Vertebral compression fractures are more common than hip fractures, yet roughly half are missed by radiologists and only one in four is ever clinically diagnosed. Many people have one — or several — without ever knowing. Here's what they are, how they cause harm over time, and what can actually be done about them in Canada.
Your spine is made up of stacked vertebrae — the bony blocks that make up your spinal column. In osteoporosis, the internal scaffold of those bones becomes thin and weak. A vertebral compression fracture (VCF) occurs when one of those bones partially collapses — typically the front edge, creating a wedge shape.
The most commonly affected area is the mid-to-lower thoracic and upper lumbar spine: roughly T7 through L1. When multiple vertebrae fracture, the progressive wedging causes the kyphosis (forward curve) often called a "dowager's hump" — though that term is outdated and a bit unfair.
One fracture increases your risk of another by approximately five times. A second VCF within two years is considered an absolute indication to start osteoporosis medication under Osteoporosis Canada guidelines — if you aren't already on treatment.
Up to 50% of VCFs are misidentified or not reported, even when they appear on imaging (PMC8203169, 2021). A 2023 study published in the Journal of the Endocrine Society found that only 25% of radiographically confirmed vertebral fractures in a cohort of over 6,000 women had ever been clinically diagnosed.
The reasons are frustratingly mundane. Many VCFs produce no acute pain event — the fracture happens gradually, over days or weeks, without anything obvious.
When there is pain, it's often dismissed as "muscle strain," "degenerative disc disease," or the general aches of aging. Both patients and clinicians frequently attribute it to something more benign.
On standard X-rays, subtle vertebral height loss can be easy to miss unless the radiologist is specifically looking for it. The WHO defines a VCF as ≥20% loss in vertebral height, but smaller fractures that are still clinically significant don't always reach that threshold on initial imaging.
The classic presentation is sudden mid-back or lower back pain in an older woman with known osteoporosis — often triggered by something as minor as reaching overhead, coughing, or getting out of a car. But many fractures are much quieter than that.
Standard lateral spine X-ray can show significant vertebral height loss, but it's not sensitive for early or subtle fractures. The most important things to know about diagnosis in Canada:
VFA (Vertebral Fracture Assessment) is a low-radiation scan that can be added to a DEXA appointment at centres that have the compatible software. It captures the lateral thoracic and lumbar spine in the same session as your bone density test, allowing a radiologist or trained software to detect vertebral height loss.
Not every DEXA centre in Canada offers VFA — it depends on the machine and software installed. If you have height loss, back pain, or significant risk factors and are scheduled for a DEXA, ask specifically: "Does this centre offer vertebral fracture assessment?"
If VFA isn't available, a plain lateral spine X-ray is the alternative. It's low-cost, widely available, and adequate for detecting moderate-to-severe VCFs. Your GP or internist can order this directly.
MRI is useful when you need to determine whether a known fracture is acute (new, painful, potentially treatable with cement augmentation) vs chronic (healed, no edema). The bone marrow edema visible on MRI in an acute fracture is what guides decisions about vertebroplasty or kyphoplasty. If you're being assessed for a surgical procedure, MRI of the relevant spinal segments is typically required.
Vertebral fractures aren't just a back pain problem. They have measurable effects on quality of life and function that are often underappreciated.
Chronic kyphosis reduces lung capacity. Studies show that thoracic hyperkyphosis from VCFs can reduce FEV1 (lung function measure) by 9% per fracture — meaning people with multiple thoracic VCFs often have shortness of breath unrelated to any lung disease.
The abdominal compression can cause chronic early satiety, nutritional challenges, and unexplained weight loss in older adults. The persistent pain and postural change also significantly increases fall risk — creating a cycle where VCFs cause instability that leads to more falls and more fractures. Understanding your overall fracture risk is important context here.
Mortality risk is also elevated. Vertebral fractures are associated with increased 5-year mortality, similar to hip fractures — but they rarely trigger the same urgency in the medical system.
Most acute VCFs are managed conservatively. Pain management — acetaminophen, NSAIDs, and occasionally short-term opioids for severe acute pain — is the immediate priority. Short-term bed rest (24–48 hours) is reasonable for severe pain, but prolonged bed rest worsens outcomes: it accelerates bone loss, deconditions muscles, and increases clot risk.
Back bracing (thoracolumbar orthosis) can reduce pain and help maintain posture during healing. It's not a long-term solution but can help in the first weeks after fracture. A physiotherapist familiar with osteoporosis can help with fitting and guidance.
This is one of the most practically important things in this entire page. Forward bending — spinal flexion — significantly increases compressive load on the front of the vertebral body, which is exactly where VCFs occur.
This means: yoga forward folds, sit-ups, toe touches, bending forward to pick things up without a hip hinge — all contraindicated if you have active or healed VCFs. A physiotherapist experienced in osteoporosis will teach you spine-safe movement patterns (hip hinges, supported extension exercises) that maintain function without loading fractured vertebrae.
Vertebroplasty involves injecting bone cement (polymethylmethacrylate) directly into the fractured vertebra under imaging guidance. The goals are pain relief and stabilization — not height restoration.
The evidence here is genuinely complex. Early randomized controlled trials comparing vertebroplasty to sham procedures showed no significant benefit (the INVEST and VERTOS II trials). However, more recent and better-designed trials (notably the VERTOS IV trial) showed meaningful pain reduction in patients with acute fractures confirmed by bone marrow edema on MRI.
The takeaway: patient selection matters enormously. Vertebroplasty appears most effective for acute painful fractures (within 6–8 weeks, with edema on MRI), less so for chronic pain or fractures without edema.
Vertebroplasty is available at major academic hospitals across Canada and is covered by provincial health insurance when medically indicated.
Kyphoplasty adds a step: a balloon is inflated inside the fractured vertebra first, partially restoring height and creating a cavity, then cement is injected into that cavity. This reduces the risk of cement leakage (a potential complication of vertebroplasty) and partially restores vertebral height — which can meaningfully reduce kyphosis.
Kyphoplasty is available at spine surgery centres in Canada, including in BC and Ontario. It's more technically demanding and costs more than vertebroplasty, but for patients with significant height loss from a recent fracture, it may offer better anatomical outcomes.
Both procedures are typically performed by interventional radiologists or spine surgeons as day procedures under local anaesthetic and sedation.
A vertebral compression fracture is a fragility fracture. Full stop. If you've had one and you're not already on osteoporosis medication, you need to discuss medication with your GP, rheumatologist, or endocrinologist. The risk of a second fracture in the next two years is high, and treatment substantially reduces that risk.
For people with very severe osteoporosis or multiple VCFs, this may be the point where anabolic medications like Forteo or Evenity become relevant rather than antiresorptives alone. Your fracture history is one of the key criteria for accessing these stronger options.
If you're not already connected to a Fracture Liaison Service (FLS) — a program that tracks and coordinates care after fragility fractures — ask your hospital or GP about access. Several major Canadian hospitals run FLS programs specifically to prevent the "second fracture" that so often follows the first.
Physiotherapy referral is warranted after any vertebral fracture — not just for pain management, but to learn safe movement, improve balance, and begin appropriate strengthening. Physio that's focused on osteoporosis-specific rehab (extension strengthening, posture training, balance) is different from standard back physiotherapy, which may not account for fracture contraindications.
Look for physiotherapists with specific osteoporosis training or experience, or ask your GP for a referral to a physiatrist (physical medicine specialist) if standard physio hasn't helped.
After acute healing, appropriate resistance exercise — focusing on spine extension, hip strengthening, and balance — is one of the best things you can do. See the exercise for osteoporosis guide for specifics on what's safe and what isn't.