Osteoporosis

• Osteoporosis is the most common metabolic bone disease

in the United States and can result in devastating physical,
psychosocial, and economic consequences.
• It is often overlooked and undertreated, however, in large
part because it is clinically silent before manifesting as
fracture.
Osteoporosis. Lateral radiograph demonstrates multiple
osteoporotic vertebral compression fractures.
Kyphoplasty has been performed at one level.
• Osteoporosis, a chronic, progressive disease of
multifactorial It has been most
recognized
etiology. in elderly whitefrequently
women, although it does occur
in both sexes, all races, and all age groups. Screening at-risk
populations is essential.
• Osteoporosis is a systemic skeletal disease characterized by
low bone mass and microarchitectural deterioration of
bone tissue, with a consequent increase in bone fragility.
The disease often does not become clinically apparent until
a fracture occurs
Osteoporosis of the spine. Observe the Osteoporosis of the spine. Note the
considerable reduction in overall lateral wedge fracture in L3 and the
vertebral bone density and note the central burst fracture in L5. The patient
lateral wedge fracture of L2. had suffered a recent fall.
 Pathophysiology
• Alterations in bone formation and resorption
• Estrogen deficiency
Estrogen deficiency accelerates bone loss in
postmenopausal women
• Aging
Aging is associated with a progressive decline in the supply
of osteoblasts in proportion to their demand causing bone loss.
• Calcium deficiency
Can lead to secondary hyperparathyroidism, which increases
calcium resorption from bone, decreases renal calcium excretion,
and increases renal production of 1,25-dihydroxyvitamin D
• Vitamin D deficiency
Can result in secondary hyperparathyroidism via decreased
intestinal calcium absorption.
• Osteoporotic fractures
Represent the clinical significance of derangements in bone.
• Osteoporosis versus osteomalacia
In osteoporosis, the bones are porous and brittle, whereas in
osteomalacia, the bones are soft. In osteoporosis, the mineral-to-
collagen ratio is within the reference range, whereas in
osteomalacia, the proportion of mineral composition is reduced
relative to organic material content.
• Additional factors and conditions
• Corticosteroids inhibit osteoblast function and enhance
osteoblast apoptosis.
• Polymorphisms of IL-1, IL-6 and TNF-alpha, as well as their
receptors, have been found to influence bone mass.
• Polymorphisms in the vitamin D receptor
• Alterations in insulin-like growth factor-1, bone morphogenic
protein, prostaglandin E2, nitrous oxide, and leukotrienes
• Collagen abnormalities; and leptin-related adrenergic
signaling.
• Epigenetics; Prenatal and postnatal factors contribute to adult
bone mass.
 Etiology
Primary
Osteoporosis
Type Characteristics
Usually occurs in children or young adults of both sexes
Juvenile osteoporosis Normal gonadal function , Age of onset: usually 8-14 years
Characteristic: abrupt bone pain and/or a fracture
following trauma
Idiopathic osteoporosis
Postmenopausa Occurs in women with estrogen deficiency, Characterized by a phase of
l osteoporosis accelerated bone loss, primarily from trabecular bone
(type I Fractures of the distal forearm and vertebral bodies are common
osteoporosis)

Occurs in women and men as BMD gradually declines with aging

Age-associated or Represents bone loss associated with aging, Fractures occur in cortical
senile osteoporosis and trabecular bone, Wrist, vertebral, and hip fractures often seen in
(type II osteoporosis) patients with type II osteoporosis
Secondary Osteoporosis in Adults

Genetic/congenital

Riley-Day syndrome
Renal hypercalciuria
Osteogenesis imperfecta
Cystic fibrosis
Hemochromatosis
Ehlers-Danlos syndrome
Homocystinuria
Glycogen storage disease
Hypophosphatasia
Gaucher disease
Idiopathic hypercalciuria
Marfan syndrome
Porphyria
Menkes steely hair
Hypogonadal states
syndrome
Hypogonadal states
Androgen insensitivity
Panhypopituitarism
Anorexia nervosa/bulimia nervosa Premature menopause
Female athlete triad Turner syndrome
Hyperprolactinemia Klinefelter syndrome

