Osteoporosis Causes, Risk Factors, Complications, Diagnosis and Treatment
The Universal Guide to Osteoporosis of the Spine: Everything you ever wanted to know, straight from the experts.
“Get a backbone.”
“Grow a spine.”
We say these phrases to someone who’s wishy-washy, who needs to stop being a doormat and start standing up for themselves. Why? Because the spine is straight and strong.
But what if it’s not? What if the bones in the spine, instead of being solid and supportive, were porous and weak?
Then you probably have osteoporosis, a condition that causes weak, fragile, easily-broken bones. The effects of osteoporosis can strike anywhere in your body—including your spine. When osteoporosis sets into your vertebrae—backbones—you’re at risk for broken backbones and all the complications that entails.
Here’s what you need to know about osteoporosis: What it is, how to find out if you have it, and—critically—how to stop its consequences and even prevent it in the first place.
More than 12 million Americans over age 50 have osteoporosis and over 50 million more have low bone density (osteopenia), putting them at risk for osteoporosis.2 Osteoporosis, which means “porous bone”, is a serious disease that causes you to lose too much bone, make too little bone, or both. As your bones lose density, they become weaker and more likely to break. People with osteopenia have lower than normal bone density, while those with osteoporosis have enough severe bone thinning to develop breaks.
Bones have a honeycomb structure with small gaps in between a lattice of bones. In osteoporosis, the gaps become bigger, causing the bones to become thinner, which weakens the bone structure. Your bones are undergoing a constant state of regeneration—old bone is broken down (resorbed) and new bone is made.
“Your bone is like a bank,” explains John R. Dimar, MD, clinical professor in the Department of Orthopaedic Surgery at University of Louisville Medical Center, and a surgeon at the the Norton Leatherman Spine Center in Kentucky. “You can increase the deposit of calcium into your bones to make them stronger until around age 30. After that, you withdraw calcium from your bones very, very slowly over decades. If you’ve worked on your bone health, you will have enough bone in the bank to ‘retire’.”
Even if you missed that opportunity, there are still things you can do at any age to boost your bone health as described in this guide (see the treatment section). When you are young you can increase the rate of new bone formation through exercise, vitamin D3 and calcium, not smoking, and drinking in moderation. When you're older, these will help slow natural, age-related bone loss. Even if you already have osteoporosis, there are medications you can take to increase bone density as described in the treatment section.
Osteoporosis is so sneaky that that it doesn’t really have symptoms—until one of your bones breaks. And if you do experience a fracture, that could be really bad news.
“Osteoporosis that leads to compression fractures will shorten your lifespan. Research clearly shows that people who fall and collapse a vertebra die sooner than people of the same age who do not have compression fractures,” says Isador H. Lieberman, MD, Director of the Scoliosis & Spine Tumor Center, Texas Back Institut.
n fact, 20% to 30% of people who fall and break a hip will die within one year due to problems related to the broken bone itself or the surgery to repair it, as well as other health problems that lead to a fall.1 Many of those who survive need long-term nursing home care.
“If you are a woman over 50 years of age, you need to ask your primary care doctor to check your bone health,” says Dr. Dimar.
If you already have osteoporosis, “be appropriately aggressive about treatment, and make sure you address your bone health,” Dr. Lieberman says.
Over 50? Female? Postmenopausal? If you answered yes to all three, you are at higher risk. Although osteoporosis affects both women and men, studies suggest that approximately one in two women—as compared to up to one in four men age 50 and older—will break a bone due to osteoporosis.
Menopause plays a big role in the development of osteoporosis in women. The loss of estrogen in the first few years after menopause causes a rapid decrease in bone loss that continues at a slower rate for the rest of a woman’s life. That is why women are at greater risk for osteoporosis than men.
“Bone loss rapidly accelerates during menopause over a period of 4 to 5 years, causing women to lose up to 25% of their bone mass,” explains Dr. Dimar. “Men start out with more dense bone mass because of the effects of testosterone, but will eventually catch up to women in terms of bone loss by the time men are 75 to 80 years old.”
Still, there are a variety of factors—both uncontrollable and controllable—that put you at risk for developing osteoporosis. You should talk with your healthcare provider about your risk factors and together you can create a plan for protecting your bones.
