Osteoporosis

Contents hide

Osteoporosis is a chronic disease affecting the bone structure, associated with disruptions in metabolic processes, resulting in a gradual decrease in bone density and disruption in bone tissue structure, leading to fractures upon minor trauma (such as falling from one’s own height).

Osteoporosis is a slow process of bone tissue deterioration in the body. Simply put, there is a significant risk of fractures in individuals with osteoporosis. Common symptoms include acute pain in the spine and extremities, as well as brittle nails. Bones can fracture even under minimal stress. One of the most prevalent outcomes of osteoporosis is vertebral fractures, which can lead to disability. Therefore, it is crucial to know everything about preventing osteoporosis, and when symptoms appear, knowing which specialist to consult.

Osteoporosis is a slow-burning bomb, so it is essential to turn to experts at the right time. You can contact us at the number mentioned above. Appointments can be scheduled any day of the week.

About the Disease

Osteoporosis is a serious disease that leads to disruption in bone tissue structure, making bones less dense and more fragile. In most cases, this disease is only discovered after a fracture occurs. Currently, the disease ranks fourth on the list of the most prevalent non-communicable diseases, after cardiovascular disorders, neoplasms, and diabetes. The disease is particularly diagnosed frequently in older adults, especially women after menopause.

Fractures in Osteoporosis:

Osteoporosis is considered a “silent epidemic”: less than 1% of those affected are aware of their condition. Its slow, painless progression results in seven vertebral fractures occurring every minute, and one fracture of the femur bone every five minutes, which is associated with osteoporosis.

Causes of Osteoporosis:

Osteoporosis is distinguished between primary and secondary types depending on the causes. Primary osteoporosis occurs in 85% of cases and is divided into four types:

Postmenopausal type:

Occurs in women with estrogen deficiency.
Characterized by a period of rapid bone loss, especially from brittle bones.
Fractures are common in the lower arm bones and spine.

Age-related type:

Occurs in both women and men due to bone loss with advancing age.
Fractures appear in cortical and brittle bones.
Fractures are common in lower arm bones, spine, and femoral neck.

Juvenile type:

Occurs in children or adolescents of both sexes with normal reproductive gland function.
Begins at age 8-14.
Severe pain and/or fractures are common after injury.

Unknown cause type (spontaneous):

Causes of development are unknown.

Secondary Osteoporosis accounts for only 15% of cases, and nine causes can be identified for its occurrence:

Genetic Disorders:

Hypercalcemia (excessive calcium secretion in the kidneys) – one of the primary secondary causes of osteoporosis.
Gaucher’s disease.
Cystic fibrosis: Genetic mutation responsible for cystic fibrosis membrane regulator.
Incomplete bone formation (“crystalline bones”).
Glycogen storage disease.
Marfan syndrome.
Ehlers-Danlos syndrome (“excessive skin elasticity”).
Homocystinuria (methionine metabolism disorder).
Porphyria (serious pigment metabolism disorder).

Conditions with Hypogonadism (sexual maturation delay):

Anorexia nervosa and bulimia.
Exercise-associated amenorrhea (menstrual disorder associated with intensive exercise).
Androgen insensitivity.
Hyperprolactinemia.
Oophorectomy (ovary removal).
Chronic kidney physical growth hormone deficiency.
Early menopause (before age 40).
Turner syndrome (chromosomal abnormality).
Klinefelter syndrome (male maturation disorder associated with an extra X chromosome).

Endocrine Disorders:

Cushing’s syndrome.
Type 1 and 2 diabetes.
Thyroid dysfunction.
Hypogonadism.
Female infertility.
Estrogen deficiency.
Pregnancy.
Prolactinoma (benign pituitary tumor).

Deficiency Conditions:

Calcium, magnesium, protein, and vitamin D deficiency.
Bariatric surgery.
Gluten sensitivity (celiac disease).
Stomach removal.
Malabsorption (failure to absorb nutrients in the small intestine).
Malnutrition (energy and protein deficiency during food intake).
Parenteral nutrition (feeding through veins).
Primary biliary cirrhosis.

Nutritional Disorders:

Vitamin A excess.
Increased dietary salt intake.

Chronic Inflammatory Diseases:

Inflammatory bowel diseases (Crohn’s disease, ulcerative colitis).
Ankylosing spondylitis.
Rheumatoid arthritis.
Systemic lupus erythematosus.

Blood Disorders:

Hemochromatosis (iron metabolism disorder).
Hemorrhage (blood clotting disorder).
Leukemia (cancer affecting blood and bone marrow).
Lymphoma (cancer of white blood cells).
Multiple myeloma (tumor consisting of altered plasma cells).
Sickle cell anemia (inherited blood disorder).
Systemic mastocytosis (excess fat cell accumulation).
Thalassemia (hemoglobin production disorder).
Waldenstrom macroglobulinemia (excess fat cell accumulation).
Thalassemia (hemoglobin production disorder).
Systemic mastocytosis (excess fat cell accumulation).

