Along the Spine, Women Buckle at Breaking Points
By JANE E. BRODY
Published: June 27, 2011
http://www.nytimes.com/



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Yvetta Fedorova

An 80-year-old friend was lifting a corner of the mattress while making her bed when, as she put it, “I broke my back.”

In fact, she suffered a vertebral fracture — a compression, or crushing, of the front of a vertebra, one of the 33 bones that form the spinal column. This injury is very common, affecting a quarter of postmenopausal women and accounting for half of the 1.5 million fractures due to bone loss that occur each year in the United States.

By age 80, two in every five women have had one or more vertebral compression fractures. They often result in chronic back pain and impair the ability to function and enjoy life. They are one reason so many people shrink in height as they age.

Multiple vertebral fractures, found in 20 percent to 30 percent of cases, often result in a hunched posture, a condition called kyphosis that impairs breathing and compresses the abdomen, leading to a protruding stomach with limited capacity.

But while vertebral fractures are a telltale sign of bone loss among women over age 50 and men over age 60, most who suffer them are unaware of the problem and receive no treatment to prevent future fractures in vertebrae, hips or wrists, the bones most likely to break under minor stress when weakened.

Yet, if a vertebral fracture is diagnosed and properly treated, the risk of future fractures, including hip fractures, is reduced by half or more, studies have shown.

“Most vertebral fractures do not come to medical attention at the time of their occurrence,” Dr. Kristine E. Ensrud and Dr. John T. Schousboe wrote recently in The New England Journal of Medicine. One reason is that the pain may be minimal at first or, if more severe, attributed to a strain that subsides over a few weeks.

Indeed, patients or their physicians are made aware of these fractures in just one-fourth to one-third of the instances in which they are discovered on X-rays, according to the doctors.

“The patient may have had a chest or back X-ray for some other reason, perhaps to rule out pneumonia, but the focus is on why the test was ordered, and an incidental finding of a vertebral fracture is ignored,” Dr. Ensrud said in an interview. “Doctors need to be more aware of this problem, and maybe patients should ask to see the report.”

Dr. Ensrud, an internist and epidemiologist who researches osteoporosis at the University of Minnesota and the Veterans Affairs Medical Center in Minneapolis, noted that in a person with severe osteoporosis, a vertebral fracture can be caused by something as mundane as coughing, sneezing, turning over in bed or stepping out of a bathtub.

In patients whose bone loss is less advanced, a fracture may occur when lifting something heavy, tripping or falling out of a chair.

“A lot of the time, people don’t recall the incident,” Dr. Ensrud said. “They just report that their back has been bothering them.” Patients also may mistakenly assume that their chronic discomfort is a result of arthritis or a normal consequence of age, and never mention it to their doctors.

About one-third of the postmenopausal women found to have vertebral fractures do not have osteoporosis as defined by bone mineral density testing, according to Dr. Ensrud and Dr. Schousboe. Rather, test scores indicate that these women are suffering from a lesser form of bone loss called osteopenia.

Yet the occurrence of vertebral fractures means that the situation is worse than bone density testing would suggest. “The identification of a vertebral fracture indicates a diagnosis of osteoporosis,” Dr. Ensrud and Dr. Schousboe concluded in their article.

Asked if such women should receive bone-preserving medication, Dr. Ensrud said emphatically, “Yes!” One major study found that a vertebral fracture raises the risk of further vertebral fractures by five times in just one year.

A vertebral fracture can be seen on an ordinary X-ray of the spine. But there is a more practical approach involving much less radiation: a scan of the spine called a lateral DEXA, an acronym for dual energy X-ray absorptiometry, as part of a routine bone density exam.

The scan requires special computer software. Patients must ask whether a particular clinic or hospital is able to perform a lateral DEXA.

If a postmenopausal woman whose bone density measures in the osteopenic range (suggesting bone loss, but not yet full-blown osteoporosis) is found to have a vertebral fracture, her doctor may decide to prescribe medication that increases bone strength. Often the drug will be a bisphosphonate like alendronate (brand name Fosamax), which is now available in an inexpensive generic form.

Future fractures can often be prevented if a bisphosphonate is taken by someone found to have one or more vertebral fractures, even if these fractures cause no discomfort. There are many other bone-building options, too, including a once-a-year injection.

In addition, patients should consume adequate amounts of calcium and vitamin D, the critical nutrients for strong bones: a total of 1,200 milligrams of calcium daily from food and supplements, and 1,000 international units daily of vitamin D.

Initially, a painful vertebral fracture may be treated with a short period of bed rest and pain medication like a nonsteroidal anti-inflammatory drug, narcotic, pain patch or an injection or nasal spray of calcitonin. But if too much time is spent in bed, the resulting weakness can increase the risk of further fractures.

Whatever is done, or not done, to treat the injury, the pain of a vertebral fracture usually subsides over the course of several weeks.

Dr. Ensrud and Dr. Schousboe cautioned in their article against rushing into two invasive procedures that have become increasingly common in this country: vertebroplasty and kyphoplasty. During these procedures, a kind of cement is injected into the compressed vertebra to stabilize it.

The operations are performed by interventional radiologists who, naturally, endorse them enthusiastically. However, two scientifically conducted studies of vertebroplasty using sham procedures as a control found no benefit with respect to pain, disability or quality of life.

Nor are these procedures completely free of risk. Although rarely, they can sometimes injure nerves or cause pulmonary embolisms. They also may result in fractures of adjacent vertebrae by increasing the mechanical stress on them.

Exercises to improve posture, strengthen back muscles and enhance mobility are less costly and likely to be more effective in the long run, the doctors wrote.

A version of this article appeared in print on June 28, 2011, on page D7 of the New York edition with the headline: Along the Spine, Women Buckle at Breaking Points.

Health Guide: Nonspecific Back Pain


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