Vertebral Fractures: New Chiropractic Test

Effective and efficient chiropractors ask the right questions; allowing them to perform the most sensitive orthopedic testing to identify damaged tissue. A recent article by Jin et al. (2020) identified a new orthopedic test to do just that. The Back Pain-Inducing Test (BPIT) recognizes symptomatic vertebral fractures (VF) with high sensitivity (99.1%) and specificity (67.9%). This isolated paper also reports good accuracy (89.0%), positive predictive value (86.6%), and negative predictive value (97.4%).*

This blog will review exactly how to perform this and other useful tests for identifying vertebral fractures.

“Approximately 80% of patients experience at least one unnoticed osteoporotic fracture before being eventually diagnosed.  Only 1/3 of patients with VFs seek medical attention due to back pain, while the rate of misdiagnosis is up to 40% at the point of care.” (1)

Physical Evaluation of Vertebral Fractures

In seniors, an increased thoracic kyphosis or loss of lumbar lordosis should raise suspicion for VF. Multiple VF's can lead to a noticeable overall loss of height. There is a high incidence of compression fractures in elderly patients whose fingertips extend to the lower thigh when standing.

Orthopedic Evaluation of Vertebral Fractures

Let’s review out top four orthopedic tests for identifying VF’s:

1. The Back Pain-Inducing Test (BPIT)

Patients completed three consecutive movements (without any help) in the following order.

• First, sitting on the table with legs dangling off the edge of the table, and then lying down in the supine position (lying supine);

• Second, changing from the supine position to the left or right decubitus position with legs flexed, and then back to the supine position (rolling over);

• Third, changing from the supine position to a sitting posture with the legs still on the bed (sitting up).

Back pain induced by any of these movements was documented using a patient-reported numerical rating scale (NRS). The following BPIT results were defined as positive:

• Patients reporting back pain occurring during any movement or

• Patients not being able to perform any of the three movements due to back pain.

 Otherwise, the test results were deemed negative. (1)

2. Supine Sign

The inability to lie supine on an exam table with only one pillow supporting the head has a relatively high sensitivity (81%) and specificity (93%) for vertebral compression fracture.

3. Seated Closed Fist Percussion

Percussion of the spine has a sensitivity and specificity near 90% for vertebral compression fracture. Acute or "active" VF will likely limit the spinal range of motion.

4. Heel Drop Test

The Heel Drop Test may increase pain originating from VF. The presence of radicular complaints or neurological findings mandates further workup to evaluate the stability of the injury.

Osteoporotic vertebral compression fractures (OVCF) are twice as common as hip fractures.

Red Flags

Clinicians should consider orthopedic referral for patients with radicular complaints attributable to VF. The presence of cauda equina symptoms (loss of bowel or bladder control, impotence, etc.) requires an immediate emergency referral.

Vertebral Fracture Patient Education

Is your patient considering invasive treatment?  Educate them with the facts concerning vertebral augmentation strategies, i.e., vertebroplasty, kyphoplasty.

1. One systematic review demonstrated that when compared to patients choosing conservative therapy, OVCF patients undergoing percutaneous vertebroplasty demonstrated greater pain relief up to 1 year postoperatively. (2)

2. Many other vertebroplasty studies have failed to show significantly better long-term outcomes compared with conservative care. (3.4)

3. Guidelines recommend that patients with stable OVCF should complete 3-4 weeks of conservative care before considering cement augmentation. (5-7)

4. Progressive increase in the fracture angle (>10 degrees) and persistent, progressive or debilitating pain may be indications for earlier operative management. (8-9)

5. Studies concerning balloon kyphoplasty fail to support superiority over conservative care. (10-16)

*These numbers are derived from one isolated paper. There has not been extensive research on this test, and the authors use a population susceptible to vertebral fractures as listed in their inclusion criteria.

All aforementioned statements are referenced within the ChiroUp condition reference.

