Decreased Lung Capacity, Spinal Fracture and Osteoporosis:Decreased Lung Capacity, Spinal Fracture and Osteoporosis:Decreased Lung Capacity, Spinal Fracture and Osteoporosis:Decreased Lung Capacity, Spinal Fracture and Osteoporosis:

Addressing Addressing Addressing Addressing the Underlying Problemsthe Underlying Problemsthe Underlying Problemsthe 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

example, one study of 10,000

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.

Undiagnosed Vertebral

Compression 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)

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)

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.

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 National National National

Osteoporosis Osteoporosis Osteoporosis Osteoporosis

Guidelines Guidelines Guidelines Guidelines

April 2014April 2014April 2014April 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 Burge et al. 2007, Incidence and Economic Burden of Osteoporosis-Related

Fractures in the US, 2005-2025. J Bone Miner Res. 2007 Mar;22(3):465-75. 2 Lau E, Ong K, Kurtz S, Schmier J, Edidin A. Mortality following the diagnosis of a

vertebral compression fracture in the Medicare population. J Bone Joint Surg Am.

2008;90:1479–1486. 3 Pongchaiyakul, et al. Asymptomatic vertebral deformity as major risk factor for

subsequent fractures and mortality. J Bone Miner Res. 2005;20:1349–1355. 4 Center, et al. Mortality after all major types of osteoporotic fracture in men and

women. Lancet. 1999;353:878–882. 5 Kado, et al. Vertebral fractures and mortality in older women. Fractures

Research Group. Arch Intern Med. 1999;159:1215–1220. 6 Lau, et al.Mortality following the diagnosis of a vertebral compression fracture in

the Medicare population. J Bone Joint Surg Am. 2008;90:1479–1486. 7 Ensrud, et al. Prevalent vertebral deformities predict mortality and

hospitalization in older women with low bone mass. J Am Geriatr Soc.

2000;48:241–249. 8 Ismail, et al. Mortality associated with vertebral deformity in men and women:

European Prospective Osteoporosis Study. Osteoporos Int. 1998;8:291–297. 9 Cauley, et al. Risk of mortality following clinical fractures. Osteoporos Int.

2000;11:556–561. 10

Hasserius, et al. Long-term morbidity and mortality after a clinically diagnosed

vertebral fracture in the elderly. Calcif Tissue Int. 2005;76:235–242. 11

Jalava, et al. Association between vertebral fracture and increased mortality in

osteoporotic patients. J Bone Miner Res. 2003;18:1254–1260. 12

Kado, et al. Incident vertebral fractures and mortality in older women: a

prospective study. Osteoporos Int. 2003;14:589–594. 13

Yang, et al. Changes of pulmonary function for patients with osteoporotic

vertebral compression fractures after kyphoplasty. J Spinal Disord Tech.

2007;20:221–25. 14

Hasserius, et al. Prevalent vertebral deformities predict increased mortality and

fracture rate in men and women. Osteoporosis Int. 2003;14:61–68.

15

Edidin, et al. Mortality Risk for Operated and Non-operated Vertebral Fracture

Patients in the Medicare Population. Journal of Bone and Mineral Research, Vol.

26, No. 7, July 2011, pp 1617–1626. 16

Leech JA, Dulberg C, Kellie S, Pattee L, Gay J. Relationship of lung function to

severity of osteoporosis in women. Am Rev Respir Dis. 1990;141:68–71. Leech JA,

Dulberg C, Kellie S, Pattee L, Gay J. Relationship of lung function to severity of

osteoporosis in women. Am Rev Respir Dis. 1990;141:68–71. 17

Pradhan BB, Bae HW, Kropf MA, Patel VV, Delamarter RB. Kyphoplasty

reduction of osteoporotic vertebral compression fractures: correction of local

kyphosis versus overall sagittal alignment. Spine. 2006;31:435–441. 18

Maestretti G, Cremer C, Otten P, Jakob RP. Prospective study of standalone

balloon kyphoplasty with calcium phosphate cement augmentation in traumatic

fractures. Eur Spine J. 2007;16:601– 610. 19

Yang, et al. Changes of pulmonary function for patients with osteoporotic

vertebral compression fractures after kyphoplasty. J Spinal Disord Tech.

2007;20:221–25. 20

Garfin, et al. New technologies in spine: kyphoplasty and vertebroplasty for the

treatment of painful osteoporotic compression fractures. Spine. 2001;26:1511–

1515. 21

Grados, et al. Long-term observations of vertebral osteoporotic fractures

treated by percutaneous vertebroplasty. Rheumatology (Oxford). 2000;39:1410–

1414. 22

Lieberman, et al. Initial outcome and efficacy of ‘‘kyphoplasty’’ in treatment of

painful osteoporotic vertebral compression fractures. Spine. 2001;26:1631–1638. 23

Zoarski, et al.Percutaneous vertebroplasty for osteoporotic compression

fractures. J Vasc Interv Radiol. 2002;13 (2 Pt 1):139–148. 24

De Negri, et al. Treatment of painful osteoporotic or traumatic vertebral

compression fractures by percutaneous vertebral augmentation procedures: a

nonrandomized comparison between vertebroplasty and kyphoplasty. Clin J Pain.

2007; 23:425–430. 25

Alvarez L, Alcaraz M, Perez-Higueras A, et al. Percutaneous vertebroplasty:

functional improvement in patients with osteoporotic ompression fractures.

Spine. 2006;31:1113–1118.