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