Volume 2 · Number 1 · March 2010
- The prevalence of vertebral fractures in patients attending Internal Medicine outpatient clinics [9-13]
- Prevalence of osteoporosis in patients with acute coronary syndrome [15-20]
- Screening points for a peripheral densitometer of the calcaneum for the diagnosis of osteoporosis [23-28]
- Vertebroplasty: An alternative therapy for painful osteoporotic vertebral fractures which do not respond to conservative treatment? Review and update [31-36]
- Bone disease following liver transplant [37-46]
- Differential diagnosis and management of pain associated with multiple vertebral hemangiomas. A case report [51-54]
Clinical judgement, empirical, intuitive and based on experience, is one of the pillars of clinical decision-making. Along with clinical tests (“evidence”), and at an equal level, it serves to adapt what science offers to the individual patient. Osteoporosis is no exception. For years, we clinicians have used a long list of clinical risk factors, some modifiable, others not, to evaluate in each patient how much risk we must counteract with our interventions in a typical cost-benefit analysis.
The problem is that the quantification of this risk has been difficult. Other fields of pathology have preceded us in the search for formulae which permit us to calculate the risk of an individual patient becoming ill, attributing its relative weight, if they have it, to each of the factors which play a role in the determining the risk. In the case of osteoporosis, the risk of fracture.
Numerous scales have come to be constructed with this intention in recent years. Scales such as ORAI, Fracture Index, etc., have enjoyed limited approval their use was complex, or because their predictive capacity was (or was seen to be) limited.
Background: Fractures are a clinical complication of osteoporosis, and among them vertebral fractures (VF) are the most frequent. This type of fracture is often asymptomatic or happens unnoticed and is not diagnosed.
Objective: To study the prevalence of previously non-diagnosed vertebral fractures in a population of post menopausal women over 50, who have attended an Internal Medicine outpatient clinic because of chronic back pain.
Material and methods: 273 women participated in the study, which comprised a group of cases (Group I) and a control group (Group II). Group I consisted of 202 post-menopausal women who had chronic back pain at the time they attended one of 13 Internal Medicine outpatient clinics across Spain. Group II was made up of 71 women who did not have back pain, and who were used as controls. To register any risk factors for osteoporosis, and any clinical symptoms, a questionnaire, previously validated and used in other similar clinical studies by SEIOMM members, was completed for all the female patients. A lateral thoracic and lumbar X-ray was also carried out on all female patients. The interpretation of the X-rays was done centrally. The Genant criteria for vertebral deformity were used for the diagnosis of the vertebral fractures.
Results: The post-menopausal women with chronic back pain were shorter in height than those who did not have back pain (154 ± 7.7 cm compared with 157 ± 7.7 cm, p= 0.005), they had a greater prevalence of kyphosis (54% vs 32.4%) and a higher prevalence of VF (15.8% vs 2.8%, p= 0.004). No statistically significant differences in the prevalence of fractures in total, hip fractures, Colles fractures and other fractures, were found between the two groups. BMI, VFs and kyphosis showed an independent and statistically significant association with back pain.
Conclusions: At the time of the study 15.8% of post-menopausal women with chronic back pain presented with at least one VF. In addition, they had a higher prevalence of kyphosis, and were on average 3cm shorter, than the women without back pain. Given that these fractures were not previously diagnosed, we suggest carrying out a lateral thoracic-lumbar X-ray on these patients, in order to establish a diagnosis and to start treatment as soon as possible.
Objectives: To assess the relationship between osteoporosis and acute coronary syndrome.
Material and Methods: This study involved 163 patients aged between 39 and 79 years, with an average age of 62 years. Of these, 83 were patients with acute coronary syndrome (90% acute myocardial infarction; 10% unstable angina). The other 80 patients belonged to a control group without cardiovascular disease.
Anthropometric measures were taken and densitometry carried out in both the lumbar spinal column and femoral neck. We considered a T-score < -2.5 DE as osteoporosis.
Results: No statistically significant differences were found regarding bone mineral density between the group of cases and the control group. Stratifying the data by osteoporotic disease, we observed that the prevalence is greater, to a statistically significant extent, in the group of patients with acute coronary syndrome. In analysing the data by sex, a greater prevalence of osteoporosis was found only in the group of women with acute coronary syndrome, the same relationship was not found in the group of men.
Conclusions: In our study we observed a greater prevalence of osteoporosis in patients with acute coronary syndrome.
