High Yield Overview

VERTEBRAL COMPRESSION FRACTURES

Osteoporotic Most Common | Anterior Column Failure | Usually Non-Operative

1.4MVCFs per year worldwide

75%Occur in osteoporotic bone

T12-L1Most common level

90%Heal with conservative care

GENANT GRADING

Grade 1 (Mild)

Pattern20-25% height loss

TreatmentAnalgesia, early mobilization

Grade 2 (Moderate)

Pattern25-40% height loss

TreatmentBrace, activity modification

Grade 3 (Severe)

PatternOver 40% height loss

TreatmentConsider cement augmentation

Critical Must-Knows

Osteoporotic VCFs are anterior column failures - PLC is intact, therefore stable
Non-operative management is first-line for most compression fractures
Kyphoplasty vs Vertebroplasty: Kyphoplasty uses balloon to restore height before cement
Red flags: Neurological deficit, PLC injury, retropulsed bone = NOT simple compression
INVEST trial: No benefit of vertebroplasty over sham procedure

Examiner's Pearls

"
Compression fractures are STABLE (anterior column only, PLC intact)
"
Kyphotic deformity greater than 30 degrees may warrant surgery
"
Pathologic fracture workup: myeloma, metastasis, lymphoma
"
Cement augmentation controversial - INVEST and VERTOS trials showed mixed results

Critical Compression Fracture Exam Points

Stability Assessment

Compression fractures are STABLE because PLC is intact. If PLC is disrupted it becomes an unstable flexion-distraction pattern, not a simple compression. Always confirm posterior column integrity.

Osteoporotic vs Pathologic

Always exclude malignancy in compression fractures. Red flags: age under 55, weight loss, night pain, multiple levels, pedicle involvement, soft tissue mass. Order myeloma screen (serum protein electrophoresis).

Cement Augmentation

Vertebroplasty vs Kyphoplasty: Both inject polymethylmethacrylate (PMMA). Kyphoplasty uses balloon to restore height first. Evidence for pain relief is controversial (INVEST trial showed no benefit vs sham).

Sagittal Balance

Progressive kyphosis leads to sagittal imbalance, pain, and functional decline. Kyphotic deformity greater than 30 degrees may warrant surgical correction. Multiple adjacent VCFs create severe deformity.

Quick Decision Guide

Presentation	Classification	Treatment	Key Pearl
Mild VCF, minimal pain	Genant Grade 1	Analgesia, early mobilization	Avoid bed rest - increases bone loss
Moderate VCF, significant pain	Genant Grade 2	TLSO brace 6-12 weeks	Physical therapy essential for outcomes
Severe VCF, refractory pain	Genant Grade 3, 6 weeks conservative failed	Discuss cement augmentation	Controversial - trial of conservative care first
Neuro deficit or instability	Burst or PLC injury	Surgical stabilization	This is NOT a simple compression fracture

Mnemonic

BONESCompression Fracture Red Flags

Bone pain at night

Concerning for malignancy

Older than 65 or younger than 50

Age extremes suspicious

Neurological symptoms

Not typical for simple compression

ESR/CRP elevated

Inflammatory or malignant process

Systemic symptoms

Weight loss, fatigue suggest pathology

Memory Hook:BONES red flags suggest this may NOT be a simple osteoporotic compression fracture!

Mnemonic

STABLEConservative Management Criteria

Single level involvement

Multiple levels raises concern

Trauma or osteoporotic etiology clear

Known mechanism

Anterior column only affected

Compression pattern

Back of spine intact

PLC preserved

Less than 30 degrees kyphosis

Acceptable deformity

Everyone neurologically intact

No deficits

Memory Hook:If STABLE, the fracture can be managed with bracing and conservative care!

Mnemonic

CEMENTCement Augmentation Indications

Conservative care failed

6 weeks without improvement

Excruciating pain limiting function

Severe symptoms

Mechanical back pain localized

Pain at fracture level

Evidence of recent fracture on MRI

Marrow edema present

No neurological deficit

Not a burst or unstable injury

Trial of non-op unsuccessful

Conservative treatment failed

Memory Hook:Only consider CEMENT augmentation after conservative care fails - evidence is controversial!

Overview and Epidemiology

Definition

Vertebral compression fractures (VCFs) represent failure of the anterior column under compressive load, resulting in loss of vertebral body height. Unlike burst fractures, the middle and posterior columns remain intact, making these inherently stable injuries.

