Vertebral Fractures

One of the saddest, and unfortunately not infrequent, things I see in our Metabolic Bone Clinic, is older adults, typically over 55y old, who have broken their spine (vertebral) bones.  When bones are so fragile with osteoporosis, they just collapse – no trauma required!  Pain can happen just out of the blue – no fall needed. When the degree of collapse of a vertebral bone is severe, pain can be very difficult to control and, in some cases, can last life-long. An osteoporotic vertebral fracture constitutes a structural weakness in the body’s main support structure, and that weakness compounds the risk of more vertebral bones breaking in turn. If multiple vertebral fractures occur then spinal deformity or ‘kyphosis’ can ensue. With kyphosis comes an increased risk of lung infection, pulmonary hypertension, heart failure and reduced life expectancy.

But wait! Isn’t osteoporosis, and the vertebral fractures it causes, preventable? Well the best osteoporosis treatments can reduce the risk of vertebral fractures occurring by 70% (i.e. Zoledronate, Denosumab, Teriparatide, and Romosozumab). But even the basic and oldest treatments (alendronic acid and risedronate) can reduce vertebral fracture risk by 35-45%. All these treatments will prevent vertebral fractures occurring in people at risk of them (before any fractures have occurred) but treatments will also prevent new fractures occurring in people who have already had one or more.   There really should be no excuse! Prevention isn’t costly – at <£1 per week, the two basic treatments cost very little (‘cheaper than chips’).

Sadly though, we frequently see people too late, long after they have been struggling with back pains undiagnosed with undisclosed fractures, and never having been offered treatment. How on earth can this happen? So this is an all-round failure of health-care, due to one, or a number of many issues: a failure of identifying people at risk of osteoporosis in Primary Care, by GPs and Musculoskeletal Services; a failure to arranging X-Rays to investigate back pain, a failure of radiologists in recognising the fractures on X-Rays once the X-Ray has been done and a failure of Hospital Specialists to investigate back pain in their patients because it is not the issue they are dealing with at the time or not the part of the patient they are interested in!

It is a welcome step in the right direction, therefore, that The National Osteoporosis Society (now The Royal Osteoporosis Society) has produced sensible guidance to the medical profession and to Healthcare Commissioners on how to go about addressing this issue of detecting osteoporotic vertebral fractures.  This advice is free on-line to anyone interested (https://nos.org.uk/media/99100/vertebral-fractures-guidelines.pdf); it is expert consensus based and straightforward. The information is all there. Congratulations to The Royal Osteoporosis Society!