Abnormal Curvatures of Vertebral Column (Moore)

Abnormal curvatures in some people result from developmental anomalies and in others from pathological processes
such as osteoporosis. Osteoporosis is characterized by a net deminer- alization of bones and results from a disruption
of the normal balance of calcium deposition and resorption. The bones become weakened and brittle and are sub- ject
to fracture. Vertebral body osteoporosis occurs in all vertebrae but is most common in thoracic vertebrae and is an
especially common finding in postmenopausal women.

hump eminentia yang bulat. dowager's h., nama populer untuk kifosis dorsalis yang disebabkan oleh fraktur baji multipel pada
vertebra torasik, ditemukan pada osteoporosis.

Excessive thoracic kyphosis (clinically shortened to kyphosis; colloquially called “humpback”) is characterized by
an abnormal increase in the thoracic curvature; the vertebral column curves posteriorly (Fig. B4.1A,B). This
abnormality can result from erosion of the anterior part of one or more vertebrae. Progressive erosion and collapse
of vertebrae results in an over- all loss of height. Dowager hump is a colloquial name for excess thoracic kyphosis in
older women resulting from osteoporosis; however, kyphosis occurs in geriatric people of both sexes.

Bone Degeneration—Osteoporosis

As people age, both the organic and inorganic components of bone decrease, often resulting in osteoporosis, a
reduction in the quantity of bone, or atrophy of skeletal tissue. The bones become brittle, lose their elasticity, and
fracture easily.

Vertebral Body Osteoporosis

Vertebral body osteoporosis is a common metabolic bone disease that is often detected during routine radiographic
studies. Osteoporosis results from a net demineralization of the bones caused by a disruption of the normal balance
of calcium deposition and resorption. As a result, the quality of bone is reduced and atrophy of skel- etal tissue
occurs. Although osteoporosis affects the entire skeleton, the most affected areas are the neck of the femur, the
bodies of vertebrae, the metacarpals (bones of the hand), and the radius. These bones become weakened and brittle,
and are subject to fracture.

1. Localized lower back pain (LBP) (pain perceived as coming from the back) is generally muscular, joint, or
fibroskeletal pain. Muscular pain is usually related to reflexive cramping (spasms) producing ischemia, often
secondarily as a result of guarding (contraction of muscles in anticipation of pain). Zyg- apophysial joint pain
is generally associated with aging (osteo- arthritis) or disease (rheumatoid arthritis) of the joints. Pain from
vertebral fractures and dislocations is no different than that from other bones and joints: The sharp pain
following a fracture is mostly periosteal in origin, whereas pain from dis- locations is ligamentous. The
acute localized pain associated with an IV disc herniation undoubtedly emanates from the disrupted
posterolateral anulus fibrosis and impingement on the posterior longitudinal ligament. Pain in all of these
latter instances is conveyed initially by the meningeal branches of the spinal nerves.

Calcium and Phosphate Homeostasis Are Linked

(SILVERTHORN)
Phosphate homeostasis is closely linked to calcium homeo- stasis. Phosphate is the second key ingredient
in the hydroxy- apatite of bone, Ca10(PO4)6(OH)2, and most phosphate in the body is found in bone.
However, phosphates have other sig- nificant physiological roles, including energy transfer and storage in
high-energy phosphate bonds, and activation or de- activation of enzymes, transporters, and ion channels
through phosphorylation and dephosphorylation. Phosphates also form part of the DNA and RNA
backbone. Phosphate homeostasis parallels that of Ca 2+. Phosphate is absorbed in the intestines, filtered
and reabsorbed in the kidneys, and divided between bone, ECF, and intracellular compartments. Vitamin
D3 enhances intestinal absorption of phosphate. Renal excretion is affected by both PTH (which pro-
motes phosphate excretion) and vitamin D3 (which promotes phosphate reabsorption).

Osteoporosis Is a Disease of Bone Loss

One of the best-known pathologies of bone function is osteoporosis, a metabolic disorder in which bone
resorption exceeds bone deposition. The result is fragile, weakened bones that are more easily fractured
(Fig. 23.10c). Most bone resorption takes place in spongy trabecular bone, particularly in the vertebrae,
hips, and wrists.

Osteoporosis is most common in women after menopause, when estrogen concentrations fall. However,
older men also develop osteoporosis. Bone loss and small fractures and com- pression in the spinal
column lead to kyphosis {hump-back}, the stooped, hunchback appearance that is characteristic of
advanced osteoporosis in the elderly. Osteoporosis is a complex disease with genetic and environmental
components. Risk factors include small, thin body type; postmenopausal age; smok- ing; and low dietary
Ca2 + intake.

For many years estrogen or estrogen/progesterone hormone replacement therapy (HRT) was used to
prevent osteoporosis. However, estrogen therapy alone increases the risk of endome- trial and possibly
other cancers, and some studies suggest that combined estrogen/progesterone HRT might increase risk
of heart attacks and strokes. A selective estrogen receptor modulator (SERM) called raloxifene has been
used to treat osteoporosis.

