Decreased Lung Capacity, Spinal Fracture and Osteoporosis: Addressing the Underlying Problems We all know that the incidence of fragility fractures increases as our patients age. But unfortunately, fewer know that vertebral compression fractures (VCFs) are a type of fragility fracture that occurs nearly twice as often (700,000/year) as hip and wrist fractures(1)—and can have serious respiratory ramifications. There is a nine percent decrease in forced vital capacity for each vertebral level fractured, which leads to a downward spiral over time. For Undiagnosed Vertebral example, one study of 10,000 Compression Fractures age-matched women showed that the life span of patients with osteoporotic spinal compression fractures is significantly decreased as compared to those with no fractures. (2) A typical VCF patient presents with back pain that is movement-related. The pain may begin mildly and worsen over time as the fracture gradually worsens. Unlike patients with hip fractures, those with VCFs don’t experience sudden pain signaling that a break has occurred. If the break is misdiagnosed as spinal arthritis—or viewed as a natural part of the aging process and left untreated—the patient is poised for a downward spiral. (3-12) (3,4,5,6,7, 8,9,10,11,12)
Treating the TWO Underlying Problems With vertebral compression fractures there are usually two underlying problems: First, the fracture itself, which needs to be repaired for healing to happen; second, the osteoporosis that weakened the bone structure, making the patient susceptible to fragility fractures.
Fracture Repair: Restoring Vertebral Height to Reduce Future Fractures Repair of a VCF can be done as an outpatient procedure in our office, using one of two minimally invasive spinal procedures that have become standard: vertebroplasty and kyphoplasty. Both are outpatient procedures that help heal the fracture by injecting acrylic cement into the collapsed vertebra. Among Medicare patients with VCFs, those receiving either procedure achieve significantly lower mortality rates than non-operated patients. (13) But whereas vertebroplasty only heals the break (through cement injection alone), kyphoplasty also restores vertebral height—and reduces future fracture risk—with cement injected into a space created by using a high-pressure balloon. The lower mortality rate for VCP patients receiving kyphoplasties vs. those receiving vertebroplasties has been attributed to improved pulmonary function. (5,14,15)
With kyphoplasty, a deflated balloon is inserted into the fracture space, inflated and removed, then acrylic cement is injected into the space created. The cement bonds with the trabecular bone creating an “internal cast” resulting in vertebral height restoration, stabilization, and pain relief.
We recommend treating VCFs with kyphoplasty, since it not only heals the fracture, but also restores vertebral height, improving pulmonary function and reducing the high risk of future fractures. (13) After an initial fracture and prior to treatment, the kyphotic angulation of the vertebra weakens the spine’s ability to handle the body’s load forces. This can lead to a domino effect on the adjacent osteoporotic vertebrae, making the patient five times more likely to have another VCF in the first year after the initial fracture, further impairing lung function.(16 ) Restoring vertebral height through kyphoplasty mitigates this domino effect: preventing future vertebral fractures, reducing spinal deformity (17,18) and providing pain relief (19,20) by restoring the spine’s ability to handle load forces. (13,20-25) (13,20,21,22,23,24, 25)
Addressing Overall Bone Health to Reduce Risk of All Fragility Fractures Unfortunately, the second part of the treatment plan—addressing the osteoporosis—is often ignored. Studies show that most patients with osteoporosis or fragility fractures are not treated to reduce risk of future breaks, even though this is key to achieving good, long-term patient outcomes. As we began treating more and more vertebral compression fractures in our office, it became clear that we were in a good position to not only help heal the break, but also help osteoporotic patients avoid future breaks by improving bone health. Consequently, Michigan Neurosurgical Institute has become a Certified Fracture Liaison Service (FLS) in order to: • Not only fix the existing fragility fractures, but also prevent future fractures. • Assist primary care and other specialists in the treatment of osteoporotic patients. Our FLS is dedicated to the patient’s long term health, and we are committed to working with referring physicians throughout the course of treatment.
National Osteoporosis Guidelines April 2014
The National Osteoporosis Foundation’s Clinician’s Guide to Prevention and Treatment of Osteoporosis states that the occurrence of any vertebral fracture in the absence of major trauma must be attributed to osteoporosis. The NOF goes on to say, “A vertebral fracture is consistent with a diagnosis of osteoporosis, even in the absence of a bone density diagnosis, and is an indication for pharmacologic treatment with osteoporosis medication to reduce subsequent fracture risk.” In addition, NOF recommends vertebral imaging to screen for spinal fractures in all post-menopausal women and men over the age of 50 with at least one osteoporosis risk factor.
Why a Fracture Liaison Service? We know that osteoporosis must be addressed, but the time and effort required to satisfy the guidelines of both the National Osteoporosis Foundation and the Centers for Medicare & Medicaid Services can represent an obstacle for some busy practitioners. A Fracture Liaison Service like ours — which specializes in helping prevent and treat osteoporosis — can activate pathways for diagnosis and treatment in several ways, such as assessing patients for increased risk of fall or osteoporotic fracture (for example, using stadiometer measurements to determine exact height loss leading to the diagnosis of vertebral fractures). Also, we will collect and enter data into National Registries to track quality of care and patient outcomes. Of course, we offer this Bone Health Clinic as a supplement to—not a replacement for—continuing care provided by you. Our goal is to help your patients achieve optimum spine health, and we are happy to assist in any way you wish. My physician assistants and I are communicating with you via written documentation—as well as personal phone calls—in order to treat patients with your permission and assistance. If you have any questions about our Bone Health Clinic, or suggestions about how we can work together to help patients avoid future fragility fractures and build stronger spines, please don’t hesitate to call. Sincerely,
Avery M. Jackson III, M.D., F.A.C.S., F.A.A.N.S. Michigan Neurosurgical Institute, P.C. Diplomate of the American Board of Neurological Surgery References 1
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