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Internal MedicineEndocrinologyOsteoporosis and Vertebral Compression Fracture

Osteoporosis and Vertebral Compression Fracture

Must-Not-Miss / Red Flags

  • Pathologic fracture: suspect malignancy or multiple myeloma if fracture occurs at atypical site (e.g., femur, pelvis) without trauma
  • Cauda equina syndrome: from vertebral fracture fragments compressing the spinal cord – saddle anesthesia, bowel/bladder dysfunction
  • Medication‑related osteonecrosis of the jaw (MRONJ): exposed bone in the jaw in patients on bisphosphonates or denosumab
Patient Explanation
“Your bones have become thinner and weaker with age, which can lead to breaks even from minor bumps. We’ll give you medicine to strengthen your bones and reduce your risk of future fractures.”
Board Fact
“A DEXA T‑score ≤‑2.5 at the lumbar spine, femoral neck, or total hip confirms osteoporosis; a T‑score between ‑1.0 and ‑2.4 is osteopenia.”
ICD-10
M81.0

Definition & Core Concept

Osteoporosis is a systemic skeletal disorder characterized by low bone mass and microarchitectural deterioration, leading to increased bone fragility and fracture risk. Vertebral compression fractures are the most common osteoporotic fractures and can occur with minimal trauma.

Epidemiology & Risk Factors

  • 10 million Americans have osteoporosis; 44 million have low bone mass
  • 1 in 2 women and 1 in 4 men >50 will have an osteoporotic fracture
  • Vertebral fractures are often clinically silent; only 1/3 are diagnosed

Pathophysiology (Rule of 3)

  1. Imbalance between bone resorption and formation: increased osteoclast activity (post‑menopause, aging) or decreased osteoblast function
  2. Estrogen deficiency → increased RANKL → osteoclast activation
  3. Loss of trabecular bone connectivity → vertebral bodies vulnerable to compression under axial load

Clinical Presentation

  • Acute vertebral fracture: sudden back pain after bending, lifting, or coughing; may be minimal trauma
  • Chronic osteoporosis: progressive kyphosis (dowager’s hump), height loss >2 inches
  • Often asymptomatic until fracture occurs

Diagnostic Workup

DEXA scan: T‑score ≤‑2.5 at lumbar spine, femoral neck, or total hip. Spine X‑ray: vertebral compression fracture (wedge deformity, decreased vertebral height). MRI: if acute fracture and neurologic symptoms (rule out cord compression). Labs: Calcium, phosphate, alkaline phosphatase, 25‑hydroxyvitamin D, PTH, TSH, renal function. Bone turnover markers: optional (not for routine diagnosis).

Management Protocol

  1. Calcium: 1,200 mg/day (diet + supplements); Vitamin D3: 800‑2,000 IU/day (target serum 25‑OH Vitamin D >30 ng/mL)
  2. Bisphosphonates: Alendronate 70 mg PO weekly or Zoledronic acid 5 mg IV annually (first‑line)
  3. Denosumab: 60 mg SC every 6 months (alternative if bisphosphonate intolerant or renal impairment)
  4. Anabolic agents: Teriparatide (PTH analog) or Romosozumab for severe osteoporosis with fractures
  5. Pain management: acute fracture – NSAIDs (if renal function allows), short‑term opioids, calcitonin (limited efficacy)
  6. Vertebroplasty/kyphoplasty: for severe acute pain not responding to conservative measures (controversial benefit)

Complications & Prognosis

  • Recurrent fractures: hip, wrist, additional vertebrae
  • Chronic pain and disability from kyphosis
  • Reduced pulmonary function from thoracic vertebral fractures
  • Atypical femoral fractures (rare, associated with long‑term bisphosphonate use)

ICU Criteria

ICU admission rarely required unless multiple fractures with severe pain crisis or complications from surgery.

Clinical Vignette

A 75‑year‑old woman with known osteoporosis (non‑compliant with Alendronate) presents with acute mid‑back pain after lifting a laundry basket. Spine X‑ray shows a new T12 compression fracture. DEXA T‑score is ‑3.2 at the lumbar spine. She is started on Alendronate, calcium, and vitamin D, with pain management and a back brace.

Pearls & Pitfalls

  • Bisphosphonates are contraindicated in severe renal impairment (eGFR <30‑35 mL/min) – Denosumab is preferred.
  • Always ensure adequate calcium and vitamin D before starting bisphosphonates or Denosumab – otherwise, hypocalcemia can occur.

Discharge & Follow-Up

DEXA every 1‑2 years to monitor response. Alendronate for 5 years, then consider “drug holiday” if fracture risk is low. Weight‑bearing exercise and fall prevention strategies.

Literature & Guidelines

NOF/Endocrine Society 2024 Osteoporosis Guidelines. PMID: 38760120.

Personal Clinical Notes