Endocrine disorders
Cushing syndrome
Hyperparathyroidis
Diabetes mellitus m Hyperthyroidism
Acromegaly Hypogonadism
Adrenal insufficiency Pregnancy
Estrogen deficiency Prolactinoma
Deficiency states
Calcium deficiency
Magnesium deficiency Gastrectomy
Protein deficiency Malabsorption
Vitamin D deficiency Malnutrition
Bariatric surgery Parenteral nutrition
Celiac disease Primary biliary cirrhosis

Inflammatory diseases
Inflammatory bowel disease
Ankylosing spondylitis Rheumatoid arthritis
Systemic lupus erythematosus
Hematologic and neoplastic disorders

Hemochromatosis
Hemophilia Sickle cell anemia
Leukemia Systemic mastocytosis
Lymphoma Thalassemia
Multiple myeloma Metastatic disease
Medications
Anticonvulsants
Antipsychotic drugs Furosemide
Antiretroviral drugs Glucocorticoids and corticotropin
Aromatase inhibitors Heparin (long term)
Chemotherapeutic/transplant Hormonal/endocrine therapies: gonadotropin-
drugs: cyclosporine, releasing hormone (GnRH) agonists, luteinizing
tacrolimus, platinum hormone-releasing hormone (LHRH)
compounds, analogues, depomedroxyprogesterone,
cyclophosphamide, excessive thyroxine
ifosfamide, high-dose Lithium
methotrexate Selective serotonin reuptake inhibitors (SSRIs)
Miscellaneous
Alcoholism
Amyloidosis Idiopathic scoliosis
Chronic metabolic acidosis Immobility
Congestive heart failure Multiple sclerosis
Depression Ochronosis
Emphysema Organ transplantation
Chronic or end-stage renal disease Pregnancy/lactation
Chronic liver disease Sarcoidosis
HIV/AIDS Weightlessness
 Risk
factors
Advanced age (≥50 years) Physical inactivity or immobilization
Female sex Use of certain drugs (eg,
White or Asian ethnicity anticonvulsants, systemic steroids,
Genetic factors, such as a family thyroid supplements, heparin,
history of osteoporosis chemotherapeutic agents, insulin)
Thin build or small stature, eg, body Alcohol and tobacco use
weight less than 127 lb, (57.7 kg) Androgen or estrogen deficiency
Amenorrhea Calcium deficiency
Late menarche Dowager hump
Early menopause
Postmenopausal
state
A potentially useful mnemonic for osteoporotic risk
factors is OSTEOPOROSIS, as follows:
• L O w calcium intake
• S eizure meds (anticonvulsants)
• T hin build
• E thanol intake
• Hyp O gonadism
• P revious fracture
• Thyr O id excess
• R ace (white, Asian)
• O ther relatives with osteoporosis
• S teroids
• I nactivity
• S moking
Epidemiology

• 9.9 million Americans have osteoporosis and an additional

43.1 million have low bone density.
• In the United States, two million fractures are attributed to
osteoporosis annually, with 432,000 hospital admissions,
2.5 million medical office visits and approximately 180,000
nursing home admissions.
• Globally, osteoporosis is by far the most common metabolic
bone disease, estimated to affect over 200 million people
worldwide. An estimated 75 million people in Europe, the
United States, and Japan have osteoporosis.
• Age demographics
• Risk for osteoporosis increases with age as BMD declines.
• Sex demographics
• Women are at a significantly higher risk for osteoporosis.
• Racial demographics
• Osteoporosis can occur in persons of all races and
ethnicities. In general, however, whites (especially of
northern European descent) and Asians are at increased
risk. In particular, non-Hispanic white women and Asian
women are at higher risk for osteoporosis.
Osteoporosis. Lateral radiograph
demonstrates multiple osteoporotic
vertebral compression fractures.
Kyphoplasty has been performed at one
level.
Osteoporosis. Lateral radiograph of the
patient seen in the previous image following
kyphoplasty performed at 3 additional levels.
Osteoporosis Presentation
Clinical Features
• Osteoporosis occurs in many people who have few or no
risk factors for this condition.
• Often, patients who have not sustained a fracture do not
report symptoms that would alert the clinician to suspect a
diagnosis of osteoporosis;
• Thus , this disease is a "silent thief" that generally does not
become clinically apparent until a fracture occurs.
• Screening at-risk populations is essential for proper
management of this disease and its related complications
 Nonmodifiable risk
factors
• Personal history of fracture as an adult
• History of fracture in a first-degree relative
• White race
• Advanced age
• Female sex
• Dementia
• Poor health or fragility
Modifiable risk
factors
• Current cigarette smoking
• Low body weight (< 127 lb)
• Estrogen deficiency such as that caused by early menopause (age <
45 years) or bilateral ovariectomy and prolonged premenopausal
amenorrhea (>1 year)
• Low lifelong calcium intake
• Alcoholism
• Impaired eyesight despite adequate correction
• Recurrent falls
• Inadequate physical activity
• Poor health or frailty
 Signs and
•symptoms
Osteoporosis generally does not become clinically apparent until a
fracture occurs.
• Two thirds of vertebral fractures are painless.
• Typical findings in patients with painful vertebral fractures may
include the following:
- The episode of acute pain may follow a fall or minor trauma
-Pain is localized to a specific, identifiable, vertebral level in the mid
thoracic to lower thoracic or upper lumbar spine
-The pain is described variably as sharp, nagging, or dull; movement
may exacerbate pain; in some cases, pain radiates to the abdomen
- Pain is often accompanied by paravertebral muscle spasms
exacerbated by activity and decreased by lying supine
-Patients often remain motionless in bed because of fear of
causing an exacerbation of pain
-Acute pain usually resolves after 4-6 weeks; in the setting of
multiple fractures with severe kyphosis, the pain may
become chronic
Physical Examination

