Pathologic Fracture

Pathologic = having to do with a pathology (a disease)
Fracture = a break in a bone

A pathologic fracture is a break in a bone that is caused by an underlying disease. At the Spine Hospital at the Neurological Institute of New York, we specialize in pathologic fractures of vertebrae, or bones of the spine.

For the most part, bones need a reason to break–for example, a significant trauma. However, some pathologies (diseases) weaken the bones of the spine. Forces as slight as the weight of the body or a minor trauma that would otherwise be tolerated can cause a fracture in the diseased bone.

Pathologic vertebral fractures may or may not cause symptoms. If pathologic fractures cause symptoms, these may include:

• pain in back, legs, and arms
• neurological impairment–such as numbness and/or weakness in the arms or legs (if the fracture has affected the spinal cord and/or nerves in the spine)

Pathologic fractures are frequently caused by tumors. Tumors may originate in the vertebrae, or may be the result of cancer that has spread from elsewhere in the body. The spread of cancer is called metastasis. The vertebrae are a common site for metastasis.

Pathologic fractures are also frequently caused by osteoporosis. Osteoporosis is a condition of weak and brittle bones that is most common in older women.

Other conditions that may weaken the vertebrae include infection, osteomalacia (a condition in which the bones become soft due to a vitamin D deficiency), and Paget’s disease (a condition in which the renewal and repair processes of bone are abnormal).

The doctor will take a complete medical history and perform a complete physical examination.
If a pathologic fracture is suspected, the doctor may order the following diagnostic procedures:

• X-ray (also known as plain films) –test that uses invisible electromagnetic energy beams (X-rays) to produce images of bones. Soft tissue structures such as the spinal cord, spinal nerves, the disc and ligaments are usually not seen on X-rays, nor on most tumors, vascular malformations, or cysts. X-rays provide an overall assessment of the bone anatomy as well as the curvature and alignment of the vertebral column. Spinal dislocation or slippage (also known as spondylolisthesis), kyphosis, scoliosis, as well as local and overall spine balance can be assessed with X-rays. Specific bony abnormalities such as bone spurs, disc space narrowing, vertebral body fracture, collapse or erosion can also be identified on plain film X-rays. Dynamic, or flexion/extension X-rays (X-rays that show the spine in motion) may be obtained to see if there is any abnormal or excessive movement or instability in the spine at the affected levels.
• Magnetic resonance imaging (MRI) – a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.
• Computed tomography scan (CT scan) – a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce detailed images of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

Nuclear bone scan – a diagnostic procedure in which a radioactive substance is injected into the body to measure activity in the bones.  (The amount of radiation is small–less than the radiation in half of one CT scan.) This scan helps identify damaged bones.

The goals of treatment are pain relief, reversal or stabilization of neurological deficits, and stabilization of the spine.

For the most part, nonoperative treatments are recommended for less severe pathologic fractures. These include taking pain medications, limiting physical activity, and wearing a brace. The brace helps support the back and prevents bending forward, which removes pressure from the fractured vertebrae.

If the fracture is caused by osteoporosis, treatment of the osteoporosis can help prevent additional fractures. Treatment may include calcium and vitamin D supplements, bisphosphonates, and weight bearing exercise.  

If the fracture is caused by metastatic cancer, treatment options vary by case. Nonsurgical option for pain relief is radiation therapy or injection of bone cement. Radiation is applied to the area of involvement in the hopes of shrinking the tumor and removing pressure from the nerves. The surgeon may perform a vertebroplasty or a kyphoplasty. During these procedures, the surgeon injects a cement mixture into the fractured bone to stabilize the fracture, treat pain, and prevent a spinal deformity from progressing.

Spine surgery is considered if the spine appears to be unstable or if there is significant compression of the neural elements.

In some cases, the surgeon may need to remove diseased bone to relieve pressure on the spinal cord and nerves. Such procedures may also require a spinal fusion to stabilize the spine until it heals. During a spinal fusion, the surgeon may place a bone graft across the area of instability, allowing the vertebrae to fuse (grow together). The surgeon may also need to perform an internal fixation, using screws and rods, to hold the vertebrae in place while the bone heals.

The surgeon will tailor the treatment to each patient and each situation.

Drs. Paul C. McCormick, Michael G. Kaiser, Peter D. Angevine, Alfred T. Ogden, Christopher E. Mandigo, Patrick C. Reid and Richard C.E. Anderson (Pediatric) are experts in pathologic fractures. He can also offer you a second opinion.