Systemic Diseases:

Mastocytosis (excess fat cell accumulation).
Thalassemia (hemoglobin production disorder).
Bone systemic diseases.

Medication Intake:

Anticonvulsants.
Psychotropic drugs.
Antivirals.
Enzyme inhibitors.
Chemotherapy.
Furosemide.
Prednisolone (more than 5 mg per day for three months or longer).
Heparin (for long periods).
Hormonal or reproductive therapy: Gonadotropin-releasing hormone (GnRH) agonists, luteinizing hormone-releasing hormone (LHRH) analogs, depo-medroxyprogesterone, excessive doses of thyroxine.
Lithium.
Antidepressants (selective serotonin reuptake inhibitors).
Acid suppressants containing aluminum (Almagel).
Proton pump inhibitors (omeprazole, lansoprazole).

Other Conditions:

Alcohol addiction.
Amyloidosis (protein accumulation outside cells).
Chronic metabolic acidosis (increased acidity).
Chronic heart failure.
Depression.
Chronic obstructive pulmonary disease, emphysema (excess air accumulation in the lungs).
Chronic kidney disease.
Chronic liver diseases.
AIDS, HIV.
Limited mobility (immobility, immobilization of part of the body).
Multiple sclerosis.
Organ transplantation.
Sarcoidosis (autoimmune diseases affecting various organs and systems of the body).
Palpitations.

Symptoms of osteoporosis:

This condition is characterized by the absence of clinical symptoms until an injury occurs. The risk of osteoporosis lies in the fact that the disease manifests through fractures resulting from minor stress. Sometimes, fractures may go unnoticed by the individual (for example, cumulative fractures, when vertebrae do not bear pressure and flatten).

The main symptoms of osteoporosis include:

Pain in the hip joints, lower back, ribs, and chest.
Recurring cramps and muscle tension.
Disturbance in posture and in different parts of the musculoskeletal system.
Onset of back pain upon minor falls or lifting any load (when moving the vertebrae).
Decrease in height (in the case of vertebral fractures due to pressure).
Sensation of heaviness between the shoulders (when moving the vertebrae).
Acute pain when in a specific position (when moving the vertebrae).

If you experience the mentioned symptoms, seek medical care immediately. Prompt diagnosis and treatment can prevent undesirable effects.

Fractures at various sites are the main complications, making the patient unable to work (often leading to disability). Among the toughest cases are fractures of the thigh, which often occur in the elderly.

Classification and stages of osteoporosis development:

In addition to classifying osteoporosis according to contributing factors, the International Classification of Diseases (ICD-10) is used to gather statistical information. According to it, osteoporosis is distinguished after menopause with pathological fracture (M80.0) and without it (M81.0), in addition to osteoporosis due to hormonal disorders (M82.1).

Osteoporosis is further categorized based on the causes into:

Osteoporosis occurring after ovarian removal (M80.1, M81.1).
Osteoporosis resulting from immobility (M80.2, M81.2).
Osteoporosis caused by intestinal absorption disorder (M80.3) and surgical intervention (M81.3).
Osteoporosis resulting from medication use (M80.4, M81.4).
Osteoporosis with multiple causes (M80.5, M81.5).
Other osteoporosis with pathological fracture (M80.8) and without it (M81.8).
Unspecified osteoporosis with pathological fracture (M80.9) and without it (M81.9).

Additionally, mixed osteoporosis can occur, for example, in a woman after menopause due to prolonged steroid doses for the treatment of a serious illness, which in itself may lead to secondary osteoporosis.

Osteoporosis can be equally distributed or localized (also referred to as regional or patchy). The second type of osteoporosis is more common not as an independent disease but as a result of immobility, post-injury, or post-surgery.

The recurrence of fractures resulting from osteoporosis by location:

Vertebrae – 46%.
Thigh neck – 20%.
Shoulder and arm – 15%.
Other sites – 19%.

Stages of osteoporosis:

Normal status: When bone density measured using Dual-energy X-ray Absorptiometry (DXA) shows a T-score greater than -1.0 SD.
Osteopenia: This is an initial decrease in bone density (T-score between -1.0 and -2.5 SD). Osteopenia does not always progress to osteoporosis, but when detected, measures are recommended to reduce the risk of osteoporosis development and associated fractures.
Osteoporosis: This stage is characterized by a T-score of -2.5 SD or less.

In some sources, osteoporosis is classified based on its effect on joints, such as knee or hip osteoporosis. However, doctors do not use this classification, as osteoporosis affects bones, not joints.

