THE BREAKING SPINE

1 Key Messages

VERTEBRAL FRACTURES • The risk of future vertebral • Mild and moderate vertebral ARE COMMON fractures increases with the fractures are frequently not number of prior vertebral recognized or reported in the • One new spinal fracture occurs fractures: compared to women patient’s medical record, leading every 22 seconds worldwide. without vertebral fractures, to under-diagnosis and under- • Vertebral or spinal osteoporotic having 2 or more prevalent treatment. vertebral fractures increases the fractures are the most common • In elderly hospitalised patients risk 7-fold of having another type of fragility fracture, yet who had a lateral chest X-ray, vertebral fracture within a year. remain largely undiagnosed and fewer than 50% of vertebral untreated. • In women over 80 years, 50% fractures later identified on • Most vertebral fractures are a have a prevalent vertebral X-rays were reported in the complication of low bone mass fracture. radiological reports. or osteoporosis. • Only about 40% of older • 20-25% of Caucasian women VERTEBRAL FRACTURES women with vertebral fractures and men over 50 years have a ARE UNDER-DIAGNOSED visible on X-ray are referred for prevalent vertebral fracture. DXA measurement of BMD and AND UNDER-TREATED the figure is even lower in men • One in five women with a • Although many spinal fractures (less than 20%). vertebral fracture will sustain cause pain and disability, they another one within twelve are often ignored or treated as months – the fracture cascade. simple back pain. VERTEBRAL FRACTURES HAVE A SEVERE IMPACT ON PEOPLE AND SOCIETY • Vertebral fractures lead to severe spinal deformity, back pain, loss of height, immobility, depression, increased number of bed days, reduced pulmonary function and premature death. • Clinical vertebral fractures new are associated with an 8-fold increase in mortality, which is similar to the increase in spinal fracture mortality seen following hip 1 fractures. every 22 seconds • The financial burden of spinal osteoporosis and associated fractures is significant and in worldwide the elderly, includes the costs of hospitalisation, subsequent rehabilitation and carers. • In the working population, medical costs associated with vertebral fractures are related to outpatient care and to the loss of working days. 2 • In the US there are WHAT HEALTH fracture assessment by DXA approximately 2 million PROFESSIONALS CAN DO can also be used. osteoporotic fractures each • Radiologists and other health year costing close to 17 billion • Health care professionals should care professionals should USD. Vertebral fractures be aware of and look out for report the findings of vertebral contribute 1 billion towards the signs of vertebral fractures: fracture as FRACTURED to avoid this cost. loss of height (more than 3 cm/ just over an inch), sudden severe ambiguity. • In Europe, new cases of or chronic back pain, increased • Effective therapies that reduce osteoporotic vertebral fractures spinal deformity or hump. the risk of vertebral fractures by were estimated to cost 719 30% - 70% in post-menopausal million EUR in year 2000. • Radiographic diagnosis is considered the best way women are widely available. • As the number of spinal to identify and confirm fractures increase, so do the the presence of vertebral mortality rates. fractures, however vertebral

3 Foreword

Vertebral osteoporotic fractures are There have been major recent vertebral fractures and osteoporosis, common around the world with advances in the identification of so that treatment to prevent future one in four women over the age vertebral fractures by vertebral fractures can be started early thus of 50 having a vertebral fracture fracture assessment (VFA) using reducing subsequent associated in her remaining lifetime. Vertebral bone densitometry. Along with morbidity and mortality. fractures have a major impact on an spinal radiographs, VFA should be Our hope is that this report will individual’s quality of life, causing considered by clinicians for use in be read and used by health care pain, height loss, depression and the early identification of vertebral professionals, national osteoporosis disability. These fractures also lead to fractures. societies, policy makers, media and significantly increased mortality. Several signs may indicate that a consumers around the world, so that Thus vertebral fractures have person has suffered one or more prevention of vertebral fractures, a large impact not only on the spinal fractures – height loss, with a reduction in the subsequent individual but also on the resources increased spinal stoop, acute negative impact on quality of life of society and healthcare systems. and/or chronic back pain. These and health care resources, may Yet these fractures remain largely signs should prompt health care become a reality. undiagnosed and untreated by professionals to evaluate patients for health care professionals – estimates are that two-thirds of all vertebral osteoporotic fractures do not come to medical attention. One vertebral fracture leads to another and another, resulting in the fracture cascade. Moreover, vertebral fractures are powerful predictors of future osteoporotic fractures of all types. Vertebral fractures that come to clinical attention are associated with an 8-fold increase in mortality, similar to that seen following hip fractures. In individuals who have sustained a vertebral fracture, excess mortality increases progressively following diagnosis and is likely to reflect co-existing co-morbidities, such as Mary L. Bouxsein Harry K. Genant impaired pulmonary function. As the PhD MD, FACR, FRCR number of spinal fractures increase, Department of Orthopedic Surgery, Professor Emeritus, University of so to do mortality rates. Harvard Medical School, Boston, USA California, San Francisco, USA Prevention of all osteoporotic fractures is a key public health goal. Diagnosis and early intervention after the first vertebral fracture has occurred would advance this goal and lead to a reduced burden of disease, along with dramatic improvements in quality of life of those who suffer from osteoporosis.

