Osteoporosis of the spine (dowager’s hump)

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247 Osteoporosis of the spine (dowager’s hump)

Instruction

Examine this patient’s spine.

Salient features

History

• History of back pain (usually the onset is sudden with severe pain in the dorsal spine)

• Spontaneous fractures and loss of height

• Long-term corticosteroid, heparin therapy or proton pump inhibitors (>7 years of last) (CMAJ 2008;179:319–26)

• Postmenopausal or has had an oopherectomy

• Smoker or consumes alcohol (>3 units/day)

• Is there a family history particularly in a parent

• What is the patient’s weight (body mass index (BMI) <22 kg/m2 is associated with osteoporosis)

• Associated conditions: rheumatoid arthritis, uncontrolled diabetes mellitus, Crohn’s disease, ankylosing spondylitis, multiple myleoma, Cushing syndrome, thyrotoxicosis, oestrogen deficiency in women and androgen deficiency in men, Marfan syndrome, Ehlers–Danlos syndrome, homocystinura.

Examination

• Elderly patient (usually a woman)

• Marked kyphosis (Fig. 247.1)

• Loss of height

• Protuberant abdomen

• Look for spinal tenderness, demonstrate straight-leg rising sign.

image

Fig. 247.1 Dowager’s hump. (A) Marked thoracic kyphosis caused by multiple osteoporotic fractures. (B) Corresponding radiograph.

(With permission from Hochberg et al. 2003.)

Diagnosis

This elderly patient with marked kyphosis (lesion) has postmenopausal osteoporosis (aetiology) complicated by frequent fractures and loss of height (functional status).

Questions

What do you understand by the term osteoporosis?

It is ‘a systemic skeletal disorder characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.’ (Am J Med 1993;94:646–50). NICE (UK National Institute for Health and Clinical Excellence) defines a diagnosis as a T score of −2.5 or below on dual-energy X-ray absorptiometry (DEXA) scanning (see below), although it says that women aged over 75 with two or more risk factors for fracture or low bone density can be assumed without a scan to have osteoporosis.

Advanced-level questions

What is the pathology of osteoporosis?

It is characterized by a decrease in the amount of bone present, so that the structural integrity of the skeleton is compromised. The rate of bone formation is normal but the rate of bone resorption is increased. This results in greater loss of trabecular bone than compact bone, accounting for the clinical features of the disease.

What are the types of osteoporosis?

• Type I results from accelerated bone loss, particularly trabecular bone, and is probably caused by oestrogen deficiency. It typically results in fractures of vertebral bodies and the distal forearm in women in their 60s and 70s.

• Type II results from age-related bone loss and is much slower. It occurs in both sexes and typically results in fracture of the proximal femur in the elderly.

• Secondary osteoporosis: accounts for about 20% of cases in women and 40% of cases in men.

What are the typical sites of fracture in osteoporosis?

Vertebrae, neck of femur and distal radius (Colles’ fracture).

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