Case Study 9.1: Acute Compression Fracture
Jason N. DaCruz
SETTING: ACUTE OR URGENT CARE
Definition and Incidence
A compression fracture is a fracture in the spine that is usually caused by osteoporosis. Compression fractures occur at a rate of 117 per 100,000 people (Savage, 2014).
Patient presents with the chief complaint of “low back pain.” She describes a sudden onset of severe back pain that began 4 days ago while grocery shopping. In the midst of bending down to pick up some groceries, she had a severe bout of intense pain, which she rated as 10 out of 10, and it was associated with significant spasm. She has had severe difficulty mobilizing since. Pain is noted with all activity, even while in bed, and exacerbated with rolling over. She was initially seen at her primary care provider’s office and was diagnosed with lumbar strain. Her initial treatment plan was pharmacologic, treated with Naprosyn (nonsteroidal anti-inflammatory) and Flexeril (muscle relaxer); the patient reports no relief from either. She denies any leg pain, paraethesias, or urinary or bowel difficulties. She has had difficulties moving about in bed and mobilizing to the extent that she is unable to perform her daily living activities.
She is currently retired.
On physical examination, the patient is a 73-year-old woman who is alert, awake, and orientated, in moderate distress secondary to pain. She is 5′3″, weighs 230 lb, and stands with a slight forward flexed posture. There is tenderness noted at the thoracolumbar junction; no palpable step off or gibbus (Latin for “hump”); no skin changes or ecchymosis surrounding the thoracolumbar spine. No paravertebral spasm is appreciated. Her lumbar mechanics are poor in flexion to 40 degrees; she is able to move with minimal extension, which causes increasing pain. Otherwise, she has a negative straight leg raise, trace reflexes at the knees and ankles bilaterally and symmetrical. She has no clonus and is neurovascularly intact.
Radiographs were obtained in anterior–posterior (AP) and lateral lumbar spine, which demonstrate a compression fracture at L1 (see Figure 9.1).
L1 compression fracture, with minimal segmental kyphosis.
If you are contemplating whether or not a fracture seen on plain radiographs is acute or chronic, consider obtaining MRI to check for acute signal changes seen on T1 and T2 images (Kim & Vaccaro, 2006). If there are acute signal changes, this will help to diagnose the issue as one that is acute in nature, versus chronic.
Once you have made the diagnosis of acute lumbar compression fracture, consider using a support brace such as Aspen corset to treat your patient. If you observe that the patient’s kyphosis is significant, greater than 25 degrees, consider Jewitt versus thoracolumbar sacral orthosis (TLSO) brace. TLSO brace is commonly used if multiple compression fractures or burst fracture are identified. It is also used in the cases in which you want to control rotation. The Jewitt brace is used mainly for simple compression fractures surrounding the thoracolumbar junction (T11, T12, L1, L2). It does not control rotation but does provide hyperextension, which is beneficial at the junction when normally these types of fractures cause kyphosis. In this case, the patient was treated with a lumbar corset with the rationale that her segmental kyphosis was 18 degrees at the time of visit, and she had been previously mobilizing without any further changes, appearing structurally stable. Discussion with the patient included repeat radiographs in 4 weeks as well as instructions to contact the office earlier if pain worsened, potentially suggestive of further compression collapse. An example of an Aspen corset is found in Figure 9.2.
It would be helpful to explain the potential use of a kyphoplasty procedure if the patient’s pain does not improve over the next 2 to 3 weeks. Kyphoplasty is a minimally invasive procedure where cement polymethylmethacrylate (PMMA) is placed into the vertebral body within a balloon by means of a small incision (Savage, Schroeder, & Anderson, 2014). Advancement of a small tube through the pedicle is performed under fluoroscopy and then the PMMA is introduced into the fracture for stabilization. Advise the patient to avoid repetitive forward bending, avoid lifting more than 10 lb, and maintain upright posture until return to clinic for a follow-up visit in 4 weeks. The patient was also instructed to contact the office earlier should the pain worsen or symptoms change.
For this patient, her 4-week check revealed that she had overall improvement in her pain by 50%. She reported residual pain upon turning in bed but is able to sleep comfortably on her recliner. She is ambulating without significant pain. She will continue restrictions of no repetitive bending, no forward flexion, no lifting of more than 10 lb, and continued use of lumbar corset brace for support.
At the follow-up visit, a repeat x-ray of the lateral lumbar spine was obtained. The patient showed no worsening of compression or segmental kyphosis.
Longer term follow-up will consist of advising the patient to: schedule follow-up visits every 4 weeks for 3 months; continue the limitations in activity and movement until the pain resolves; and report persistent or intensified pain. If pain persists or intensifies, consult with interventional radiologist for kyphoplasty. Generally, compression fractures are monitored over 3 months with repeat x-rays. No physical therapy is recommended.
