Osteoporosis: Vertebroplasty and Kyphoplasty
Introduction
Osteoporosis, which means "porous bones," causes bones to become weak and brittle — so brittle that even mild stresses like bending over, lifting a vacuum cleaner or coughing can cause a fracture. In most cases, bones weaken when you have low levels of calcium, phosphorus and other minerals in your bones.
A common result of osteoporosis is fractures — most of them in the spine, hip or wrist. Although it's often thought of as a women's disease, osteoporosis also affects many men. And aside from people who have osteoporosis, many more have low bone density.
It's never too late — or too early — to do something about osteoporosis. You can take steps to keep bones strong and healthy throughout life.
Signs and symptoms
In the early stages of bone loss, you usually have no pain or other symptoms. But once bones have been weakened by osteoporosis, you may have osteoporosis symptoms that include:
Back pain, which can be severe if you have a fractured or collapsed vertebra of height over time, with an accompanying stooped posture
Causes
The strength of your bones depends on their size and density; bone density depends in part on the amount of calcium, phosphorus and other minerals bones contain. When your bones contain fewer minerals than normal, they're less strong and eventually lose their internal supporting structure.
The process of bone remodeling
Scientists have yet to learn all the reasons why this occurs, but the process involves how bone is made. Bone is continuously changing — new bone is made and old bone is broken down — a process called remodeling, or bone turnover.
A full cycle of bone remodeling takes about two to three months. When you're young, your body makes new bone faster than it breaks down old bone, and your bone mass increases. You reach your peak bone mass in your mid-30s. After that, bone remodeling continues, but you lose slightly more than you gain. At menopause, when estrogen levels drop, bone loss in women increases dramatically. Although many factors contribute to bone loss, the leading cause in women is decreased estrogen production during menopause.
Your risk of developing osteoporosis depends on how much bone mass you attained between ages 25 and 35 (peak bone mass) and how rapidly you lose it later. The higher your peak bone mass, the more bone you have "in the bank" and the less likely you are to develop osteoporosis as you age. Not getting enough vitamin D and calcium in your diet may lead to a lower peak bone mass and accelerated bone loss later.
What keeps bones healthy
Three factors that you can influence are essential for keeping your bones healthy throughout your life:
Regular exercise
Adequate amounts of calcium
Adequate amounts of vitamin D, which is essential for absorbing calcium
Risk factors
A number of factors can increase the likelihood that you'll develop osteoporosis, including:
Your sex. Fractures from osteoporosis are about twice as common in women as they are in men. That's because women start out with lower bone mass and tend to live longer. They also experience a sudden drop in estrogen at menopause that accelerates bone loss. Slender, small-framed women are particularly at risk. Men who have low levels of the male hormone testosterone also are at increased risk. The risk of osteoporosis in men is greatest from age 75 on.
Age. The older you get, the higher your risk of osteoporosis. Your bones become weaker as you age.
Race. You're at greatest risk of osteoporosis if you're white or of Southeast Asian descent. Black and Hispanic men and women have a lower, but still significant, risk.
Family history. Osteoporosis runs in families. For that reason, having a parent or sibling with osteoporosis puts you at greater risk, especially if you also have a family history of fractures.
Frame size. Men and women who are exceptionally thin or have small body frames tend to have higher risk because they may have less bone mass to draw from as they age.
Tobacco use. The exact role tobacco plays in osteoporosis isn't clearly understood, but researchers do know that tobacco use contributes to weak bones.
Lifetime exposure to estrogen. The greater a woman's lifetime exposure to estrogen, the lower her risk of osteoporosis. For example, you have a lower risk if you have a late menopause or you began menstruating at an earlier than average age. But your risk of osteoporosis is increased if your lifetime exposure to estrogen has been deficient, such as from infrequent menstrual periods or menopause before age 45.
Eating disorders. Women and men with anorexia nervosa or bulimia are at higher risk of lower bone density in their lower backs and hips.
Corticosteroid medications. Long-term use of corticosteroid medications, such as prednisone, cortisone, prednisolone and dexamethasone, is damaging to bone. These medications are common treatments for chronic conditions, such as asthma, rheumatoid arthritis and psoriasis. If you need to take a steroid medication for long periods, your doctor should monitor your bone density and recommend other drugs to help prevent bone loss.
Thyroid hormone. Too much thyroid hormone also can cause bone loss. This can occur either because your thyroid is overactive (hyperthyroidism) or because you take excess amounts of thyroid hormone medication to treat an underactive thyroid (hypothyroidism).