Uncontrollable Risk Factors for osteoporosis, in addition to age, sex and menopause, may include:
- Being a white or Asian woman (although all races can be affected)
- Having an oophorectomy (removal of ovaries)
- Family history of osteoporosis (genetics
- Low body weight/having a small body frame
- Previous broken bones or height loss
- Multiple myeloma
Controllable Risk Factors for osteoporosis may include:
- Not getting FDA-recommended levels of calcium and vitamin D for your age and sex
- Not eating enough fruits and vegetables
- Getting too much protein, sodium, and/or caffeine
- Being inactive
- Drinking too much alcohol
- Obesity and weight gain
Certain medications can increase the risk of osteoporosis, including steroids, antacids, proton pump inhibitors, and anticonvulsants. Certain diseases also can increase your risk, such as autoimmune disorders, diabetes, kidney or liver disease, and gastrointestinal diseases (colitis, Crohn’s disease, celiac disease).
There are no symptoms of osteoporosis except when bone loss leads to a fracture. Thus, bone density screening is the only way to know if you have osteoporosis or osteopenia. Bone density is commonly measured in your spine, hips, and wrists using a dual-energy X-ray absorptiometry (DEXA) scan. The DEXA test calculates a score (called a T-score) and the lower your score, the greater your risk of bone fracture.
The degree of bone thinning determines whether you have osteoporosis versus osteopenia. If you consider bone loss on a spectrum, osteopenia means that you are starting to lose bone density and osteoporosis means that bone thinning has progressed past a cutoff mark on the DEXA scan score.
The US Preventive Services Task Force recommends bone density tests for all women ages 65 years and older as well as younger postmenopausal women with risk factors for osteoporosis.5 The National Osteoporosis Foundation recommends bone density testing for men ages 70 years and older, men ages 50-69 years with osteoporosis risk factors, as well anyone 50 years of age and older who has recently broken a bone.6
Dr. Dimar advocates for all women ages 50 and older, especially those with other risk factors, to have a bone mineral test. “By the time a woman with osteoporosis reaches age 65 and has a fracture, she has lost years of treatment with vitamin D3, calcium, and osteoporosis medications,” he says.
Spine surgeons are also able to screen for osteoporosis using CT scans that are commonly taken before spine surgery. This may eliminate the need for additional DEXA testing and can determine if a person needs to boost their bone density before spine surgery using vitamin supplementation and osteoporosis medications.
Your doctor may also order more tests to see if there is an underlying cause of your bone thinning. Tests may include measurement of:
- Calcium blood levels
- Vitamin D3 levels
- Certain hormones levels (eg, parathyroid hormone and thyroid hormones).
Osteoporosis typically has no symptoms until a bone breaks and you feel pain. Bone pain is described as more intense than typical low back pain, Dr. Lieberman says. Fractures from osteoporosis typically occur in the spine, sacrum, hip, and wrist, but other bones can break from osteoporosis too. These fractures can lead to balance problems that increase the risk of falls and future fractures.
For example, as bones in the spine develop compression fractures from osteoporosis, they may change shape from a rectangle to a wedge. If the compressed part of the vertebra is in the front of the spine, the spine may lean forward into a stooped or hunched posture (kyphosis), causing balance issues. Also, this rounded spine position places pressure on the stomach, causing people to feel full faster and sometimes leading to malnourishment, Dr. Lieberman explains.
“When broken bones from osteoporosis heal, the joints can become arthritic very quickly causing more pain and requiring treatment,” Dr. Lieberman says. Occasionally, when the spine collapses from osteoporosis, the spinal cord or nerves exiting the spine become compressed or irritated, causing further pain and dysfunction, Dr. Lieberman said.
Vertebral Compression Fracture — VCF
The most common complication of osteoporosis is vertebral compression fractures (VCF). In people with advanced osteoporosis, compression fractures can occur while going about one’s daily activities, such as bending or carrying heavy loads, or as the result of a minor fall.
The vertebrae are the building blocks of the spine stacked one on top of each other. With osteoporosis the blocks become hollow boxes. Compression fractures occur when the vertebrae collapse. Spinal compression fractures may lead to difficulty walking and/or loss of balance leading to an increased risk of falling and breaking a hip, or other bones.
