Osteoporotic Vertebral Fractures

What are osteoporosis & osteopenia?

These are conditions in which bone becomes less dense, more fragile, and less resistant, increasing the risk of fracture even with minimal stress.

In simple terms, in osteoporosis bone loses part of its mass and structural quality—almost as if the skeleton becomes “thinner from within.” Osteopenia represents an intermediate stage: bones are weaker than normal but not as severely compromised as in osteoporosis. In both conditions, the risk increases for:

• Vertebral compression fractures (most commonly in the thoracic and lumbar spine).
• Hip fractures following a fall.
• Wrist fractures or other fractures after minor trauma.

Osteoporosis is predominantly a disease of older age, particularly in postmenopausal women, but it can also occur in men or younger women when secondary causes are present (endocrine disorders, chronic corticosteroid use, etc.).

How common are they & who is at greatest risk?

Osteoporosis and osteopenia are extremely common. Risk increases with age, sex, hormonal changes, and specific lifestyle factors.

Major high-risk groups include:

• Postmenopausal women—due to a sharp decline in estrogen levels.
• Men over 70 years.
• Individuals with a family history of osteoporosis or hip fractures.
• Patients with long-term corticosteroid use (e.g., for rheumatologic diseases).
• Individuals with endocrine disorders (hyperthyroidism, hyperparathyroidism, diabetes).
• People with gastrointestinal diseases that impair calcium absorption (e.g., celiac disease, inflammatory bowel disease).
• Smokers, those with excessive alcohol intake, sedentary lifestyle, or low body weight.

The more risk factors that coexist, the higher the likelihood of developing osteoporosis and fractures— and the more important early screening becomes.

How does bone normally function & what changes in osteoporosis?

Bone is not a “static material” but a living tissue that is constantly being broken down and rebuilt. In osteoporosis, this balance is disrupted.

In a healthy skeleton, two main types of cells work in coordination:

• Osteoclasts—“break down” old or damaged bone.
• Osteoblasts—“build” new, healthy bone.

In osteoporosis:

• osteoclast activity predominates,
• new bone formation cannot keep pace with bone loss,
• bone density decreases and microarchitecture deteriorates (thinning of trabeculae, formation of microscopic “voids”).

Particularly in the vertebrae (which are composed mainly of trabecular bone), this loss of mass can lead to compression fractures even with minimal stress (e.g., lifting a bag, sudden trunk flexion, coughing).

How does it present clinically – what happens in the spine?

Osteoporosis often remains “silent” until a fracture occurs. At that point, pain and spinal deformity prompt the patient to seek medical care.

Typical features include:

• Vertebral compression fractures—acute or subacute back or thoracic pain that worsens with standing or walking and improves when lying down.
• Progressive kyphosis (“hunching”), loss of height, and deformity.
• Fractures may be asymptomatic and detected incidentally on X-rays or CT/MRI.

Neurological symptoms (numbness, weakness) typically occur only in more severe cases, when vertebral collapse with posterior displacement compresses the spinal cord or nerve roots.

How is the diagnosis made (DEXA, T-score, FRAX)?

Diagnosis is based on a combination of clinical data, imaging, and bone mineral density measurement.

1. Bone mineral density measurement – DEXA

DEXA (Dual-Energy X-ray Absorptiometry) is the gold-standard test for measuring bone density. It is typically performed at:

• the hip,
• the lumbar spine—with caution for degenerative changes that may falsely elevate values,
• or the forearm/wrist when indicated.

DEXA provides two key metrics:

• T-score: comparison with a young, healthy reference population (< 30 years). Used for diagnosing osteopenia/osteoporosis.
• Z-score: comparison with individuals of the same age, sex, and ethnicity. Useful for identifying secondary causes.

Diagnostic thresholds:

• Normal: T-score > −1.0
• Osteopenia: T-score between −1.0 and −2.5
• Osteoporosis: T-score ≤ −2.5 and/or a low-energy hip or vertebral fracture, regardless of T-score.

2. Fracture risk assessment – FRAX

The FRAX tool estimates the 10-year fracture risk (hip and major osteoporotic fractures) based on:

• age, sex, weight/height,
• prior low-energy fracture,
• smoking, alcohol use, corticosteroid therapy,
• family history of hip fracture,
• bone density at the femoral neck.

The combination of DEXA + FRAX helps determine whether pharmacologic therapy is indicated or whether intensified prevention and monitoring are sufficient.

When should I be screened for osteoporosis?

Screening is not only for those who have already sustained a fracture. The goal is prevention of the first fracture.