Other medications. Long-term use of the blood-thinning medication heparin, the cancer treatment drug methotrexate, some anti-seizure medications, diuretics and aluminum-containing antacids also can cause bone loss.
Breast cancer. Postmenopausal women who have had breast cancer are at increased risk of osteoporosis, especially if they were treated with chemotherapy or aromatase inhibitors such as anastrozole and letrozole, which suppress estrogen. This isn't true for women treated with tamoxifen, which may reduce the risk of fractures.
Low calcium intake. A lifelong lack of calcium plays a major role in the development of osteoporosis. Low calcium intake contributes to poor bone density, early bone loss and an increased risk of fractures.
Medical conditions and procedures that decrease calcium absorption. Stomach surgery (gastrectomy) can affect your body's ability to absorb calcium. So can conditions such as Crohn's disease, celiac disease, vitamin D deficiency, anorexia nervosa and Cushing's disease — a rare disorder in which your adrenal glands produce excessive corticosteroid hormones.
Sedentary lifestyle. Bone health begins in childhood. Children who are physically active and consume adequate amounts of calcium-containing foods have the greatest bone density. Any weight-bearing exercise is beneficial, but jumping and hopping seem particularly helpful for creating healthy bones. Exercise throughout life is important, but you can increase your bone density at any age.
Chronic alcoholism. For men, alcoholism is one of the leading risk factors for osteoporosis. Excess consumption of alcohol reduces bone formation and interferes with the body's ability to absorb calcium.
When to seek medical advice
Early detection is important in osteoporosis. Consider your risk factors, then discuss your prevention strategy with your doctor. If you're a woman, it's best to do this well before menopause.
Screening and diagnosis
Osteopenia refers to mild bone loss that isn't severe enough to be called osteoporosis, but that increases your risk of osteoporosis. Doctors can detect osteopenia or early signs of osteoporosis using a variety of devices to measure bone density.
Dual energy X-ray absorptiometry
The best screening test is dual energy X-ray absorptiometry (DEXA). This procedure is quick, simple and gives accurate results. It measures the density of bones in your spine, hip and wrist — the areas most likely to be affected by osteoporosis — and it's used to accurately follow changes in these bones over time.
Other tests that can accurately measure bone density include:
Ultrasound
Quantitative computerized tomography (CT) scanning
Should you have a test?
If you're a woman, the National Osteoporosis Foundation recommends that you have a bone density test if you aren't taking estrogen and any of the following conditions apply to you:
You're older than age 65, regardless of risk factors.
You're postmenopausal and have at least one risk factor for osteoporosis, including having fractured a bone.
You have a vertebral abnormality.
You use medications, such as prednisone, that can cause osteoporosis.
You have type 1 diabetes, liver disease, kidney disease, thyroid disease or a family history of osteoporosis.
You experienced early menopause.
Doctors don't generally recommend osteoporosis screening for men because the disease is less common in men than it is in women.
Complications
Fractures are the most frequent and serious complication of osteoporosis. They often occur in your spine or hips — bones that directly support your weight. Hip fractures usually result from a fall. Although most people do relatively well with modern surgical treatment, hip fractures can result in disability and even death from postoperative complications, especially in older adults. Wrist fractures from falls also are common.
In some cases, spinal fractures can occur without any fall or injury simply because the bones in your back (vertebrae) become so weakened that they begin to compress. Compression fractures can cause severe pain and require a long recovery. If you have many such fractures, you can lose several inches of height as your posture becomes stooped.
Treatment
Hormone therapy
Hormone therapy (HT) was once the mainstay of treatment for osteoporosis. But because of concerns about its safety and because other treatments are available, the role of hormone therapy in managing osteoporosis is changing. Most problems have been linked to certain oral types of HT, either taken in combination with progestin or alone. If you're interested in hormone therapy, other forms are available, including patches, creams and the vaginal ring.
Discuss the various options with your doctor to determine which might be best for you.
Prescription medications
If HT isn't for you, and lifestyle changes don't help control your osteoporosis, prescription drugs can help slow bone loss and may even increase bone density over time. They include:
Bisphosphonates. Much like estrogen, this group of drugs can inhibit bone breakdown, preserve bone mass, and even increase bone density in your spine and hip, reducing the risk of fractures.
Bisphosphonates may be especially beneficial for men, young adults and people with steroid-induced osteoporosis. They're also used to prevent osteoporosis in people who require long-term steroid treatment for a disease such as asthma or arthritis.
