What is the treatment for osteopenia of the spine?

Treatment of Osteopenia of the Spine

All patients with spinal osteopenia should receive calcium supplementation (1000-1200 mg/day) and vitamin D (600-800 IU/day), with pharmacologic treatment reserved for those at high fracture risk (10-year major osteoporotic fracture risk ≥20% or hip fracture risk ≥3%, or history of fragility fracture). 1

Risk Stratification: Who Needs Pharmacologic Treatment?

The decision to treat osteopenia pharmacologically depends on fracture risk assessment, not bone density alone 1, 2:

• Calculate 10-year fracture risk using the WHO FRAX tool 1
• Treat if major osteoporotic fracture risk ≥20% OR hip fracture risk ≥3% 1
• Treat any patient with prior low-trauma/fragility fracture, regardless of FRAX score or BMD 1
• Without these criteria, the number needed to treat exceeds 100, making widespread pharmacologic treatment inadvisable 2

Universal Non-Pharmacologic Management (All Patients)

Every patient with spinal osteopenia requires 1, 3:

• Calcium: 1000-1200 mg daily 1
• Vitamin D: 600-800 IU daily, targeting serum level ≥20 ng/mL 1
• Weight-bearing exercise: walking 3-5 miles per week can improve spine and hip bone density 1, 3
• Smoking cessation and alcohol limitation 1
• Correction of vitamin D deficiency before initiating other treatments 3

Pharmacologic Treatment Algorithm for High-Risk Patients

First-Line Therapy: Oral Bisphosphonates 1, 4, 5

Oral bisphosphonates are the initial treatment of choice for most postmenopausal women and men ≥50 years meeting treatment thresholds 1:

• Alendronate 70 mg once weekly 6, 5
• Risedronate 35 mg once weekly 6, 5
• Ibandronate 150 mg once monthly 6, 5

These agents increase BMD and reduce fracture risk, though alendronate and risedronate have stronger evidence for reducing both spine and non-spine fractures 5.

Alternative Therapies (Second-Line or Special Circumstances) 1

Consider when patients are intolerant to oral bisphosphonates or have contraindications:

• IV bisphosphonates (zoledronic acid) 1
• Raloxifene (selective estrogen receptor modulator) 1
• Denosumab (anti-RANKL antibody) 1

Important caveat: Denosumab discontinuation may increase vertebral fracture risk; transition to bisphosphonate therapy upon stopping 6.

Anabolic Therapy for Very High-Risk Patients 6, 7, 4

For patients with very low bone density or existing fractures, consider teriparatide as initial therapy 4, 5:

• Teriparatide 20 mcg subcutaneously daily for up to 2 years 7, 5
• Increases lumbar spine BMD by 5.9-9.7% and reduces vertebral fractures 7
• Particularly effective in spine surgery candidates with osteoporosis, reducing screw loosening and improving fusion rates 6

Special Consideration: Patients Undergoing Spine Surgery

For osteopenic/osteoporotic patients planning spinal instrumentation, preoperative teriparatide should be considered to decrease postoperative complications including screw loosening and delayed fusion 6:

• Grade B recommendation for preoperative teriparatide 6
• Insufficient evidence for bisphosphonates alone to reduce postoperative adverse events 6
• Preoperative screening with DXA (T-score), CT (Hounsfield units <97.9), and vitamin D levels (<20 ng/mL) predicts increased risk of complications 6

Evaluation for Secondary Causes

All patients with osteopenia require evaluation for secondary causes of bone loss 1, 8:

• First-line labs: CBC, comprehensive metabolic panel, 25-hydroxyvitamin D (92% sensitivity when combined) 8
• Additional testing based on clinical suspicion: TSH, PTH, sex hormones, inflammatory markers 8
• Common secondary causes: vitamin D deficiency, hypogonadism, hyperthyroidism, hyperparathyroidism, malabsorption, glucocorticoid use 8

Monitoring Strategy

Repeat DXA scanning frequency depends on treatment status and risk 1:

• Every 2-3 years for low-risk patients not on treatment 1
• Every 1-2 years for patients on treatment or at higher risk 1
• Re-evaluate for secondary causes if BMD decreases despite treatment 8

Common Pitfalls to Avoid

• Do not treat based on T-score alone without fracture risk assessment—this leads to overtreatment with NNT >100 2
• Do not overlook vitamin D deficiency—correct this before initiating other therapies 3
• Do not abruptly discontinue denosumab—transition to bisphosphonate to prevent rebound vertebral fractures 6
• Do not assume bisphosphonates are adequate for spine surgery patients—teriparatide has superior evidence for reducing surgical complications 6