Management of Osteoporosis and Spinal Fractures: Contemporary Guidelines and Evolving Paradigms

Physicians involved in treating spine fractures secondary to osteopenia and osteoporosis should know the pathogenesis and current guidelines on managing the underlying diminished bone mineral density, as worldwide fracture prevention campaigns are trailing behind in meeting their goals. This is a narrative review exploring the various imaging and laboratory tests used to diagnose osteoporotic fractures and a comprehensive compilation of contemporary medical and surgical management. We have incorporated salient recommendations from the Endocrine Society, the American Association of Clinical Endocrinology (AACE), and the American Society for Bone and Mineral Research (ASBMR). The use of modern scoring systems such as Fracture Risk Assessment Tool (FRAX®) for evaluating fracture risk in osteoporosis with a 10-year probability of hip fracture and major fractures in the spine, forearm, hip, or shoulder is highlighted. This osteoporosis risk assessment tool can be easily incorporated into the preoperative bone health optimization strategies, especially before elective spine surgery in osteoporotic patients. The role of primary surgical intervention for vertebral compression fracture and secondary fracture prevention with pharmacological therapy is described, with randomized clinical trial-based wisdom on its timing and dosage, drug holiday, adverse effects, and relevant evidence-based literature. We also aim to present an evidence-based clinical management algorithm for treating osteoporotic vertebral body compression fractures, tumor-induced osteoporosis, or hardware stabilization in elderly trauma patients in the setting of their impaired bone health. The recent guidelines and recommendations on surgical intervention by various medical societies are covered, along with outcome studies that reveal the efficacy of cement augmentation of vertebral compression fractures via vertebroplasty and balloon kyphoplasty versus conservative medical management in the elderly population.     

骨质疏松性椎体压缩骨折的临床及影像学分析

目的：探讨老年性骨质疏松性椎体压缩骨折的临床及影像学特点。材料与方法：分析158例经临床和影像学诊断为骨质疏松症合并椎体压缩骨折的临床和影像学资料,并对其DR平片、CT图像、MRI图像对比分析。结果：①老年性骨质疏松性椎体压缩骨折多发生于脊柱胸腰段,以椎体进行性塌陷变形或后突畸形为主要影像表现。②本组脊柱压缩骨折中,胸椎骨折35例,腰椎骨折54例,胸腰段骨折69例,其中以胸12腰1压缩骨折最常见,占44％。结论：老年性骨质疏松性椎体压缩骨折以女性多见,其临床和影像学表现具有一定特征性。     

Vesselplasty versus vertebroplasty in the treatment of osteoporotic vertebral compression fractures with posterior wall rupture

ObjectiveThis study was performed to compare the effectiveness and safety of vesselplasty versus vertebroplasty in the treatment of osteoporotic compression fractures with posterior wall rupture.MethodsPatients who underwent treatment of a single osteoporotic vertebral compression fracture with posterior wall rupture from January 2016 to February 2020 were retrospectively reviewed. They were divided into a vesselplasty group (n = 17) and a vertebroplasty group (n = 43). Pain relief, radiographic outcomes, and bone cement leakage were compared between the two groups.ResultsThere were no significant differences in the operation time, postoperative pain relief, vertebral compression recovery, or local Cobb angle improvement between the two groups. However, the overall bone cement leakage rate (29.4% vs. 67.4%) and spinal canal leakage rate (0.0% vs. 30.2%) were significantly lower in the vesselplasty group than vertebroplasty group.ConclusionsVesselplasty offers similar pain relief and vertebral compression recovery but lower spinal canal leakage compared with vertebroplasty. Vesselplasty is thus a better option than vertebroplasty for patients with osteoporotic compression fractures with posterior wall rupture.     

