From the Guidelines
Asymptomatic patients with osteoporosis should still be evaluated for compression fractures, even without symptoms, as approximately two-thirds of vertebral compression fractures are asymptomatic, yet significantly increase the risk for future fractures 1. The evaluation for compression fractures is crucial in osteoporosis management, as it can identify patients at high risk for future fractures and allow for early intervention to prevent complications such as height loss, kyphosis, and respiratory compromise.
- Screening can be done through lateral spine imaging (X-ray or vertebral fracture assessment by DXA) as part of osteoporosis management.
- If compression fractures are identified in asymptomatic patients, treatment implications include more aggressive osteoporosis management, possibly with anabolic agents like teriparatide, abaloparatide, or romosozumab rather than antiresorptive medications alone.
- The presence of vertebral fractures may also change fracture risk calculations and influence treatment decisions, even when the patient reports no pain or symptoms.
- Regular monitoring for vertebral fractures is particularly important in patients with significant risk factors such as advanced age, previous fractures, or very low bone mineral density, as stated in the recent study published in Mayo Clinic Proceedings 1. Key points to consider in the evaluation and management of asymptomatic patients with osteoporosis include:
- The use of dedicated vertebral imaging and review of past imaging to identify fractures in patients at high risk for vertebral fractures.
- The importance of recognizing that most fragility fractures occur in patients with bone mineral density T scores higher than 2.5, and these fractures confirm the presence of skeletal fragility even in the presence of a well-maintained bone mineral density 1.
- The need for a comprehensive evaluation, including exclusion of contributing factors for osteoporosis and assessment of clinical risk factors for fracture, followed by appropriate pharmacological intervention designed to reduce the risk of future fracture.
From the Research
Importance of Ruling Out Compression Fractures
- Vertebral compression fractures are a hallmark of osteoporosis and can occur even in asymptomatic patients 2, 3
- These fractures can increase the risk of additional fractures, making it essential to evaluate and manage them promptly 2, 3, 4
- Asymptomatic vertebral compression fractures can still pose a significant risk for future fractures, emphasizing the need for thorough evaluation and treatment 3, 5
Diagnosis and Management
- Diagnosis of vertebral compression fractures involves clinical evaluation, imaging, and laboratory tests, including conventional radiology, bone mineral density testing, and magnetic resonance imaging 2, 4
- Management of osteoporotic vertebral fractures includes conservative care, such as bed rest, pain medication, physiotherapy, and bracing, as well as surgical options like vertebral augmentation techniques 4, 5
- Treatment with effective antifracture medication can prevent fractures and improve outcomes in patients with osteoporosis 6
Risk Assessment and Prevention
- Any new fracture in an adult aged 50 years or older signifies an elevated risk for subsequent fractures, making it crucial to assess and manage osteoporosis promptly 6
- Clinical or subclinical vertebral fractures are associated with a increased risk for additional fractures, highlighting the need for routine osteoporosis detection, diagnosis, and treatment in all adult healthcare settings 6
- Prevention strategies include adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention 6