Should a woman with a T score of -1.4 in the lumbar (L) spine on Dual-Energy X-ray Absorptiometry (DEXA) and a history of chronic compression fracture at Thoracic 11 (T11) be treated with prescription osteoporosis medications?

Treatment of Osteoporosis in a Woman with T-score -1.4 and Chronic T11 Compression Fracture

A woman with a T-score of -1.4 in the lumbar spine and a chronic compression fracture at T11 should be treated with prescription osteoporosis medications, as the presence of a vertebral fracture indicates osteoporosis regardless of the T-score. 1

Diagnostic Considerations

The diagnostic approach in this case requires careful consideration of both the BMD measurement and the presence of a fracture:

• The T-score of -1.4 falls within the "osteopenia" or "low bone mass" range (T-score between -1.0 and -2.5) 1
• However, several medical societies (including EANM, ASBMR, and CSEM) pragmatically propose that osteoporosis may be presumed in the presence of a prior low-trauma major osteoporotic fracture, even with a normal BMD 1
• A vertebral compression fracture is considered a major osteoporotic fracture and is diagnostic of osteoporosis regardless of BMD values 1

Treatment Algorithm

1. Confirm fracture etiology:

   • Determine if the T11 compression fracture was low-trauma/fragility-related
   • Historical information about the circumstances of fracture is valuable to clarify this 1

2. Risk stratification:

   • The patient should be considered at high risk for future fractures due to:
     • Existing vertebral compression fracture
     • T-score in the osteopenic range (-1.4)
   • A U.S. NHANES study showed that among participants ≥65 years with vertebral fractures, the mean femoral neck T-score was -1.4, and only 38% had osteoporosis by BMD criteria alone 1

3. First-line treatment:

   • Oral bisphosphonate (such as alendronate) is the recommended first-line therapy 1, 2
   • Alendronate has demonstrated significant increases in BMD at the lumbar spine, femoral neck, and trochanter 2

4. Alternative treatments (if oral bisphosphonates are not appropriate):

   • IV bisphosphonates
   • Denosumab (60mg subcutaneously every 6 months) 1, 3
   • For postmenopausal women, raloxifene may be considered if no other therapy is available 1
   • For very high-risk patients, anabolic agents (teriparatide) may be considered 1

5. Adjunctive measures:

   • Calcium supplementation (1,000-1,200 mg/day)
   • Vitamin D supplementation (600-800 IU/day, aiming for serum level ≥20 ng/ml) 1
   • Weight-bearing and resistance training exercises
   • Smoking cessation and limiting alcohol intake 4

Monitoring

• Repeat BMD measurements should be conducted at the same facility with the same DXA system when possible 1
• Follow-up DXA scans are typically recommended every 1-2 years for high-risk individuals 5
• Quantitative BMD comparison with serial measurements should be based on absolute BMD values in g/cm², not T-scores or Z-scores 1

Clinical Considerations and Pitfalls

• Important caveat: It's essential to determine if the vertebral fracture was truly low-trauma. If the fracture was associated with significant trauma, treatment decisions may differ 1
• Monitoring challenges: When comparing serial DXA scans, be aware that changes must exceed the least significant change (LSC) to be considered clinically meaningful 1
• Diagnostic confusion: A T-score alone may underestimate fracture risk in patients with vertebral fractures, as demonstrated by the NHANES study showing many patients with vertebral fractures had T-scores better than -2.5 1

The presence of a vertebral compression fracture significantly increases the risk of future fractures, regardless of BMD values, and therefore warrants pharmacologic intervention to reduce morbidity and mortality associated with subsequent fractures.