Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Vertebra (Pathological)


Related Terms

  • Osteoporotic Vertebral Fracture
  • Pathologic Fracture
  • Pathological Cervical Fracture
  • Pathological Compression Fracture
  • Pathological Lumbar Fracture
  • Pathological Spine Fracture
  • Pathological Thoraco-lumbar Fracture

Differential Diagnosis

Specialists

  • Endocrinologist
  • Infectious Disease Internist
  • Neurosurgeon
  • Occupational Therapist
  • Oncologist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Radiologist

Comorbid Conditions

Factors Influencing Duration

The underlying disease that resulted in the fracture is the greatest influence on the disability. If the pathologic fracture occurred in a vertebra weakened by the presence of cancer or tumor, progression of the tumor and response to treatment will determine duration.

Other factors include the individual's age, the severity of the injury, the amount of impingement on the spinal cord and nerve roots, the presence of complications (e.g., infection), the individual's occupation, and risk factors involved with work. Pain tolerance and the individual's ability to modify job responsibilities may affect the length of disability.

Medical Codes

ICD-9-CM:
733.13 - Pathological Fracture of Vertebra; Collapse of Vertebra, NOS

Overview

Pathological fractures of the vertebrae are breaks in the bones that form the spine that occur when bone is weakened by an underlying, pre-existing disease or condition. When the structure of the normal bone is altered by the primary disease, the vertebra gives way with a spontaneous fracture or with a fracture after only minimal trauma.

The vertebral fracture may result from trauma or what would seem to be normal activity. The fracture occurs throughout the weakened vertebral body, causing it to collapse. This type of fracture is often referred to as a compression fracture. Pathologic fractures can occur in any region of the spinal column, but the most common area of involvement is the thoraco-lumbar region, including the thoraco-lumbar junction, where the thoracic spine (thoracic vertebra T12) meets the lumbar spine (lumbar vertebra L1). Vertebral fractures secondary to osteoporosis may occur at more than one spinal level.

Underlying disorders that may weaken bone and result in pathological vertebral fracture include bone infections such as hematogenous osteomyelitis and bone tuberculosis; metabolic bone diseases such as osteoporosis, osteomalacia, hyperparathyroidism, and renal osteodystrophy; and tumors such as multiple myeloma, chordoma, and metastatic carcinoma. Pathologic vertebral fractures can also be secondary to rheumatoid arthritis. Individuals undergoing long-term corticosteroid treatment may also develop weakened vertebrae that can predispose them to fractures.

Unlike traumatic, nonpathologic fractures in which pain decreases with time as the fracture heals, pathologic fractures secondary to bone infection or tumor usually have pain that worsens over time, until the infection or tumor is recognized and treated.

Treatment of pathologic fracture will always include treatment of the underlying disease. Pain from compression fractures related to osteoporosis will generally improve with time as the fracture heals.

Incidence and Prevalence: In the US, approximately 700,000 vertebral fractures are caused by osteoporosis annually (Dawson). The prevalence rate increases steadily with age: it is 20% for women aged 50 and 65% in older women (Reiter). Because of the lack of a standardized definition of a vertebral fracture and the fact that mild pathological compression fractures are often missed, prevalence estimates vary.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals at increased risk for pathological fractures of the vertebrae include those with underlying infection, metabolic bone disease, or cancerous lesions that may weaken bone. Elderly individuals are at greater risk for pathological vertebral fractures than younger individuals because of the increase in chronic disease, metabolic disease, and age-related bone degeneration in this population. Osteoporosis is a major contributor to pathological fracture, especially in postmenopausal women with osteoporosis. Risk factors for osteoporosis include being female, elderly, or white; having an estrogen deficiency; and smoking.