We calculate specific triage thresholds for the PIXI-LUNAR heel densitometer to give a 90% specificity for osteoporosis and normal bone mineral density (BMD) at the hip or spine.
693 women aged 30-93 years (mean age 58.2 ± 9.6 years) referred for osteoporosis study, underwent hip and spine BMD measurements (HOLOGIC) by dual energy X-ray absortiometry (DXA), also had a peripheral heel DXA densitometry (PIXI-LUNAR). The os calcis T-scores for all woman were subjected to a receiver operator characteristic (ROC) analysis with the definition of osteoporosis (T-score ≤ -2.5) and BMD normal (T-score > -1) made at the the lumbar spine or femoral neck.
Patients with a heel T-score of above +0.6 are very likely to have normal bone density on axial densitometry, whilst patients with heel T-score of below -1.3 are very likely to have osteoporosis at the hip or spine. Only patients whose measurements lie between the thresholds should be referred for axial DXA.
Project financed by the Generalitat Valenciana – Conselleria de Sanitat – DOGV 5337 – 1.09.2007 – Resolution 20 10 2007
Vertebroplasty: An alternative therapy for painful osteoporotic vertebral fractures which do not respond to conservative treatment? Review and update
Purpose: To review and update the available literature of vertebroplastia: a procedure for treating painful compression fractures of the thoracic and lumbar spine that don’t have responded to a conservative treatment.
Material and methods: A review of the literature was performed about the procedure, indications, complications and results based on PubMed and academic Google using the following keywords: vertebroplasty, compression vertebral fractures, polimetilmetacrilato, PMMA and osteoporosis.
Results: Description of the procedure, indications and complications. Several studies with few number of patients have indicated a high rate of successes an a low rate of complications. Recently, two double blind, randomized clinical trials have been published, comparing vertebroplasty with a simulation of it. The results of these studies don´t support the realization of vertebroplasty for the treatment of pain in osteoporotic compression fractures.
Conclusions: The clinical results of vertebroplasty were promising. Recently, the publication of two randomized clinical trials with greater evidence than previous ones, contradicts it.
Several questions without answer arise: Can this procedure be effective in a subgroup of patients? Could be effective in medium-long term? Are there other options to treat patients that don´t respond to conventional treatment?
Liver transplant is now well established in the management of chronic terminal hepatopathy. With the follow up of these patients, we are getting to know pathologies derived from their earlier diseases and those from the organ transplant, among which are those produced by the immunosuppression (cyclosporine, FK506, sirolimus, glucocorticoids) necessary for their treatment. Among these complications with affect the quality of life in these patients are osteoporosis and fractures, which can appear mainly in the first 6-12 months after transplant, but which can continue to a lesser extent in the following years. Vertebral fractures, and those of the ribs, are the most frequent, in 65% and 24% of patients, with negative prognostic factors such as age and primary biliary cirrhosis. So, it is a severe form of osteoporosis which is analysed in this work, and to which we bring our therapeutic experience. With antiresorptive drugs, positive results have been reported for the prevention and treatment of this bone loss.
OP is a generalised disease of the skeleton characterised by low bone mass and an alteration in bone micro-architecture, with an increase in its fragility and consequently, a greater tendency to fracture1. Primary OP is that in which the reduction in bone mass can be explained by the changes brought about by aging, such as the hormonal changes produced in the menopause; the concept of secondary OP is reserved for that which can be caused or exacerbated by other pathologies or medications2. The prevalence of secondary OP is highly variable, depending on age, sex, racial group, etc. In addition, it is not always possible to talk of an isolated cause as the origin of many cases of osteoporosis, rather, a multifactorial etiology is quite frequently found. Thus, while the prevalence of cases of secondary OP in males reaches 64%3, in perimenopausal women the prevalence is around 50%, diminishing after the menopause to a not insignificant level of 20 to 30%2.
OP is a multifactorial disease to whose genesis contribute numerous genetic and environmental factors; each factor carries a relatively small weight in the development of the disease, with the exception of ageing and the menopause. The causes of secondary OP are multiple, from genetic, endocrinal, gastrointestinal and haemetologicial diseases, to nutritional and pharmacological factors.
Although the diagnosis of OP is established through densitometric criteria, supported on occasions by clinical criteria4, there are alterations in other imaging tests –conventional X-ray, computerised tomography (CT) and magnetic resonance (MR)– which should make us suspect this diagnosis. Thus, many cases of OP may be suspected in a casual way through an X-ray examination for another reason, or in subjects with fractures and risk factors for the disease.