Etiology

Osteoporotic VCFs (75%)

Post-menopausal women, elderly men
Minimal trauma mechanism (bending, coughing, lifting)
T-score less than -2.5 on DEXA scan
Most common at thoracolumbar junction (T12-L1)

Pathologic VCFs (10-15%)

Metastatic disease (breast, prostate, lung, renal, thyroid)
Multiple myeloma
Primary bone tumors
Metabolic bone disease

Traumatic VCFs (10-15%)

High-energy mechanism in young patients
Fall from height, motor vehicle accident
Often associated with other injuries

Pathologic Fracture Workup

Always exclude malignancy before diagnosing osteoporotic VCF:

Full blood count, ESR, CRP
Serum protein electrophoresis (myeloma)
Calcium, alkaline phosphatase
Consider CT chest/abdomen/pelvis if red flags present
Pedicle involvement strongly suggests malignancy (not osteoporosis)

Australian Context

Osteoporosis is a significant health burden in Australia: 1.2 million Australians have osteoporosis, with VCFs being the most common osteoporotic fracture. Medicare provides Pharmaceutical Benefits Scheme (PBS) subsidies for bisphosphonates and denosumab in patients meeting bone mineral density criteria.

Anatomy and Biomechanics

Three-Column Model (Denis)

Understanding why compression fractures are stable:

Anterior Column:

Anterior longitudinal ligament (ALL)
Anterior 2/3 of vertebral body
Anterior annulus fibrosus
FAILS in compression fractures

Middle Column:

Posterior 1/3 of vertebral body
Posterior annulus fibrosus
Posterior longitudinal ligament (PLL)
INTACT in compression fractures (distinguishes from burst)

Posterior Column:

Posterior bony arch
Facet joints and capsules
Posterior ligamentous complex (PLC)
INTACT in compression fractures (key to stability)

Compression vs Burst Fracture

Feature	Compression Fracture	Burst Fracture
Column involvement	Anterior only	Anterior + Middle
Middle column	Intact	Failed (retropulsion possible)
PLC status	Intact	May be intact or disrupted
Stability	Stable	Potentially unstable
Neurological risk	Low	Higher (canal compromise)
TLICS score	1-2 (compression)	2-4 (burst morphology)

Biomechanics of Failure

Vertebral body is 90% trabecular bone - preferentially affected by osteoporosis. Under axial compression, the anterior cortex fails first, creating the characteristic wedge deformity. The posterior cortex and middle column remain intact because the neutral axis of the spine is posterior.

Classification

Genant Semi-Quantitative Grading

Standard classification for osteoporotic VCFs based on height loss:

Grade 0 - Normal

No discernible height reduction
Intact vertebral body

Grade 1 - Mild (Wedge/Biconcave/Crush)

20-25% reduction in anterior, middle, or posterior height
Mild deformity visible on lateral radiograph

Grade 2 - Moderate

25-40% height reduction
Clear wedging or biconcavity
May cause localized kyphosis

Grade 3 - Severe

Over 40% height reduction
Significant vertebral collapse
Often symptomatic with localized pain

Genant Score Application

Serial imaging essential: Compare to prior imaging to determine acuity. Acute fractures show marrow edema on MRI (T2 hyperintensity, T1 hypointensity). Chronic fractures may be stable and asymptomatic despite severe height loss.

Clinical Assessment

History Taking

Mechanism: Minimal trauma? (osteoporotic) vs high-energy (traumatic)
Pain characteristics: Localized, worse with movement
Red flags: Night pain, weight loss, prior malignancy
Functional status: Mobility, activities of daily living
Osteoporosis risk factors: Age, female, smoking, steroids

Physical Examination

Inspection: Loss of lordosis, kyphotic posture
Palpation: Midline tenderness at fracture level
Percussion: Pain over spinous process
Neurological exam: Usually normal (if not, reassess diagnosis)
Gait: Altered stance phase due to pain

Key Clinical Findings

Pain Pattern:

Acute, localized mid-back pain
Exacerbated by trunk flexion and rotation
Relieved by recumbency
May radiate to flanks (referred pain)

Red Flags Requiring Further Investigation:

Neurological deficit (suggests burst, not compression)
Multiple levels (myeloma, metastases)
Age under 55 without trauma
Known history of malignancy
Constitutional symptoms

Neurological Examination is MANDATORY

If neurological deficit is present, this is NOT a simple compression fracture. Consider burst fracture with retropulsed bone, pathologic fracture with epidural extension, or cauda equina syndrome. Urgent MRI and surgical consultation required.