Source: Medical Disability Advisor



Diagnosis

History: The individual may complain of sudden onset of back pain, often after lifting, although there may not be any history of trauma or change in activity level. If the collapse of the vertebra occurs more slowly, the individual may report milder back pain with more gradual onset. An increase in the curvature of the upper back (kyphosis) may be noted by the individual. If the fracture has caused pressure on the spinal cord, the individual may report numbness, tingling, or weakness in the lower extremities. Depending on the location of the fracture, the individual may report problems with urination or bowel movements. In some cases, there may be only very mild or no symptoms of compression fracture. Details of any possible injury may be helpful, and obtaining a complete history of current and prior illness will be essential to determine the primary illness responsible for pathologic fracture.

Physical exam: Inspection and touching (palpation) help to determine the area to be x-rayed. In some cases, the individual may show signs of hunchback (kyphosis). Attention must also be given to the causative disease process involved, although it may not be discovered until after initial x-rays are taken.

Tests: Routine x-rays (anteroposterior and lateral views), CT, and MRI are the usual methods used to diagnose spinal fractures, supplemented at times by bone scanning. MRI permits visualization of the spinal cord. Although the fracture may be evident with plain x-rays, a bone scan is often required to detect a compression fracture. Bone scans are often ordered to determine if the bone infection or bone tumor is present in other bones, in addition to the vertebra with the pathologic fracture. Measuring bone density by dual-energy x-ray absorptiometry (DEXA), dual photon absorptiometry (DPA), or quantitative computed tomography (QCT) may be done as part of testing for osteoporosis. Various additional tests, including comprehensive diagnostic laboratory testing, may be performed to identify or confirm the underlying disease process.

Source: Medical Disability Advisor



Treatment

Treatment is determined primarily by the underlying bone pathology. Osteoporotic fractures generally heal normally with conservative treatment to reduce pain. If deformity is significant, bone cement (polymethyl methacrylate) may be injected into the bone to stabilize the fracture (vertebroplasty), or the deformity may first be reduced, after which bone cement is injected to stabilize the fracture (kyphoplasty). Supplemental medical treatment to prevent fractures (e.g., exogenous calcium, hormone therapy, an appropriate exercise regimen) may be recommended for individuals with osteoporosis.

In elderly patients with osteoporotic disease and age-related degeneration of bone, early mobilization is recommended after pathologic fracture to reduce associated morbidity and mortality (Reiter).

In general, pathologic fractures secondary to infection or tumor will not begin to heal until the individual receives treatment for the infection or tumor. Most fracture pain responds to medication. Some type of orthotic (brace or corset) may be recommended for comfort. Ice (or heat), whirlpool treatments, if available, and gentle massage may also be recommended.

Surgical treatment of pathologic vertebral fracture is rare.

Source: Medical Disability Advisor



Prognosis

The outcome varies tremendously according to the underlying diagnosis (primary illness). Most osteoporotic compression fractures heal within 6 to 8 weeks with conservative treatment, whereas fractures caused by metastatic disease may not have successful outcomes. If the pathologic fracture occurred in a vertebra weakened by the presence of cancer or tumor in the vertebra itself, treatment of the tumor will determine the prognosis and the extent of associated disability.

Fractures of the spine resulting from osteoporosis may heal but with residual deformity, which may cause pain. Fractures may occur at multiple levels, increasing the risk of deformity. Vertebroplasty and kyphoplasty may significantly decrease the deformity and chance of chronic pain. Women who have osteoporotic vertebral fractures are at high risk of having other fractures; 20% of women with pathologic fracture secondary to osteoporosis fracture a different bone within one year (Reiter).

Surgical treatment (stabilization or fusion) of pathological vertebral fractures is a highly specialized option, due to large variations in actual outcome. Recurrence of pathological vertebral fractures is common, since the underlying disease condition is often chronic.

Source: Medical Disability Advisor



Rehabilitation

The rehabilitation of pathological vertebral fractures depends on the location and severity of the fracture and the underlying pathology.

The primary goal of rehabilitation is pain management and maximizing the patient's independence in all activities of daily living (Braddom). Rehabilitation includes gait training with devices as needed and general conditioning exercises. The focus must be on promoting optimal quality of life for the patient (Bucholz).