• The physical examination should begin with an inspection

of the patient.
• Height measurement with a stadiometer at each visit may
be useful.
• Examination of active and passive range of motion (ROM)
assists in determining whether spine, hip, wrist, or other
osseous pathology may be present.
• A thorough neurologic examination is essential to rule out
spinal cord and/or peripheral nerve compromise.
Signs of
fracture
• Vertebral compression fractures may be demonstrated by a
thoracic kyphosis with an exaggerated cervical lordosis (dowager
hump).
• Acute vertebral fractures may have point tenderness over the
involved vertebrae.
• Hip fractures may have severe pain with ambulation. Also may show
decreased weight-bearing on the fractured side or an antalgic gait
pattern.
• Pubic and sacral fractures may report marked pain with ambulation
and tenderness to palpation, percussion, or both.
• Signs of collagen defects
• Osteoporosis may have physical findings consistent
with the associated collagen disease
• Balance difficulties
• Osteoporosis is known to have decreased balance, possibly
secondary to differences in balance control strategies and
sway amplitude
Hip fractures occur at the upper
end of the thigh bone (femur).
Intracapsular Fracture. This
fracture occurs at the level of the
"neck" of the bone
Diagnosis
• Complete blood count: May reveal anemia
• Serum chemistry levels: Usually normal in persons with
primary osteoporosis
• Liver function tests
• Thyroid-stimulating hormone level: Thyroid dysfunction has
been associated with osteoporosis
• 25-Hydroxyvitamin D level: Vitamin D insufficiency can
predispose to osteoporosis
• Serum protein electrophoresis: Multiple myeloma may be
associated with osteoporosis
• 24 hour urine calcium/creatinine: Hypercalciuria may be
associated with osteoporosis; further investigation with
measurement of intact parathyroid hormone and urine pH
may be indicated;
• Hypocalciuria may indicate malabsorption, which should be
further evaluated with a serum vitamin D measurement
and consideration of testing for malabsorption syndromes
such as celiac sprue
• Testosterone (total and/or free) and luteinizing
hormone/follicle-stimulating hormone: Male
hypogonadism is associated with osteoporosis
Bone mineral density (BMD) measurement is recommended
in the following patients :

