Reader's Question 1: I am 60 years old and recently went for a chest x-ray. While the lung fields were clear, the radiologist discovered a vertebral fracture. I don't remember this happening and I have no back pain. I went for a bone density and my T score of my spine was -1.0. Should I be treated?
Reader's Question 2: I am 57 years old and I have a neurological disease that stops me from walking. I took a bone density and it showed my hip's T score was -1.6. Should I be treated?
The new National Osteoporosis Foundation (NOF) updated guidelines clarifies these questions.
Post menopausal women and men age 50 and older presenting with the following should be treated:
- A hip or vertebral fracture (either with symptoms or discovered on studies)
- Other prior fractures and low bone mass (T score between -1.0 and -2.5 at the hip or spine)
- T-score ≤ -2.5 at the hip or spine with no secondary causes for disease
- Low bone mass (T score between -1.0 and -2.5 at the hip or spine) and secondary causes associated with high risk of fractures (such as steroid use or immobility)
- Low bone mass (T score between -1.0 and -2.5 at the hip or spine) and 10 year probability of hip fracture ≥ 3% or a 10 year probability of any major osteoporosis related fracture of ≥ 20% based on the WHO algorithm (see my previous blog re: using the FRAX ® calculator available at http://www.shef.ac.uk/FRAX/)
The first question comes up very often. Frequently one comes to my office with a "silent" vertebral fracture. They have no idea that they broke a bone in their spine, although they may not be surprised as they may have lost considerable height. Abnormalities can be discovered either on lateral vertebral assessment (lateral bone densities done to look for fractures), x-rays of the spine, CT scan's or chest x-rays. These latter studies are often done for other reasons. The NOF guidelines are important to note in this situation. One of the highest risks for a vertebral fracture, is the history of a previous fracture. It is therefore important to be treated aggressively to prevent additional fractures from occurring. This is important as multiple fractures can make one bent forward (a.k.a. Kyphosis) and limit their ability to breath.
The second question focuses on disease that can make one more likely to have a fracture. One of these, lack of mobility is included in those more likely to fracture. Other important conditions include the use of steroids as well as the anti-estrogen medications (aromatase inhibitors) used in breast cancer. In these scenarios, one should be treated more aggressively, since fractures can occur even when the bone density does not appear that low.
As always, one must discuss the risks and benefits of treatment with their physician and one should carefully evaluate their own personal situation to determine if treatment is appropriate for them.
 Clinician's Guide to Prevention and Treatment of Osteoporosis, National Osteoporosis Foundation 2008
Published On: May 22, 2008