Is a lumbar spine compression fracture in an older adult patient with scoliosis and a history of osteoporosis (bone disease characterized by low bone mass and density) considered a fragility fracture?

Is Lumbar Spine Compression Fracture in Relationship to Scoliosis Considered a Fragility Fracture?

Yes, a lumbar spine compression fracture in an older adult with scoliosis and osteoporosis is definitively a fragility fracture that confirms skeletal fragility and requires immediate evaluation and treatment for underlying metabolic bone disease, regardless of bone mineral density measurements. 1

Definition and Classification

A fragility fracture is defined as a fracture sustained from a fall from standing height or lower that would not cause a fracture in most healthy persons. 1 Vertebral compression fractures are the most common type of osteoporotic fragility fracture and represent a hallmark of osteoporosis. 2, 3

• The presence of scoliosis does not exclude the fracture from being classified as a fragility fracture when it occurs in the context of osteoporosis and low-energy trauma. 1
• Scoliosis in adults with metabolic bone disease (particularly osteoporosis) combined with asymmetric arthritic disease and/or vertebral fractures represents a recognized subtype of secondary adult scoliosis. 4

Critical Clinical Implications

Most fragility fractures occur in individuals with bone mineral density T-scores higher than -2.5, and the fracture itself confirms skeletal fragility even when bone density appears preserved. 1, 5 This is a crucial point that is frequently missed in clinical practice.

Imminent Fracture Risk

• The fracture risk is highest in the immediate 1-2 years following a vertebral compression fracture, described as "imminent fracture risk." 1, 5
• The relative risk of subsequent fracture is increased approximately 2-fold after any fragility fracture. 1
• Vertebral fractures have consistently been associated with increased imminent fracture risk. 1

The Osteoporosis Care Gap

Approximately 70% of patients who could benefit from osteoporosis treatment do not receive it, representing a patient care crisis. 1, 5 This care gap is particularly problematic because:

• Most patients with fragility fractures are not identified as having underlying metabolic bone disease. 1
• Even when diagnosed, evaluation and pharmacological intervention is offered to only a small percentage of individuals. 1
• Only one-quarter of patients diagnosed with an osteoporotic fracture are referred or treated for osteoporosis. 3

Required Evaluation and Management

Systematic Fracture Risk Assessment

Every patient aged 50 years and over with a vertebral compression fracture requires systematic evaluation for risk of subsequent fractures. 1, 5 This includes:

• DXA scan of spine and hip for bone mineral density assessment. 1, 6
• Vertebral imaging (radiography or vertebral fracture assessment) to detect additional subclinical vertebral fractures, which are frequently present in patients with a recent non-vertebral fracture. 1, 6
• Laboratory evaluation including calcium, vitamin D, parathyroid hormone, basic metabolic panel, thyroid function, and assessment for secondary causes of osteoporosis. 1, 5, 6
• Falls risk evaluation starting with history of falls during the last year, followed by specific tests when indicated. 1

Treatment Indication

A new atraumatic compression fracture itself is an indication for pharmacologic treatment regardless of bone mineral density. 5, 6 The fracture confirms skeletal fragility and warrants intervention. 1

Optimal Care Delivery

Referral to a Fracture Liaison Service (FLS) with a dedicated coordinator is the most effective organizational structure for preventing subsequent fractures. 5 FLS programs:

• Increase medication initiation and adherence (38% vs 17% without FLS). 7
• Significantly improve implementation of osteoporosis treatment after a fragility fracture (45% vs 26% in control groups). 1
• If FLS is unavailable, direct referral to endocrinology, rheumatology, or an orthopedic bone health clinic for osteoporosis management should occur within 4-6 weeks. 5, 6

Common Pitfalls to Avoid

• Do not attribute the fracture solely to scoliosis and miss the underlying osteoporosis diagnosis. The presence of scoliosis with metabolic bone disease represents a recognized pattern where asymmetric degeneration and osteoporosis work synergistically to promote fracture. 4
• Do not wait for BMD confirmation before initiating treatment—the fracture itself confirms skeletal fragility. 1, 5
• Do not assume the fracture is being managed elsewhere—approximately two-thirds of vertebral compression fractures that occur each year are not accurately diagnosed and therefore not treated. 2
• Ensure discharge documentation explicitly states the presence of a fragility fracture, need for osteoporosis evaluation and treatment, specific outpatient referrals arranged, and patient education provided about fracture risk. 5