Investigations

ImmediatePlain Radiographs

If diagnosis unclearCT Spine

Within 48-72 hours if surgery consideredMRI Spine

Outpatient follow-upDEXA Scan

If red flags presentMalignancy Screen

Imaging Features

Modality	What to Look For	Key Finding
X-ray	Height loss, wedging	Greater than 20% height loss = fracture
CT	Posterior wall	Intact posterior wall = compression (not burst)
MRI T1	Marrow signal	Low signal = acute or malignancy
MRI T2/STIR	Edema	High signal = acute fracture (within 6-8 weeks)
MRI post-contrast	Enhancement pattern	Focal enhancement in pedicle = metastasis

Vertebral compression fracture on X-ray and MRI comparison — Two-panel imaging comparison of vertebral compression fracture (A, B). (A) Lateral lumbar spine X-ray showing vertebral compression fracture with anterior wedging and height loss. (B) Sagittal T2-weighted MRI showing corresponding compression fracture with marrow edema signal change (bright signal) indicating acute injury - this finding is critical for identifying recent fractures that may benefit from cement augmentation.Credit: PMC - CC BY 4.0

MRI Acuity Assessment

Marrow edema on STIR/T2 indicates fracture is acute (within 6-8 weeks). This is important for cement augmentation - only effective for recent, symptomatic fractures. Chronic healed fractures without edema will not benefit from vertebroplasty.

Management Algorithm

Management

Non-Operative Treatment (First-Line for Most VCFs)

Acute Phase (0-2 weeks):

Adequate analgesia (paracetamol, NSAIDs, short-term opioids)
Avoid prolonged bed rest (accelerates bone loss)
Gentle mobilization as tolerated
Physical therapy assessment

Subacute Phase (2-6 weeks):

TLSO or Jewett brace for comfort (if needed)
Progressive mobilization program
Physical therapy for core strengthening
Falls prevention assessment

Chronic Phase (6-12 weeks):

Gradual return to normal activities
Ongoing physical therapy
Weight-bearing exercise program
Osteoporosis treatment initiation (bisphosphonates/denosumab)

Why Avoid Bed Rest?

Bed rest accelerates bone loss at 1-2% per week. The goal is early mobilization to maintain bone density and prevent deconditioning. Bracing is for comfort, not essential for healing of stable fractures.

Surgical Technique

Vertebroplasty/Kyphoplasty Technique

Patient Positioning:

Prone on radiolucent table
Bolsters under chest and pelvis (for lordosis)
Arms forward, face in padded rest
Biplanar fluoroscopy required

Approach:

Transpedicular or parapedicular
11-gauge or 13-gauge trocar
Local anesthesia with sedation or GA

Procedure Steps:

AP view: Align pedicle at lateral edge of vertebral body
Lateral view: Ensure trocar tip in anterior 1/3 of body
For kyphoplasty: Inflate balloon, restore height
Mix PMMA, allow partial polymerization (toothpaste consistency)
Inject under live fluoroscopy (monitor for extravasation)
Inject 2-4ml per side (typically bilateral approach)

Complications: PMMA extravasation (10-30%), adjacent level fracture (15-20% at 1 year), pulmonary embolism (rare but serious), and infection (less than 1%).

Balloon kyphoplasty case showing pre and post-operative imaging — Comprehensive balloon kyphoplasty case (a-d). Top row: Pre-operative AP and lateral X-rays with arrows indicating the compression fracture level, and sagittal MRI showing acute compression fracture with marrow edema. Bottom row: Post-kyphoplasty axial CT showing cement distribution within the vertebral body, and post-operative imaging demonstrating restored vertebral height and cement placement.Credit: PMC - CC BY 4.0

Complications

Complications of Treatment

Complication	Incidence	Prevention/Management
Adjacent level fracture	15-25% at 1 year	Optimize osteoporosis treatment, monitor kyphosis
PMMA extravasation	10-30%	Inject under live fluoro, appropriate cement viscosity
Progressive kyphosis	5-10%	Serial imaging, consider fusion if progressing
Chronic pain	20-30%	Multimodal pain management, physical therapy
Pulmonary embolism (cement)	Rare (less than 1%)	Monitor viscosity, small volume injection

Adjacent Level Fracture

15-25% of patients will sustain another vertebral fracture within 1 year. Controversial whether cement augmentation increases this risk (altered load transfer) or if it represents the natural history of osteoporosis. Treat the underlying osteoporosis aggressively.