The most effective drugs for preventing or treating osteoporosis act more directly on bone metabolism.
They include bisphosphonates, which induce osteoclast apoptosis and suppress bone resorption, and
teriparatide, a PTH derivative, which stimulates formation of new bone. Teriparatide consists of the first
34 amino acids of the 84-amino acid PTH molecule and must be injected rather than taken orally.
Currently clinical studies are investigating whether some combination of bisphosphonates and
teriparatide is more effective in combating osteoporosis than either drug alone.

To avoid osteoporosis in later years, young women need to maintain adequate dietary calcium intake and
perform weight-bearing exercises, such as running or aerobics, which increase bone density. Loss of bone
mass begins by age 30, long before people think they are at risk, and many women suffer from low bone
mass (osteopenia) before they are aware of a problem. Bone mass testing can help with early diagnosis of
osteopenia.

Osteoclasts are responsible for dissolving bone.

Osteoclasts attach around their periphery to a section of matrix, much like a suction cup (Fig. 23.10c). The
central region of the osteoclast secretes hydrochloric acid with the aid of carbonic anhydrase and an H+-
ATPase. Osteoclasts also secrete protease enzymes that work at low pH. The combination of acid and
enzymes dissolves the calcified hydroxyapatite matrix and its collagen support. Ca2 + from hydroxyapatite
becomes part of the ionized Ca2 + pool and can enter the blood.

Bone mass in the body is another example of mass balance. In children, bone deposition exceeds bone
resorption, and bone mass increases. In young adults up to about age 30, deposition and resorption are
balanced. From age 30 on, resorption begins to exceed deposition, with concurrent loss of bone from the
skeleton.
Osteoporosis can result in vertebral body fractures. If left untreated, these usually lead to an
increasingly bent posture, i.e., hunchback development of the back. This is often
accompanied by a noticeable loss of body size in those affected. Both can lead to shortening,
hardening and stiffness of the muscles and tendons. The accompanying chronic back pain is
mainly caused by static changes of the entire spinal column. The hunchback, also called
dowager’s hump in connection with osteoporosis, shifts the body’s centre of gravity forward.
This is referred to by the doctor as pathological kyphosis (curvature). The changed structure
results in an increased tendency to sway. This can in turn lead to a higher risk of falling.
The Spinomed spine straightening back orthoses can counteract this poor posture.

Causes for a dowager’s hump / hunchback

A dowager’s hump is usually caused by vertebral fractures due to osteoporosis. This is a

metabolism-related skeletal disease that is also known as “bone loss”. Post-menopausal and
elderly women are particularly affected. The earlier colloquial expression therefore for the
hunchback associated with the disease is “dowager’s hump”.

In osteoporosis, the bones lose density and stability. Fractures are particularly common in the
femur and spine. If the vertebral bodies collapse, it is referred to as “compression fractures".

Symptoms of dowager’s hump / hunchback

The complaint of back pain is considered to be the main symptom of osteoporotic vertebral
fracture. If there is acute back pain, then vertebral fractures are suspected – especially if the
affected person is over 50 years old and there are risk factors for osteoporosis. In
osteoporosis, pulmonary function may also be impaired by fractures (bone fractures) and
curvature in the thoracic spine.

There are sophisticated ways of kyphosis measurement with x-rays but that approach is
generally not accessible to many people. Fortunately, a group of researchers(2) recently had a
very clever idea and found a simple way to measure kyphosis — our forward head posture —
without expensive equipment. They developed a technique called hyperkyphotic measures
using distance to wall.

How to Do the Kyphosis Measurement

Here is how they do a kyphosis measurement.

 Line up — heels, sacrum, mid-back, and as much as ahead as possible — flat against
a wall.
 For purposes of today’s video, we’re just using the post here on my pulley system.
 If you’re a clinician watching this, or if you want to do this for yourself, you could
use a flat wall.
 You want to measure the distance between your C7 and the wall.
 How do you figure out where C7 is? Let’s find C7.
 Take your index finger and place it down your neck.
 Come to one bony prominence, a bony bit here that sticks out more than the others —
that’s usually your first thoracic.
 Our spine goes from cervical to thoracic — so that’s the first thoracic.
 Look for the last cervical or C7.
  Take your third finger and place it just above.
 As you bring your head down, and then bring your head back up, the bone that you
were feeling should disappear underneath your fingers.
 If the bone disappears, that is your C7.
 That is what you’re going to measure when you come up to the wall.
 Go up against the wall and feel the distance between your vertebrae and the post.
 I have roughly a finger width.
 Determine that width in centimetres.

Scoring the Kyphosis Measurement Results

Here are the guidelines to determine your level of kyphosis or Dowager’s Hump:

 Very mild kyphosis is considered anything under five centimetres.

 Between 5.1 and eight was considered moderate.
 Eight centimetres or above is considered severe.

If you score between very mild to moderate, this would be an opportune time to start focusing
on changing your alignment for the better. Because if you wait until it gets severe, and when
that distance is more in the range of eight centimetres or more, then that also was shown to
have a higher rate of fractures of the vertebrae.

HOW TO TREAT IT ? brace, breast reduction