4 normal bone osteoporotic bone

Osteoporosis is a disease characterised by low bone mass and deterioration in the micro- architecture of bone tissue

About Osteoporosis

Osteoporosis is a disease painful but the broken bones that caused by routine activities such characterised by low bone mass result cause pain and increased as bending forward, twisting and/ and deterioration in the micro- morbidity and mortality. or lifting light objects. Falls are also architecture of bone tissue, leading associated with vertebral fractures. to an increased risk of fracture. The prevalence (the number of Osteoporosis occurs when the bone HIP FRACTURES fractures at any one time in a mass decreases more quickly than Hip fractures are the most community) of vertebral fractures is the body can replace it, leading to a devastating fracture in terms of similar in men and women. In men net loss of bone strength. As a result morbidity and mortality, as 20% of this is thought to be occupation- bones become fragile, so that even those who suffer a hip fracture die associated. However the incidence a slight bump or fall can lead to within 6 months after the fracture. (number of new fractures) of bone fractures. These are known as Most hip fractures take place after a vertebral fracture is about one- fragility fractures. Osteoporosis has fall. The exponential rise in rates of third higher in women than men no signs or symptoms until a fracture hip fracture with age in both men between 50-60 years, and doubles occurs – this is why it is often called and women results from both an after age 70. a ‘silent disease’. age-related decrease in bone mass Osteoporosis affects all bones in at the proximal femur and the age- WRIST FRACTURES the body however fractures occur related increase in falls. most frequently in the vertebrae Most wrist fractures happen in women, occurring earlier than hip (spine), wrist and hip. Osteoporotic VERTEBRAL FRACTURES fractures of the pelvis, upper arm and vertebral fractures, with the and lower leg are also common Vertebral fractures are the most incidence increasing with age. The and are associated with significant common osteoporotic fracture. incidence of wrist fractures in men is disability. Fragile bones are not Vertebral fractures are frequently low and does not increase with age.

5 Pathophysiology of Osteoporosis and Vertebral Fractures There are two types of bone: cortical (compact) and trabecular YOUNG (cancellous). Cortical bone comprises approximately 80% of the skeleton and is found in the shafts of long bones (such as the femur or thigh bone) and on the outer surface of flat bones. Trabecular bone is found mainly at the ends of long bones, the inner parts of flat bones, and in ELDERLY the bones of the spine. Cortical bone consists of compact bone arranged concentrically around central canals containing blood vessels and nerves. Trabecular bone is composed of interconnecting Health Reproduced from Mosekilde L. (1998) Tech Care. 6: 287 and courtesy of D. Dempster. plates and rods within which lies FIGURE 1 bone marrow. Age-related changes in bone microarchitecture During the first decades of life, bones grow (i.e., get longer) and get stronger WITH AGEING ➞ as bone mass increases. Approximately BONE VOLUME

80% of adult bone mass is acquired ➞ TRABECULAR THICKNESS during puberty, and optimal peak ➞ bone mass depends on adequate TRABECULAR NUMBER ➞ nutrition, exercise, and sun exposure, CONNECTIVITY

which is needed for the body to ➞ produce Vitamin D, MECHANICAL STRENGTH which helps the body absorb calcium ➞ CORTICAL POROSITY from our diet. Deficits in nutrition or exercise at this critical time for skeletal health can lead to lifelong deficits in bone strength. Between 20 and 30 yrs of age, peak bone mass is achieved. After this time, the skeleton With increased age, the balance bone strength and ultimately an undergoes a continual, coordinated between bone breakdown (or increased risk of fracture. In addition, process of bone breakdown and resorption) and bone building (or certain drugs and diseases can cause rebuilding, termed bone remodelling. formation) tends to get out of bone loss and increased skeletal Bone remodelling is driven by the balance, with greater resorption fragility. body’s need for calcium and is than formation. This is likely due The bones of the spine (vertebral influenced by a number of hormones to a number of factors, including body) consist mainly of trabecular and growth factors, and also possibly the decline in sex hormone levels in bone with an outer layer of cortical by the need to repair regions of the women and men, insufficient dietary bone. Trabecular bone has a large bone that have become damaged due intake of calcium, and/or inadequate surface area and lies in close to daily use. This coordinated process vitamin D. This imbalance in bone proximity to the marrow cells that of bone breakdown and rebuilding remodelling leads to progressive are involved in the formation and allows the skeleton to remain healthy bone loss, deterioration of the removal of bone. As bone loss initially throughout life. bones’ microstructure, a decline in

6 20 – 25% of Caucasian women and men over 50 years having a prevalent vertebral fracture

combined. For men, the risk is higher than the risk for prostate cancer. In the US there are approximately 2 million fractures annually, including 700,000 vertebral fractures, 400,000 wrist fractures, 300,000 hip fractures, 130,000 pelvic fractures and 680,000 fractures at other sites. Approximately 50% of people with one osteoporotic fracture will have another, with the risk of new fractures rising exponentially with each fracture. Of particular importance, a vertebral (spinal) fracture occurs every 22 seconds worldwide with 20 – 25% starts at the bone surfaces, changes minimal trauma, such as stepping off of Caucasian women and men over in bone mass occur earlier and to a a curb. Vertebral fractures also occur 50 years having a prevalent vertebral greater extent, in trabecular bone like as a result of falls. fracture. The occurrence of vertebral the vertebrae, than in areas of the fractures increases with age, such skeleton that are mainly cortical, such that an estimated 50% of women as the femur (thigh bone). A COMMON DISEASE over 80 years has a prevalent Vertebral fractures occur when one Worldwide an osteoporotic fracture vertebral fracture. of the bones in the spinal column occurs every 3 seconds. At 50 years Osteoporosis affects approximately collapses, or fractures. In people of age, one in two women and one 200 million women worldwide who have poor bone strength, these in five men will suffer a fracture in • 1/10 of women aged 60 fractures can occur during activities their remaining lifetime. For women • 1/5 of women aged 70 of daily living, such as lifting an this risk is higher than the risk of • 2/5 of women aged 80 object, or turning over in bed, or with breast, ovarian and uterine cancer • 2/3 of women aged 90

