Review
Diagnosis and management of vertebral fractures in elderly adults

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Abstract

We reviewed the epidemiology, diagnosis, and treatment of vertebral fractures due to osteoporosis in the elderly. Vertebral fractures are underdiagnosed despite their high prevalence in both men and women. Clinical consequences of vertebral fractures include increased risk of future vertebral and hip fracture, acute and chronic back pain, decreased quality of life, and increased mortality. Patients with vertebral fractures have functional impairment and increased mortality similar to those with hip fractures. Asymptomatic fractures identified on radiograph also affect quality of life and mortality. A vertebral fracture is a clinical marker for a subsequent fracture and should trigger assessment and diagnosis of osteoporosis. The care of patients with vertebral fractures includes pain management, rehabilitation, and prevention of further fractures. There is evidence from randomized controlled trials that pharmacologic therapy can reduce the risk of future fractures by 40% to 50%. Vertebroplasty may be effective in the control of pain and in obtaining stability of the spine.

Section snippets

Epidemiology

Only about 30% of vertebral fractures are diagnosed in clinical practice (11), because the diagnosis depends on a patient reporting back pain of sufficient severity to trigger obtaining a radiograph 12, 13. The prevalence of radiographically identified vertebral deformities rises from 5% between ages 50 to 54 years to 50% at age 80 to 84 years (14). The prevalence of vertebral deformity is similar in men and women, at least in Europe, and varies between 12% and 20% depending on the diagnostic

Clinical consequences of vertebral fractures

Vertebral fractures typically occur at the thoracolumbar junction (T12-L1) and in the midthoracic area (T7-T8) (13), and have both acute and chronic sequelae (Table 1). In older women, the functional impairment due to vertebral fractures is similar to that seen following hip fracture, and includes difficulty with bending, lifting, descending stairs, and cooking (24). In a prospective study of men and women, overall function declined at similar rates among patients with vertebral fractures as

Diagnosis

Typically, there is no history of trauma before a vertebral fracture (12). Clinical vertebral fractures present with back pain at the level of the fracture, which may radiate in a radicular fashion. Height loss (>2 cm to 4 cm since age 25 years) can help to identify women with vertebral fractures (47). Finally, radiographic vertebral deformities may be detected on radiographs ordered for other purposes.

Kyphosis is an important indicator of vertebral compressions in the elderly. Loss of more

Strategies for the prevention of future vertebral fractures

Calcium and vitamin D insufficiency and deficiency are frequent in the elderly due to reduced intake of these nutrients, as well as impaired enteral absorption of calcium and reduced cutaneous synthesis of vitamin D. The prevalence of vitamin D deficiency is high in the institutionalized and community-living elderly, ranging from 5% to 18% 81, 82, 83. Some patients develop secondary hyperparathyroidism.

Vitamin D supplementation has had inconsistent effects on fracture reduction (84), but the

Conclusion

Vertebral fractures in the elderly are associated with morbidity, reduced quality of life, and increased mortality. A vertebral fracture is a clinical marker for subsequent vertebral and hip fractures. A clinical or radiographic vertebral fracture should result in assessment for, and treatment of, osteoporosis (2). Practical recommendations for identifying people with vertebral fractures include assessment of height loss, inquiring about back pain, and examining patients for spinal deformity.

Acknowledgements

The authors wish to thank Elke Henneberg, the research assistant for this project, for her help in coordinating the consensus conference. The authors also wish to acknowledge the following persons for their involvement in the consensus review: R. G. Crilly, MD (University of Western Ontario), L. Dian, MD (University of British Columbia), D. A. Hanley, MD (University of Calgary), R. G. Josse, MD (University of Toronto), C. Kovacs, MD (Memorial University of Newfoundland), G. Lacombe, MD (CUSE,

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