Postoperative Care

After Cement Augmentation

Day of procedureDay 0

Post-op day 1Day 1

7-14 daysWeek 1-2

6 weeks6 weeks

Long-termOngoing

Osteoporosis Treatment is ESSENTIAL

Treating the fracture without treating osteoporosis is incomplete care. Initiate bisphosphonates or denosumab, ensure calcium/vitamin D supplementation, and coordinate with endocrinology or geriatrician. 25% will have another VCF within 1 year if osteoporosis untreated.

Outcomes and Prognosis

Natural History

90% of compression fractures heal with conservative management
Pain typically improves significantly by 6-12 weeks
Residual deformity common but often asymptomatic
25% will sustain another VCF within 1 year (osteoporotic cascade)
4x increased mortality risk compared to age-matched controls

Prognostic Factors

Good Prognosis:

Single level involvement
Genant Grade 1-2
Minimal pre-fracture functional impairment
Good compliance with osteoporosis treatment
Access to physical therapy

Poor Prognosis:

Multiple levels
Severe kyphosis (over 30 degrees)
Inadequate osteoporosis treatment
Poor baseline function
Associated medical comorbidities

Quality of Life Impact

VCFs significantly impact quality of life - chronic pain, reduced mobility, loss of independence, depression. Comprehensive management includes not just fracture treatment but pain management, physical therapy, falls prevention, and psychological support.

Evidence and Guidelines

Level I

Kallmes et al. (2009)

📚 INVEST Trial (Investigational Vertebroplasty Safety and Efficacy Trial)

Key Findings:

Multicenter RCT: 131 patients with VCF
Vertebroplasty vs sham procedure (local anesthetic only)
No significant difference in pain or disability at any time point
Crossover permitted at 1 month - similar improvement in both groups

Clinical Implication: Questioned efficacy of vertebroplasty. Selection of patients with acute fractures and marrow edema may be key.

Source: NEJM. 2009;361(6):569-79

Level I

Klazen et al. (2010)

📚 VERTOS II Trial

Key Findings:

Open-label RCT: 202 patients with acute VCF (less than 6 weeks, marrow edema on MRI)
Vertebroplasty vs conservative care
Significant pain relief at 1 month favoring vertebroplasty
Difference equalized by 12 months

Clinical Implication: Acute fractures with marrow edema may benefit from vertebroplasty in the short term.

Source: Lancet. 2010;376(9746):1085-92

Level I

Wardlaw et al. (2009)

📚 FREE Trial (Fracture Reduction Evaluation)

Key Findings:

Multicenter RCT: 300 patients with VCF
Kyphoplasty vs non-surgical care
Faster pain relief and QoL improvement at 1 month with kyphoplasty
Benefit maintained at 12 months

Clinical Implication: Kyphoplasty may offer advantages over pure conservative care, especially early pain relief.

Source: Lancet. 2009;373(9668):1016-24

Level I

Clark et al. (2016)

📚 VAPOUR Trial

Key Findings:

Double-blind RCT: 120 patients with acute VCF (less than 6 weeks)
Vertebroplasty vs sham procedure
Greater pain relief at 14 days with vertebroplasty (NRS 2.6 vs 1.0)
Suggests timing is critical - acute fractures benefit

Clinical Implication: Vertebroplasty may be effective in ACUTE fractures (less than 6 weeks). Patient selection is key.

Source: Lancet. 2016;388(10052):1408-16

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 72-year-old woman presents with acute mid-back pain after bending to pick up groceries. Lateral X-ray shows 30% height loss at T12. She is neurologically intact. How would you manage this patient?"

