Osteoporotic Spine Fractures
Osteoporotic Spine Fractures
The condition
Osteoporosis is a common condition in elderly patients, in particular women. The reason for this are hormonal changes after the menopause. The estimated life time risk to suffer an osteoporotic vertebral fracture is around 5% for men and 16% for women. There are, however, other causes for osteoporosis like use of steroids (tablets or injections – not topical creams). Osteoporosis results in fragile bone due to a lack of bone mass and changes in the bony microarchitecture. The spine, neck of femur (hip) and radius (wrist) are the most common sites of fractures due to osteoporosis. Click here for guidelines for assessment and treatment of these fractures.
Making the diagnosis
A DEXA (Dual Energy X-ray Absorption) scan can estimate the density of the bone. The scan measures usually the density of the bone in the lumbar spine and thigh bone (proximal femur). The result is expressed in a T-score and Z-score.
Plain x-rays usually show the vertebral collapse. In some patients an MRI scan is indicated so ensure that there is no underlying sinister cause (see ‘red flags’ on the ‘Low back pain’ page) like a tumour, in particular metastasis or myeloma.
Before proceeding to any invasive procedure like a vertebroplasty or kyphoplasty(see below), it is important to know whether it is the fracture which is causing the pain. An isotope bone scan or special MRI sequence (STIR) can assess this and it is essential that patients have these investigations. Many patients who had these fracture will have some pain but it might be caused by the muscles, ligaments or ribs.
Clinical assessment
Taking an accurate history of the injury, other illnesses and looking for risk factors are important steps. A thorough examination will establish whether there is pain on palpation or percussion in the area. The neurological examination will reveal any pressure on nerves or spinal cord which is rare in osteoporotic fractures.
Treatment
The most important treatment should focus on the underlying osteoporosis and patient should be started as soon as possible to prevent other fractures. Patients should be given adequate pain killers to help them staying mobile. The biggest risk for patients suffering osteoporotic fractures are complications due to immobility such as pneumonia and deep vein thrombosis (blood clots) in the legs.
Braces can be helpful to reduce pain and prevent angulation (kyphosis) of the spinal segment involved. These should be custom made or fitted by a trained physiotherapist or surgical appliances department. Simple 'over-the-counter' belts are not sufficient. The duration of the treatment and wearing of the belt should be supervised by a spine surgeon or trained physiotherapist.
Vertebroplasty or kyphoplasty are very good treatment options for patients who suffer severe and persistent pain. Open surgery is indicated only in very rare cases of severe or progressive deformity, spinal cord or cauda equina compression.
Outlook
Most patients with osteoporotic fractures can be treated non-operative. There is a risk of further fractures if the osteoporosis is not treated or if the normal structure of the spine changes and the spine bends forward (kyphosis) because of the wedge-shape of the collapsed vertebral body.