• References

  Jin H, Ma X, Liu Y, et al. Back Pain-Inducing Test, a Novel and Sensitive Screening Test for Painful Osteoporotic Vertebral Fractures: A Prospective Clinical Study. J Bone Miner Res. 2020;35(3):488‐ doi:10.1002/jbmr.3912 Link

  Mattie R, Laimi K, Yu S, Saltychev M. Comparing percutaneous vertebroplasty and conservative therapy for treating osteoporotic compression fractures in the thoracic and lumbar spine: a systematic review and meta-analysis. JBJS. 2016 Jun 15;98(12):1041-51. Link

  Kallmes DF, Comstock BA, Heagerty PJ, Turner JA, Wilson DJ, Diamond TH, Edwards R, Gray LA, Stout L, Owen S, Hollingworth W. A randomized trial of vertebroplasty for osteoporotic spinal fractures. New England Journal of Medicine. 2009 Aug 6;361(6):569-79. Link

  Buchbinder R, Osborne RH, Ebeling PR, Wark JD, Mitchell P, Wriedt C, Graves S, Staples MP, Murphy B. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. New England Journal of Medicine. 2009 Aug 6;361(6):557-68. Link

  Klazen CA, Lohle PN, de Vries J, Jansen FH, Tielbeek AV, Blonk MC, Venmans A, van Rooij WJ, Schoemaker MC, Juttmann JR, Lo TH. Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial. The Lancet. 2010 Sep 25;376(9746):1085-92. Link

  Lee HM, Park SY, Lee SH, Suh SW, Hong JY. Comparative analysis of clinical outcomes in patients with osteoporotic vertebral compression fractures (OVCFs): conservative treatment versus balloon kyphoplasty. The Spine Journal. 2012 Nov 1;12(11):998-1005. Link

  Haczynski J, Jakimiuk A. Vertebral fractures: a hidden problem of osteoporosis. Med Sci Monit. 2001;7(5):1108-7. Link

  Mehta JS, Reed MR, McVie JL, Sanderson PL. Weight-bearing radiographs in thoracolumbar fractures: do they influence management?. Spine. 2004 Mar 1;29(5):564-7. Link

  Gibson L. The mechanical behaviour of cancellous bone. Journal of biomechanics. 1985 Jan 1;18(5):317-28. Link

  Liu JT, Liao WJ, Tan WC, Lee JK, Liu CH, Chen YH, Lin TB. Balloon kyphoplasty versus vertebroplasty for treatment of osteoporotic vertebral compression fracture: a prospective, comparative, and randomized clinical study. Osteoporosis international. 2010 Feb 1;21(2):359-64. Link

  Yang H, Wang G, Liu J, et al. Balloon kyphoplasty in the treatment of osteoporotic vertebral compression fracture nonunion. Orthopedics 2010;33:24.

  Dixon RG, Mathis JM. Vertebroplasty and kyphoplasty: rapid pain relief for vertebral compression fractures. Current osteoporosis reports. 2004 Dec 1;2(4):111-5. Link

  Mathis JM, Ortiz AO, Zoarski GH. Vertebroplasty versus kyphoplasty: a comparison and contrast. AJNR Am J Neuroradiol 2004;25:840–5.

  Chen JK, Lee HM, Shih JT, Hung ST. Combined extraforaminal and intradiscal cement leakage following percutaneous vertebroplasty. Spine. 2007 May 20;32(12):E358-62. Link

  Park SY, Modi HN, Suh SW, Hong JY, Noh W, Yang JH. Epidural cement leakage through pedicle violation after balloon kyphoplasty causing paraparesis in osteoporotic vertebral compression fractures-a report of two cases. Journal of orthopaedic surgery and research. 2010 Dec;5(1):54. Link

  Longo UG, Loppini M, Denaro L, Maffulli N, Denaro V. Conservative management of patients with an osteoporotic vertebral fracture: a review of the literature. The Journal of bone and joint surgery. British volume. 2012 Feb;94(2):152-7. Link