EXCEPTIONAL ANSWER

For this common scenario. This is a likely osteoporotic vertebral compression fracture given the low-energy mechanism in an elderly female. I would confirm neurological integrity with full examination and ensure there are no red flags for pathologic fracture such as night pain, weight loss, or known malignancy. For investigation, I would obtain CT to confirm posterior wall integrity distinguishing compression from burst. MRI would determine fracture acuity and exclude malignancy. Initial management would be non-operative with adequate analgesia, early mobilization avoiding bed rest, and physical therapy. I would arrange DEXA scan and initiate osteoporosis treatment with bisphosphonates and calcium/vitamin D supplementation. If pain persists beyond 6 weeks despite conservative measures and MRI confirms ongoing marrow edema, I would discuss cement augmentation options while explaining the controversial evidence from the INVEST trial.

KEY POINTS TO SCORE

Confirm diagnosis (CT for posterior wall, MRI for acuity)

Rule out red flags (neurology, malignancy)

Conservative management is mainstay (analgesia, mobilization)

Avoid bed rest

Treat underlying osteoporosis (DEXA, medical therapy)

COMMON TRAPS

✗Missing neurological deficit or instability

✗Ignoring osteoporosis treatment

✗Prescribing prolonged bed rest

LIKELY FOLLOW-UPS

"What if the CT showed posterior wall involvement?"

"How would you counsel her regarding vertebroplasty vs kyphoplasty?"

"What are the risks of cement augmentation?"

VIVA SCENARIOAdvanced

EXAMINER

"A 58-year-old man with known prostate cancer presents with new thoracolumbar pain and imaging showing multiple vertebral compression fractures at T10, T11, and L2. Discuss your approach."

EXCEPTIONAL ANSWER

For this concerning scenario. Multiple vertebral compression fractures in a patient with known prostate cancer raises high suspicion for pathologic fractures from metastatic disease rather than osteoporosis. I would perform a thorough history focusing on red flags including night pain, constitutional symptoms, and duration. Examination would confirm neurological status and look for cord compression signs. Investigation should include MRI of entire spine with contrast to assess all levels, exclude epidural disease, and characterize lesions. Blood tests including PSA, calcium, and alkaline phosphatase would help staging. I would involve the oncology team for systemic management and staging workup. If neurologically intact with no epidural disease, management may be palliative radiotherapy and systemic therapy based on oncology recommendations. If there is cord compression or spinal instability, urgent surgical decompression and stabilization would be indicated. This patient needs multidisciplinary team discussion.

KEY POINTS TO SCORE

Multiple levels + history of cancer = Pathologic fracture until proven otherwise

Red flags: Night pain, multiple levels, weight loss

MRI entire spine essential

Multidisciplinary management (Oncology, Spine)

Surgery if unstable or cord compression

COMMON TRAPS

✗Assuming osteoporosis in patient with cancer history

✗Missing cord compression signs

✗Failing to image entire spine

LIKELY FOLLOW-UPS

"What imaging features would distinguish metastatic from osteoporotic fracture?"

"How would you manage impending cord compression?"

"What is the role of cement augmentation in pathologic fractures?"

VIVA SCENARIOAdvanced

EXAMINER

"Discuss the evidence for and against vertebroplasty in osteoporotic compression fractures."

EXCEPTIONAL ANSWER

This is a highly controversial topic with conflicting evidence. Against vertebroplasty, the INVEST trial published in NEJM 2009 compared vertebroplasty to sham procedure and found no significant difference in pain or disability at any timepoint. This was a well-designed, blinded RCT that challenged routine use. Supporting vertebroplasty, the VERTOS II trial showed better pain relief at 1 month, and the VAPOUR trial suggested benefit in acute fractures less than 6 weeks old when marrow edema is present. The timing appears important. My current practice would be to manage most compression fractures conservatively initially, which is successful in 90% of cases. I would consider cement augmentation only for patients with persistent severe pain beyond 6 weeks, confirmed acute fracture on MRI with ongoing edema, and after thorough discussion about the uncertain benefit based on current evidence. I would also always ensure concurrent osteoporosis treatment to prevent adjacent level fractures.

KEY POINTS TO SCORE

INVEST trial: No difference vs Sham

VERTOS II: Short-term benefit

Indications: Refractory pain greater than 6 weeks, Acute fracture (edema)

Controversial efficacy - selective use only

Risks: Extravasation, PE, Adjacent fracture

COMMON TRAPS

✗Quoting only positive trials (must know INVEST)

✗Offering as first-line treatment

✗Ignoring risks in consent discussion

LIKELY FOLLOW-UPS

"What are the potential harms of cement augmentation?"

"How do you explain the difference between INVEST and VERTOS results?"