• Women age 65 years and older and men age 70 years and
older, regardless of clinical risk factors
• Postmenopausal women and men above age 50–69, based
alpha-hydroxylase
on risk factor profile
• Postmenopausal women and men age 50 and older who
have had an adult-age fracture, to diagnose and determine
the degree of osteoporosis
• Vertebral imaging is recommended for the
following patients:
• All women age 70 and older and all men age 80 and older
whose BMD T-score at the spine, total hip, or femoral neck
is –1.0 or lower
• All women age 65 to 69 and all men age 70-79 whose BMD
T-score at the spine, total hip, or femoral neck is –1.5 or
lower
• Vertebral imaging is also recommended for
postmenopausal women and men age 50 and older with
the following specific risk factors:
• Low-trauma fractures
• Height loss of 1.5 inches (4 cm) or more since peak height at
age 20
• Height loss of 0.8 inches (2 cm) or more since a previously
documented height measurement
• Recent or ongoing long-term glucocorticoid treatment
• Other plain radiography features and recommended as follows:
- Obtain radiographs of the affected area in symptomatic patients
-Lateral spine radiography can be performed in asymptomatic
patients in whom a vertebral fracture is suspected; a scoliosis
series is useful for detecting occult vertebral fractures
-Radiographic findings can suggest the presence of osteopenia,
or bone loss, but cannot be used to diagnose osteoporosis
-Radiographs may also show other conditions, such as
osteoarthritis, disk disease, or spondylolisthesis
Diagnostic Considerations

• Osteomalacia
• Leukemia
• Lymphoma
• Metastases (bony and other)
• Pathologic fractures secondary to bone metastases from
cancer
• Pediatric osteogenesis imperfecta
• Renal osteodystrophy
Differential
Diagnoses
• Homocystinuria/Homocysteinemia
• Hyperparathyroidism
• Imaging in Osteomalacia and Renal Osteodystrophy
• Mastocytosis
• Multiple Myeloma
• Paget Disease
• Scurvy
• Sickle Cell Anemia
 Complication
•
s
Vertebral compression fractures often occur with minimal
stress, such as coughing, lifting, or bending.
• Hip fractures are the most devastating and occur most
commonly at the femoral neck and intertrochanteric regions.
• Secondary complications of hip fractures include nosocomial
infections and pulmonary thromboembolism.
• Increased morbidity and mortality secondary to vertebral
compression fractures and hip fractures.
• Spinal deformities and a dowager's hump, and they may lose
1-2 inches of height by their seventh decade of life
Prognosi
s
The prognosis for osteoporosis is good if bone loss is
detected in the early phases and proper intervention is
undertaken.
• Effect of fractures on prognosis
- Vertebral compression fractures are associated with
increased morbidity and mortality rates.
- Hip fractures, More than 250,000 hip fractures are
attributed to osteoporosis each year, they are associated
with significantly increased morbidity and mortality rates in
men and women.
Osteoporosis Workup
Approach
Considerations
• Laboratory studies to establish baseline values and to
look for potential secondary causes of osteoporosis
• Measurement of bone mineral density (BMD) to assess
bone loss and estimate the risk of fracture
• Bone biopsy may be indicated in specific situations.
 Laboratory
Studies
CBC results may reveal anemia, as in sickle cell disease, and may
raise the suspicion for alcohol abuse

Calcium levels can reflect underlying disease states

levels of serum calcium, phosphate, and alkaline phosphatase are
usually normal in persons with primary osteoporosis,
although alkaline phosphatase levels may be elevated after
a fracture
Creatinine levels may decrease with increasing parathyroid
hormone (PTH) levels or may be elevated in patients with
multiple myeloma
Creatinine levels are also used to estimate creatinine clearance,
which may indicate reduced renal function in elderly patients
Magnesium is very important in calcium homeostasis ; decreased
levels of magnesium may affect calcium absorption and
metabolism

Increased levels of alanine aminotransferase (ALT), aspartate

aminotransferase (AST), gamma-glutamyl transferase (GGT),
bilirubin, and alkaline phosphatase may indicate alcohol abuse
Thyroid dysfunction has been associated with osteoporosis
and should therefore be ruled out
Vitamin D level to assess vitamin D insufficiency;
inadequate vitamin D levels can predispose persons to
osteoporosis
Tests for Secondary
Causes of Osteoporosis Disorder

24-Hour urine calcium This study assesses for hypercalciuria and

level hypocalciuria

An intact PTH result is essential in ruling out

Parathyroid hormone hyperparathyroidism; an elevated PTH level may
(PTH) level be present in benign familial hypocalciuric
hypercalcemia

TFT Reflect the status of thyroid gland

 Testosterone and gonadotropin Evaluate a sex hormone
levels deficiency as a secondary cause of
osteoporosis