7 Osteoporosis A growing public health problem

With advancing age, bone mineral While about half of all hip fractures density (BMD) decreases and among elderly people today occur Eva Saraiva the prevalence of osteoporosis in Europe and North America, this Rio de Janeiro, Brazil increases. The risk of sustaining proportion will fall to around one a fracture increases exponentially quarter in 2050, by which time Benedicta Eva Saraiva lives in the Botafogo with age due not only to the steep increases in hip fracture neighbourhood of Rio de Janeiro. Now decrease in BMD, but also due to rates will be seen throughout 77 years of age, Eva was diagnosed with the increased rate of falls among Asia and Latin America. Thus, the osteoporosis over a year ago, following the elderly. greatest increase in the number of a fracture of her femur (hip). Not long osteoporotic fractures is likely to be after the hip fracture, she suffered a spinal The elderly represent the in the Middle East, Asia, and Latin fracture which was extremely painful and fastest growing segment of the America, where life expectancy greatly reduced her mobility for some time. population. Thus as life expectancy is predicted to increase the most increases for the majority of the Despite the serious situation, Eva did not in the coming decades. In Asia, give up. She found a specialized clinic where world’s population, the financial a 7-fold increase in the elderly she was able to benefit from a targeted and human costs associated with population is predicted between physiotherapy programme which helped osteoporotic fractures will increase the years 2000 and 2050. It is immensely in her recovery. She currently exponentially. For example, in estimated that, in Asia and Latin has a doctor who monitors her treatment Europe the population aged 80 of osteoporosis which includes calcium and America, the total number of hip years or more will increase by vitamin D supplementation. Like many older fractures will increase more than 160% in women and by 239% in people, Eva must also take medication for five-fold between 1990 and 2050. other health problems, including high blood men between 2000 and 2050. pressure, anaemia and a thyroid disorder. With great perseverance and willpower, Eva is able to carry out many of her routine daily activities – she still washes, irons, sweeps, and cooks for herself and her husband. She also goes to church services and to the supermarket or even just for a leisurely stroll FIGURE 2 Increased burden of osteoporotic fractures worldwide whenever possible, although almost always accompanied by her husband, Francisco. 3250 His steady support makes her less fearful of falling on the poorly maintained city 1990 sidewalks. 800 2050 “I cannot carry bags, but I know that walking is an important part of my treatment. The fact that I really enjoy 600 walking helps a lot too,” she said. Eva and her husband don’t have a car, so they often ride the bus around town. “I am as cautious 400 as possible when getting on or off the bus, but I never refrain from doing anything I need or want to do. If I have a handrail and Hip fractures (x1000) 200 someone to help me, I’ll go anywhere.” TOTAL HIP FRACTURES Eva welcomes and supports the initiatives WORLDWIDE 0 undertaken in Brazil by FENAPCO (National North Latin 1990 1.66 million Europe Asia Federation of Osteoporosis Patients America America 2050 6.26 million Associations). Looking back at these past years of treatment, she concludes that it is very important that people know what Adapted from Cooper C et al. (1992) Osteoporos Int 2: 285 osteoporosis is and how to prevent it.

8

Epidemiology ➞

Vertebral (spinal) fractures are the exponentially with the number and most common fragility fracture and severity of prevalent fractures. are the hallmark of osteoporosis, For example, compared to women occurring in 30-50% of people over without vertebral fractures, having the age of 50. It is estimated that two or more prevalent vertebral one new vertebral fracture occurs fractures increases the risk seven-fold every 22 seconds worldwide. FIGURE 3 Vertebral of having another vertebral fracture In 2000 there were an estimated 9 within a year. Of great concern is the fractures increase the risk million new osteoporotic fractures, high rate of subsequent vertebral of subsequent fragility of which 1.6 million were at the following an initial fracture – often fractures hip, 1.7 million at the forearm and referred to as the ‘vertebral fracture 1.4 million were clinical vertebral cascade’. As many as 20% of Women with vertebral fractures that came to medical women with a prevalent vertebral fractures have a 5-fold attention. In the US alone it is fracture will suffer a new fracture increased risk of a new estimated that at least 700,000 within a year. vertebral fractures occur each year. vertebral fracture and a The presence of a vertebral fracture Vertebral fractures are critically not only increases the risk of new 2-fold increased risk of important because they are a vertebral fractures, but also increases hip fracture strong predictor of fracture risk, at the risk of ANY fracture, including any skeletal site, independent of hip fractures. Compared to those One woman in five will bone mineral density (BMD). The without a vertebral fracture, the suffer from another risk of sustaining a new vertebral presence of one vertebral fracture vertebral fracture within fracture is several times higher in increases the risk of non vertebral those who already have a vertebral fractures by 2 to 3-fold, and that of a year fracture compared to those with no hip fractures by 2-fold. vertebral fracture. This risk increases

FIGURE 4 Age-specific and sex-specific incidence of osteoporotic fractures 400 Radiographic Vertebral Hip Wrist 300

200

100 Rate per 10 000 year

0

50-54 55-59 60-64 65-69 70-74 75-79 80-84 ≥85 50-54 55-59 60-64 65-69 70-74 75-79 80-84 ≥85 MEN WOMEN Age (years)

Adapted from Sambrook P and Cooper C (2006) Lancet 367: 2010

9 Morbidity and Mortality

Vertebral fractures lead to Following a vertebral fracture, the Vertebral fractures are associated significantly increased morbidity excess mortality appears to increase with a 16% reduction in expected and mortality. In fact all progressively after diagnosis of five year survival. osteoporotic fractures increase the fracture and is likely to reflect patient disability, with fractures of co-existing co-morbidities, such as the hip and vertebrae associated impaired pulmonary function. with increased mortality, in both men and women. FIGURE 5 All types of vertebral fractures are associated with Even a single vertebral fracture morbidity 100 can lead to a progressive loss of 93.2 height, increased kyphosis (stoop), severe and chronic back pain, 76.2 reduced mobility and reduced 75 pulmonary function.