Preventing osteoporotic fractures in older people

While fractures at the spine, wrist and hip are regarded as classical osteoporotic fractures, all fragility fractures in the elderly should be considered as osteoporotic once pathological fracture (e.g. metastatic disease) has been excluded. The assessment of fracture risk should take account of specific risk factors in addition to bone mineral density (BMD). The WHO has produced FRAX, a well validated tool that estimates the probability of a major osteoporotic fracture in the next 10 years. The algorithm is specifically designed for primary care. After age and prior fragility fracture, BMD is the next major determinant of fracture risk. Rather than scanning all individuals with a risk factor, measurements should be targeted to those whose probability of fracture lies close to the intervention threshold where knowledge of BMD will influence management. Individuals with a low trauma vertebral fracture or low BMD for age should be investigated for underlying causes of osteoporosis. Secondary causes account for up to 40% of cases of osteoporosis in women and 60% in men. The goal of osteoporosis management is to reduce the future risk of fracture. Lifestyle modification includes measures to reduce falls risk and bone loss such as exercise, adequate dietary calcium and avoidance of smoking and excessive alcohol consumption. All patients with an osteoporotic fracture and those at high risk should be assessed for falls risk. Combined therapy, with calcium and vitamin D, has been shown to reduce hip fracture risk in the frail elderly and should be considered in all older patients who are housebound or in residential care. Alendronate and risedronate are available as once-weekly preparations with evidence for significant reductions in vertebral and non-vertebral fractures. Denosumab is approved for osteoporosis in postmenopausal women at increased risk of fractures. Strontium ranelate has been shown to reduce fracture risk significantly in postmenopausal women.     

椎体后凸成形术治疗骨质疏松性椎体压缩性骨折

目的：探讨球囊扩张椎体后凸成形术在治疗骨质疏松性椎体压缩性骨折中的应用。方法：8例骨质疏松性椎体压缩性骨折患者,其中男性2例,女性6例;椎体单节段5例,双节段3侧;共11个椎体。均为新鲜骨折（2～6周）,采用球囊扩张后凸成形术治疗,随访3～9个月,观察患者腰背部疼痛变化的情况,测量椎体高度恢复程度及观察有无再塌陷。结果：8例患者术后3d内疼痛缓解,6例达到CR级,2例达到PR级。术后椎体高度恢复明显,随访发现患椎未出现塌陷。结论：球囊扩张椎体后凸成形术可有效恢复椎体的高度,迅速缓解疼痛,改善患者的生活质量,明显减少骨水泥的渗漏率。     

Alendronate adherence and its impact on hip-fracture risk in patients with established osteoporosis in Taiwan

A pharmacoepidemiology study was conducted using the health insurance database in Taiwan to assess compliance with osteoporosis drug regimens and the impact of compliance on the risk for secondary fractures. Patients >50 years of age with vertebral/hip fracture who had been started on alendronate therapy for the first time only after the fracture were included. Compliance was measured using the medication possession ratio (MPR) and was included as a time-dependent covariate in the Cox model to compare the difference between compliant (MPR ≥ 80%) and noncompliant patients (MPR <80%) with respect to risk for subsequent hip fractures. Only 38% of the study population remained compliant during the first year of treatment. Over the 4-year follow-up period, the risk of hip fracture among the compliant patients was 70% lower than that among the noncompliant ones (adjusted hazard ratio (HR) 0.30). Among patients with osteoporosis in Taiwan who had experienced a fracture and had started alendronate therapy, compliance with the dosage regimen was suboptimal. It was also found that compliance significantly reduced the risk of secondary hip fracture up to 4 years.     

Osteoporosis in older men

Historically, the focus in osteoporosis has been on postmenopausal women. In the past few years, information about osteoporosis in other populations, including men, has begun to emerge. Although less common in older men, osteoporosis nonetheless represents a major health concern. Approximately 30% of hip fractures worldwide occur in men, resulting in significant mortality and loss of independence. The incidence of osteoporotic fractures in men is increasing. The reason for this is unclear, but improvement in longevity and better management of other chronic diseases most likely play a role. Two recent studies have addressed the question of fracture risk in men past middle age and have estimated that men > 50 years of age have a 19% to 25% lifelong risk of osteoporotic fracture. Mortality is higher following hip fracture and pain is more intense in men than in women following severe vertebral fracture.     

经皮穿刺椎体成形术治疗老年椎体骨质疏松性压缩骨折

目的:探讨经皮穿刺椎体成形术(PVP)治疗老年椎体骨质疏松性压缩骨折的效果。方法:对17例老年患者的21个椎体,在C臂X光机透视下经皮经椎弓根向椎体内穿刺并注入聚甲基丙烯酸甲酯(PMMA),并对止痛效果进行评估。结果:17例患者中有15例获得随访。随访时间3～7个月(平均4．5个月)。无一例术后再发生椎体压缩。有4例发生骨水泥外溢。术后所有患者疼痛明显缓解或消失。结论:PVP治疗老年椎体骨质疏松性压缩骨折有显著的止痛效果,是一种较好的脊柱微创治疗技术。     

Comparison of serum and urinary C-terminal telopeptide of type I collagen in aging, menopause and osteoporosis.