An occupational therapist may evaluate work and home conditions to make adjustments that will help decrease mechanical stress as the pathological conditions progress.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical and Surgical
SpecialistFracture, Vertebra (Pathological)
Occupational or Physical TherapistVaries by pathology
Note on Nonsurgical and Surgical Guidelines: Frequency of physician and rehabilitation visits depends on the location and underlying etiology, and the associated pain and functional limitations.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

The most common complications of pathological vertebral fractures are hunchback (kyphosis) and decreased height. Compression fractures of the vertebrae can also cause compression and irritation of spinal nerve roots and / or the spinal cord. Multiple vertebral compression fractures of the thoracic spine with accompanying kyphosis can cause the individual to hyperextend the neck, leading to neck pain and muscle fatigue. Kyphosis can also limit total lung capacity and exercise tolerance. Chronic pain resulting from vertebral fracture can lead to depression. Recurrent fracture is a common complication, especially for osteoporotic vertebral fracture.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Restrictions and accommodations depend on the underlying disease process, and therefore, the predicted life expectancy of the individual, the number of vertebrae involved, work expectations, and the type of treatment the individual receives for the underlying condition are all factors to be considered. Restrictions include avoidance of any lifting, overhead work, carrying, pushing, and prolonged standing or sitting. Use of a corset should not affect dexterity. Safety issues and drug testing policies must be reviewed if pain medication is required.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does the individual have osteoporosis, or any other underlying metabolic bone disease, bone infection, or cancer?
  • Does individual have any underlying infections? Is he or she receiving long-term corticosteroid treatment?
  • Have conditions with similar symptoms been ruled out?
  • Did individual have sudden onset of back pain while lifting? Or did individual report milder back pain with more gradual onset?
  • If any injury occurred, was mechanism determined?
  • Is there an increase in the curvature of the upper back?
  • Does individual report problems with urination or bowel movements? Does individual report numbness, tingling, or weakness?
  • Upon palpation, was the physician able to localize the affected area? Was kyphosis present?
  • Is the causative disease process apparent?
  • Has diagnostic laboratory testing identified or confirmed a specific primary disease?
  • Has individual had x-rays, CT, and MRI?
  • Was a bone scan done?
  • Has a bone biopsy proven the diagnosis of the underlying bone disorder?
  • In the case of underlying osteoporosis, have additional vertebral fractures been ruled out?

Regarding treatment:

  • Has consultation with the appropriate specialist been obtained?
  • Did individual respond to medication?
  • Was an orthotic recommended for comfort?
  • Were ice, heat, whirlpool treatments, and gentle massage utilized?
  • Is the underlying condition being treated?

Regarding prognosis:

  • Is individual active in rehabilitation?
  • Has individual responded to treatment?
  • Have any complications developed?
  • Is individual's employer able to accommodate any necessary restrictions?
  • Does individual have kyphosis and decreased height?
  • Is there irritation of spinal nerve roots? Is radiculopathy or neurologic deficit present?
  • Does individual have multiple vertebral compression fractures?
  • Is there limited total lung capacity and exercise intolerance?

Source: Medical Disability Advisor



References

Cited

Braddom, Randolph L. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia: W.B. Saunders, 2006.

Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 6th ed. Philadelphia: Lippincott, Williams & Wilkins, 2005.

Dawson, Edgar G. "Osteoporosis: The Silent Thief." Spine Universe. Ed. Susan Spinasanta. 1 Jul. 2004. Cleveland Clinic. 26 Jan. 2009 <http://www.spineuniverse.com/displayarticle.php/article81.html>.

Reiter, Timothy G., et al. "Vertebral Fracture." eMedicine. Eds. Michael G. Nosko, et al. 8 Jul. 2004. Medscape. 26 Jan. 2009 <emedicine.com/med/topic2895.htm>.

Source: Medical Disability Advisor






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