The psychological impact of 52.7 vertebral fractures is profound. 50

The loss of mobility, pain and 36.8 noticeable spinal deformity Patients (%) 26.9 frequently lead to depression, loss Limited Activity 25 of self-esteem, fear of falling and Bed Rest social isolation. DUE TO BACK PAIN 3.9 Vertebral fractures are associated 0 with difficulty in many activities No Incident Radiographic Clinical of daily living, including forward Fracture Fracture Fracture bending, rising from a chair, dressing and climbing stairs. They Adapted from Nevitt MC et al. (2000) Arch Intern Med 160: 77 lead to a slower walking pace, use of walking aids and decreased FIGURE 6 Mortality rates by number of prevalent vertebral fractures independence – all leading to a significant negative impact on 50 quality of life. P FOR TREND < 0.001 People with vertebral fractures 40 are at increased risk of death compared to people of similar age 30 with no vertebral fractures. The increased risk of death is greater in men than women with five-year 20 survival after a vertebral fracture at 72% for men and 84% for women. Long term mortality after 10 a vertebral fracture is similar to Mortality (per 1000 person-years) the mortality after a hip fracture 0 (8-fold increase) and significantly 0 1 2 3 4 5+ higher in comparison with the Number of Vertebral Fractures general population.

Adapted from Kado DM et al. (1999) Arch Intern Med 159: 1215

10 Financial Burden HIP VERTEBRAL OTHER Osteoporotic fractures place a deterioration in quality of life significant burden on society in and time spent by family 22% general and have a huge economic members as carers. Treatment 6% impact. However as so few vertebral of co-morbid conditions after fractures are diagnosed and treated, a fracture constitutes 75% of 72% it is difficult to estimate the exact the overall healthcare cost of financial burden related to these osteoporotic fractures. fractures. The costs associated with Despite only a minority of vertebral osteoporotic fractures are predicted fractures coming to clinical to rise markedly in the next 40 years. FIGURE 7 Direct costs of attention, in patients 45 years and For example, in Europe, the total over they account for around 52,000 direct costs of osteoporotic fractures vertebral fractures hospital admissions each year in are over 36 billion EUR annually 6% of the total direct cost the US and 2,188 in the UK. One and are expected to increase to 54 third of vertebral fractures need billion and 77 billion EUR in 2025 of osteoporotic fractures, hospitalisation and account for as and 2050 respectively. In the US costing 1 billion USD in many hospital bed days as other in 2005, there were over 2 million the US in 2005 common medical conditions. fractures at a total cost of 17 billion USD. By 2025, the annual number of The financial burden of osteoporotic In Europe, the cost was fractures is projected to increase by fractures includes direct costs 50%, costing over 25 billion USD. In 719 million EUR in 2005 (hospital acute care, in-hospital China, 1.5 billion USD was spent on rehabilitation, outpatient services, treating hip fractures alone in 2006, long- term nursing care) and with this figure expected to rise to indirect costs (morbidity, loss 12.5 billion USD in 2020, and up to of working days). Some costs 265 billion USD in 2050. Adapted from Burge R et al. (2007) J Bone are difficult to quantify such as Miner Res 22: 465 Kanis JA, Johnell O (2005) Osteoporos Int 16: 229 FIGURE 8 Projected costs of osteoporotic fractures

