Vertebral compression fractures are the most common osteoporotic fracture — more common than hip fractures. Up to half are never clinically diagnosed. If you have osteoporosis and back pain, this page is worth reading carefully.
A vertebral compression fracture (VCF) occurs when a vertebral body — the rounded block of bone that makes up the spine — partially or completely collapses. The most common pattern is an anterior wedge fracture: the front of the vertebra crumbles while the back remains more intact, causing the spine to gradually curve forward.
VCFs occur most often in the thoracic spine (upper and mid back) and the lumbar spine (lower back). The T12-L1 junction — where the thoracic and lumbar regions meet — is the single most common site. This is a zone of mechanical transition that concentrates stress during normal movement.
In people with osteoporosis, the force required to cause a VCF can be surprisingly small: bending forward to pick something up, sneezing forcefully, or even rolling over in bed. Bone that has lost density fractures at loads that healthy bone would tolerate easily.
A 2021 review (PMCID: PMC8203169) found that VCFs are misdiagnosed or missed entirely at rates up to 50%. A widely cited Endocrine Society analysis found that only 1 in 4 radiographically confirmed VCFs are ever clinically diagnosed. This is not a minor gap — it means the majority of people walking around with fractured vertebrae have been told they have "degenerative disc disease," "muscle spasm," or "arthritis."
The reasons for this are structural. VCF pain often mimics other common back problems. Unless a lateral spine X-ray is specifically ordered, the fracture won't appear on standard imaging ordered for back pain (which often starts with AP X-ray or is skipped entirely). Physicians not trained in osteoporosis may not consider VCF when the patient has no acute trauma history.
An acute fracture often presents as sudden, severe back pain in the mid or lower back. The pain typically worsens with standing, walking, and transitioning from sitting to standing. Some patients describe feeling or hearing a "pop" at the moment of fracture. The pain may radiate around the ribcage or into the abdomen.
Lying flat — which unloads the spine — often provides the most relief. If bending forward makes pain dramatically worse and lying down dramatically better, that pattern is consistent with a vertebral fracture.
Chronic VCFs may present as a dull, persistent ache in the mid or lower back, worsening with prolonged standing or sitting. Some patients never recall an acute event. The fracture occurred, healed partially in a compressed position, and produces ongoing mechanical strain.
These patients are often told their back pain is "normal for their age" — a missed diagnostic opportunity.
Multiple anterior wedge fractures cause progressive thoracic kyphosis with measurable downstream effects: reduced lung capacity (from compressed thoracic cage), early satiety from stomach compression (the stomach is pushed upward), and substantially increased fall risk from a shifted centre of gravity.
These are not minor quality-of-life issues. Thoracic kyphosis from untreated VCFs is associated with increased mortality in older adults, largely mediated through respiratory compromise and fall-related injury.
The standard initial screening tool for VCF is a lateral spine X-ray — the image taken from the side, which shows the height of each vertebral body. Anterior wedge collapse is visible as a difference in height between the front and back of the vertebra. This test is inexpensive, widely available, and can be done at any radiology clinic in Canada.
Ask specifically for a "lateral spine X-ray" including both thoracic and lumbar regions. A standard AP spine film (front-facing) does not reliably detect VCFs.
MRI is the best tool for determining whether a fracture is acute (recent) or chronic (old and healed). It shows bone marrow oedema, which indicates active fracture. This distinction matters for treatment planning, particularly for surgical referral. MRI also identifies spinal cord or nerve root compromise if neurological symptoms are present.
Wait times for MRI in Canada range from weeks to months in most provinces unless the referral is marked urgent. For acute severe pain, ER presentation may accelerate access.
Some DEXA centres in Canada offer Vertebral Fracture Assessment (VFA) — lateral spine imaging done during your bone density scan without additional radiation beyond the DEXA itself. VFA can detect vertebral fractures that you and your doctor didn't know about, and it changes management when fractures are found.
Not every DEXA centre offers VFA. Ask when booking your DEXA scan whether VFA is available at that location. If your centre doesn't offer it, ask for a referral to one that does, particularly if you have risk factors for undetected VCF.
