Prevalence and Pathophysiology of spinal insufficiency fractures<\/b><\/p>\n
Spinal insufficiency fractures, unlike traumatic fractures, occur due to reduced bone mass and microarchitectural deterioration, which impair the bone\u2019s ability to withstand normal stress. As a result, low-level trauma and even everyday activities can lead to fractures in structurally compromised bone, without the need for excessive external force (<\/span>ii)<\/span>.<\/span><\/p>\n Incidence of spinal insufficiency fractures is greater in the over 50s, affecting women more than men (<\/span>iv)<\/span>.<\/span>Spinal fractures often occur following low-level trauma (e.g. a fall from standing height or lower) and can be very painful. Frequently, these present as occult fractures with Insidious, progressive pain, often worse on standing and weight-bearing (5)<\/span>.\u00a0 Duration of symptoms varies, and although a single event can be <\/span>recalled, often patients present with a progressive pain over weeks or months (<\/span>iv)<\/span>. Notably, 50-70% of are asymptomatic and identified incidentally.\u00a0<\/span><\/p>\n Risk Factors for spinal insufficiency fractures<\/b><\/p>\n Osteoporosis is by far the most common cause of abnormal bone health and low bone mass. The causes of abnormal bone quality can be categorised into intrinsic factors and extrinsic factors.\u00a0\u00a0\u00a0<\/span><\/p>\n Table 1: Risk factors for spinal insufficiency fractures<\/span><\/i><\/p>\n <\/p>\n Figure 1: Risk factors for spinal insufficiency fractures<\/span><\/i><\/p>\n The work up of suspected insufficiency spinal fractures<\/b><\/p>\n The flowchart below summarises patient workup and management. Each domain is discussed in detail further below.<\/span><\/p>\n Figure 2: Spinal insufficiency fracture work up flowchart<\/span><\/i><\/p>\n \u2022 MRI: 2<\/span>nd<\/span> line; can usually differentiate marrow oedema secondary to insufficiency fractures from malignancy; guide regarding recency of fracture; more sensitive than CT (<\/span>xi, 20)<\/span> Clinical History<\/b><\/p>\n A note about red flags<\/b><\/p>\n Basic Observations & Physical Examination<\/b><\/p>\n\n
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\n Risk Factors<\/span><\/td>\n<\/tr>\n \n Intrinsic risk factors<\/b><\/td>\n Extrinsic risk factors<\/b><\/td>\n<\/tr>\n \n Osteoporosis<\/span><\/td>\n Extended corticosteroid use<\/span><\/td>\n<\/tr>\n \n Malignancy\u00a0<\/span><\/td>\n History of radiation therapy<\/span><\/td>\n<\/tr>\n \n Hypertension<\/span><\/td>\n high-dose fluoride therapy<\/span><\/td>\n<\/tr>\n \n Diabetes<\/span><\/td>\n Smoking \/ Alcohol<\/span><\/td>\n<\/tr>\n \n Paget\u2019s disease<\/span><\/td>\n High Mechanical load\u00a0<\/span><\/td>\n<\/tr>\n \n Hyperparathyroidism<\/span><\/td>\n Post arthroplasty<\/span><\/td>\n<\/tr>\n \n Hypocalcaemia<\/span><\/td>\n Vitamin D Deficiency<\/span><\/td>\n<\/tr>\n \n Cushing\u2019s syndrome<\/span><\/td>\n Post-surgical complications<\/span><\/td>\n<\/tr>\n \n Systemic lupus erythematosus<\/span><\/td>\n Pre-existing insufficiency fractures<\/span><\/td>\n<\/tr>\n \n Rheumatoid Arthritis<\/span><\/td>\n Aromatase inhibitors<\/span><\/td>\n<\/tr>\n \n Chronic kidney disease<\/span><\/td>\n Anti-epileptics<\/span><\/td>\n<\/tr>\n \n Primary biliary cirrhosis<\/span><\/td>\n <\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n ![\"\"](\"https:\/\/blogs.bmj.com\/bjsm\/files\/2025\/11\/Figure-1-Risk-factors-for-spinal-insufficiency-fractures-212x300.png\")
<\/p>\n![\"\"](\"https:\/\/blogs.bmj.com\/bjsm\/files\/2025\/11\/Figure-2-Spinal-insufficiency-fracture-work-up-flowchart-300x300.png\")