265

80

60

40 2005 2006 2025 2020 Direct Cost (Billions) 20 2050

0 Europe (EUR) USA (USD) China (USD)

Europe: Kanis Ja, Johnell O (2005) Osteoporos Int16: 229 USA: Burge R et al. (2007) J Bone Miner Res 22:465 China: Mithal A et al. (2009) The Asian Audit, IOF: 15 11 Under-detection and Under-diagnosis Vertebral fractures generally occur investigation of back pain and earlier in life than hip fractures 16% are old fractures detected Raphael Sidler and thus can be important early incidentally during work-up or Sursee, Switzerland indicators of poor skeletal health. unrelated investigations. Vertebral fractures are powerful There are several reasons why so Ten years ago, Raphael Sidler, 46, didn’t know the meaning of the word predictors of future spine and hip many vertebral fractures do not osteoporosis. He did not realize that fractures, so accurate diagnosis come to medical attention: and clear reporting of these osteoporosis was the insidious cause of • The occurrence of a spinal or multiple fractures and severe back pain fractures is essential, yet only about vertebral fracture generally dating back to his twenties. At age 33 a third of vertebral fractures come does not require emergency Raphael felt yet another ‘snap’ in his back to clinical attention. Furthermore, care, unlike hip and other and this time insisted on an MRI. As a result, there is considerable evidence osteoporotic fractures six vertebral fractures were diagnosed and that vertebral fractures are under- a subsequent DXA exam confirmed severe reported, and when they are • The person suspects their osteoporosis. “The diagnosis was tough, but it was a relief to know the cause of years of reported, appropriate intervention sudden back pain maybe due to suffering,” he says. is often not initiated. arthritis, a muscle strain or other causes To date Rafael has suffered 11 spinal Studies show that vertebral fractures as well as leg and toe fractures. fractures are often not diagnosed • The physician does not Several vertebral fractures were such that, only about 30% of recognize height loss, back spontaneous, others caused by a minor vertebral fractures come to pain and increased stoop fall, or something as simple as bending medical attention. Most of these as signs that a fracture has over to tie a shoelace. Since his diagnosis, (84%) are detected during routine occurred Raphael has been well cared for, receiving weekly physiotherapy, and drug treatment for osteoporosis and pain management. He ensures that his diet is rich in calcium and practices a safe regimen of postural exercises. Under-diagnosed vertebral fractures Osteoporosis has changed Raphael’s life FIGURE 9 completely. The years of uncertainty, 140 constant pain, and damaged self esteem all helped to contribute to depression. He has 120 had to give up many of the things he loves doing, including bike riding and singing in 100 a choir, and his social life has become more and more restricted. But the most difficult 80 of all was having to give up his work in the family business. Even when feeling relatively 60 well, Raphael must lie down frequently to rest and is physically incapable of working as Study 1 40 934 hospitalized women with he used to. Sadly, he says, “Osteoporosis is a a lateral chest X-ray disease of restrictions - it makes many things 20 Study 2 difficult to do and leads to isolation and a 459 elderly patients lonely life.” 0 Fracture Fracture Fracture Received As a volunteer for OsteoSwiss, the Swiss identified noted in noted in osteoporosis patient organization, Raphael continues to by study radiology medical treatment radiologists report record make a valuable contribution to society by leading a patient self-help group and sharing his hard won knowledge about the disease. Study 1: Gehlbach SH et al. (2000) Osteoporos Int 11: 577 He hopes that by raising awareness of Study 2: Majumdar SR et al. (2005) Arch Intern Med 165: 905 osteoporosis, he will be able to help others. 12 Vertebral fractures are under-diagnosed worldwide

MISSED DIAGNOSIS OF VERTEBRAL FRACTURE North America 45.2% Latin America 46.5% Europe, South Africa, Australia 29.5% • Vertebral fractures are not GLOBAL RATE 34.0% always painful and as a result are not on the radar of the patient or physician • Some vertebral fractures are of slow onset and therefore difficult to detect In elderly hospitalized patients who This is despite the fact that: This clearly highlights the need for had a lateral chest X-ray, less than continuing education of both health 50% of vertebral fractures which • There are validated radiologic care professionals and patients. were retrospectively identified on techniques for diagnosis these X-rays were reported in the Overall, 30-50% of vertebral • The presence of a vertebral radiological reports and even fewer fractures are misdiagnosed or not fracture markedly increases the in the medical records. Only about mentioned in radiology reports risk for future fractures 40% of older women with vertebral (false negatives), attributable in fractures visible on X-ray are referred • There are effective and safe part to a lack of detection or use for DXA measurement of BMD and treatments available of ambiguous terminology by the the figure is even lower (less than reporting practitioner (Impact Study • Evidence based guidelines for 20%) for men. Only one fifth of 2005). On the other hand, only 5% diagnosis and management of patients identified with vertebral of vertebral fractures are wrongly osteoporosis, including vertebral fractures received appropriate diagnosed (false positives). fractures have been published in treatment for osteoporosis. most countries

Sudden severe back pain may be a sign of vertebral fractures

13 Signs of Vertebral Fractures There are several important signs All health care professionals that show that one or more vertebral involved in the care of people with Krishna fractures may have occurred: osteoporosis should be aware of these signs, particularly in their Delhi, India • Loss of height (more than 3 cm/ patients over 50 years of age. just over an inch) Ms. Krishna, aged 62, is a former government civil servant who for years • Sudden severe back pain in the carried out a demanding job at a children’s mid and lower spine immunization centre. At the age of 55 she sustained her first fracture, breaking her • Increased stoop or ‘dowager’s right shoulder. The fracture was treated and hump’ subsequently healed, but doctors did not test her for osteoporosis. Ms Krishna’s life took a dramatic turn four years later, when she fractured her hip after a minor fall. This marked the beginning of a long tale of woes. The fracture did not heal correctly and she has suffered extreme pain ever since. Disabled to the point of being almost bedridden, Ms. Krishna was unable to work and consequently lost her job. She somehow managed to carry on with her family’s support. Despite the previous fractures and obvious signs of spinal deformity, doctors still did not diagnose osteoporosis. Gradually Ms. Krishna developed chronic back pain and her back began to stoop. With her negligible financial resources, she had no choice but to bear the pain and cope with an uncertain future. Ms. Krishna’s family contacted the Arthritis Foundation of India Trust (AFI) after reading about the organization in a local newspaper. FIGURE 9 Clinical consequences: reduced AFI arranged for testing, determining that Ms Krishna had vertebral fractures and was independence and quality of life suffering from severe osteoporosis (with a T-score of less than -3.5 standard deviation). • KYPHOSIS • LIMITATION OF SPINE MOBILITY (DIFFICULTY AFI has since provided care, offering free • LOSS OF HEIGHT medication, testing and physiotherapy. IN BENDING, RISING, • BULGING ABDOMEN DRESSING, CLIMBING Since joining a local support group, Ms STAIRS) Krishna says, “My outlook towards life • ACUTE AND CHRONIC has changed. I am becoming more and BACK PAIN • NEED TO USE A WALKING AID more independent now and am feeling • BREATHING DIFFICULTIES hopeful.” She exercises regularly and follows guidelines to reduce fracture risk. Although • DEPRESSION unable to work, she walks with support and • REFLUX AND OTHER GI finds happiness in spending time with her SYMPTOMS granddaughter. Her message to others – “Do not ignore proper calcium intake and adopt a good lifestyle, so that you do not suffer the way I did.”