MCQ Practice Points

Stability Question

Q: Why are vertebral compression fractures classified as stable injuries? A: The posterior ligamentous complex (PLC) is intact. Compression fractures involve anterior column failure only. If PLC is disrupted, it becomes a flexion-distraction injury requiring different treatment.

INVEST Trial Question

Q: What did the INVEST trial (NEJM 2009) demonstrate regarding vertebroplasty? A: No significant difference in pain or disability between vertebroplasty and sham procedure at any time point. This is frequently tested - vertebroplasty evidence is controversial.

Adjacent Level Fracture Question

Q: What is the risk of subsequent vertebral fracture after an osteoporotic VCF? A: 25% within 1 year (osteoporotic cascade). This emphasizes that treating the underlying osteoporosis is as important as treating the fracture itself.

MRI Acuity Question

Q: What MRI finding indicates an acute vs chronic compression fracture? A: Marrow edema on STIR/T2 indicates acute fracture (within 6-8 weeks). Fat signal suggests chronic healed fracture. Only acute fractures with edema may benefit from cement augmentation.

Pathologic Fracture Question

Q: What imaging finding suggests metastatic rather than osteoporotic VCF? A: Pedicle involvement. Osteoporosis affects trabecular bone of the vertebral body; cortical pedicles are relatively spared. Pedicle loss = malignancy until proven otherwise.

Classification Question

Q: What percentage height loss defines a Grade 2 VCF on the Genant classification? A: 26-40% height loss. Grade 1 is 20-25%, Grade 2 is 26-40%, Grade 3 is greater than 40%. Grade 2-3 fractures may warrant closer monitoring.

Australian Context

Epidemiology

1.2 million Australians have osteoporosis
VCFs are the most common osteoporotic fracture
66% of VCFs are never clinically diagnosed
Significant contributor to aged care admissions

Healthcare System

PBS-subsidised bisphosphonates for proven osteoporosis
Denosumab available for bisphosphonate failure/intolerance
Fracture Liaison Services in major hospitals
ANZBMS guidelines for secondary prevention

Medicolegal Considerations

Key documentation requirements:

Document neurological examination thoroughly
Document discussion of osteoporosis treatment
Document counseling about controversial evidence for cement augmentation
Informed consent for procedural risks including adjacent level fracture
Document referral to Fracture Liaison Service or GP for osteoporosis follow-up

Consent for Cement Augmentation

Specific risks to discuss: PMMA extravasation, adjacent level fracture (15-25% at 1 year), no guarantee of pain relief (INVEST trial), pulmonary embolism (rare), infection. Explain that evidence is controversial and conservative management works for most patients.

VERTEBRAL COMPRESSION FRACTURES

High-Yield Exam Summary

Key Anatomy

•Anterior column ONLY involved - stable fracture
•PLC intact (distinguishes from burst/distraction)
•Vertebral body is 90% trabecular bone - osteoporosis target
•T12-L1 most common level (thoracolumbar junction)

Genant Classification

•Grade 1 (Mild): 20-25% height loss
•Grade 2 (Moderate): 25-40% height loss
•Grade 3 (Severe): Over 40% height loss
•MRI determines acuity (edema = acute)

Treatment Algorithm

•Most (90%) heal with conservative care
•Avoid bed rest - early mobilization essential
•Cement augmentation if 6 weeks conservative fails
•Surgery rare - reassess diagnosis if considering

Key Evidence

•INVEST trial: Vertebroplasty = sham procedure
•VERTOS II: Short-term benefit only
•VAPOUR: Acute fractures may benefit
•Adjacent level fracture 15-25% at 1 year

Red Flags for Malignancy

•Pedicle involvement (not just body)
•Multiple levels without trauma
•Age under 55 without mechanism
•Night pain, weight loss, known cancer

Australian Context

•1.2 million Australians with osteoporosis
•PBS bisphosphonates for secondary prevention
•Fracture Liaison Services - refer for follow-up
•25% will have another VCF within 1 year