BACKGROUND: Urinary C-terminal telopeptide of type I collagen (u-CTx) has been reported to be a sensitive biochemical marker of bone turnover. There have been two assays for urinary CTx, which are alpha-CTx and beta-CTx. A newly developed immunoassay for serum CTx (s-CTx) is now available for assessment of bone resorption. We evaluated the effects of aging, menopause, and osteoporosis on the measurements of serum CTx and compared them to urinary CTx assays. Methods: In 79 premenopausal healthy women, 80 postmenopausal healthy women, 61 osteoporotic patients with vertebral fractures and 34 osteoporotic patients with hip fractures, s-CTx and urinary beta-CTx (u-betaCTx) were measured by ELISAs, and urinary alpha-CTx (u-alphaCTx) was measured by an RIA. RESULTS: In all subjects, s-CTx significantly correlated with both u-alphaCTx (r=0.54) and u-betaCTx (r=0.51). There was no significant difference among s-CTx, u-alphaCTx and u-betaCTx in the T-scores of the postmenopausal group over the premenopausal group. These findings indicate that the value of s-CTx, as well as urinary CTxs, reflected the increase of bone resorption associated with menopause with a high degree of sensitivity. Patients with vertebral fractures had moderately increased concentrations of bone resorption markers compared to age-matched healthy postmenopausal women (T-score; s-CTx: 0.8, u-alphaCTx: 0.9, u-betaCTx: 0.7), whereas bone resorption markers in hip fracture patients were greatly increased compared to healthy postmenopausal women (T-score; s-CTx: 1.1, u-alphaCTx: 1.3 u-betaCTx: 1.3). The T-scores of u-CTxs against the postmenopausal group in vertebral fracture group and in hip fracture group were not significantly different from those of s-CTx. CONCLUSIONS: s-CTx, as well as urinary CTxs, reflects the increase of bone resorption in patients with vertebral fractures and hip fractures.     

IVIM-DWI联合MRS鉴别诊断骨质疏松与转移性椎体压缩性骨折

目的 探讨体素内不相干运动DWI（IVIM-DWI）联合MRS鉴别骨质疏松与骨转移所致椎体压缩性骨折的价值。方法 收集因椎体压缩性骨折接受CT扫描并难以诊断的患者共70例,基于病理或临床随访结果将其分为骨质疏松组和转移组。对所有患者均行常规矢状位T1W、T2W、STIR序列和IVIM-DWI、¹H-MRS扫描。测定4.7 ppm处水信号和1.3 ppm处脂质的相对峰下面积,评估IVIM-DWI参数和MRS参数,通过ROC曲线评估MRS、IVIM-DWI及两者联合对转移性椎体压缩性骨折的诊断效能,并计算曲线下面积（AUC）。结果 转移组的f值、D值和FF显著低于骨质疏松组,D^*值明显高于骨质疏松组（P均<0.05）。MRS、IVIM-DWI及二者联合诊断骨质疏松和转移性椎体压缩骨折的敏感度、特异度、准确率分别为87.50%（28/32）、57.89（22/38）、71.43%（50/70）,78.13%（25/32）、89.47%（34/38）、84.28%（59/70）及90.63%（29/32）、97.37（37/38）、94.29%（66/70）。MRS、IVIM-DWI及二者联合的AUC分别为0.73、0.88和0.94（P均<0.05）。结论 IVIM-DWI联合MRS可提高鉴别诊断骨质疏松与转移性椎体压缩性骨折的效能。     

Kyphoplasty. A treatment for osteoporotic vertebral compression fractures

Patients experience more than 700,000 osteoporotic vertebral compression fractures each year in the United States, primarily because of bone brittleness and the inability of the vertebrae to resist increased forces applied to them. Patients diagnosed with this type of fracture are given the option of conservative or operative treatment approaches. Although a typical compression fracture generally heals in 6 to 12 weeks, patients may be offered the kyphoplasty procedure, which reduces the fracture and stabilizes it with cement. Although this procedure is not without risk, it is deemed a safe and effective treatment option. This article reviews the indications, implications, and care provided to patients pursuing kyphoplasty after osteoporotic vertebral compression fracture.     

