Osteoporosis/Kyphosis/Fracture
Jill C. Cash and Julie Barnes
Definition
A.Osteoporosis is a condition of reduced bone mass resulting in bone fragility and fracture. The World Health Organization (WHO) has defined it as spinal or hip bone mineral density (BMD) of 2.5 standard deviations or more below the mean for healthy, young women (T-score of –2.5 or below) as measured by dual energy x-ray absorptiometry.
BMD is performed on the lumbar spine, hip, and/or forearm.
B.Clinical diagnosis of osteoporosis can also be defined as having a fragility fracture of the spine, hip, wrist, pelvis, rib, and/or humerus without evidence of a BMD.
C.Osteopenia is defined as low bone mass of the spinal or hip BMD between 1 and 2.5 standard deviations below the mean as evidenced by the T-score (T-score between −1.0 and −2.5).
D.Kyphosis (dowager’s hump) is the forward curvature of the thoracic spine. It is estimated that kyphosis occurs in approximately 20% to 40% of patients older than 60 years of age. Kyphosis may occur because of many different causes, including vertebral fractures, muscle weakness, degenerative disk disease, postural changes, and genetic/metabolic changes. Kyphosis is associated with other conditions such as decreased pulmonary function, back pain, increased risk of fracture of the spine, limited mobility, and an increase in mortality.
E.Osteoporotic fracture occurs from a fall while standing at normal height or less, without any type of trauma and/or while performing daily activities. A vertebral compression fracture is the most common type of osteoporotic fracture:
F.Vertebral fractures: There are three primary types of vertebral fractures:
1.Biconcave deformity.
2.Wedge fracture.
3.Compression fracture.
Incidence
A.There are approximately 25 million people in the United States diagnosed with osteoporosis; 80% of those are women. Women are diagnosed with osteoporosis six to eight times more often than men and this is thought to be related to hormone deficiency (estrogen). The peak incidence of fractures in men occurs 10 years later in life than for women, at roughly 70 years of age.
B.Approximately 50% to 60% of 50-year-old women sustain osteoporosis-related fractures during their remaining life. Spinal fractures occur in 25% of White women by age 65 years, causing pain, deformity, and disability. Most common fractures include 25% at distal radius (Colles’ fracture), 50% in vertebrae, and 25% in the hip.
C.Approximately 33% of all women and 17% of men suffer a hip fracture before age 90 years, and 20% of those who sustain a fracture die within 3 months of the event.
Pathogenesis
A.Osteoporosis occurs because of bone reabsorption being greater than bone formation.
Predisposing Factors
A.Hypogonadal states, particularly menopause.
B.Small body frame, low body weight (<127 lbs).
C.Cigarette smoking.
D.Low calcium intake.
E.Lack of weight-bearing exercise.
F.Family history of hip/pelvic fracture.
G.Excessive alcohol intake.
H.Asian or Caucasian.
I.Advanced age.
J.Previous fracture.
K.Secondary causes:
1.Hyperparathyroidism.
2.Hyperthyroidism.
3.Cushing’s syndrome.
4.Multiple myeloma.
5.Thyroid replacement therapy.
6.Corticosteroid therapy.
7.Renal disease.
Common Complaints
A.Loss of height.
B.Kyphosis, or dowager’s hump.
C.Back pain as a result of a compression fracture.
Other Signs and Symptoms
A.Cervical lordosis.
B.Fracture with little or no trauma.
C.Crush fracture of vertebra.
D.Pain.
Subjective Data
A.Explore history of the following:
1.Loss of height. Ask patient to compare current height with height written on the driver’s license if height unknown.
2.Low initial bone mass add period.
3.Early menopause, oophorectomy, postmenopause, or amenorrhea.
4.European or Asian family origin.
5.Family history of spinal fractures and osteoporosis.
6.Sedentary lifestyle with little weight-bearing activity.
7.Endocrine disorders.
8.Review medications taken in the present and past, including over-the-counter (OTC) and herbal supplements, with attention to medications such as corticosteroids, barbiturates, heparin, and thyroid hormone.
9.Dietary review for low calcium and vitamin D intake add period.
10.Increased alcohol, caffeine, and protein intake add period.
11.Renal disease/dialysis add period.
B.Determine onset, duration, location, and characteristic of back pain if present.
C.Has the patient had any recent falls?
Physical Examination
A.Check pulse, blood pressure (BP), height, and weight.
B.Inspect:
1.Compare present height with previous height.
2.Observe presence of dorsal kyphosis.
3.Observe physical abnormalities that interfere with mobility.
C.Palpate the joints and over the back for pain.
Diagnostic Tests
A.Laboratory studies:
1.Women: Comprehensive metabolic profile (CMP) (CMP; calcium, phosphorus, albumin, total protein, creatinine, liver enzymes, alkaline phosphatase, electrolytes), thyroid-stimulating hormone (TSH), and 25-hydroxyvitamin D (25[OH]D) level.
2.Men: CMP (calcium, phosphorus, albumin, total protein, creatinine, liver enzymes, alkaline phosphatase, electrolytes), TSH, 25(OH)D level, and testosterone level.
3.Complete blood count (CBC), erythrocyte sedimentation rate (ESR), and serum protein electrophoresis to rule out multiple myeloma and leukemia if concerned.
B.BMD or dual-energy x-ray absorptiometry (DEXA) scan:
1.The DEXA scan measures bone density of the lumbar spine and/or hip. Medicare will reimburse for this test to be performed every 2 years. If the spine is compressed or has severe scoliosis, BMD values may not be valid for the lumbar spine. Consider assessing the forearm for radial interpretation.
2.The result of this procedure is read in T-scores
or Z-scores.
