HERSHEY – Osteoporosis is a bone disease characterized by decreased bone mass as a result of the loss of calcium from the bone matrix. Osteoporosis is the most common metabolic disorder of bone, affecting approximately 100 million people worldwide. It is estimated that in the United States, at least 10 million people suffer from osteoporosis and an additional 18 million are at increased risk for developing this condition.
What increases the risk of osteoporosis?
The risk of osteoporosis increases with age for both men and women. Individuals with low body weight, recent weight loss or history of such fractures in the family, as well as smokers, are at especially high risk. The American Academy of Orthopedic Surgery recommends bone mineral density scans for Caucasian women older than 65 years of age and postmenopausal women with one or more risk factors.
What are the most common complications of osteoporosis?
Vertebral compression fractures, which are fractures of the vertebrae in the spine, are the most common complications of osteoporosis. There also is increased risk of other fractures such as hip or rib fractures. It is estimated that approximately 25 percent of American women who reach menopause will experience at least one osteoporosis-related vertebral compression fracture. Osteoporosis also affects 33 percent of men by age 75. Each year approximately 700,000 patients present with vertebral compression fractures, with 70,000 of those requiring hospitalization with an average hospital stay of eight days. Patients diagnosed with a single osteoporotic vertebral compression fracture have a five-fold incidence of subsequent fractures.
What are the symptoms of osteoporotic vertebral compression fracture?
A considerable number of OVCFs can go unnoticed and be found accidentally on a routine X-ray. Patients usually present with back pain, which can occur after a regular activity such as bending, standing up from a sitting position, coughing or sneezing. In acute stages localized tenderness over the involved level is usually present and helps to identify an acute fracture. Patients with multiple osteoporotic compression fractures will commonly have a spine deformity called dowager’s hump. Multiple compression fractures can lead to loss of height.
How is a diagnosis of osteoporotic compression fracture made?
In addition to the findings of the examination, X-rays and MRI confirm the diagnosis. MRI also helps to determine the age of the fracture, which has important implications for what treatment modality might be helpful to the patient.
How can risk of osteoporotic compression fractures be reduced?
The most important treatment principal of osteoporosis is prevention. Postmenopausal women with osteoporosis should be treated with a daily intake of 1,500 milligrams of calcium and 400 IU of vitamin D. Cigarette smoking should be strongly discouraged, and alcohol consumption should be allowed only in moderation. Certain medications such as biphosphonates significantly reduce the risk of new vertebral compression fractures by almost 50 percent. Other medications aimed at increasing bone deposition of calcium are also available and should be prescribed by a physician experienced in treating patients with osteoporosis.
How can the pain related to OVCF be managed?
Many patients will experience a gradual improvement of their pain over the course of six to eight weeks. However, some patients will experience prolonged pain and disability. During the acute period a short term of bed rest, usually no longer than one week, should be followed by a gradual increase of activity level. Pain relief should be provided with such medications as acetaminophen and nonsteroidal anti-inflammatory medications.
Certain patients can benefit from wearing a back brace. Due to their side-effect potential, narcotic painkillers should be reserved for the patients whose pain failed to respond to the above mentioned measures.
What are the treatment options for patients whose pain does not subside?
Vertebral body augmentation is a minimally invasive procedure in which a needle is placed, under X-ray guidance, into a collapsed vertebra, and cement is injected. This results in fracture stabilization, which in turn leads to pain relief. Currently there are two techniques known as vertebroplasty and kyphoplasty. Both of them have a similar success rate in decreasing pain and improving function in 78 percent to 90 percent of patients with persistent pain secondary to OVCF. Kyphoplasty seems to be able to restore the height of the collapsed vertebra better than vertebroplasty. Complications such as infection, worsened pain, leakage of the cement into the bloodstream and compression of the spinal cord by the cement or fragments of the collapsed vertebra have been reported, with the incidence ranging from 0.5 percent to less than 5 percent. The risk increases with the number of vertebrae injected with cement.
Conclusion
With the aging population the incidence of OVCF is increasing. These fractures can lead to significant pain and loss of function. The best approach is prevention of these fractures by decreasing modifiable risk factors such as smoking, excessive weight loss, excessive alcohol consumption and adequate consumption of calcium and vitamin D. Patients with an established diagnosis of osteoporosis will benefit from taking medications that facilitate calcium deposition in bones. Those patients who have persistent pain from OVCF after eight to 12 weeks of conservative therapy can benefit from vertebral body augmentation procedures such as vertebroplasty and kyphoplasty.
Vitaly Gordin is director of the Pain Medicine Division in the Department of Anesthesiology at Penn State Milton S. Hershey Medical Center and associate professor of anesthesiology at Penn State College of Medicine.