Vertebral Compression Fractures:
When Back Pain Is a Broken Bone

What a vertebral compression fracture is

The spine is built from stacked, roughly cylindrical bones called vertebral bodies. In healthy bone they easily carry the weight of the upper body. When bone has been thinned by osteoporosis, a vertebral body can collapse under everyday loads — bending forward, lifting, a minor fall, sometimes with no remembered event at all. The front of the vertebra usually collapses more than the back, leaving it wedge-shaped. In Japan this is commonly called kotsusoshōshō-sei tsuitai kossetsu (骨粗鬆症性椎体骨折), or simply assaku kossetsu (圧迫骨折).

Most fractures occur around the junction of the thoracic and lumbar spine — roughly the level of the lower ribs to the upper waist — where the relatively rigid chest meets the more mobile lower back. They are most common in post-menopausal women, but men are affected too, as are people taking long-term steroid medication. Vertebral fractures can also result from high-energy trauma or, less commonly, from tumours weakening the bone; this column focuses on the osteoporotic type.

How common they are

Vertebral fractures are often described as the hallmark fracture of osteoporosis. In a population-based study from Rochester, Minnesota, 83% of newly diagnosed vertebral fractures followed moderate or no trauma, and the incidence in women was almost twice that in men, rising steeply with age (Cooper et al., Journal of Bone and Mineral Research, 1992). Because many fractures cause only mild or vague symptoms, the number seen in clinics is generally thought to underestimate how many actually occur. With one of the world's oldest populations, Japan has a particular interest in these fractures, and Japanese spine groups have produced much of the recent research on how they heal.

Symptoms

The classic presentation is sudden back pain in an older adult, often after a trivial event, that is worst when moving — getting out of bed, turning over, standing up from a chair — and eases somewhat when lying still. The pain is usually felt at the level of the fracture and may wrap around the side of the chest or abdomen like a band. Over time, one or more fractures can lead to loss of height and a more stooped, rounded upper back (kyphosis), which can in turn affect breathing, appetite and balance.

Not every fracture announces itself. Some people have only a dull ache, and some notice nothing until a chest X-ray or CT taken for another reason shows a collapsed vertebra. Leg weakness, numbness or difficulty controlling the bladder or bowel are not typical and suggest the fracture may be pressing on the spinal cord or nerves — these need urgent assessment.

How it's diagnosed

Diagnosis combines the story, an examination (often tenderness when the spine is gently tapped), and imaging. Imaging has three jobs: confirming a fracture, judging whether it is new or old, and ruling out other causes.

Test	What it shows	Limitations
X-ray	Loss of vertebral height and wedge shape; standing and lying views can show whether the vertebra moves or collapses further	A fresh fracture may look normal at first; hard to tell new from old
MRI	Bone-marrow oedema marking a recent fracture; signal patterns associated with delayed healing; nerve or cord involvement	Not suitable for everyone (some implants); longer scan time
CT	Fine bony detail — useful when fracture fragments may extend toward the spinal canal	Radiation exposure; less useful for judging fracture age
Bone density (DXA)	Confirms and quantifies osteoporosis to guide medication	Does not show the fracture itself

Blood tests are often used to check calcium, vitamin D and kidney function, and to look for less common causes of fragile bone. When features are unusual — a fracture high in the thoracic spine, no history suggestive of osteoporosis, unexplained weight loss — doctors will also consider whether a tumour might be responsible.

Treatment options

Treatment has two separate goals: managing the current fracture — pain relief and maintaining mobility while the bone heals — and preventing the next one. The second is just as important as the first and is easily overlooked.

Non-surgical care

The great majority of osteoporotic vertebral fractures are treated without surgery. Typical elements include pain medication, a short period of reduced activity followed by early, gradual mobilisation (prolonged bed rest carries its own risks in older adults, including muscle loss and blood clots), and often a brace or corset for several weeks. Physiotherapy focusing on posture, back-extensor strength and balance is commonly added once the acute pain settles.

Vertebroplasty and balloon kyphoplasty

In vertebroplasty, bone cement is injected through a needle into the fractured vertebra to stabilise it. Balloon kyphoplasty first inflates a small balloon inside the vertebra to create a cavity and partly restore height, then fills it with cement. Both are performed through small punctures in the back. They became widely used on the basis of rapid pain relief seen in early studies — but the evidence has proved more complicated than first appeared.

Trial	Comparison	Main finding
Buchbinder 2009	Vertebroplasty vs sham (78 patients)	No significant advantage at any time point up to 6 months; both groups improved
FREE 2009	Balloon kyphoplasty vs non-surgical care (300 patients)	Greater improvement in physical function at 1 month in the kyphoplasty group; not blinded
VERTOS II 2010	Vertebroplasty vs conservative care (202 patients)	Greater pain reduction at 1 month and 1 year; not blinded
VAPOUR 2016	Vertebroplasty vs sham, fractures under 6 weeks old (120 patients)	More patients had low pain at 14 days with vertebroplasty (44% vs 21%)
VERTOS IV 2018	Vertebroplasty vs sham (180 patients)	No significant difference in pain relief over 12 months

The pattern that emerges is that trials comparing cement procedures with usual care — where patients know which treatment they received — tend to show benefit, while most trials using a sham (simulated) procedure show both groups improving to a similar degree. The VAPOUR trial, which enrolled patients with very recent fractures, many of them in hospital, is the main sham-controlled exception.

Professional guidance on these procedures differs between countries, and specialists continue to debate whether particular groups — for example, people with severe pain that is not improving, or fractures at high risk of nonunion — may benefit. Balloon kyphoplasty is available under Japan's national health insurance for painful osteoporotic fractures that have not responded adequately to conservative treatment. For anyone considering a cement procedure, the most useful conversation with a spine specialist covers how long the pain has lasted, how it is affecting daily life, what the imaging shows, and the evidence for and against the procedure in their particular situation.

Surgery for complicated fractures

Open surgery — usually stabilisation with screws and rods, sometimes combined with decompression of the nerves — is reserved for a small minority: fractures that compress the spinal cord or nerves, progressive collapse causing severe deformity, or painful nonunion that does not respond to other measures. These are major operations in an older population, and the decision is individualised.

Preventing the next fracture

A vertebral compression fracture is not only a painful injury; it is strong evidence that the skeleton as a whole is fragile. The risk of a further fracture is highest in the months that follow.

After a vertebral fracture, a bone density scan and a discussion of osteoporosis medication are generally recommended. Options include bisphosphonates, denosumab, and bone-forming agents such as teriparatide, abaloparatide and romosozumab; which is suitable depends on fracture history, bone density, kidney function and other health factors. Adequate calcium, vitamin D and protein, regular weight-bearing and balance exercise, stopping smoking, limiting alcohol and reducing fall hazards at home all play a part. For more on these measures, see the column on osteoporosis and bone health.

When to see a doctor

New back pain in an older adult — especially after a minor fall or lift, or in someone known to have osteoporosis or taking steroid medication — is worth having checked rather than assumed to be a strained muscle. Seek urgent attention for leg weakness or numbness, difficulty walking, changes in bladder or bowel control, fever, or unexplained weight loss. Unexplained height loss of a few centimetres or a newly rounded upper back are also good reasons to ask about a spine X-ray and bone density test. In Tokyo, an orthopaedic spine specialist, or an osteoporosis clinic for bone-health management, is usually the most appropriate first contact.