Osteoporosis and Vertebral Compression Fractures

Description:

Osteoporosis is a decline in overall bone mass in the axial and appendicular skeleton
Affects 15-20 million people in the US
Peak bone mass is reached between ages 16-25 years
With age, bone resorption exceeds bone formation
Women are at increased risk in the 15-20 years after menopause, directly linked to estrogen deficiency
Certain environmental factors may accelerate osteoporosis:

Vertebral compression fractures are one of most frequent manifestations of osteoporosis in elderly with >700,000 compression fractures annually
Most patients are asymptomatic

Signs/Symptoms:

Symptomatic compression fractures involve pain localized to fractured level
Frequently no history of trauma or inciting event
Often family members will notice the patient’s back becoming progressively more rounded (kyphotic)
This spinal deformity is known as “dowager’s hump” (right)
Generally there is no neurologic dysfunction and no radiation of pain in dermatomal patterns

Imaging:

Plain radiographs and densitometric scans are major imaging modalities
Dual-energy x-ray absorptiometry (DEXA scan) has been most useful form of densitometric scans due to its high presicion (0.5-2%) and minimal amounts of radiation
DEXA scan assesses and quantitates osteoporosis
AP & Lateral plain films of affected area demonstrate severity of osteoporotic fractures(s)
MRI is valuable in evaluation of persistently painful, non-united, or pathologic fractures
MRI is also helpful in determining the acuity of a compression fracture seen on plain film

Severe T-11 compression fracture with marked wedging and kyphosis

Treatment:

Osteoporosis

Prevention is the best treatment for osteoporosis
Maximizing bone density prior to onset of bone loss is optimal regimen
Estrogen replacement is controversial but is effective at halting the post-menopausal decline in bone density in women
Calcitonin and parathyroid hormone are effective therapies in certain patients
Bisphosphonates (etidronate and alendronate) prevent osteoclastic resorption of bone
Bisphosphonates are the only FDA approved pharmacotherapy for increasing bone density. Unfortunately, the increase is small

Vertebral Compression Fractures

Initial treatment involves analgesics therapy and bracing for comfort
Evaluation and treatment for osteoporosis should be initiated
Surgical treatment is required compression fractures with associated neurologic compromise or spinal cord compression

Patients with persistent pain after conservative therapy may undergoe percutaneous stabilizing techniques
polymethylmethacrylate (PMMA) bone cement is injected into the fracture percutaneously through pedicles into vertebral body under fluoroscopic guidance

Both methods show excellent symptomatic relief and have shown to be safe and efficacious