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\n Category<\/b><\/td>\n Details<\/b><\/td>\n<\/tr>\n \n Key Clinical History Questions<\/b><\/td>\n \u2022 Pain characteristics: onset, duration, site (typically midline), worse with activity,\u00a0 improved\u00a0 by rest <\/span>
\n<\/span>\u2022 Night pain: common in malignancy or acute fractures <\/span>
\n<\/span>\u2022 Recent trauma or load-related pain: even minimal trauma may be significant in weakened bone <\/span>
\n<\/span>\u2022 Unexplained weight loss\/night sweats\/fatigue: raise concern for malignancy or infection <\/span>
\n<\/span>\u2022 History of malignancy: particularly breast, prostate, lung, myeloma <\/span>
\n<\/span>\u2022 Febrile illness or systemic infection symptoms <\/span>
\n<\/span>\u2022 Neurological symptoms: weakness, numbness, bladder\/bowel dysfunction <\/span>
\n<\/span>\u2022 Frailty or sarcopenia: poor musculoskeletal reserve, increased fracture risk<\/span>\u2022Age\u00a0<\/span>\u2022Previous history of fragility fracture<\/span>\u2022 Parent history of fractured hip<\/span>
\n<\/span>\u2022 Glucocorticoid use <\/span>
\n<\/span>\u2022 History of rheumatoid arthritis<\/span>\u2022Smoking and alcohol consumption<\/span><\/td>\n<\/tr>\n\n Basic Observations & Physical Examination<\/b><\/td>\n \u2022 Vital signs: temperature, heart rate, blood pressure <\/span>
\n<\/span>\u2022 Height and weight: compare with previous records <\/span>
\n<\/span>\u2022 Palpation: midline spinal tenderness, pain on percussion <\/span>
\n<\/span>\u2022 Spinal alignment: visible scoliosis or kyphosis\u00a0<\/span>\u2022 Height loss: \u22654 cm can suggest vertebral fracture (18, 19)<\/span>.<\/span>
\n<\/span>\u2022 Range of motion: reduced flexibility, stiffness <\/span>
\n<\/span>\u2022 Gait and balance: assess functional impact and compensatory mechanisms<\/span><\/td>\n<\/tr>\n\n Laboratory Investigations<\/b><\/td>\n \u2022 Myeloma screen: serum protein electrophoresis, free light chains, Bence Jones proteins <\/span>
\n<\/span>\u2022 Calcium: elevated in malignancy or hyperparathyroidism <\/span>
\n<\/span>\u2022 Parathyroid hormone (PTH): assess for hyperparathyroidism <\/span>
\n<\/span>\u2022 Vitamin D: deficiency increases risk of insufficiency fractures <\/span>
\n<\/span>\u2022 ESR\/CRP: raised in infection or malignancy<\/span>
\n<\/span>\u2022 Renal function: assess creatinine, urea (important for myeloma and calcium balance)<\/span>\u2022 Coeliac serology: tTG-igA, EMA, IgA\u00a0<\/span>\u2022 Thyroid Function: TSH, T4<\/span>\u2022 FBC, TFT, Testosterone, PSA in men<\/span><\/td>\n<\/tr>\n\n Imaging & Diagnostic Tests<\/b><\/td>\n \u2022 X-ray: 1<\/span>st<\/span> line; useful for monitoring changes; may miss early fractures<\/span><\/p>\n
\n<\/span>\u2022 CT scan: detailed bony anatomy; useful if MRI is contraindicated <\/span>
\n<\/span>\u2022 DXA scan: measures bone mineral density; T-score \u2264 -2.5 = osteoporosis <\/span>
\n<\/span>\u2022 Ultrasound: limited role; may assess sarcopenia\/muscle mass <\/span>
\n<\/span>\u2022 Risk tools: e.g. FRAX score for estimating fracture risk<\/span><\/td>\n<\/tr>\n\n Red Flags for Serious Pathology<\/b><\/td>\n \u2022 History of malignancy or known metastasis <\/span>
\n<\/span>\u2022 Night pain and unexplained weight loss <\/span>
\n<\/span>\u2022 Systemic illness: fever, fatigue, raised inflammatory markers <\/span>
\n<\/span>\u2022 Progressive neurological deficits <\/span>
\n<\/span>\u2022 Lack of response to conservative treatment (4\u20136 weeks) <\/span>
\n<\/span>\u2022 Age >50 with new back pain or history of trauma<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n
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