Osteoporosis and kyphotic deformity: A very real risk for post-menopausal women

Kyphosis (hunchback) or kyphotic deformity refers to an abnormal spinal curvature with rounding of the upper back, which commonly occurs in older people. A common risk factor for the development of kyphosis in older people is osteoporosis, a condition characterized by increased bone loss resulting in bone fragility leading to fractures after minor falls and occasionally without any fall or trauma. Osteoporosis is common in the elderly population, with a high prevalence in post-menopausal women. Women are at increased risk of developing osteoporosis as compared to their male counterparts, primarily due to reduced estrogen synthesis after menopause. This hormone is responsible for maintaining healthy and strong bones in females. Some women may lose almost 25% of the bone mass within a decade of menopause.

OSTEOPOROSIS AND KYPHOSIS

Osteoporosis causes the spinal bone (vertebrae) to weaken, resulting in vertebral fractures and wedging. Approximately 33 per cent of women above 50 years of age suffers from vertebral fractures. Although around 60 per cent of vertebral fractures remain undiagnosed due to a lack of symptoms, these fractures can occasionally lead to severe back pain making all movements painful and difficult. These vertebral fractures cause the normally square-shaped vertebrae to become wedged leading to an increased curvature of the spine (kyphotic deformity), a stooped posture, height loss and a protuberant abdomen.

ROLE OF IMAGING IN ESTABLISHING DIAGNOSIS

Imaging plays an important role in confirming the diagnosis. For example, a 71-year-lady visited our hospital complaining of severe worsening back pain following a fall in the bathroom six weeks ago. Physical examination revealed a kyphotic spine in the standing position with significant pain associated will all movements. There was no history of hypertension, diabetes, or coronary heart disease. An x-ray of the spine revealed a collapse of multiple vertebra with kyphosis at the thoracolumbar junction and an MRI showed an acute (recent) fracture of the L1 vertebra and multiple healed fractures contributing to the spinal kyphosis. A DEXA scan, which assesses bone mineral density, revealed a T score of 3.2 in lumbar spine, is also useful to monitor response to treatment. A bone metabolic work-up (blood tests) confirmed the diagnosis of postmenopausal osteoporosis.

TREATMENT OF THIS CONDITION

The treatment of kyphosis or kyphotic deformity, caused due to osteoporosis, depends upon various factors, including the age and severity of the disease. A majority of osteoporotic vertebral fractures heal and become painless over a period of time. Hence, the first line of treatment is a combination of simple medications and spinal brace to reduce pain on one hand and management of osteoporosis on the other hand.

Medical management of osteoporosis

Medical management of osteoporosis includes calcium and vitamin D supplementation together with medications to increase bone strength either in the form of bisphosphonates (available in the form of oral tablets and injections), injectable teriparetide (a form of parathyroid hormone) or injectable denosumab. If the pain does not settle within a reasonable period of time and is causing significant disability, injection of bone cement to stabilize the fractured vertebrae (percutaneous procedure) and surgery may be considered.

Lifestyle modifications

In addition to the medical management of osteoporosis, lifestyle changes are crucial. Keep in mind the following to improve bone strength.

• Cessation of smoking and excess alcohol intake
• Improving diet to include proteins and calcium
• Sunlight exposure to raise the vitamin D levels
• Increasing activities like walking and aerobics (after pain settles)

In addition, a "fall prevention" programme to improve balance and coordination will also help to a great extent. Here's what you can do.

• Install grab bars in the bathing and toilet area
• Ensure adequate lighting especially at night
• Ensure that loose carpets and toys are not lying around. This helps to reduce falls in the elderly.
• Seek timely treatment of eye problems like cataract and neurological illnesses that affect walking and balance will also reduce the incidence of falls.

PREVENTION

It is important to identify the risk factors for osteoporosis in an individual for developing a preventive strategy. Risk factors include family history, sedentary lifestyle, calcium and vitamin D deficiency, excessive alcohol consumption and smoking, and use of medications like steroids.

Understanding the risk factors and modifying lifestyle can help to prevent osteoporosis and related spine complications. Peak bone mass is achieved at around the age of 30 years and bones become weaker with age especially after the age of 50-60 years and after menopause. A high peak bone mass can be achieved by encouraging youngsters to stay active, participate in sports and maintain a healthy lifestyle. The achievement of a higher peak bone mass reduces the risk of critical osteoporosis and fractures even after menopause and advancing age.

Universal recommendations of the National Osteoporosis Foundation (2015) include -

1. Adequate amounts of calcium (1000-1200 mg/day) in the diet in persons older than 50 years and incorporating calcium supplements if the diet is inadequate. Dairy products are a good source of calcium.
2. Advice on Vitamin D intake (800-1000 IU/day) including supplements if necessary, for individuals over the age of 50 years. Vitamin D can be produced by the body on exposure to sunlight and from foods like oily fish and egg yolk.
3. Regular weight-bearing and muscle strengthening exercises improve agility, strength, posture and balance, maintain or improve bone strength and reduce the risk of falls.
4. Cessation of tobacco smoking and excessive alcohol intake.
5. DEXA scan to assess bone mineral density is recommended in all post-menopausal women above the age of 65 years and men above 70 years. Men and women above the age of 50 years who have had a fracture or are at a high risk for osteoporosis are also advised to undergo a DEXA scan.

CONCLUSION

Osteoporosis is a common cause of vertebral fractures and kyphosis or kyphotic deformity. Maintaining good bone health through diet and exercises can prevent osteoporotic fractures and related complications. It is also important to seek medical advice for sudden onset back pain in older individuals especially after a fall, gradual kyphosis and reduced height to initiate early and effective treatment.

(This article is authored by Dr Thomas Joseph Kishen, Consultant, Spine Care, Manipal Hospitals)