Vertebral pain conditions: osteoporosis with pathological fracture

It happens again and again that pathological fractures of the spine, which have occurred without adequate force, are detected during imaging examinations. Advanced osteoporosis is often the underlying cause. This metabolic disease of bone leads to a loss of bone substance, structure and function and is associated with an increased risk of fracture. Quantitative computed tomography is one of the imaging techniques used in diagnostics.

In such pathologic fractures of the spine detected during imaging examinations, vertebral alterations with subsidence of the base and/or top plates up to wedge- or fish vertebrae-like deformations are detectable [1]. Significant demineralization of the skeleton need not always be associated with a pathological fracture. Various diseases can be associated with decalcification of the bone structure. Overview 1 lists differential diagnoses of vertebral deformities [1,2].

Osteoporosis is a metabolic disease of bone with loss of bone substance, structure and function [3]. History, clinical examination, imaging diagnostics and densitometry together with laboratory parameters (including hormone status, vitamin D, other bone metabolism parameters) can lead to clarification [4–6]. In particular, vitamin D levels should be measured because this vitamin plays an important role in calcium metabolism, deficiencies are prevalent and can lead to secondary hyperparathyroidism. A clear classification of osteoporosis in women, recommended by WHO, can be found in Table 1. About 90% of osteoporotic diseases are postmenopausal or senile and differ in diagnostic criteria [7] (Tab. 2). Secondary osteoporosis is caused by gastrointestinal diseases with resorption disorders, by endocrinological changes or hematological problems. The symptomatology of fractures occurring in osteoporosis is varied and is associated with often long temporal courses of back pain, acute pain in the case of acute fracture, and can lead to deformity of the spine in the long course (“widow’s hump”) [4]. Osteoporosis is also a significant financial burden on the national economy. A study published in the late 1990s demonstrated costs in the United States and Europe of more than $23 billion, caused by 2.3 million osteoporotic fractures [2]. Fractures of the femoral neck are associated with a 10% to 20% increase in mortality, and 19% of patients become long-term care cases. Prophylaxis is therefore of decisive importance. In cases of significant vertebral deformity, vertebroplasty or kyphoplasty can significantly alleviate symptoms and stabilize the vertebrae.

Radiographically, there is evidence of osteoporosis with increased radiolucency of the skeletal components, and in images especially of the thoracic spine (BWS) and lumbar spine (LWS) deformities of the vertebrae, primarily with subsidence of the vertebral end plates or more severe deformities. There is often a lack of anamnestic evidence of adequate trauma. Vertebral changes can also be verified in cross-sectional imaging (computed tomography and magnetic resonance imaging ), and spongiosa edema [8] detectable in MRI should be considered a sure sign of fresh sintering in the context of osteoporosis.

Today, several methods are available for quantifying bone density, which differ in terms of the information they provide about the situation of bone metabolism. How the results are interpreted also depends to an extent that should not be underestimated on the examiner’s experience with the corresponding modality (overview 2). The sonographic measurement is evaluated extremely critically. It is also not possible to quantify the mineral salt content of the bones by magnetic resonance imaging.

Case studies

Case 1 shows a pathologic fracture in a 77-year-old man after trivial loading. Lumbar vertebral body 1 (LWK 1) is significantly compressed, the posterior edge of the vertebra tilted intraspinally and caused spinal stenosis. Quantitative computed tomography (QCT) then performed demonstrated senile osteoporosis with a T-score of -4.4 with an absolute value of calcium hydroxyapatite of 58.4 mg/ml (Fig. 1).

In case 2 , a 62-year-old man with worsening thoracic spine (HR) pain was found to have numerous fresh osteoporotic sintering lesions with consecutive increased kyphosis. MRI showed significant spongiosaedema of the vertebrae. An X-ray examination of the thorax 4 years later revealed a condition after vertebroplasty of several middle thoracic vertebrae (Fig. 2).

In case 3, lumbar CT demonstrated a cover plate impression of LWK 3 (sagittal 2D reconstruction) in a 72-year-old female patient, and there was acute lumbar pain. QCT documented significant osteoporosis with mineral salt levels of 24 mg/ml, corresponding to a significantly increased fracture risk (Fig. 3).

Case 4 demonstrates diffuse demineralization of the skeleton, fish vertebrae-like compression of BWK 11, and numerous vertebral endplate collapses in the lumbar spine (LS) in a 64-year-old patient with plasmacytoma ( Fig. 4).

Take-Home Messages

Osteoporosis is a disease that places a significant financial burden on the national economy.
Prophylaxis of osteoporosis is important to avoid severe courses.
Imaging techniques can detect osteoporotic fractures.
Quantifying modalities (QCT, DXA) are very important in osteoporosis diagnostics and can verify therapy results in the course.
Vertebro- and kyphoplasty are procedures that stabilize the vertebrae.

Literature:

Ringe JD, Meunier PJ: Osteoporotic Fractures in the Elderly. Stuttgart & New York: Georg Thieme Verlag 1996; 63-80.
Rings JD: Osteoporosis. Stuttgart & New York: Georg Thieme Verlag 1997; 6-7.
Weiske R, Lingg G, Güler CC (eds.): Osteoporosis. Gustav Fischer Verlag Jena 1998: 1-4.
Capatina C, et al: Vitamin d deficiency in postmenopausal women – biological correlates. Maedica 2014; 9(4): 316-322.
Mikosch P: Diagnosis of osteoporosis in geriatric patients – possibilities and limitations. Wien Med Wochenschr 2012; 162(5-6): 99-109.
Platitsyna NG, Bolotnova TV: Vitamin D deficiency as a risk factor for chronic non-infectious diseases. Adv Gerontol 2017; 30(6): 873-879.
Dören M, et al: Prophylaxis and therapy of osteoporosis with estrogens and progestogens. Stuttgart&New York: Georg Thieme Verlag 1997: 13-25 (1997).
Gualdi G, et al: Vertebral fractures: radiological diagnosis, differential diagnosis and prognostic implications. Clin Ter 2007; 158(4): 355-361.
Osteoporosis: Diagnostic and Therapy Center Munich, www.osteoporosezentrum.de