The fact which drives the publication of this clinical case in our environment is based on three fundamental aspects: 1) the importance of specific X-ray examinations distinct from bone densitometry in the diagnosis of OP, 2) a review, in practical terms, of the epidemiology of secondary OP and 3) the necessity of maintaining clinical suspicion in selected patients, with negative results in the usual screening tests, which allow us to establish an early diagnosis of potentially curable diseases whose late diagnosis can result in high morbimortiality.
Differential diagnosis and management of pain associated with multiple vertebral hemangiomas. A case report
We present a case of a woman of 71 years of age with a history of epilepsy, mixed hyperlipemia, depressive syndrome and established osteoporosis, having had a previous Colles fracture on the left-hand side at the age of 52. She was following treatment with 750 mg/day of valproic acid, 40 mg/day of atorvastatin, 100 mg/day of trazodone, 20 mg/day of omeprazol, 35 mg weekly of risedronate and calcium and vitamin D supplements (550 mg/day of calcium element and 400 UI of vitamin D). For at least the last 10 years she presented with back pain, which improved only partially with rest and on occasion the pain, both dorsal and lumbar, woke her in the night. This pain had increased progressively in intensity such that it interfered with the basic activities of daily life. For this reason she was studied five years previously in another clinic without their arriving at a conclusive diagnosis. Nuclear Magnetic Resonance (NMR) of the spinal column had been carried out in which various lytic lesions were found, suggestive of metastasis in D6-D8. However, after an exhaustive examination, which included bone gammagraphy, computerised axial tomography (CAT), thoraco-abdominal mammography, tumour markers, proteinogram and thyroidal echogram, no primary tumour was found and only analgesic treatment was prescribed. 100 μg/hour every 72 hours of transdermic fentanil, 575 mg (3 cp/day) of metamizol and 300 mg/day of gabapentine was usually used.
She attended our clinic due to an increase in the intensity of these back pains, fundamentally in the last few months, without a clearly associated constitutional syndrome, nor previous trauma, or reduction in spirits. She did not have measurable fever, retained her strength and mobility, was able to walk without support and did not present sensory disturbances of any kind.
In the physical examination there was nothing noteworthy, except for pain on tapping the irradiated middle dorsal processes on the right-hand side, without palpable soft tissue mass. The neurological examination showed everything to be completely normal.
The analyses carried out showed discrete normochromic normocytic anaemia (haemoglobin 10.8 g /dL, haematocrit 31.7%, VCM 91.8 fL) with normal levels in the rest of the haemogram series and a velocity of globular sedimentation (VGS) of 35 mm (the second hour was not needed). The times of coagulation and biochemistry (which included the metabolism of iron, hepatic and lipid profile, proteinogram, thyroid hormones and levels of vitamin B12) were normal. The same was the case with the elemental urine analysis. A Mantoux test and blood tests for salmonella and brucella were carried out, all tests being negative. Similarly, levels of anti-streptolysin-O (ASLO) were less than 200
Our objective has been to develop a position document on the role of calcium and vitamin D in the treatment of osteoporosis, identifying and assessing the grade of evidence which supports the recommendations.
To achieve this aim, the published studies on aspects of pharmacokinetics of calcium, and the usefulness of calcium and vitamin D in the reduction of risk of fragility-related fracture, given on its own, as well as, more commonly used in combination with other drugs, have been reviewed, developing through their analysis, the current recommendations. These have been produced through a pre-specified and reproducible process, which included an accepted model for the evaluation and citing of evidence which supports them. The document, once drafted by the co-ordinators, was reviewed and discussed by all the panel members, to produce the definitive recommendations.
Calcium and vitamin D in themselves have shown their usefulness in the reduction of risk of both vertebral fracture, and hip and non-vertebral fracture. Administered in combination with different drugs they also reduce the risk of new osteoporotic fractures. All treatments indicated for osteoporosis should be administered with a supplement of calcium and vitamin D. To ensure optimum absorption, the calcium and vitamin D should be administered in small doses throughout the day. The calcium salt most used is calcium carbonate, of which there has been the greatest experience, it being, also, the cheapest. Calcium carbonate should be administered with meals for the best absorption. There are no pivotal studies with drugs used for the treatment of osteoporosis carried out with other salts of calcium. Calcium carbonate slightly increases the risk of urolitiasis. Calcium citrate is indicated in those patients with achlorhydia and reduces the risk of urolitiasis, being indicated as the drug of first choice for these patients.