Osteoporotic Vertebral Fractures: are we doing enough?

Vertebral fractures are one of the most common osteoporotic fractures, yet they are the one that we miss most often. **Case study** A 58-year-old woman presents with mid/lower back pain. She was lifting shopping bags out of her car boot and felt a twinge in her back. The pain progressively got worse over the next few days. It felt like a bad ‘back spasm’, similar to one she’d had before, and the pain wrapped around into her ribs. She has seen her GP, had one chiro and four physio sessions. Her pain was improving but she felt progress was too slow and her exercises were not helping. She had a lot of discomfort washing the dishes, sitting for prolonged periods and was unable to go for her usual long walk. Her pain was eased by lying down. At her first appointment I asked her what height she was and she said 5ft 5. I measured her and she was just over 5ft 3. Her imaging showed a vertebral fracture at T12 and evidence of an older fracture at T6. I see some version of this patient most weeks. If you work in MSK, you have almost certainly seen a similar case too. With the above history, would a vertebral fracture have been your working diagnosis? Would you have asked her height or measured her in clinic? **The silent fracture** Vertebral fractures are among the most common fragility fractures caused by osteoporosis, but they are also the least likely to be diagnosed. \[1] One vertebral fracture occurs every 22 seconds worldwide! \[2] Yet only 33% of vertebral fractures come to clinical attention, with nearly 70% going undiagnosed. \[3]There are a few reasons vertebral fractures go underdiagnosed: \* 65-75% of vertebral fractures have little to no symptoms. \[4,5] They often show up years later as height loss or increased kyphosis, which gets put down to ‘old age’. \* For symptomatic fractures many present like the typical non-specific back pain we treat every day and they have similar healing timeframes, with most of the acute pain resolving within the first 6-12 weeks. \* Even when imaging does happen they are frequently missed. This is because sometimes they are not being looked for (referral letters have ‘low back pain’ written on them instead of ‘suspected vertebral fracture’), end plate changes can be subtle and easily missed, and even if they are noticed they are instead reported as ‘wedging, loss of height, or compression’. \[6] Most of us could recite the red flags to screen for Cauda Equina Syndrome or spinal malignancy, but are we as confident when it comes to identifying signs of an osteoporotic vertebral fracture? **Why one fracture matters** A vertebral fracture is rarely a one-off event, it’s usually the beginning of a steady decline. Vertebral fractures can have a devastating impact on people’s lives. 1 in 5 women who have a vertebral fracture will have another one within a year. \[7,8] Over 55% of older women with a hip fracture have evidence of a prior vertebral fracture. \[9] Yet only 1 in 8 people with a hip fracture are taking osteoporosis medication at the time of the fracture. \[10] If we improved our diagnosis of vertebral fractures and addressed it much earlier, could we prevent future hip fractures?We all know the statistic that up to 20% of people will die within one year following a hip fracture, but a less known fact is that up to 15% of men will die within one year following an osteoporotic vertebral fracture. \[11] Medication can reduce the risk of vertebral fractures by 30-70%. \[12,13] If you see someone with an osteoporotic vertebral fracture make sure they have been referred to their GP or a specialist for osteoporosis treatment. **What should make you think vertebral fracture?** Back pain is the most common presentation we see, and people with osteoporosis also get back pain (that is not a vertebral fracture). We can’t send every patient into a blind panic that they might have a fracture, so when should we consider that back pain might be something more? \* ***Risk factors in clinical history*.** Has the person had a previous fragility fracture, taken corticosteroids for more than three months, or been diagnosed with rheumatoid arthritis? \* ***Height loss*.** A historic height loss of over 4cm, or more than 2cm in a recorded period of time should prompt further assessment. Don’t just ask how tall people are - measure them in clinic. \* ***Sudden back pain after minimal or no trauma*.** Lifting shopping, bending to the dishwasher, or coughing can all cause vertebral fractures in people with osteoporosis. \* ***New or worsening kyphosis*.** Alongside assessing their spinal curve, measure wall-occiput and rib-pelvis distance. A wall-occiput distance of greater than 0 cm, or a rib-pelvis distance of less than two finger widths can be suggestive of a vertebral fracture. \[14] \* ***Pain that behaves differently.*** Pain from a vertebral fracture is often worse with standing, washing the dishes, sitting for long periods and is eased by lying flat on their back. Many people experience pain that wraps around their ribs like a vice grip. If someone isn’t responding as usual, and their symptoms don’t fit the typical pattern, consider their risk factors and whether it could be a vertebral fracture. \* ***Stopping or missing a dose of Denosumab (Prolia).*** Stopping Denosumab medication is associated with rebound bone turnover, loss of bone mineral density (BMD) and an increased rate of vertebral fractures. A case study showed a cumulative 50 vertebral fractures between nine women after stopping Denosumab. \[15] Stopping Denosumab should always be done alongside a specialist with a clear treatment and monitoring plan. If your patient is taking Denosumab make sure they haven’t missed a dose or have stopped taking it themselves. \* ***Pregnancy and Lactation* *Associated Osteoporosis.*** PAO/PLO is uncommon, but if someone presents with severe back pain, especially if combined with height loss in pregnancy or while breastfeeding, consider vertebral fractures. Low bone mineral density is recognised as the most robust risk factor for fragility fractures, but 55-70% of fractures occur in people *without* an osteoporosis diagnosis on their DXA scan. \[16] Don’t just rely on a DXA result to rule out a fracture - combine it with clinical history, risk factors, and fracture risk. **Why do we panic when we know it’s a vertebral fracture?** If we miss a vertebral fracture, or someone has a silent fracture, we rehab that patient like any other back pain patient. We load them, progress them, and get them back to their life. But this often changes once we hear vertebral fracture. People with osteoporosis are told to be careful - no bending, no twisting, no lifting. And this often creates a lot of fear. Yes, exercise modifications are important and needed. But fear of sustaining another fracture is the thing I hear most often in clinic. By the time people reach me, they have stopped going to the gym, significantly reduced their activity levels, stopped gardening or picking up their grandkids. They are deconditioned and therefore at a higher fall and fracture risk. But the fear doesn’t stop with patients, fear has crept into our own clinical practice and we are underloading the people who need to be loaded the most. **How should we approach exercise?** The Royal Osteoporosis Society’s consensus statement, Strong, Steady and Straight, advises that exercise is safe and beneficial for people with osteoporosis, including after a vertebral fracture \[17]. It recommends progressive resistance training, balance training, exercises to support spinal posture, and impact at an appropriate level. In a study looking at women aged 65 and over, who had a vertebral fracture, a 12-week supervised resistance and balance programme improved their strength and balance, and reduced their fear of falling \[18]. In the first 12 weeks after an acute fracture, the priority is pain management, and light activity as tolerated. It’s important to understand the location and fracture type so you can modify necessary movements. I educate people on ‘spine safe movements’ and how to modify day to day activities… This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe