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

Abstract

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.

Keywords: Cement augmentation; Kyphoplasty; Osteoporosis; Postmenopausal; Spinal fractures; bone density.

Figure 1.

Physiology of bone formation and mechanism of action of drugs used for management of osteoporosis. Mineral deposition into new bone and resorption of old bone are interconnected. Osteocytes, osteoblasts and osteoclasts are key cells involved in bone remodeling. Treatment for osteoporosis are targeted at regulators of osteoclasts and osteoblasts, like RANKL and OPG.

Figure 2.

Modalities for diagnosis of osteoporosis and assessment of fractures. Top: Fracture Risk Assessment Tool (FRAX®) is an online questionnaire with 12 questions in estimating fracture risk. Bottom left: High resolution quantitative computed tomography. Bottom right: Dual-energy x-ray absorptiometry (DEXA) scan. Images courtesy of HOLOGIC, Inc and affiliates.

Figure 3.

Algorithm for management of osteoporosis. We considered use of DEXA scan and FRAX® to determine osteoporosis. Low risk subjects (<20%) with risk factors could be considered for pharmacological treatment. Subjects with high risk (>20%), prior fragility fracture or more than one fragility fracture should be considered for pharmacotherapy or kyphoplasty/vertebroplasty.

Figure 4.

Demonstration of MRI STIR sequences in identifying the acuity of fracture, in patients with multiple vertebral body compression fractures. The acute fracture with bone marrow edema will be bright on STIR while chronic or remote fractures will remain isointense with adjacent normal vertebral bodies (Figures A and B).