The typical presentation of compression fracture is elderly patients with a known history of osteopenia or osteoporosis. A common rule of thumb is that once the pain has dissipated, the compression fracture has healed. If pain persists or intensifies, consultation with a spine surgeon is recommended at a point postinjury that seems appropriate, based upon the patient presentation and your experience.
Kim, D. H., & Vaccaro, A. R. (2006). Osteoporotic compression fractures of the spine: Current options and considerations for treatment. Spine Journal, 6, 479–487.
Savage, J. W., Schroeder, G. D., & Anderson, P. A. (2014). Vertebroplasty and kyphoplasty for the treatment of osteoporotic vertebra. Journal of the American Academy of Orthopaedic Surgeons, 22, 653–664.
Case Study 9.2: Acute Disc Herniation
Jason N. DaCruz
SETTING: URGENT CARE/PRIMARY CARE
Definition and Incidence
A lumbar disc herniation is a common low back disorder and defined by the disc (nucleous pulposa) being extruded into the spinal canal.
A 37-year-old male patient presents with a 3-week history of progressively worsening subjective left-sided low back pain as well as left leg pain, which he described as a consistent 8 out of 10 pain. He describes no particular injury or event that exacerbated his condition. He has a history of relatively mild low back complaints for years prior to this flare up. He describes the pain worsening with bending forward as well as prolonged periods of sitting. The leg pain travels in a distribution of posterior buttock, thigh, and lateral calf, and at times has a sensation of tingling into the great toe. He has been seen by a chiropractor over the past 3 weeks with no benefit. Ibuprofen and some Flexeril have been of no great benefit to him.
He is a police officer in a town near his home. He is married and has two daughters, ages 8 and 6.
On exam, he’s a heavyset gentleman, alert, awake, and orientated. He is 6′ tall and 275 lb. His lumbar mechanics are restricted and elicit pain. He demonstrates constraint in forward flexion to 40 degrees, and greater with reproducible left leg pain. There are no significant difficulties with lumbar extension. A positive straight leg raise is demonstrated at 60 degrees. Deep tendon reflexes are symmetrical and 1+ at the knees and ankles. With strength testing, he has 4 out of 5 dorsiflexion. Foot weakness is appreciated on the left. There is no weakness exhibited with plantar flexion, and he has 5 out of 5 quadriceps strength. Hip mechanics are unremarkable in internal and external rotation, which are full and pain-free motion. He denies any bowel or bladder dysfunction.
It is important that you rule out Cauda Equina syndrome. This is a rare condition that occurs with approximately 2% of all herniated discs (Greenhalgh, Truman, Webster, & Selfe, 2015). The condition is considered a medical emergency, and is evidenced by bowel and/or bladder dysfunction, reduced sensation in the saddle area, or sexual dysfunction (Fraser, Roberts, & Murphy, 2009).
Radiographs are obtained and include both AP and LAT views, which reveal relative disc space collapse at L4-5 and L5-S1, with no sign of any instability or spondylolisthesis (see Figures 9.3 and 9.4).
Acute disc herniation at L5.
He was placed on a tapering dose of dexamethasone 2 mg over the ensuing 8 days (two tablets four times a day for 2 days, one tablet four times a day for 2 days, one tablet twice a day for 2 days, one tablet once a day for 2 days), as well as Baclofen 10 mg every 8 hours as needed for spasm. He was also placed into an Aspen brace corset for comfort (see Figure 9.2). Because of the objective findings of dorsiflexion weakness, associated with an L5 root dysfunction, an MRI was subsequently obtained.
Educate your patient on treatment options for disc herniation. Options to further consider would be a possible L4-5 epidural cortisone injection. Commonly when patients have intractable type pain it is difficult to have them entertain physical therapy, secondary to a pure pain issue. Often, an epidural injection will decrease the amount of radicular pain, so that the patient can then be mobilized. With less discomfort, physical therapy would be a good initial treatment plan, working two to three times a week for a minimum of 6 weeks with a physical therapist.
The patient returned after obtaining an MRI within 3 days. The MRI confirmed the suspected L5 disc herniation (see Figures 9.5 and 9.6). After reviewing the MRI findings with the patient and given the patient’s continued pain complex with associated weakness, he was referred to an orthopedic spine surgeon for further management. He subsequently underwent an L4-5 discectomy with complete resolution of his leg pain postoperatively, and improvement of his dorsiflexion strength.
Fraser, S., Roberts, L., & Murphy, E. (2009). Cauda equina syndrome: A literature review of its definition and clinical presentation. Archives of Physical Medicine & Rehabilitation, 90(11), 1964–1968. doi:10.1016/j.apmr.2009.03.021
Greenhalgh, S., Truman, C., Webster, V., & Selfe, J. (2015). An investigation into the patient experience of cauda equina syndrome: A qualitative study. Physiotherapy Practice & Research, 36(1), 23–31. doi:10.3233/PPR-140047