椎体成形穿刺注射骨水泥防止灾难性并发症：87例137个椎体资料分析

背景：椎体成形治疗老年骨质疏松椎体压缩性骨折效果确切,但一些热点问题仍无定论。目的：探讨椎体成形技术治疗老年骨质疏松椎体压缩性骨折过程中穿刺损伤、骨水泥注射剂量、多椎体成形及骨水泥渗漏等问题的解决方案。方法：回顾性分析经皮穿刺椎体成形技术治疗骨质疏松椎体压缩性骨折87例137个椎体。全部经单侧椎弓根穿刺,骨水泥稀薄期注射,骨水泥注射量为3～7.5mL,胸椎3mL以上,腰椎4.5mL以上,平均4.8mL,多椎体者均一次手术完成。结果与结论：随访6～30个月,治疗后第2天和最终随访时患者目测类比疼痛评分及Oswestry功能障碍指数评分均显著低于治疗前（P〈0.01）。所有患者胸腰背疼痛明显缓解,其中58例疼痛完全消失;1例术中出现骨水泥单体中毒症状,28例出现不同程度骨水泥渗漏,但未出现临床症状。137个椎体中骨水泥渗透达到和超过中线119个,占87.2%。提示椎体成形技术是治疗老年骨质疏松椎体压缩性骨折的有效方法。骨水泥稀薄期注射能够获得良好的渗透效果;在局麻药限量范围内,一次可完成3个以上椎体成形;严格正规的操作技术是预防骨水泥渗漏灾难性并发症最重要的方法。     

Measurements of urinary nonisomerized form of type I collagen degradation products (alpha-CTx) in aging, menopause, and osteoporosis with fractures

We have evaluated the effect of aging, menopause, and osteoporosis on the measurements of urinary nonisomerized form of type I collagen degradation products (alpha-CTx). In 18 children, 86 premenopausal healthy women, 144 postmenopausal healthy women, 74 patients with vertebral fractures and 61 patients with hip fractures, alpha-CTx excretions were measured by a RIA. The age-related changes of alpha-CTx in healthy females show that the values were extremely high before the age of 16 years and decreased between ages 16 and 29, and that after the age of 40 years, the values tended to increase and to vary widely with age. In menopause, alpha-CTx in postmenopausal subjects was significantly higher than those in premenopausal subjects. There was no significant correlation between alpha-CTx and years since menopause in 102 postmenopausal subjects. Alpha-CTx in the vertebral fracture group were higher than those in the postmenopause group, but not significantly. Alpha-CTx in the hip fracture group were significantly higher than those in postmenopause and vertebral fracture groups. In age-matched comparisons, the values of the patients with vertebral fracture and the patients with hip fracture were significantly higher than those of corresponded age-matched postmenopausal women. Alpha-CTx well reflects an increase of bone resorption associated with bone modeling at childhood and high bone resorption after the menopause and higher bone resorption in osteoporotic patients with fractures.     

经皮椎体后凸成形术与保守治疗在老年骨质疏松性胸腰椎压缩性骨折中的临床效果比较

目的比较分析经皮椎体后凸成形术与保守治疗在老年骨质疏松性胸腰椎压缩性骨折患者治疗中的临床效果。方法将88例老年骨质疏松性胸腰椎压缩性骨折患者随机分为观察组与对照组,各44例。观察组行经皮椎体后凸成形术治疗,对照组行保守治疗。比较两组疗效。结果治疗后1周、3个月,两组患者的VAS及ODI评分均降低,且观察组低于对照组(P<0.05)。治疗后3个月,两组患者的椎体压缩率、骨钙素、骨密度、CTX-1水平均降低,脊柱后凸角均减小,但观察组骨钙素及骨密度高于对照组,椎体压缩率、CTX-1水平低于对照组,脊柱后凸角小于对照组(P<0.05)。观察组患者的临床治疗优良率高于对照组(P<0.05)。结论经皮椎体后凸成形术治疗老年骨质疏松性胸腰椎压缩性骨折的效果确切,可有效缓解患者疼痛,改善伤椎功能及骨相关指标。     

Vertebroplasty and kyphoplasty

Vertebral compression fractures occur more frequently than hip and ankle fractures combined. These fragility fractures frequently result in both acute and chronic pain, but more importantly are a source of increased morbidity and possibly mortality. Percutaneous vertebral augmentation offers a minimally invasive approach for the treatment of vertebral compression fractures. The history, technique, and results of vertebroplasty and kyphoplasty are reviewed. Both methods allow for the introduction of bone cement into the fracture site with clinical results indicating substantial pain relief in approximately 90% of patients.     

