or other serious adverse events.
Patients should be informed about both the high‐ to moderate‐quality evidence that shows no important benefit of vertebroplasty and its potential for harm.

Cochrane 2018

Neurosurgical teams are sometimes slightly more optimistic and state:

Patients with persistent pain lasting more than 3 months may be good candidates for vertebroplasty.”

Zileli 2022

Based on my professional experience, I tend to believe that this surgical procedure does not offer significant benefits, apart from providing something new to try for individuals who are suffering (although it is likely that the pain remains or returns).

I have had dozens of patients who have undergone this surgical procedure, either immediately after the compression fracture or months or even years later. Often, these were individuals whom I saw before and after the procedure.

Both in the short and long term, neither these individuals nor myself have observed a noticeable decrease (or even a slight decrease) in pain or an increased ease of movement. However, the surgical teams were satisfied with the outcome based on radiographic evidence and considered it a success.

In rare cases, a Spine Jack implant is proposed.

Vertebroplasty (also known as cementoplasty or kyphoplasty) is sometimes used. However, recent data from the international literature do not demonstrate a significant benefit considering the potential risks.

Physiotherapy treatment, rehabilitation, exercises?

The best way to prevent vertebral compression is to have an active lifestyle, a proper diet, and receive osteoporosis treatment for at least 5 years (Zileli, 2022).

Engaging in suitable exercises that align with one’s health condition and pain, either alone or with the guidance of a physiotherapist, can provide more pain relief than doing nothing (Bolton, 2022). However, similar to braces, it does not have an impact on healing time, quality of life, etc.

On the other hand, exercise in general offers additional positive effects on physical and mental health, which is not the case with brace!

There isn’t a specific exercise or set of exercises recommended as superior to others. What matters is finding a physical activity (not necessarily weightlifting exercises) that adequately engages your muscles, joints, and heart based on your level of fitness, without exacerbating or increasing pain.

What does a typical physiotherapy management plan look like?

We assess your vertebral fracture and its consequences, as well as your overall health and lifestyle. What bothers you the most? What specific activity do you absolutely want to regain (an achievable and realistic goal)?

We propose solutions to address the problems you are facing:

• Answering your questions, providing reassurance, and guiding you on what you can or cannot do.
• Providing advice on pain management, improving sleep, getting up, moving around, and reducing the risk of falls at home.
• Recommending suitable physical activities to maintain your physical fitness, autonomy, or prevent the risk of falls.

Massage or other pain-relieving techniques often used by physiotherapists (such as ultrasound therapy, TENS, stretching, manual therapy, etc.) are not part of the recommended treatments but are sometimes used for individuals who are seeking different approaches to find relief.

Natural remedies?

Of course, we often feel inclined to try as many things as possible to recover faster, such as using essential oils, applying creams or ointments, seeking acupuncture, trying an anti-inflammatory or antioxidant diet, and so on.

Along the way, we may also encounter healthcare professionals or loved ones who recommend certain solutions that have shown to “work.”

If you’ve read my previous responses, you may know that I always strive to recommend treatments with:

• Maximum effectiveness (theoretical/empirical)
• Minimum side effects
• Minimum cost (in terms of time, energy, and money)
• Minimum dependence on a third party or equipment

In this context, for vertebral compression, the best natural remedy is the passage of time and maintaining minimal physical activity.

Osteopathy?

Osteopathy is not among the recommended treatments for vertebral fractures.

The potential balance of benefits and risks is unfavorable for any form of manipulation/manual therapy on the back during the consolidation period, whether performed by a physiotherapist or an osteopath.