Complications of osteoporosis primarily relate to fracture outcomes:

Compression fractures of the vertebrae often occur with minimal stress, such as coughing, lifting objects, or bending. Vertebrae in the mid-back, lower back, and upper waist are commonly affected. Gradual vertebral fracture may occur in many patients and may not be accompanied by symptoms.
Fractures of the thigh are highly susceptible and occur in the femoral bone and the femoral neck area. These fractures typically occur from a fall on the side. Complications of femoral fractures may include hospital-acquired infection and pulmonary artery embolism.
All fractures can lead to additional complications, including chronic pain from compression fractures, increased incidence of injury, and death. Patients with multiple fractures suffer from severe pain leading to functional limitations and decreased quality of life. They are also at risk of complications associated with disability after fractures, such as deep vein thrombosis and ulcers.
In patients with multiple vertebral fractures leading to severe deformity in the chest, chronic respiratory dysfunction occurs.
Patients with osteoporosis develop deformities in the spinal bones and a “widow’s hump” back, leading to a height decrease of 3-5 cm. Alongside chronic pain and reduced functional abilities, this can lead to decreased self-esteem and be a cause of depression.

Diagnosis:

For establishing an osteoporosis treatment plan, a comprehensive diagnosis is necessary, including medical history collection, patient examination, evaluation of the hormonal and immune systems.

Diagnosis includes:

Assessing fracture risk using a specialized scale (FRAX tool).
Performing X-ray examination of the spine.
Comprehensive blood analysis.
Conducting bone density measurement (densitometry) to assess bone density.
Studying thyroid and parathyroid gland function.

When selecting an osteoporosis treatment plan, laboratory test results are considered:

Complete blood count: Including red blood cell count, platelets, hemoglobin, and leukocyte count.
Biochemical analyses: Determining glucose, urea, bilirubin, phosphorus, alkaline phosphatase, and calcium levels. TSH (Thyroid Stimulating Hormone), vitamin D.
Identifying bone tissue turnover markers.
Determining hormone levels.

Treatment continues for a long period, and patients are advised to undergo regular examinations and tests to monitor treatment effectiveness and avoid potential complications of osteoporosis.

Treatment
The goals of osteoporosis treatment include preventing or reducing the number of fractures, increasing bone density, and improving bone remodeling indicators.
Prevention of fractures in osteoporosis first requires lifestyle modifications:

Increasing weight and performing exercises to strengthen muscles and improve balance.
Ensuring adequate intake of calcium and vitamin D as adjunctive therapy.

Pharmacological Treatment
Pharmacological treatment for osteoporosis is prescribed for postmenopausal women and men over 50 years old in the following cases:

Fracture in the hip or spine.
DXA scan results – T-score is equal to or less than -2.5 SD for the hip or spine after excluding secondary causes of osteoporosis.
Low bone mass (T-score between -1.0 and -2.5 SD for the hip or spine) and a fracture probability in the next 10 years of 3% or more by FRAX scale for hip fracture or 20% or more for major osteoporotic fracture.
Federal clinical guidelines for the diagnosis, treatment, and prevention of osteoporosis include the use of:
Anti-resorptive medications – targeting bone resorption inhibition, acting on bone cells such as bisphosphonates and denosumab. (Zoledronic acid)
Anabolic medications – targeting bone formation enhancement such as teriparatide.

Surgical Treatment

Surgical treatment is used in cases of high fracture risks or immediately after a fracture. Surgery is recommended in pathological fractures. This procedure not only improves the individual’s quality of life but also helps them mobilize faster, thereby reducing the risks associated with prolonged bed rest. This intervention can be performed even in elderly patients. The following methods are used for treatment:

Hip fixation (Osteosynthesis): A procedure that uses plates or wires to fix bone fractures, promoting their healing and restoring limb function.
Joint replacement (Endoprosthesis): Involves complete or partial joint replacement. This procedure allows for full limb function restoration for at least 16-20 years. After the surgery, patients are prescribed pain relievers and antibiotics, and recovery sessions are conducted, including physical therapy exercises and sessions.

It is important to note that in cases of osteoporosis, strenuous loading should be avoided, and preference should be given to a quiet lifestyle.

Other Treatments
Mechanical spine care and extension in osteoporosis medical treatment have a good effect, including mechanical support for the spine and in some cases, the use of lower back braces (orthotic braces). They serve a supportive role, partially relieving axial pressure on the thoracic and lumbar sections of the spine and restricting movements in the spine. The use of braces is recommended when the patient intends to walk or stand for more than an hour, but it is important to limit the wearing time, as prolonged immobilization contributes to bone mineral loss.

Surgical treatment is used in cases of hip fractures, as well as when there are clear deviations in the patient’s chest, due to multiple vertebral fractures. During the rehabilitation period after fractures, sessions with a sports medical therapy coach (LFC), respiratory therapy, and exercises to strengthen chest and rib muscles are recommended.

Article Author:

Dr. Ibrahim Mansour
A general practitioner and orthopedic specialist with 9 years of experience in the emergency department. Specializes in treating infectious diseases and gastrointestinal diseases, with a focus on skeletal aspects using therapeutic, surgical, and conservative methods for injuries, including sports-related ones, and major joint diseases in the extremities. His area of interest includes joint-preserving procedures in the knee and hip joints.