Side effects, which can be severe, include nausea, abdominal pain, and the risk of an inflamed esophagus or esophageal ulcers, especially if you've had acid reflux or ulcers in the past. Bisphosphonates that can be taken once a week or once a month may cause fewer stomach problems. If you can't tolerate oral bisphosphonates, your doctor may recommend periodic intravenous infusions of bisphosphonate preparations.
Raloxifene (Evista). This medication belongs to a class of drugs called selective estrogen receptor modulators (SERMs). Raloxifene mimics estrogen's beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen, such as increased risk of uterine cancer and, possibly, breast cancer. Hot flashes are a common side effect of raloxifene, and you shouldn't use this drug if you have a history of blood clots. This drug is approved only for women with osteoporosis and is not currently approved for use in men.
Calcitonin. A hormone produced by your thyroid gland, calcitonin reduces bone resorption and may slow bone loss. It may also prevent spine fractures, and may even provide some pain relief from compression fractures. It's usually administered as a nasal spray and causes nasal irritation in some people who use it, but it's also available as an injection. Because calcitonin isn't as potent as bisphosphonates, it's normally reserved for people who can't take other drugs.
Tamoxifen. This synthetic hormone is used to treat breast cancer and is given to certain high-risk women to help reduce their chances of developing breast cancer. Although tamoxifen blocks estrogen's effect on breast tissue, it has an estrogen-like effect on other cells in your body, including your bone cells. As a result, tamoxifen appears to reduce the risk of fractures, especially in women older than 50. Possible side effects of tamoxifen include hot flashes, stomach upset, and vaginal dryness or discharge.
Procedures
Vertebroplasty
What is Vertebroplasty?
Vertebroplasty is an image-guided, minimally invasive, nonsurgical therapy used to strengthen a broken vertebra (spinal bone) that has been weakened by osteoporosis or, less commonly, cancer. Vertebroplasty can increase the patient's functional abilities, allow a return to the previous level of activity, and prevent further vertebral collapse. It is usually successful at alleviating the pain caused by a compression fracture. Often performed on an outpatient basis, vertebroplasty is accomplished by injecting an orthopedic cement mixture through a needle into the fractured bone.
What are some common uses of the procedure?
Vertebroplasty is used to treat pain caused by osteoporotic compression fractures. Vertebroplasty is often performed on patients too elderly or frail to tolerate open spinal surgery, or with bones too weak for surgical spinal repair. Patients with vertebral damage due to a malignant tumour may sometimes benefit from vertebroplasty. In rare cases, it can be used in younger patients whose osteoporosis is caused by long-term steroid treatment or a metabolic disorder. Typically, vertebroplasty is recommended after simpler treatments—such as bedrest, a back brace or pain medication—have been ineffective, or once medications have begun to cause other problems, such as stomach ulcers. Vertebroplasty can be performed right away in patients who have severe pain requiring hospitalization or conditions limiting bedrest and medications.
How should I prepare for the procedure?
First, you'll be clinically evaluated. The evaluation generally includes diagnostic imaging, blood tests and a physical exam. Diagnostic imaging such as spine x-rays, a radioisotope bone scan or magnetic resonance (MR) imaging will be done to confirm the presence of a compression fracture that is amenable to vertebroplasty. If an MR cannot be performed, because of a pacemaker or other medical factor, a CT scan can be substituted. In preparation for the clinical evaluation and physical exam, you should obtain and bring with you any previous diagnostic images, especially x-rays or MR films. Be sure to tell your doctor if you are allergic to x-ray contrast material, which contains iodine.
Most medical facilities provide patients with pre-procedure instructions. Instructions will typically tell you not to eat for at least six hours before the procedure. If you are diabetic, you should contact your doctor for instructions on regulating your blood sugar and medications. On the day of the procedure, if your doctor instructs you to take your usual medications, swallow your medication with sips of water or clear liquid up to three hours before the procedure. Avoid drinking orange juice, cream and milk.
If you take an anticoagulation medication (blood thinners such as Warfarin), you will have to stop the treatment until coagulation becomes normal, usually within three to five days. Contact your doctor before stopping any medication to determine if it is safe for you. On the day of the procedure, patients who use blood thinners should report to the hospital a little earlier for a blood test to verify that their anticoagulant has stopped working. If you are unable to interrupt your anticoagulant regimen, a short in-patient stay for intravenous treatment with heparin may be required. All patients should arrange for an adult to drive them home after the procedure.
What does the equipment look like?
