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Osteoporosis – Dr Ketan Khurjekar

Back Pain in elderly women: A New Demon!

Dr Ketan Khurjekar

M S (Ortho), D N B, M N A M S, M Ch (UK)

Head of Spine Surgery Dept, Sancheti Hospital, Pune.

In true sense Spine is a Back bone of our Body. Strength in our back is rendered by calcium densed vertebrae and toned paraspinal muscles. Function of vertebral column is to protect the delicate spinal cord and to give a good posture.

Few days back, in out patient clinic, I saw one 60 years young lady and one 45 years old lady. The former one had mild low back pain while the later complained of generalised back pain of moderate to severe grade. What exactly must have happened?

I explained both of them the same thing; Strength in back is rendered by calcium densed vertebrae and toned paraspinal muscles. If you loose on either, the back pain will start. The 60 year old lady had started developing early changes of decreased calcium in bones which we call as osteopenia, but she had good strength in her paraspinal (back) muscles which supported her weaker vertebrae. As against that, the 45 year old lady had weaker paraspinal muscles as well osteoporotic bones. She was the victim of osteoporotic back pain.

What is Osteoporosis?

Osteoporosis is a systemic skeletal disease, characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk (WHO, 1994). In other words weaker bones which are fragile and amenable to easy fractures.

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Normal Bone as against the Osteoporotic Bone

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Very commonly we are put forward with series of questions. Is it a disease?

  • Is it hereditary?
  • Is it only in women?
  • Is it only a condition of old age?

And the most important – Can we prevent Osteoporosis?

As we grow old, it is accepted that bones are going to become weaker. If fragility of bones is going to be in physiological limit then definitely it is not called Osteoporosis. Age related Osteoporosis is called senile one. Estrogen is stimulator in increasing bone mass. After women achieve menopause or after the surgical removal of uterus (Hysterectomy), the symptoms of osteoporosis are felt. Osteoporosis is commoner in women because of postmenopausal hormonal changes.

Osteoporosis- A Silent Killer

Bone loss occurs without symptoms, making osteoporosis, a “silent killer.” Many people do not realize they have osteoporosis until they have a fracture. Fractures can cause pain or occur without pain. It is commoner to get hip and spine fractures with osteoporosis. As against the western population, osteoporosis is greatly under diagnosed and under treated in our country, even in the most high risk patients who have already fractured. The problem is particularly acute in rural areas but as well as seen in urban areas.

Following are the facts which we are absolutely unaware of-

  • Each year, there are an estimated 500,000 spinal fractures, 300,000 hip fractures, 200,000 broken wrists, and 300,000 fractures of other bones.  About 80% of these fractures occur from relatively minor falls or accidents.
  • Between 25% and 60% of women over 60 years of age develop spinal compression fractures.
    A woman’s risk of developing an osteoporosis-related hip fracture is equal to her combined risk of developing breast uterine and ovarian cancer.
  • By age 90, one third of all women and 17% of men have sustained a hip fracture.

Though all above facts appear scary, they pose realistic picture and most important- they are preventable.

Bone is built in the first two decades of life. The critical years for building bone mass are from prior to adolescence to about age 30. The best prevention for osteoporosis is to build strong bones (maximize peak bone mass) during childhood and early adulthood. Prevention consists of a combination of adequate calcium and vitamin D intake, weight-bearing exercise and healthy lifestyle, including avoiding smoking and excessive alcohol intake. It is difficult to cure osteoporosis; we can slow down the process. Prevention takes edge over treatment.

Signs & Symptoms of Vertebral Fracture

  • Sudden onset of back pain.
  • Limited spinal mobility.
  • Height loss.
  • Deformity & Instability.
  • Back pain worsening on standing.

Osteoporotic Spinal Fractures pose a major concern, and we need to identify individuals at high risks.

  • Early menopause and associated back pain
  • Less calcium intake in diet and those who don’t get enough vitamin D
  • Age > 70
  • Lack of exercise, immobilisation
  • Malabsorption syndromes, Diabetes Mellitus
  • Patient on treatment with Phenytoin, Steroids
  • Smoking and excessive alcohol

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Radiograph of the thoracolumbar spine is   mandatory to

document Osteoporosis, normal  alignment of the vertebrae,

disc spaces, and  spinal curves. Bone densitometry, also

known as Dexa scan is a choice of investigation to grade the severity

of osteoporosis. T score being the indicator; result below -1 is

considered normal. T score value more than -2-5 is osteoporosis,

while between -1 and -2.5 is considered as osteopenic.

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A . Normal Vertebra, B. Osteopenia, C. Osteoporosis, D. Osteoporosis with fracture.

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Why elderly people are more afflicted?

  •     Decreased bone mass.
  •     Increased tendency to fall.
  •      Impaired protective neuromuscular responses which will lead to repetitive fall.

 

 

 

Osteoporosis Preventation

1 Calcium rich diet

a. vegetable: beet root, methi, spinach, lady finger, cauliflower, rajgira, nachani.

b. Fruits: Grapes, Orange, Banana, apple, Khajur

c. Poultry & dairy products: milk, cheese

d. Nuts: Ground nuts, Almonds, Pista

     10     2.Regular Physical Exercise.

       3.Diet Modification.

       4.Change in life style habbits.

       5.Prevention of repeated fall.

       6.Stop Smoking and Alcohol Intake.

 

Treatment.

  1. Daily Oral Calcium Supplement 1200 mg. calcium daily
  2. Vitamin D Supplement (Calcitriol).
  3. Exposure to early morning sunlight.
  4. Other newer medications.
  5. Surgical – Vertebroplasty.

X-ray:- Osteoporotic Vertebral Fracture treated in the form of Cement Augmentation of the vertebra called Vertebroplasty.

Vertebroplasty and Kyphoplasty are minimally invasive procedures which aim at pain relief, and stabilization of the vertebral body. Kyphoplasty, has the ability to provide some correction of deformity with partial restoration of vertebral body heigh

 On whom to perform vertebroplasty or kyphoplasty ?

  • Painful vertebral fracture at the end of 3 to 6 weeks
  • Disabling back pain leading to immobilization
  • High Roland – Morris and ODI scores (High Pain scores)
  • MRI showing change in bone marrow signals- suggestive of non-healing fracture

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Procedure of Vertebroplasty (Cement Augmentation in Fractured Vertebra)

Advantages of Vertebroplasty

  • Quicker pain relief
  • Early mobilisation of patient
  • Patient as well as Surgeon friendly

 

Procedure of Vertebroplasty:

 

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