Osteoporosis of Spine
Osteoporosis is a very common condition seen in the orthopedic and spine patient population. Osteoporosis can be distinguished from osteopenia based on the severity of the condition. Osteoporosis is a severe decrease in the density of bone while osteopenia is a mild decrease in the density of bone. Osteoporosis can be further distinguished by osteomalacia, a condition where the quality of bone is abnormal.
Osteoporosis is most commonly caused by hormonal changes in females after menopause (postmenopausal osteoporosis) and by changes in bone metabolism with age (senile osteoporosis). Secondary osteoprosis is weakness in the bone due to another medical problem (e.g. chronic renal disease)
Four common types of fractures present in a patient with us to process these are: proximal humerus fractures, distal radius fractures, hip fractures, and vertebral compression fractures. The vertebral compression fractures commonly occur in the thoracolumbar region from T10 to L2.
The thoracolumbar osteoporotic fractures can normally be divided into two categories. The first category is the compression fracture in which the vertebral body collapses but the posterior vertebral body wall remains intact, thus the chances of a neurological are very slim. This patient can be treated with a Jewett brace for period of 3 months with good results. Occasional pain medication may be needed while the fracture is healing. If the patient cannot tolerate a brace and/or requires narcotic medications despite the brace, a vertebral augmentation procedure can be considered. Vertebral augmentation is a procedure that helps the fracture heal by placing a biological cement in the areas of the fracture, thus healing the fracture and eliminating the patient's pain. There are some risks associated with a vertebral augmentation and thus the should be considered as a secondary rather than a first-line treatment.
The second type of fracture that can be present in a patient with an osteoporotic vertebral fracture is a burst fracture. This is different from a compression fracture in that the posterior body wall is disrupted and thus the chances of a neurological injury are somewhat higher. This patient must be evaluated carefully and watched carefully if non-operative treatment is considered. Due the patient's age and medical comorbidities, surgical treatment is not recommended unless the patient develops impending spinal instability and/or neurological compromise. These osteoporotic burst fractures are usually managed in a rigid TLSO brace for a three to six month period of time with close observation. The patient may pain medications in addition to the brace while the fracture heals. While vertebral augmentation can be considered in these patients, it is much higher risk because of the lack of the posterior vertebral body wall that usually prevents the extravasation of cement into the spinal canal. Thus, if the procedure is considered in these patients it should be performed by experienced interventional neuroradiologist with access to the most advanced imaging models.
The large majority of patients with vertebral compression fractures are successfully treated without a vertebral augmentation and/or surgery. Surgery is reserved for cases of increasing instability and/or neurological compromise due to the patient's medical frailty, age, and bone density. Usually the surgery required in these situations is a large, long surgery that requires extensive decompression and multiple point fixation. In these situations, the patient and surgeon must weigh the surgical risk of morbidity and mortality whe compared to non-operative treatment.
The main goal of osteoporosis care is prevent a decrease in bone density throughout prior to menopause and old age with a healthy diet, minimal medications and active exercise. Once an osteoporotic fracture occurs, the goal is to treat that fracture in a conservative manner and address the underlying osteoprosis to prevent the development of subsequent fractures in the future. The mainstay of osteoporotic treatment is in the prevention of thse fractures. If the patient continues to have osteoporotic fractures and/or a low bone density score despite conventional treatment, a referral to an endocrinologist may be warranted.
Please discuss bone density and osteoporosis with your primary care physician. If you have any questions regarding the spine orthopedic factors/issues, please discuss these with a board certified orthopedic spine surgeon.