Thoracolumbar Compression Fracture¶

Definition¶

A vertebral compression fracture (VCF) is a fracture involving primarily the anterior column of a vertebral body, resulting in loss of anterior height with preservation of the posterior vertebral body wall and middle column. Compression fractures are the most common type of spinal fracture and are frequently associated with osteoporosis, particularly in postmenopausal women.

Mechanism¶

Traumatic Compression Fractures¶

Result from axial loading with flexion, concentrating force on the anterior vertebral body. The middle column acts as a fulcrum. High-energy mechanisms include falls, motor vehicle collisions, and sports injuries.

Osteoporotic Compression Fractures¶

Result from minimal or no trauma in patients with weakened bone. Activities as simple as bending, lifting, coughing, or sneezing can cause fractures in severely osteoporotic individuals. Osteoporotic VCFs affect approximately 700,000 individuals annually in the United States, and 40% of women will have at least one by age 80.

Pathological Compression Fractures¶

Caused by weakening of the vertebral body by tumor (most commonly metastatic disease from breast, lung, prostate, kidney, or thyroid carcinoma, or multiple myeloma) or infection.

Imaging Findings¶

Radiography¶

• Lateral view — Anterior wedge deformity with loss of anterior vertebral body height. The posterior wall height is preserved.
• Genant Classification based on height loss: Grade 1 (mild, 20–25%), Grade 2 (moderate, 25–40%), Grade 3 (severe, >40%)
• Multiple compression fractures may produce progressive thoracic kyphosis ("dowager's hump")

CT¶

• Anterior column height loss with intact posterior vertebral body cortex (distinguishes from burst fracture)
• No retropulsion of fragments into the spinal canal
• Normal interpedicular distance (unlike burst fractures)
• May demonstrate vacuum cleft sign (intravertebral gas) in chronic nonunited fractures (Kümmel disease)

MRI¶

MRI is crucial for:

• Distinguishing acute from chronic fractures — Acute fractures show bone marrow edema (high STIR signal, low T1 signal); chronic fractures show fatty marrow (high T1 signal, low STIR signal)
• Distinguishing osteoporotic from pathological fractures — Malignant fractures tend to show convex posterior vertebral body contour, epidural mass, pedicle involvement, and heterogeneous enhancement. Benign fractures tend to show retropulsion of a posterior fragment, band-like edema pattern, and normal marrow signal in uninvolved vertebrae.

Classification¶

AO Spine¶

• A1 — Compression fracture involving a single endplate, no posterior wall involvement
• A2 — Split fracture involving both endplates, no posterior wall involvement

Denis¶

Compression fractures involve failure of the anterior column only. The middle column acts as a fulcrum and remains intact. These are inherently stable injuries.

Management¶

Conservative treatment is standard for most compression fractures:

• Analgesics (avoiding opioid dependence)
• Activity modification and early mobilization
• Thoracolumbar orthosis (TLSO) for comfort and postural support
• Treatment of underlying osteoporosis (bisphosphonates, calcium, vitamin D)

Vertebral augmentation (vertebroplasty or kyphoplasty) may be considered for refractory pain after 4–6 weeks of conservative treatment. Evidence for their efficacy over sham procedures remains debated.

Surgical stabilization is rarely needed for isolated compression fractures unless there is progressive kyphosis or neurological compromise.

Key Points¶

• Compression fractures involve the anterior column only, with intact posterior wall and middle column
• They are the most common spinal fracture type, frequently associated with osteoporosis
• CT shows anterior wedge deformity with preserved posterior wall and normal interpedicular distance
• MRI distinguishes acute from chronic fractures and benign from malignant etiologies
• Treatment is predominantly conservative; vertebral augmentation is reserved for refractory pain
• Always consider pathological causes (metastatic disease, myeloma) in patients without significant osteoporosis or history of trauma

References¶

1. Vu C, Gendelberg D. Classifications in Brief: AO Thoracolumbar Classification System. Clin Orthop Relat Res. 2020;478(2):434–440. https://pmc.ncbi.nlm.nih.gov/articles/PMC7438146/
2. Lee JY, Vaccaro AR, Lim MR, et al. Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma. J Orthop Sci. 2005;10(6):671–675. https://pmc.ncbi.nlm.nih.gov/articles/PMC2779435/
3. Jiménez-Almonte JH, King JD, Luo TD, Cassidy RC, Aneja A. Classifications in Brief: Thoracolumbar Injury Classification and Injury Severity Score System. Clin Orthop Relat Res. 2018;476(6):1352–1358. https://pmc.ncbi.nlm.nih.gov/articles/PMC6263590/
4. Donnally CJ III, Margetis K, Varacallo MA. Vertebral Compression Fractures. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2025. https://www.ncbi.nlm.nih.gov/books/NBK448171/
5. Mauch JT, Carr CM, Cloft H, Diehn FE. Review of the Imaging Features of Benign Osteoporotic and Malignant Vertebral Compression Fractures. AJNR Am J Neuroradiol. 2018;39(9):1584–1592. https://pmc.ncbi.nlm.nih.gov/articles/PMC7655272/
6. Genant HK, Wu CY, van Kuijk C, Nevitt MC. Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res. 1993;8(9):1137–1148. https://pubmed.ncbi.nlm.nih.gov/8237484/
7. Muijs SPJ, Foppen W, Smithuis F, Smithuis R. AO Spine Classification of Thoracolumbar Fractures. The Radiology Assistant; 2024. https://radiologyassistant.nl/musculoskeletal/spine/ao-classification

Related Articles¶

• Thoracolumbar Burst Fracture
• Acute vs Chronic Compression Fracture
• Insufficiency Fractures
• Denis Three-Column Model