A hollow needle (trocar) is passed into the vertebral bone and a cement mixture including polymethylmethacrylate (PMMA), barium powder and a solvent is injected. The cement mixture resembles toothpaste or epoxy. The physician will monitor the entire procedure on a fluoroscopy imaging screen and make sure that the cement mixture does not back up into the spinal canal.
Sedation medication will be administered through an intravenous catheter. A Foley catheter may be placed in your bladder. You will be attached to equipment that monitors your heart beat and blood pressure throughout the procedure.
How does the procedure work?
Vertebroplasty is highly effective because after osteoporosis has made bones very porous, the cement fills the spaces and strengthens the bone so it is less likely to fracture again. After vertebroplasty, the cement stabilizes the fracture, which is thought to provide the pain relief. Patients begin regaining mobility within 24 hours and are usually able to reduce, or even eliminate, their pain medication.
How is the procedure performed?
Vertebroplasty is generally performed in the morning. You will be sedated and receive a local anesthetic to numb the skin and the muscles near the spinal fracture. Intravenous antibiotics may also be administered to prevent infection. Through a small incision and guided by a fluoroscope, a hollow needle is passed through the spinal muscles until its tip is precisely positioned within the fractured vertebra.
Then the interventional radiologist may perform an examination called intraosseous venography to make sure the needle has reached a safe spot within the fractured bone. Once the needle is shown to be in the proper location, the orthopedic cement is injected. Medical-grade cement hardens quickly, over the next 10 to 20 minutes. A CT scan may be performed at the end of the procedure to check the distribution of the cement. The longest part of vertebroplasty involves setting up the equipment and making sure the needle is perfectly positioned in the collapsed vertebra.
Vertebroplasty usually takes less than two hours (longer if more than one site is being treated). Although you will not be allowed to drive after the procedure, you can go home with an adult, if the distance is short. Otherwise, an overnight stay at a nearby hotel is advised. Hospitalization is required only if the patient is unusually frail, has no one to help them at home, or requires further monitoring following the procedure.
What will I experience during the procedure?
You'll be lying face down throughout the procedure. Sedation medications will help you stay calm and minimize any discomfort you might feel during the vertebroplasty. You'll be conscious, though drowsy, and able to hear anything that's said in the room. During the procedure you'll be asked questions such as, "Does this hurt?" It's important for you to be able to tell your doctor whether you are feeling any pain. Because of the position you'll be in, you won't be able to see the image on the fluoroscope.
For two or three days afterward, you may feel a bit sore at the point of the needle insertion. You can use an icepack to relieve any discomfort but be sure to protect your skin from the ice with a cloth; use the pack for only 15 minutes per hour. The tiny incision will be closed with a strip of tape and covered with a bandage that should remain on for several days. It's important that the injection site remain clean. You can shower while the bandage is still on.
Bedrest is recommended for the first 24 hours following vertebroplasty, though you can get up to use the bathroom. Increase your activity gradually and resume all your regular medications. If you take blood thinners, check with your doctor, but you may be able to restart them the day after the procedure.
Who interprets the results and how do I get them?
Most patients are able to bear weight very soon after undergoing vertebroplasty. They can get up to walk after resting in bed for about an hour afterward and the interventional radiologist can often tell at that point if the procedure was successful. In some cases, it can take a few days for the doctor to be able to make this assessment.
Usually, patients will receive follow-up phone calls within the first week after vertebroplasty to check on their progress and answer any questions. The referring physician or primary care provider provides follow-up care.
What are the benefits vs. risks?
Benefits
Because the pain of a compression fracture is alleviated by Vertebroplasty, patients feel significant relief almost immediately. After just a few weeks, two-thirds of patients are able to lower their doses of pain medication significantly. Many patients become symptom-free.
About 75 percent of patients regain lost mobility and become more active, which helps combat osteoporosis. After vertebroplasty, patients who had been immobile can get out of bed, reducing their risk of pneumonia. Increased activity builds more muscle strength, further encouraging mobility.
Risks
Usually, vertebroplasty is a safe and effective procedure.
A small amount of orthopedic cement can leak out of the vertebral body. This does not usually cause a serious problem, unless the leakage moves into a potentially dangerous location such as the spinal canal.
Other possible complications include infection, bleeding, increased back pain and neurological symptoms such as numbness or tingling. Paralysis is extremely rare. Sometimes the procedure causes another fracture in the spine or ribs.
What are the limitations of Vertebroplasty?
Vertebroplasty is not used for herniated disks or arthritic back pain.
Vertebroplasty is not generally recommended for otherwise healthy younger patients, mostly because there is limited experience with cement in a vertebral body for longer time periods.