14 Identification

Clinical guidelines developed by inadequately standardized and warranted if the results of the the International Osteoporosis interpreted. test would reasonably influence Foundation and other osteoporosis therapeutic choices to reduce A lateral spine radiograph (X-ray) is societies around the world fracture risk. Follow-up imaging the best investigation to confirm the recognize the importance of with radiography or computed presence of spinal fractures in clinical vertebral fractures, along with low tomography is advisable if practice. Early radiographic diagnosis BMD, as key risk factors for use substantial numbers of vertebrae followed by appropriate therapy will in patient evaluation. However, are not evaluable, if the presence help prevent further fractures. while BMD measured by DXA is of deformity is uncertain, if widely used in patient evaluation, Recent advances in DXA technology abnormalities are potentially due radiologic assessment of vertebral allow for vertebral fracture to malignancy, or if deformities are fractures is not commonly assessment (VFA) at the time of noted in a person with a history of performed, or if performed, is a bone densitometry test. It is relevant malignancy.

FIGURE 10 SEMI-QUANTITATIVE VISUAL GRADING OF VERTEBRAL FRACTURES

Grade 0 Normal, unfractured vertebra

Grade 1 Mild fracture with 20-25% reduction in anterior, middle or posterior heights relative to the same adjacent vertebrae

Grade 2 Moderate fracture with 25-40% reduction in anterior, middle or posterior heights relative to the same adjacent vertebrae

Grade 3 Severe fracture with >40% reduction in anterior, middle or posterior heights relative to the same adjacent vertebrae ‘Genant SQ scoring’ adapted from Genant, et. al., JBMR 1993

15 TYPES OF VERTEBRAL ➞ FRACTURES Spinal osteoporotic fractures usually occur in the mid (thoracic area) or lower spine (lumbar area). The bones in the spine affected by osteoporosis can become wedged or compressed due to their reduced strength. Depending on how the ➞ bone is affected it may be referred to as a ‘crush’, ‘wedge’ or ‘collapse’ fracture. Although spinal bones do heal, they usually do not return to their previous shape. This can lead to

a number of obvious spinal changes. • If a number of ‘wedge’ fractures ➞ occur together then the spine can tip forward leading to an increased stoop or ‘dowager’s hump’. • If a number of ‘wedge’ or ‘crush’ FIGURE 11 fractures occur, the spine can Severe vertebral fracture of T12 on VFA thoraco-limbar spine shorten leading to height loss. image (center) and radiographs of thoratic spine (left) and lumbar spine (right).

IDENTIFICATION OF VERTEBRAL FRACTURES Key Points

• Currently many mild and some • State-of-the-art DXA-based • All vertebral fractures identified moderate vertebral fractures Vertebral Fracture Assessment should be reported as are often not being recognised (VFA) is nearly as accurate FRACTURED to avoid ambiguity and reported, leading to under- as radiographs in detecting caused by other terminology diagnosis and under-treatment fractured vertebra • Early radiographic diagnosis • A radiographic diagnosis • DXA-BMD can be performed to followed by appropriate therapy is considered the best way diagnose osteoporosis and DXA- will help prevent subsequent to identify and confirm the VFA can be performed to detect fractures presence of vertebral fractures in vertebral fractures at the same clinical practice clinical visit

16 Treatment and Management

DRUG THERAPY MANAGEMENT OF • abdominal bracing exercises; Effective therapies (anti-resorptive SYMPTOMATIC VERTEBRAL • physiotherapy – postural exercise and anabolic agents) are widely FRACTURES program, muscle strengthening and falls prevention program, available and can reduce new For people who experience a spinal hydrotherapy; vertebral fractures by 30% to fracture, their doctor may also 70% in postmenopausal women. recommend the following: • local steroid injections; Similar efficacy is observed in men. These treatments should be taken • pain relief with anti- • vertebral augmentation with with adequate supplementation inflammatory and pain vertebroplasty or kyphoplasty. with calcium and vitamin D. medications; Appropriate medications should • short-term bed rest in cases of always be discussed with a doctor. severe pain (patients should begin The following therapies have mobilizing as soon as possible been shown to be effective in the within the limits of their pain); treatment of vertebral fractures: • alendronate • denosumab • ibandronate • parathyroid hormone • raloxifene • risedronate • strontium ranelate • zolendronate The availability of these medications varies between countries and regions.

