Osteoporotic spine fractures-Important facts

Osteoporotic spine fractures spine can lead to severe complications in the elderly. The fractures can occur even with trivial trauma. One fracture may increase the risk for further fractures and additional disabilities for the patient.

An osteoporotic vertebral fracture, also known as fragility fracture are fractures occurring in osteoporotic or weak bones. Fragility fractures are quite common in elderly females. Vertebral osteoporotic fractures are important to recognise and treat, as they increase the risk of death, compared to the general population. The risk of death is highest in the first year after a fracture. Increased mortality risk gradually reduces after first year but can last up to 5-7 years of fracture. If you suffer from a second fragility fracture, which occurs quite often, the period with an increased risk of death gets further prolonged.

Only one third of osteoporotic spine fractures come to clinical attention or produce significant symptoms, which makes the matter worse. This also makes collecting exact numbers and complications difficult. Studies suggest that mortality after osteoporotic spine fractures is slightly less than those of hip fractures. An estimated 24% of hip fracture patients aged 50 and over die in the first year following their fracture. With an increase in life expectancy and ageing population, we need to increase the awareness levels towards osteoporosis which not only increases risk of death but also imposes severe lifestyle restrictions.

What are the symptoms of an osteoporotic spine fracture?

Recent onset pain in back after an insignificant fall is the most common presentation. Patients may not even recall the fall or trauma. While the pain is quite severe in some patients, it may be of very low intensity in others. If the pain is mild, it may be erroneously attributed to Lumbar spondylosis.

Some patients do not have pain and present with reduction in height and may even loose an inch of their height over a year before presenting. This happens after vertebral fractures at multiple levels. These fractures may also lead to a progressive stooping posture resulting from a kyphotic deformity of spine due to vertebral compression fractures. 

Kyphosis is basically an abnormal forward angulation of the spine. A kyphotic deformity may lead to constant pain, difficulty in walking and activities of daily living. The forward angulation of spine in kyphosis reduces the internal space available for internal organs like lungs and stomach which makes it difficult to breathe and eat.

How is an osteoporotic spine fracture diagnosed?

As previously mentioned, a large proportion of patients may not be symptomatic. Having a high index of suspicion is the key, both from the perspective of a patient and a doctor This is where awareness programs come in.

A clinical examination may reveal spine tenderness, stooped posture, or weakness resulting from pinching of nerves. An x-ray and CT scan of spine will reveal the fracture and any abnormal alignment of the spine. CT scan is better at defining bony anatomy and extent of fractures.

MRI of the spine can help differentiate a recent fracture from an old silent fracture. MRI also shows whether the fracture is causing pressure on the nerves or not. DEXA scans or bone densitometry scans give an estimate of the degree of weakness, and are useful for comparing the effects of treatment during follow-up.

What are the treatment options for Osteoporotic spine fractures?

Treatment varies upon the symptoms and degree of vertebral collapse. Patients with just pain are managed initially with rest and analgesics. Patients who fail to respond and have persistent pain after six weeks of conservative management, can be offered vertebral augmentation procedures, like Vertebroplasty and Kyphoplasty. In Vertebroplasty, bone cement is injected into the vertebra through needles that are placed into the vertebral bodies under X-ray guidance.

If the patients have significant vertebral height loss from a fracture, some height of individual vertebra can be restored using Kyphoplasty. In this technique, a balloon is inflated inside the collapsed vertebra to restore height upto a certain extent. After balloon inflation cement is injected into the fractured bone. Vertebroplasty and Kyphoplasty have become quite popular because they offer good pain relief. Patients can resume normal activities after the procedure, thereby reducing the medical complications associated with bed rest in the elderly. Vertebroplasty and Kyphoplasty are quite safe procedures. Vertebroplasty does not require hospital admission and is done under local anaesthesia or mild sedation. On the other hand Kyphoplasty requires a short hospital stay and general anaesthesia for the procedure.

In patients with neurological deficits like leg weakness and kyphotic deformity, treatment may require complex procedure involving decompression of the nerves and internal stabilisation with vertebral screws. These surgeries may be especially difficult with a high risk of an adverse outcome, considering the elderly population at risk of these fractures.

How to prevent further fragility fractures?

Having Calcium and Vitamin D supplements are usually started, but may not help much in improving bone strength alone. Certain medications need to be started to prevent bones from weakening further by stopping the normal physiologic resorption and strengthening them by promoting re-mineralization. These therapies need to be monitored for their effects on bone strength and their side effects.

One needs to be in constant touch with a spine surgeon, physiotherapist and a physician after an osteoporotic fracture.

Disclaimer- This is for the general awareness of the patients and cannot replace expert medical advice. Patient treatments need to be individualised and that can be decided based on clinical examination and evaluation by a trained physician.

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References- Mortality and osteoporotic fractures: is the link causal, and is it modifiable?

Impact of fractures on quality of life in patients with osteoporosis: a US cross-sectional survey

Vertebroplasty and Kyphoplasty for Osteoporotic Vertebral Fractures: What Are the Latest Data?