Osteoporosis is the most common metabolic bone disorder and affects a large portion of the population. Osteoporosis is defined as a decrease in bone mass, specifically bone mineral density. According to the World Health Organization (WHO), a person has osteoporosis if their bone mineral density is 2.5 standard deviations below that of a normal 25 year-old person or if they have a sustained a fracture due to diminished bone mass. Although a vertebral compression fracture is generally not as severe as a hip fracture for an elderly person, it is still a very common condition that can be quite disabling and lead to the development of additional orthopaedic and medical problems.
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How is it diagnosed?
The diagnosis of osteoporosis and a compression fracture should be suspected in any patient with back pain over 50 years old, as well as anyone younger who has significant risk factor(s). An X-ray is required to confirm the presence of a fracture and may also suggest osteoporosis. A DEXA scan is essential to determine the severity of bone mass loss and can be used to track improvement in bone mass after treatment is initiated. Additional imaging such as bone scan, CT and/or MRI may also be useful in various clinical scenarios to evaluate nerve compression or other pathologic entities. Laboratory tests are critical to evaluate for secondary causes of osteoporosis and pathologic conditions such as lymphoma, leukemia and multiple myeloma.
What are the treatment options?
One of the best treatments for osteoporosis is prevention. Therefore, specific guidelines have been issued regarding the recommended intake of calcium and vitamin D by the National Research Council.
Recommended Daily Intake
Infants (0-1)- Calcium (mg/day) 400, Vitamin D (IU) 400
Children (1-10)- Calcium (mg/day) 800, Vitamin D (IU) 400-600
Adolescents (10-24)- Calcium (mg/day) 1,200, Vitamin D (IU) 800
Adults- Calcium (mg/day) 1000 Vitamin D (IU) 400
In addition to adequate nutrient intake, a regular weight-bearing exercise program is recommended for people throughout life to help prevent osteoporosis and maintain bone stock. For postmenopausal women, hormone replacement therapy is highly recommended except in women with a strong family history of breast cancer or a personal history of blood clots or stroke. In addition to many regular estrogens and estrogen/progesterone combinations available, raloxifene is a selective estrogen-receptor modulator that is FDA-approved for prevention of bone loss in menopausal women. Anti-resorptive agents, such as bisphosphonates and calcitonin, are medications that reduce bone loss and often help restore bone mass. Alendronate and risedronate are two oral bisphosphonates that are FDA-approved for use in the treatment of osteoporosis. The primary side effects include dyspepsia and gastric upset. Calcitonin is FDA-approved for osteoporosis and can be administered by injection, using a nasal spray or by rectal suppository. Of note, calcitonin is also known for its pain reducing effects and can significantly decrease the pain associated with osteoporotic fractures and stress fractures.
A patient who has recently developed an osteoporotic spinal compression fracture will generally be recommended for a Jewitt-style back brace and be issued pain medications. Patients will also be evaluated by an X-ray and DEXA scan. Treatment with anti-resorptive agents will be considered. Females will be considered for hormone replacement therapy.
Patients with osteoporotic compression fractures who fail to improve with conservative treatments will be considered for surgery. Kyphoplasty and vertebroplasty are relatively new techniques that allow a compression fracture to be stabilized with bone cement. The procedure is minimally-invasive and the cement is injected into the fractured bone through a percutaneous incision. Patients generally have rapid improvement of pain and the rate of complication is very low.