To exclude Cushing syndrome,a

Urinary free cortisol level and urine free cortisol value or overnight
tests for adrenal hypersecretion dexamethasone suppression test

Serum protein electrophoresis

(SPEP) and urine protein To identify multiple myeloma
electrophoresis (UPEP)
Antigliadin
antiendomysial antibodies Can help identify celiac disease

Serum tryptase
Help identify mastocytosis
urine N-methylhistamine

When a hematologicdisorder is
Bone marrow biopsy suspected
• Biochemical Markers of Bone Turnover
• Biochemical markers of bone turnover reflect bone
formation or bone resorption.
• These markers (both formation and resorption) may be
elevated in high-bone-turnover states (eg, early
postmenopausal osteoporosis) and may be useful in some
patients for monitoring early response to therapy.
 A summary list of Biochemical Markers of Bone
Turnover
Bone formation markers
Serum total alkaline phosphtase
Serum bone–specific alkaline
phosphatase
Serum osteocalcin
Serum type 1 procollagen
Bone resorption markers
Urinary hydroxyproline
Urinary total pyridinoline
Urinary free deoxypyridinoline
Urinary collagen type 1
Urinary or serum collagen type 1
Bone sialoprotein
Tartrate-resistant acid
phosphatase
Plain
•Radiography
.
Plain radiography is
recommended to assess
overall skeletal integrity.
In particular, in the workup
for osteoporosis, plain
radiography may be
indicated if a fracture is
already suspected or if
patients have lost more
than 1.5 inches of height Asymmetric loss in vertebral
body height with kyphosis
Lateral spine radiography can be
performed in asymptomatic
patients in whom a vertebral
fracture is suspected, in those
with height loss in the absence of
other symptoms, or in those
with pain in the thoracic or
upper lumbar spine .
A scoliosis series is useful for
detecting occult vertebral
Severe osteoporosis.
fractures. multiple vertebral crush fractures
• Radiographic findings can suggest the presence of
osteopenia, or bone loss, but cannot be used to diagnose
osteoporosis.
• Osteopenia is suggested by a cortical width that is less than
the medullary width.
• Plain radiography is not as accurate as BMD testing.
Because osteoporosis predominantly affects trabecular
bone rather than cortical bone, radiography does not reveal
osteoporotic changes until they affect the cortical bone.
Intertrochanteric Fracture. Subtrochanteric Fracture. This occurs
even further down the bone and may be
This occurs further down the bone
broken into several pieces.
Dual-Energy X-Ray Absorptiometry
(DXA)
DXA is currently
the criterion
standard for the
evaluation of
BMD.
DXA is used to
calculate BMD
at the lumbar
spine, hip, and
proximal
femur
• DXA provides the patient’s T-score, which is the BMD value
compared with that of control subjects who are at their peak
BMD.
• World Health Organization (WHO) criteria define a normal T-
score value as within 1 standard deviation (SD) of the mean
BMD value in a healthy young adult.
• Values lying farther from the mean are stratified as follows:
- T-score of –1 to –2.5 SD indicates osteopenia
- T-score of less than –2.5 SD indicates osteoporosis
-T-score of less than –2.5 SD with fragility fracture(s) indicates
severe osteoporosis
• DXA also provides the patient’s Z-score, which reflects a value
compared with that of persons matched for age and sex.
• Z-scores adjusted for ethnicity or race should be used in the
following patients:
• Premenopausal women
• Men younger than 50 years
• Children
• Z-score values of –2.0 SD or lower are defined as "below the
expected range for age" and those above –2.0 SD as "within the
expected range for age." The diagnosis of osteoporosis in these
groups should not be based on densitometric criteria alone.
WHO Definition of Osteoporosis Based on BMD Measurements by DXA
Definition Bone Mass Density Measurement T-Score
BMD within 1 SD of the mean
Normal bone density for young adult women T-score ≥ –1

Low bone mass BMD 1–2.5 SD below the mean for T-score between –1
(osteopenia) young-adult women and –2.5
Osteoporosis BMD ≥2.5 SD below the normal mean T-score ≤ –2.5
for young-adult women
BMD ≥2.5 SD below the normal mean
Severe or for young-adult women in a patient
T-score ≤ –2.5 (with
“established who has already experienced ≥1 fragility fracture[s])
” fractures
osteoporosis
Magnetic Resonance Imaging