Osteoporosis in men

Osteoporosis in men is now recognized as an increasingly important public health issue. About 30 percent of hip fractures occur in men, and one in eight men older than 50 years will have an osteoporotic fracture. Because of their greater peak bone mass, men usually present with hip, vertebral body, or distal wrist fractures 10 years later than women. Hip fractures in men, however, result in a 31 percent mortality rate at one year after fracture versus a rate of 17 percent in women. Major risk factors for osteoporosis in men are glucocorticoid use for longer than six months, osteopenia seen on plain radiographs, a history of nontraumatic fracture, hypogonadism, and advancing age. Bisphosphonates and teriparatide (recombinant parathyhroid hormone) have recently been approved for use in men and should be considered along with supplemental calcium and vitamin D. Increased awareness by physicians of risk factors for male osteoporosis--and early diagnosis and treatment--are needed to decrease the morbidity and mortality resulting from osteoporotic fractures.     

Incidence and costs of osteoporosis-associated hip fractures in Austria.

This study is an investigation into the epidemiologic and socioeconomic impact of osteoporosis-associated hip fractures in Austria. We determined age- and gender-specific incidence rates of osteoporosis-associated hip fractures for all patients treated in hospitals in 1995 and calculated mortality rates, hospitalization days and direct costs of hospitalization. The data were obtained from the hospital discharge statistics for all general hospitals and for all hospitals of the General Austrian Accident Insurance. To calculate the portion of hip fractures attributable to osteoporosis in a given age-group, a basic, non-osteoporotic incidence of hip fractures was determined for ages 20-39, using gender-specific regression models. 11,379 patients with osteoporotic hip fractures underwent treatment in Austrian hospitals in 1995, accounting for 79 percent of all hip fracture patients treated. 82 percent of those were female, with the highest incidence among women aged 95 years and older with a rate of 3,000/100,000. For male patients the highest incidence was observed for the age-group of 90-94 years with 1,743/100,000. International comparisons indicate these incidence rates to be similar to those reported for the Swiss population. In 1995, 778 patients or 6.8 percent of all patients with osteoporotic hip fractures died during hospitalization. Hospital care of patients with osteoporotic hip fractures required an overall 250,268 bed-days with an age-group-specific length of stay between 8.5-27 days for female and 16-23 days for male patients. The total cost of hospital treatment of osteoporotic hip fractures in Austria was ATS 1,043,379,000 (US$ 103,509,800), with average costs per patient of ATS 91,700 (US$ 9,097). Due to the aging of the population in the years to come, an increase of osteoporotic hip fractures among individuals aged 50 years and older must be expected. The economic importance of this development and its impact on the health care system must be considered as significant.     

改良小剂量骨水泥椎体成形治疗急性骨质疏松性压缩骨折

背景：经皮椎体成形技术已成为临床治疗脊柱骨质疏松性骨折的有效手段,但存在骨水泥渗漏风险。目的：探讨改良小剂量骨水泥椎体成形治疗急性骨质疏松性压缩骨折的效果。方法：选择2008年9月至2011年2月收治的32例骨质疏松性压缩骨折患者进行经皮椎体成形治疗,将患者按照骨水泥注入量分为改良小剂量组和常规剂量组,改良小剂量组骨水泥注入量为2-4 mL,常规剂量组骨水泥注入量为4-6 mL,将同期入院急性骨质疏松压缩骨折因手术禁忌无法进行椎体成形治疗的患者列为对照组。结果与结论：改良小剂量组和常规剂量组末次随访时疼痛缓解及椎体高度恢复率明显优于对照组（P＜0.05）。改良小剂量组骨水泥渗漏率、末次随访时相邻节段椎体继发骨折发生率明显低于常规剂量组（P＜0.05）,末次随访时椎体高度恢复率低于常规剂量组（P＜0.05）。说明椎体成形治疗操作过程中,应用改良小剂量骨水泥方法在达到满意临床效果同时,可有效减少骨水泥渗漏、相邻节段继发骨折等并发症发生率。     

高黏度骨水泥在修复骨质疏松性胸腰椎骨折中的应用

背景：椎体成形和椎体后凸成形目前已被广泛应用于骨质疏松性胸腰椎压缩性骨折治疗中,但存在骨水泥渗漏问题,尤其是对于椎体后壁破裂患者更易发生骨水泥渗漏。目的：观察采用高黏度骨水泥及其椎体成形修复骨质疏松性胸腰椎压缩性骨折的疗效。方法：回顾分析采用高黏度骨水泥及其椎体成形修复的20例骨质疏松性胸腰椎压缩性骨折患者的临床资料,治疗后采用目测类比评分评估腰背部疼痛,ODI评分评估腰背部功能,SF-36健康调查评分表评估生活质量,Frankel评分评估神经功能,影像学观察骨水泥渗漏、肺栓塞、邻近椎体骨折等并发症发生情况,X射线评估伤椎椎体前缘高度恢复。