Presentation

Classification

Treatment

Key Pearl

Mild VCF, minimal pain

Genant Grade 1

Analgesia, early mobilization

Avoid bed rest - increases bone loss

Moderate VCF, significant pain

Genant Grade 2

TLSO brace 6-12 weeks

Physical therapy essential for outcomes

Severe VCF, refractory pain

Genant Grade 3, 6 weeks conservative failed

Discuss cement augmentation

Controversial - trial of conservative care first

Neuro deficit or instability

Burst or PLC injury

Surgical stabilization

This is NOT a simple compression fracture

Feature

Compression Fracture

Burst Fracture

Column involvement

Anterior only

Anterior + Middle

Middle column

Intact

Failed (retropulsion possible)

PLC status

Intact

May be intact or disrupted

Stability

Stable

Potentially unstable

Neurological risk

Low

Higher (canal compromise)

TLICS score

1-2 (compression)

2-4 (burst morphology)

Genant Semi-Quantitative Grading

Standard classification for osteoporotic VCFs based on height loss:

Grade 0 - Normal

No discernible height reduction
Intact vertebral body

Grade 1 - Mild (Wedge/Biconcave/Crush)

20-25% reduction in anterior, middle, or posterior height
Mild deformity visible on lateral radiograph

Grade 2 - Moderate

25-40% height reduction
Clear wedging or biconcavity
May cause localized kyphosis

Grade 3 - Severe

Over 40% height reduction
Significant vertebral collapse
Often symptomatic with localized pain

Genant Score Application

Modality

What to Look For

Key Finding

X-ray

Height loss, wedging

Greater than 20% height loss = fracture

Posterior wall

Intact posterior wall = compression (not burst)

MRI T1

Marrow signal

Low signal = acute or malignancy

MRI T2/STIR

Edema

High signal = acute fracture (within 6-8 weeks)

MRI post-contrast

Enhancement pattern

Focal enhancement in pedicle = metastasis

Complication

Incidence

Prevention/Management

Adjacent level fracture

15-25% at 1 year

Optimize osteoporosis treatment, monitor kyphosis

PMMA extravasation

10-30%

Inject under live fluoro, appropriate cement viscosity

Progressive kyphosis

5-10%

Serial imaging, consider fusion if progressing

Chronic pain

20-30%

Multimodal pain management, physical therapy

Pulmonary embolism (cement)

Rare (less than 1%)

Monitor viscosity, small volume injection

Vertebral Compression Fractures

Vertebral Compression Fractures

VERTEBRAL COMPRESSION FRACTURES

GENANT GRADING

Critical Must-Knows

Examiner's Pearls

Critical Compression Fracture Exam Points

Stability Assessment

Osteoporotic vs Pathologic

Cement Augmentation

Sagittal Balance

Quick Decision Guide

BONESCompression Fracture Red Flags

STABLEConservative Management Criteria

CEMENTCement Augmentation Indications

Overview and Epidemiology

Definition

Etiology

Pathologic Fracture Workup

Anatomy and Biomechanics

Three-Column Model (Denis)

Compression vs Burst Fracture

Classification

Genant Semi-Quantitative Grading

AO Spine Classification for Thoracolumbar Injuries

A1 vs A3/A4

Fracture Morphology Patterns

Clinical Assessment

History Taking

Physical Examination

Key Clinical Findings

Neurological Examination is MANDATORY

Investigations

Imaging Features

Management Algorithm

Management

Non-Operative Treatment (First-Line for Most VCFs)

Vertebroplasty vs Kyphoplasty

Evidence is Controversial

When Surgery is Indicated

Surgical Technique

Vertebroplasty/Kyphoplasty Technique

Posterior Instrumented Fusion (When Required)

Complications

Complications of Treatment

Adjacent Level Fracture

Postoperative Care

After Cement Augmentation

Outcomes and Prognosis

Natural History

Prognostic Factors

Quality of Life Impact

Evidence and Guidelines

Exam Viva Scenarios

MCQ Practice Points

Australian Context

Epidemiology

Healthcare System

Medicolegal Considerations

VERTEBRAL COMPRESSION FRACTURES

Key Anatomy

Genant Classification

Treatment Algorithm

Key Evidence

Red Flags for Malignancy

Australian Context

Vertebral Compression Fractures

Vertebral Compression Fractures

VERTEBRAL COMPRESSION FRACTURES

GENANT GRADING

Critical Must-Knows

Examiner's Pearls

Critical Compression Fracture Exam Points

Stability Assessment

Osteoporotic vs Pathologic

Cement Augmentation

Sagittal Balance

Quick Decision Guide

BONESCompression Fracture Red Flags

STABLEConservative Management Criteria