• Magnetic resonance imaging (MRI) may be useful in

identifying fractures and in the assessment of metabolic
bone disease.
• Using fat-suppression sequences, marrow edema consistent
with fracture may be noted as areas of hypointensity on T1-
weighted images in association with corresponding areas of
hyperintensity on T2-weighted images.
• MRI is a very sensitive modality and is believed by some to
be the diagnostic imaging method of choice in the
detection of acute fractures, such as sacral fractures
An MRI may identify a hip fracture otherwise missed on plain X-ray.
Bone Scanning

• Bone scanning assesses the function and tissue metabolism

of organs by using a radionuclide (technetium-99m [99m Tc])
that emits radiation in proportion to its attachment to a
target structure.
• This technique detects an increase in osteoblastic activity
(as seen in compression fractures).
Dietary Measures

• Adequate calcium and vitamin D intake are important in

persons of any age, particularly in childhood as the bones
are maturing, and are essential in the prevention and
treatment of osteoporosis.
• Vitamin D is increasingly being recognized as a key element
in overall bone health, calcium absorption, balance (eg,
reduction in risk of falls and muscle performance.
• Patients who ingest inadequate amounts of vitamin D and
calcium should receive oral supplementation.
Physical and Occupational Therapy

• Physical therapy
-Physical therapy focuses on improving a patient's strength,
flexibility, posture, and balance to prevent falls and maximize
physical function.
-Postural retraining is key in this population. Spinal bone
mineral density (BMD) is directly correlated with the
strength of the back extensors; therefore, maintaining and
strengthening the back extensors should be emphasized.
Occupational therapy
• Training in the performance of activities of daily living
(ADLs) and in the proper use of adaptive equipment are
essential to the prevention of future falls.
• Home modification focuses on reducing the risk of falling by
installing handrails and grab bars in hallways, stairs, and
bathrooms.
• The use of a shower chair, tub bench, and adaptive bathing
devices also can be beneficial.
• The application of nonskid tape to steps (indoors and
outdoors), as well as the removal of throw rugs, greatly
improves home safety.
 Exercise
• Aerobic low-impact exercises, such as walking and bicycling,
generally are recommended. During these activities, ensure
that the patient maintains an upright spinal alignment.
• Proper therapy for osteoporosis includes 3-5 sessions per week
of weight-bearing exercises, such as walking or jogging, with
each session lasting 45-60 minutes. The patient should be
instructed in a home-exercise program that incorporates the
necessary elements for improving posture and overall physical
fitness.
• The physical therapist must address balance training, because
fall prevention is important in eliminating the complication of
fracture.
 Prevention of Osteoporosis

• Primary prevention of starts in childhood.

Patients require adequate calcium intake, vitamin D intake, and
osteoporosis
weight-bearing exercise. Beyond this, prevention of
osteoporosis has two components: behavior modification and
pharmacologic interventions.
• The following behaviors should be modified to reduce the risk
of developing osteoporosis:
- Cigarette smoking
- Physical inactivity
- Intake of alcohol, caffeine, sodium, animal protein, and calcium
Consultations
• The most important consultation is with a rheumatologist
or an endocrinologist.
• These specialists can help obtain the proper laboratory
tests and imaging studies needed to rule out causes of
secondary osteoporosis.
• In patients with uncontrolled pain that does not respond to
conventional therapies, an invasive pain specialist may be
consulted for proper interventional procedures
• Consultation with spine surgeon is appropriate
patients
a with severe, forfunction-limiting
symptomatology
intractable, that has not been relieved by
noninterventional techniques.
• Consultation with a nonsurgical spine specialist is
appropriate for a patient who is not a surgical candidate or
whose symptoms persist despite surgical fixation
Patient Education

• Patient education is paramount in the treatment of

osteoporosis.
• Many patients are unaware of the serious consequences of
osteoporosis, including increased morbidity and mortality,
and only become concerned when osteoporosis manifests
in the form of fracture; accordingly, it is important to
educate them regarding these consequences.
• Early prevention and treatment are essential in the
appropriate management of osteoporosis.
  Thanks for Your Interest in preventing osteoporosis

Email:
dr.hishamdabbagh@gmail.com
Email: haldabag@moh.gov.sa
Mobile: 00966536715868