Most acute VCFs heal over 6–12 weeks with conservative management. The bone heals, though it may heal in a compressed shape — this is why early diagnosis and treatment of osteoporosis matters for preventing the next fracture.
Pain management options include acetaminophen (preferred for regular use) and short-term NSAIDs (ibuprofen, naproxen) with caution around GI side effects in older adults. Calcitonin nasal spray (Miacalcin) was historically used for VCF pain and has modest evidence for acute pain relief, though it is no longer a first-line recommendation.
Rigid or semi-rigid back bracing may help some patients with acute pain by limiting spinal flexion. A physiotherapist or physiatrist can fit an appropriate brace. Avoid prolonged bed rest — short-term rest is fine, but immobility delays recovery and accelerates bone and muscle loss.
Physiotherapy for VCF focuses on extension exercises (backward bending, which opens the compressed anterior wedge) rather than flexion exercises (forward bending, which compresses it further). Standard physiotherapy programs that include forward bending — common for non-specific back pain — can worsen VCF outcomes.
Ensure your physiotherapist is aware you have a confirmed or suspected VCF. The protocol for VCF rehabilitation differs significantly from general back pain physiotherapy.
Both procedures involve injecting bone cement (polymethylmethacrylate) into the fractured vertebra under imaging guidance to stabilize it. Kyphoplasty uses an inflatable balloon to first create a cavity and partially restore vertebral height before injecting cement. Vertebroplasty injects cement directly without height restoration.
The evidence for these procedures is nuanced. The VERTOS IV trial (2018) found vertebroplasty superior to sham procedure for acute severe VCF pain in carefully selected patients. Earlier trials (INVEST, VERTOS II) produced mixed results, partly due to patient selection. Current Canadian practice uses these procedures selectively — primarily for acute fractures with severe pain not responding to conservative management after 3–6 weeks.
These procedures require assessment by an orthopedic surgeon, neurosurgeon, or interventional radiologist with spine expertise. They are not appropriate for all VCFs and carry procedural risks including cement leakage.
Every VCF is a mandatory trigger for reassessing osteoporosis treatment. A vertebral fracture in a patient not on treatment means starting medication. A fracture in a patient on bisphosphonates may indicate treatment failure and warrants considering anabolic therapy.
The guidelines from Osteoporosis Canada and the American Society of Bone and Mineral Research are clear: a vertebral fracture, particularly if moderate or severe, is a strong indication for anabolic agents (teriparatide or romosozumab) — see the bone-building medications guide for details on these options.
One VCF dramatically increases the risk of a subsequent VCF. The risk of a second vertebral fracture within the year following the first is approximately 5-fold higher than baseline. This is the cascade fracture effect, driven by two mechanisms: the underlying bone fragility that caused the first fracture is unchanged, and progressive kyphosis from the first fracture increases mechanical load on adjacent vertebrae.
If you were already on a bisphosphonate when the fracture occurred, this is the time to discuss with your physician whether a stronger antiresorptive (zoledronic acid IV) or an anabolic agent is appropriate. See the bisphosphonate drug holiday guide to understand where a drug holiday should and should not fit into this picture — a drug holiday is not appropriate after a new fracture.
For complex VCF management, the relevant specialties are physiatry (rehabilitation medicine), rheumatology with bone expertise, spine surgery (orthopedic or neurosurgical), and interventional radiology for procedural intervention. Wait times in most provinces range from 3–9 months for non-urgent specialist appointments.
Acute severe pain, new neurological symptoms, or suspected instability warrant ER evaluation. Most Canadian ERs can order a lateral spine X-ray and MRI and arrange urgent specialist consultation. Don't wait weeks in severe pain — ER presentation for acute VCF is appropriate and will typically result in faster imaging and pain management.
Fracture Liaison Services (FLS), where available in larger Canadian centres, coordinate post-fracture osteoporosis assessment and treatment initiation. Ask your hospital or orthopedic clinic whether an FLS program exists in your area.