Effective therapy can reduce the risk of vertebral fractures by 30-70%

17 Youssef Eid TREATMENT OF SYMPTOMATIC VERTEBRAL FRACTURES Bed rest (in the case of severe pain) al-Hawamdeh Pharmacological treatment Amman, Jordan • analgesics Dr. Youssef Hawamdeh, a 59 year old • opioids pharmacist, can consider himself to be a fortunate man. Despite suffering vertebral Physical therapy fractures in a fall at age 55, he has been able to resume his regular daily routine with Bracing no long-term impact on his quality of life. “I will never allow osteoporosis to change my Local steroid injections life,” he says. Vertebral augmentation Unlike many sufferers, Youssef has not gone on to experience further fractures and • vertebroplasty the terrible impact of what is termed the • kyphoplasty ‘fracture cascade’. This positive outcome can be attributed in part to the prompt diagnosis and treatment that he received following the accident. Suffering severe pain and bruising, Youssef was immediately admitted to hospital for three days where he underwent REHABILITATION & PAIN treatment administered by extensive testing. Doctors discovered that MANAGEMENT physiotherapists using electrical he had suffered vertebral crush fractures nerve stimulation) and relaxation and had bone density loss. After two weeks For those suffering from severe techniques have been shown to be of bed rest and pain management he was spinal osteoporosis, a rehabilitation largely able to resume normal activities. effective. program may be recommended. Since the diagnosis, Youssef has strictly Regardless of whether this is an A physiotherapist will often also adhered to his doctor’s prescribed inpatient program or an outpatient prescribe a specific back and medication for osteoporosis, which includes program, it is important to always abdominal strengthening exercise calcium and vitamin D supplementation. exercise under the supervision of a program. Strengthening back He is vigilant about his movements - avoids extensor muscles has been shown heavy lifting and careful when bending. physiotherapist (or other appropriate heath care professional) to reduce to help reduce the risk of future Yet otherwise, his daily activities have not vertebral fractures. changed. He still swims regularly, plays the risk of injury and falling. with his grandchildren and puts in a full The pain from spinal fractures is Additionally, hydrotherapy can be day’s work at the pharmacy. As a practicing useful for rehabilitation following Muslim, he is still able to kneel in prayer. often short-term (6-8 weeks) and usually resolves as the fracture fractures. The warmth and buoyancy Asked about his risk for osteoporosis, heals. However, permanent changes of the water makes slow, gentle Youssef said, “I do not know how I got this to posture from several vertebral movements easier and is also disease.” He reports no family history of osteoporotic fractures can lead to a good place to start a general osteoporosis or any other risk factors. severe chronic pain. strengthening program. One positive effect of the diagnosis was that For people with multiple crush It is important to avoid activities he shed some extra weight at his doctor’s that involve bending forward from recommendation and he feels much better fractures pain relief medications the waist, especially whilst carrying today because of that. With a laugh he also given in combination with notes another benefit – “I didn’t ask for Transcutaneous Electro Nerve objects because it increases the risk sympathy, but my family makes sure they do Stimulation (TENS; a common of vertebral fractures. not strain me in any way, and I don’t have to help with the washing up.” 18 Surgical Options

Some previous studies have found vertebral height restoration than vertebral fractures. However, VP that medical management of conventional conservative medical or BKP cannot be substituted for symptomatic vertebral fractures treatment. However, the long term appropriate medical management often fails to improve pain and benefits of these techniques have of osteoporosis in patients with mobility particularly in cases of not been clearly demonstrated. fragility fractures, where the future chronic pain related to spinal Further prospective randomized risk of subsequent fractures must deformity. controlled studies are needed to be evaluated individually, and assess long-term effects and safety/ each patient treated according to Minimally invasive procedures for complications. the importance of that risk. These vertebral compression fractures procedures do not reduce the risk of that fail to respond to conventional Physicians should be aware of future fractures and so drug therapy medical therapy, in particular pain these existing techniques, which is still required. relief are available in many countries. have the potential to improve the quality of life of people with VERTEBROPLASTY (VP) VP aims to relieve pain and prevent further collapse of the vertebrae. It is usually performed by interventional radiologists or orthopaedic surgeons FIGURE 12 MINIMALLY INVASIVE PROCEDURE FOR using imaging guidance. The collapsed vertebrae is stabilized VERTEBRAL FRACTURES with the injection of bone cement into the vertebral body. This can reduce pain, and help prevent height Cement is used to form an loss and spinal kyphosis (stoop) internal cast that holds the vertebra in place commonly seen as a result of several spinal osteoporotic fractures. spine BALLOON KYPHOPLASTY (BKP) needle BKP aims to relieve pain, stabilize the fracture, restore lost vertebral body height, and correct and prevent progression of kyphotic deformity. cement The procedure involves the insertion of two inflatable bone tamps (balloons) into the vertebrae. After inflation, the balloon creates a cavity that is filled with bone cement. The creation of this cavity is thought to decrease the risk of cement leakage. Overall, VP and BKP are relatively safe procedures that can permit quicker pain relief, recovery of mobility and in some cases Courtesy of Kyphon images

19 Prevention Strategies

Managing osteoporosis and • Awareness of personal risk: preventing fractures is vitally High-risk individuals (family Salima Ladak- important. Bone health can be history, smoker, corticosteroid better maintained over a lifetime by use, rheumatoid arthritis) should Kachra attention to these key prevention be assessed for fracture risk and Toronto, Canada strategies: for any prevalent fractures • Adequate calcium – ensure you For people in need of treatment, At only 25, Salima Ladak-Kachra sustained are getting the recommended appropriate pharmacological four vertebral fractures after slipping and daily intake of calcium through therapies are widely available and falling on a ceramic floor. “The excruciating food and/or supplementation include anti-resorptive and anabolic pain and emotional distress that I endured agents previously mentioned on • Adequate vitamin D, though is something that I do not want others page 17. Pharmacological therapy to go through,” says Salima. A DXA scan safe expose to sunlight. can reduce the risk of vertebral later revealed severe osteopenia in both Individuals who are vitamin D fractures by 30%-70%. the spine and femur as well as old healing deficient should also consider vertebral fractures. supplementation Salima recalls her long recovery. “I went • Bone-friendly through severe pain, and was not able exercises to walk, shower, eat or dress without REMEMBER assistance… In the months that followed, (weight-bearing, I lost one inch in height and my waist size strengthening, increased...“ Constantly sleepy from the pain balance- osteoporosis killers and with constant pain in her back, she coordination). had trouble performing daily tasks and began For vertebral to suffer both physically and emotionally – fractures, is treatable & putting a strain on her marriage. strengthening Prior to the fall, Salima had seen a few the back extensor fractures are physicians complaining of back pain, but, muscles is probably due to her young age, she was important not checked for osteoporosis. In retrospect, preventable risk factors would have been apparent: Both parents suffer from the disease, and she had a low BMI and a history of poor calcium intake and little exercise in her youth. Today Salima still copes with back pain on a daily basis, and has difficulty bending or sitting without support or for prolonged periods. Yet she has taken a proactive role in her recovery, ensuring adequate calcium and vitamin D intake, following a targeted exercise regimen, and increasing her BMI. She uses proper techniques in bending and sitting, refrains from heavy lifting, and receives help with chores when necessary. As a result of her own devastating experience, Salima now dedicates her life to bone health advocacy. She is co-founder of The Bone Wellness Centre, a health facility which supports awareness, prevention and diagnosis of osteoporosis.

