Bone mass typically peaks around age 35 and starts to decrease progressively thereafter. It has been estimated that 90% of women above the age of 75 are clinically diagnosed with osteoporosis.

The lifetime risk of a symptomatic osteoporotic fracture has been reported as 16% for females and 5% for males. Fractures of the vertebrae (spine), hips, and distal radius (wrist) are the more commonly encountered fractures related to osteoporosis, with osteoporotic spine fractures being the most commonly seen. These fractures may occur even without a history of a fall due to the fragility of the skeleton.

Patients with osteoporotic spine fractures, also known as osteoporotic compression fractures, may experience significant pain and reduced mobility.

Complications of such fractures include chronic pain, spinal deformity such as kyphosis (hunched back), spinal cord compression leading to paralysis or loss of bladder or bowel control, and breathing difficulties. Various studies have shown a 30% increase in mortality upon diagnosis of an osteoporotic spine fracture.

Diagnosis and Assessment

Medical history including history of previous fracture (including hip fractures in the family), smoking, alcohol intake, steroid intake, presence of rheumatoid arthritis, and previous deficient bone mineral density of the hip.

Physical examination to assess the posture of the spine on standing, gait patterns, and neurological integrity of the lower extremities.

Investigations

X-rays

X-rays of the spine – to assess the presence of fracture and the alignment of the spine.

MRI

MRI scan – to evaluate the age of the fracture and the degree of nerve compression.

Bone Mineral Density

Bone mineral density test of the lumbar spine and hip – to assess the severity of osteoporosis.

Blood Investigations

Blood investigations may be done to rule out secondary causes of osteoporosis.

Treatment

Non-Surgical Treatment

Patients with painful compression fractures are traditionally treated with bed rest, braces, and medications to relieve pain while healing occurs. Gentle physiotherapy is also recommended when pain becomes more tolerable.

Cement Stabilisation

However, when the fracture fails to heal and patients develop persistent pain, they may benefit from injection of bone cement into the fractured vertebra to provide immediate stabilisation. There are three main adopted methods:

(i) Vertebroplasty

This procedure is a minimally invasive percutaneous (without surgical incision) technique in which the integrity and structure of a damaged or destroyed vertebral body is augmented through the use of bone cement. This procedure has gained widespread acceptance because of its efficacy and ability to be performed under sedation instead of general anaesthesia, thus allowing it to be performed as a day surgery procedure.

Vertebroplasty surgical procedure which uses the minimally invasive percutaneous technique

(ii) Kyphoplasty

This procedure is an improved version of vertebroplasty, where an inflatable balloon is inserted into the fractured vertebra to create a void for cement filling (the balloon is removed prior to cement injection). This method further raises the safety level of the procedure, as the risk of cement leakage may be reduced significantly compared to vertebroplasty.

(iii) Stenting

Stenting in the fractured vertebra reinforced by injection of bone cement around it is another modification of the vertebroplasty technique. The stent and the cement help maintain the integrity of the fractured vertebra.

$A stent that helps to maintain the fractured vertebra.$

Apart from managing the osteoporotic spinal fracture, it is important to treat the general osteoporosis condition as well. This can be achieved with various medications. Available options include oral weekly risedronate, six monthly injection of denosumab, daily injection of teriparatide or monthly injection of romosozumab.

Surgery

In severe cases of osteoporotic fractures causing neurological compromise, spine surgery may be required. This entails decompression of the nerves as well as stabilisation of the fractured vertebrae via titanium screws inserted above and below the fractured vertebra. Such screws may be reinforced with cement to strengthen the purchase of the screws into the vertebrae, helping to prevent implant failure.

$An x-ray of eight titanium screws was inserted above and below the fractured vertebra$

When to Consult a Spine Specialist

Osteoporotic spine fractures may cause persistent back pain, spinal deformity, reduced mobility, and neurological symptoms. Early assessment by a spine specialist may help guide appropriate osteoporosis treatment and prevent worsening spinal collapse or nerve compression.

	Dr Hee Hwan Tak Orthopaedic Surgeon & Spine Specialist MBBS (Singapore) \| FRCS (Edinburgh) \| FRCS (Glasgow) \| FAMS (Ortho)
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Osteoporotic Spine Fractures