The procedure cannot serve as a preventive treatment to help patients with osteoporosis avoid future fractures. It is used only to repair a known, non-healing compression fracture.
Vertebroplasty will not correct an osteoporosis-induced curvature of the spine, but it may keep the curvature from worsening.
It may be difficult for someone with severe emphysema or other lung disease to lie facedown for the one to two hours vertebroplasty requires. The healthcare team will try to make special accommodations for a patient with this type of condition.
Patients with a healed vertebral fracture are not candidates for vertebroplasty.
Prevention
Getting adequate calcium and vitamin D is an important factor in reducing your risk of osteoporosis. If you already have osteoporosis, getting adequate calcium and vitamin D, as well as taking other measures, can help prevent your bones from becoming weaker. In some cases you may even be able to replace bone you've lost.
The amount of calcium you need to stay healthy changes over your lifetime. Your body's demand for calcium is greatest during childhood and adolescence, when your skeleton is growing rapidly, and during pregnancy and breast-feeding. Postmenopausal women and older men also need to consume more calcium. As you age, your body becomes less efficient at absorbing calcium, and you're more likely to take medications that interfere with calcium absorption.
How much calcium and vitamin D?
Getting enough vitamin D is just as important as getting adequate amounts of calcium. Not only does vitamin D improve bone health by helping calcium absorption, but it also may improve muscle strength.
Although many people get adequate amounts of vitamin D from sunlight, this may not be a good source if you live in high latitudes, if you're housebound, or if you regularly use sunscreen or you avoid the sun entirely because of the risk of skin cancer. Although vitamin D is present in oily fish such as tuna and sardines and in egg yolks, you probably don't eat these on a daily basis. Calcium supplements with added vitamin D are a good alternative.
As for calcium, dairy products are one, but by no means the only, source. Almonds, broccoli, cooked kale, canned salmon with the bones, oats and soy products such as tofu also are rich in calcium. If you find it difficult to get enough calcium from your diet, consider calcium supplements. Supplements are inexpensive and generally are well tolerated and well absorbed if taken properly. Sometimes calcium supplements can cause constipation. If this is a problem for you, drink more water and try using a fiber supplement. In addition, check the type of calcium you're using.
Calcium and vitamin D supplements are most effective taken together in divided doses with food.
Other tips for prevention.
These measures also may help you prevent bone loss:
Exercise. Exercise can help you build strong bones and slow bone loss. Combine strength training exercises with weight-bearing exercises. Strength training helps strengthen muscles and bones in your arms and upper spine, and weight-bearing exercises — such as walking, jogging, running, stair climbing, skipping rope, skiing and impact-producing sports — mainly affect the bones in your legs, hips and lower spine. Swimming, cycling and machines such as elliptical trainers can provide a good cardiovascular workout, but because they're low impact, they're not as helpful for improving bone health as weight-bearing exercises are.
Don't smoke. Smoking increases bone loss, perhaps by decreasing the amount of estrogen a woman's body makes and by reducing the absorption of calcium in your intestine. The effects on bone of secondhand smoke aren't yet known.
Consider hormone therapy. Hormone therapy can reduce a woman's risk of osteoporosis during and after menopause. But because of the risk of side effects, discuss the options with your doctor and decide what's best for you. Testosterone replacement therapy works only for men with osteoporosis caused by low testosterone levels. Taking it when you have normal testosterone levels won't increase bone mass.
Avoid excessive alcohol. Consuming more than two alcoholic drinks a day may decrease bone formation and reduce your body's ability to absorb calcium. There's no clear link between moderate alcohol intake and osteoporosis.
Limit caffeine. Moderate caffeine consumption — about two to three cups of coffee a day — won't harm you as long as your diet contains adequate calcium.
Self-care
These suggestions may help relieve symptoms and maintain your independence if you have osteoporosis:
Maintain good posture. Good posture — which involves keeping your head held high, chin in, shoulders back, upper back flat and lower spine arched — helps you avoid stress on your spine. When you sit or drive, place a rolled towel in the small of your back. Don't lean over while reading or doing handwork. When lifting, bend at your knees, not your waist, and lift with your legs, keeping your upper back straight.
Prevent falls. Wear low-heeled shoes with nonslip soles and check your house for electrical cords, area rugs and slippery surfaces that might cause you to trip or fall. Keep rooms brightly lit, install grab bars just inside and outside your shower door, and make sure you can get in and out of your bed easily.
Manage pain. Discuss pain management strategies with your doctor. Don't ignore chronic pain. Left untreated, it can limit your mobility and cause even more pain.