20 Don’t miss the signs of a breaking spine

TIPS FOR CLINICIANS AND OTHER HEALTH CARE PROFESSIONALS Evaluate your patients over 50 years of age, particularly those with known risk factors for osteoporosis, and look for: • Loss of height (more than 3 cm / just over an inch) • Sudden severe back pain in the mid and lower spine • Increased stoop or ‘dowager’s hump’ Do a baseline height measurement of your patients and do yearly comparisons Consider using lateral DXA (or VFA) to identify vertebral fractures Use lateral spinal x-rays to confirm vertebral fractures Initiate treatment for people with prevalent vertebral fractures with appropriate therapy to prevent further fractures

TIPS FOR PHYSIOTHERAPISTS Prescribe postural exercises and abdominal bracing for your spinal osteoporosis patients Consider appropriate exercise to help relieve the pain and some of the symptoms of increased kyphosis and other postural changes Be aware of the signs that another vertebral fracture may have occurred (as listed above) and do a baseline height measurement Use pain management techniques in the acute phase –TENS, hydrotherapy, gentle strengthening exercise program (include spinal strengthening exercises) Consider Tai Chi programs that can be useful for gentle muscle strengthening, and for improving balance and coordination Advise your patients to avoid; • bending forward from the waist • sudden, abrupt movements • jumping, jarring and twisting movements • high-intensity exercise

21 TIPS FOR RADIOLOGISTS Recognize the importance of the identification of vertebral fractures using radiography, DXA- based VFA and other spinal imaging techniques Report all osteoporotic fractures as FRACTURED to avoid ambiguity Give grades of fractures (mild, moderate, severe) Indicate if the vertebral fracture is osteoporotic, traumatic or pathological & suggest further appropriate imaging, if relevant If the change in vertebral shape is not due to a fracture, use the term ‘deformity’ and suggest cause (e.g. congenital anomaly) Give number of fractures

Have you lost height (more than 3 cm - just over 1 in)? Patient Have you had sudden, severe back pain in recent times? Checklist Have you noticed an increased stoop in your spine? These actions will help patients Do you have a family history of osteoporosis? receive effective treatment earlier and prevent subsequent fractures Do you have frequent falls?

REPORT any of the above to your doctor and discuss treatment options

22 About IOF The International Osteoporosis Foundation (IOF) is a not for profit, nongovernmental umbrella organization dedicated to the worldwide fight against osteoporosis, the disease known as “the silent epidemic”. IOF’s members – committees of scientific researchers, patient, medical and research societies and industry representatives from around the world – share a common vision of a world without osteoporotic fractures. IOF now represents 195 societies in 92 locations around the world. http://www.iofbonehealth.org

Glossary

FRACTURE break/broken bone INCIDENCE number of new fractures in a given population in one year PREVALENCE number of people who have a fracture at a defined point in time MORBIDITY reduced health quality MORTALITY death VERTEBRA individual bone of the spine FEMUR hip bone DXA dual-energy X-ray absorptiometry (instrument used to measure bone mineral density) BMD bone mineral density (how much calcium per unit size is in the bone) PULMONARY to do with lungs/respiratory system MICRO-ARCHITECTURE the scaffolding structure of bone that gives it strength

References & Bibliography

This document is based on several main sources • Vertebral Fracture Initiative, IOF CSA Bone Imaging Working Group, 2010. • Epidemiology of Osteoporosis in Best Practice & Research, Clinical Epidemiology & Metabolism. Vol. 22, No. 5, pp. 671- 685, 2008. Elsevier. C Holroyd, C Cooper, Elaine Dennison. • Osteoblast; Spinal Fractures, winter 2009. Osteoporosis Australia. • Balloon kyphoplasty and vertebroplasty in the management of vertebral compression fractures. Draft manuscript. IOF CSA Fracture Working Group, 2010.

FOR A COMPLETE LIST OF REFERENCES VISIT WWW.IOFBONEHEALTH.ORG

23 “IOF urges everyone to be on the alert for possible signs of osteoporotic spinal fractures - height-loss, back pain and increased stoop. ” PROF CYRUS COOPER Chair of the Committee of Scientific Advisors, IOF

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AUTHORS Dr Mary L Bouxsein Harvard Medical School, Boston, USA International Osteoporosis Foundation Dr Harry K Genant University of California, San Francisco, USA rue Juste-Olivier, 9 EDITORS Judy Stenmark IOF CH-1260 Nyon Laura Misteli IOF Switzerland REVIEWERS Prof Cyrus Cooper, Dr Elaine Dennison, Dr Nick Harvey T +41 22 994 01 00 MRC Epidemiology Resource Centre, University of Southampton , UK F +41 22 994 01 01 Dr Denys Wahl IOF [email protected] DESIGN Gilberto Domingues Lontro IOF www.iofbonehealth.org

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©2010 International Osteoporosis Foundation Cover photo by Gilberto Domingues Lontro