T-scores are evaluated for postmenopausal women and older men. A T-score is a number given to identify the amount of bone present when compared with other healthy adults. Z-scores are recommended for premenopausal women. A Z-score is a score given to identify the amount of bone present when compared with other people of the same age, gender, and weight.
3.The WHO Fracture Risk Assessment Tool (FRAX) was developed to determine the absolute fracture risk of breaking a bone in the next 10 years. This tool may be used with the BMD results to determine who needs to be treated with medication for prevention of fracture when treatment is unclear. FRAX should be used on women who have not previously been treated with antiresorptive therapy when T-scores are between −1.5 and −2.5. The FRAX tool can also be used on patients who have been treated with prior antiresorptive medications if they have been off these medications for more than 2 years. FRAX scoring is not recommended for patients currently being prescribed antiresorptive medications.
C.Radiography: X-ray the lumbar and thoracic spine for suspected vertebral fracture and/or for height loss greater than 2 in. Consider a CT to assess for instability of a wedge fracture. An MRI is recommended to assess for the extent of a compression fracture and/or possible malignancy.
Differential Diagnoses
A.Osteoporosis.
B.Osteoarthritis (OA).
C.Secondary causes:
1.Thyroid disease.
2.Glucocorticoid therapy.
3.Malabsorption syndromes.
4.Renal or collagen disease.
5.Vitamin D deficiency.
6.Metastatic cancer.
7.Multiple myeloma.
Plan
A.General interventions:
1.Lifestyle changes should be introduced to the patient.
2.Educating the patient regarding proper diet with calcium and vitamin D intake daily along with weight-bearing exercises daily to keep the bone strong is imperative for all patients.
B.Patient teaching:
1.Educate the patient regarding calcium and vitamin D intake in diet:
a.Calcium intake:
i.Men younger than 50 years up to 69 years: 1,000 mg/d.
ii.Men older than 70 years: 1,200 mg/d.
iii.Women younger than or equal to 50 years: 1,000 mg/d.
iv.Women older than 50 years: 1,200 mg/d.
v.Food sources high in calcium include salmon or sardines with bones, low-fat yogurt and skim milk, green vegetables, and cheese.
b.Vitamin D intake:
i.Men younger than 50 years of age: 400 to 800 IU/d.
ii.Men 51 to 69 years: 800 to 1,000 IU/d.
iii.Men older than 70 years of age: 800 to 1,000 IU/d.
iv.Women younger than 50 years of age: 400 to 800 IU/d.
v.Women 50 years of age and older: 800 to 1,000 IU/d.
vi.Food sources high in vitamin D include vitamin D–fortified milk and cereals, fish liver oils, cod liver oil, mushrooms, herring, catfish, salmon, sardines, egg yolks, cheese, and beef liver.
2.Encourage the patient to eliminate alcohol and caffeine from diet.
3.Encourage the patient to eliminate cigarette smoking.
4.Prescribe regular moderate exercise, such as 30 minutes of walking at least three times per week. Walking 50 to 60 minutes three times per week provides optimal benefits.
5.Fall prevention: Advise the patient to avoid medications that may cause drowsiness and precipitate falls. Use extra light at night in the bathroom to help prevent falls. Remove all loose rugs and clutter from the home. Install hand rails on steps.
6.Discuss safety issues and fall prevention with the patient and family.
C.Pharmaceutical therapy:
1.Calcium supplements.
Calcium supplements may be contraindicated in patients who have a history of renal stones.
2.Calcium carbonate (Os-Cal) 500 mg is given orally one to three times per day, or Tums one tablet orally two to three times a day. See the section Plan
earlier for recommendations.
3.Vitamin D supplements: See the section Plan
earlier for recommendations. Patients diagnosed with vitamin D deficiency should ingest an increased dosage, according to the deficiency.
4.Biphosphonates: First-line therapy recommended for osteoporosis:
a.Acts by reducing bone resorption and bone loss by preventing osteoclast activity.
b.May be given daily, weekly, or monthly:
i.Alendronate sodium (Fosamax): Available in 5, 10, 35, 40, and 70 mg tablets; 70 mg liquid; 70 mg tablet + 2,800 IU vitamin D tablet.
ii.Risedronate (Actonel): Available as 5 mg daily, 35 mg weekly, or 150 mg monthly.
iii.Zoledronic (Reclast): 5 mg/100 mL (Intravenous [IV]) infusion once yearly as 15-minute infusion. Check serum creatinine and calcium before infusion.
c.Instruct the patient to take oral medication with 6 to 8 ounces of water one-half hour before breakfast or any medication for the day. Advise standing or sitting upright after taking medication. No food should be ingested for 30 minutes after taking the medication. Precautions should be used for patients who have upper GI side effects.
d.Studies support the efficacy of treatment with bisphosphonates for up to 5 years. After 5 years of treatment, reassess the treatment options. Treatment beyond 5 years of bisphosphonate therapy is highly individualized.
5.Receptor activator of nuclear factor kappa B ligand (RANKL):
a.Acts by inhibiting osteoclast formation, decreasing bone resorption, reducing bone fracture, and increasing bone density:
i.Denosumab (Prolia) 60-mg subcutaneous injection once every 6 months. Patients with chronic kidney disease and/or a risk of hypocalcemia should have a serum calcium level checked 10 days after the administration.
6.Selective estrogen receptor modulator (SERM):
a.Raloxifene (Evista): 60 mg orally daily.
b.For postmenopausal women, it prevents osteoporosis, is cardio-protective, and appears to decrease estrogen-recepted breast cancer by 65% for more than 8 years (National Osteoporosis Foundation, n.d.-a, n.d.-b). Patient may note side effects of increased vasomotor symptoms and increased risk of venous thromboembolism.