In general, screening is recommended for:

• Women ≥ 65 years: routine bone density testing.
• Men ≥ 70 years: particularly if additional risk factors are present.
• Postmenopausal women < 65 years with significant risk factors (prior fracture, corticosteroid use, etc.).
• Individuals of any age with a low-energy fracture (e.g., vertebral or hip fracture after a simple fall).
• Individuals with chronic diseases or treatments that affect bone (endocrine, gastrointestinal, renal, etc.).

Your physician will assess overall risk and recommend the appropriate screening strategy.

What can I do for prevention (calcium, vitamin D, exercise, lifestyle)?

Prevention begins with simple daily measures: appropriate nutrition, regular physical activity, smoking cessation, and fall prevention.

Nutrition & supplements

• Calcium – a total intake of approximately 1,000–1,200 mg/day is recommended (from diet and supplements if needed). Major sources: dairy products, leafy greens, nuts.
• Vitamin D – essential for calcium absorption. Typically 800–1,000 IU/day is recommended in older adults, individualized based on serum 25(OH)D levels.

Exercise & muscle strengthening

• Weight-bearing exercise (walking, light jogging, dancing) – stimulates bone formation.
• Balance & core strengthening exercises – reduce fall risk.
• Avoid prolonged immobility; inactivity accelerates bone loss.

Lifestyle

• Smoking cessation – smoking accelerates bone loss.
• Limit alcohol – avoid excessive intake.
• Maintain a healthy body weight – very low weight increases risk.

Which medications are available & when are they started?

Pharmacologic therapy is not required for everyone, but it is critical in patients with prior fractures or very low bone density / high FRAX scores.

Major medication categories (examples):

• Bisphosphonates (alendronate, risedronate, zoledronic acid, etc.) – reduce osteoclast activity, stabilizing or increasing bone density.
• Hormonal therapy / SERMs (where appropriate, mainly in early postmenopause, with careful risk–benefit assessment).
• Parathyroid hormone / anabolic agents (teriparatide) – stimulate new bone formation in selected severe cases.
• RANKL inhibitors (denosumab) – inhibit osteoclast maturation.

A low-energy hip or vertebral fracture is in itself an indication for treatment, regardless of the exact T-score. In other cases, the decision is based on:

• T-score (especially ≤ −2.5),
• FRAX (high 10-year fracture risk),
• overall clinical profile and risk assessment.

How are vertebral compression fractures treated?

The goals are pain relief, early mobilization, and prevention of further deformity.

Conservative management

• Short-term rest and unloading (not prolonged immobilization).
• Analgesics – escalated according to pain severity.
• Spinal bracing (LSO/TLSO) in selected cases.
• Physical therapy focused on paraspinal strengthening & balance.

Minimally invasive techniques

• Vertebroplasty / kyphoplasty – injection of specialized bone cement into the vertebral body (with balloon-assisted height restoration in kyphoplasty), aiming to:
  • provide rapid pain relief,
  • stabilize the fracture,
  • partially restore height and reduce kyphosis in selected cases.

Open surgery

In more complex fractures with neurological deficit, significant instability, or progressive deformity, the following may be required:

• decompression of neural elements (spinal cord/nerve roots),
• instrumented fusion (screws, rods) to restore alignment and stability.

Decisions are individualized based on age, comorbidities, pain severity, neurological status, and overall functional capacity.

Why does osteoporosis matter if I need spine surgery?

Osteoporosis does not preclude surgery, but it increases technical complexity and the risk of complications. It requires careful preoperative planning.

Key factors evaluated by the neurosurgical team include:

• Bone quality – ideally supported by recent DEXA or other indicators.
• Risk of hardware loosening – severely osteoporotic bone increases the risk of screw pull-out or fusion failure.
• Possibility of pre-treatment (e.g., bisphosphonates/anabolic agents).
• Use of augmentative techniques – e.g., cement augmentation, larger or multi-axial screws, additional fixation points (longer constructs).

The overarching goal is one: a stable, durable construct that allows decompression of neural structures, correction of deformity, and preservation of mobility and quality of life, with the lowest possible risk of complications.

Practical tips for daily life & fall prevention

The best “treatment” for osteoporotic fractures is prevention. Small adjustments in daily life can significantly reduce risk.

Examples include:

• Safe home environment – remove loose rugs, cables, and small obstacles; ensure adequate lighting in hallways and bathrooms.
• Bathroom safety – non-slip mats, grab bars, shower seats for vulnerable individuals.
• Footwear – stable, closed shoes with non-slip soles; avoid loose slippers.
• Vision & hearing checks – timely correction with glasses or hearing aids as needed.
• Medication review – avoid excessive sedation or hypotension that may cause dizziness/falls.
• Regular balance exercises (e.g., physiotherapy programs, simple home routines).