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PATIENT STORY

An 83-year-old woman accompanied by her 56-year-old daughter presents to the office with severe upper back pain over the past 2 days. Her medical problems include hypothyroidism, for which she is on replacement medication, and mild hypertension, which is controlled with a diuretic. She has known osteopenia and was taking calcium and vitamin D but had not tolerated a bisphosphonate. Physical examination reveals moderate thoracic kyphosis and tenderness over several lower thoracic vertebrae. A plain radiograph demonstrates vertebral compression fractures (Figure 234-1A). The daughter asks about management options for pain and prevention of future fractures and also about screening for herself. As there was a suggestion of multiple compression fractures, a CT was ordered to better visualize the fractures (Figure 234-1B).

FIGURE 234-1

Osteoporosis-related thoracic vertebral compression fractures in an 83-year-old woman with kyphosis. A. Lower thoracic vertebral compression fractures seen on the lateral plain radiograph. B. Same fractures visualized more clearly on a lateral CT of the spine. (Reproduced with permission from Rebecca Loredo-Hernandez, MD.)

INTRODUCTION

  • Osteoporosis is a skeletal disorder characterized by low bone mineral density (BMD) ≤2.5 standard deviations (SD) of the mean for a gender-matched young white adult and compromised bone strength predisposing a person to fracture from minimal trauma.

  • Osteopenia is defined as a BMD measurement of between 1.0 and 2.5 SD below the gender-matched young white adult mean. The World Health Organization also defines osteoporosis as a history of fragility fractures and osteopenia.1

  • The National Osteoporosis Foundation reported in 2014 that fewer than 25% of elderly women who had an osteoporotic fracture received a BMD study or medication to treat osteoporosis 6 months after the fracture, despite availability of cost-effective therapy.2

EPIDEMIOLOGY

  • Approximately 12 million Americans older than age 50 years have osteopenia.3

  • Half of all postmenopausal women will have an osteoporosis-related fracture in their lifetime; 25% will experience a vertebral deformity and 15% will suffer a hip fracture.3

  • Low BMD at the femoral neck (T-score of -2.5 or below) is found in 21% of postmenopausal white women,16% of postmenopausal Mexican American women, and 10% of postmenopausal African-American women.

  • About 1 in 5 older men are at risk of an osteoporosis-related fracture.3

  • Vertebral fractures can cause severe pain and lead to 150,000 hospital admissions per year in the United States.

  • Following a hip fracture, up to 20% of women die within 2 years and more than half are unable to return to independent living.4

ETIOLOGY AND PATHOPHYSIOLOGY

  • Primary osteoporosis is a result of either aging changes or menopause.

    • Usually affects those older than age 70 years.

    • Proportionate loss of cortical ...

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