One or more of the following symptoms can indicate a compression fracture:
- Sudden, severe back pain
- Worsening of pain when standing or walking
- Some pain relief when lying down
- Pain when bending or twisting
- Loss of height
*Vertebral compression fractures can change the shape of the spine. One such deformity is known as kyphosis but often called “dowager’s hump” or “humpback.”
Treatment of Compression Fractures
Treatment includes pain medication, bracing, treatment of the osteoporosis, and in cases where the collapse is progressive or the pain is persistent, surgery. There are currently two therapeutic and preventative treatments for compression fractures called vertebroplasty and kyphoplasty. Although vertebroplasty and kyphoplasty are different procedures, both utilize injectable orthopaedic cement to stabilize the fracture, strengthen the spine, and relieve pain. Kyphoplasty may help restore some of the lost height of the vertebral body.
Osteoporosis medications can help increase bone density and strength or slow future bone loss to reduce the risk for osteoporotic fractures. Osteoporosis medications include bisphosphonates (FosamaxTM), denosumab (ProliaTM), the parathyroid hormones teriparatide (ForteoTM) and abaloparatide (TYMLOSTM), romosozumab (EvenityTM), raloxifene (EvistaTM), and hormone therapy (estrogen for women).8 As all medications may cause side effects, your doctor will work with you to select which treatment is best for you.
Treatment usually starts with bisphosphonates, which slow down the rate of bone loss, Dr. Dimar explains. If bone mineral density has improved at 3 to 5 years while taking bisphosphonates, your doctor may recommend that you take a “drug holiday” (a break from treatment) as longer use may actually make your bones more brittle and, in some cases, may lead to a fracture of the femur (thigh bone).
Medications in this class include:
- Alendronate (Fosamax)
- Ibandronate (BonivaTM)
- Risedronate (ActonelTM)
- Zoledronic acid (ReclastTM)
Denosumab works in a similar way to and can be given as initial treatment instead of bisphosphonates. You’ll get it twice a year as an injection, and you may need to take it continuously, as stopping treatment could put your bones at risk for fracture.
Teriparatide is recommended for women at very high risk of fracture. This medication works differently than bisphosphonates and denosumab in that it stimulates new bone formation. It should not be used for more than 2 years.
“Your doctor will likely alternate back and forth between a bisphosphonate, which slows down bone reabsorption, and teriparatide, which increases bone formation, because that is what normally happens in the body to build strong bones,” Dr. Dimar explains.
Postmenopausal women at very high risk of fracture can be treated with the most recently approved osteoporosis medication—romosozumab—for up to 1 year. This medication should not be used in women at high risk of heart disease or stroke until more research is available.
Raloxifene and estrogen can be used in select postmenopausal women. Your doctor can tell you which treatments are best for you based on your medical history.
How Does Osteoporosis Influence Spine Surgery?
Osteoporosis and vitamin D3 deficiency are linked to poor outcomes from spine surgery, Dr. Dimar explains.3,4 Studies suggest that people with vitamin D3 deficiency and/or osteoporosis undergoing spinal fusion are at greater risk for nonunion (surgery failure) and complications such as fractures and loosening of screws.
In fact, your spine surgeon should consider testing you for osteoporosis before surgery and may need to delay your surgery to treat osteoporosis. Presurgical treatment of osteoporosis includes calcium and vitamin D3 supplements as well as prescription medications.
Despite the risk factors, osteoporosis is a highly preventable bone disease. Prevention begins with eating a well-balanced diet rich in vitamins and minerals including appropriate amounts of calcium and vitamin D3, exercising daily, regular exposure to sunlight, and making healthy lifestyle choices, such as not smoking or drinking too much alcohol.
Experts recommend taking 1,200 mg calcium for women ≥50 years older.7 For men, the recommended daily intake of calcium is 1,000 mg from age 50 years to 69 years and then increases to 1,200 mg in men ≥70 years of age.7
Foods that are high in calcium include:
- Dairy products
- Alternative milk products (fortified almond, soy, oat, and coconut milk)
- Dark green leafy vegetables (collard greens, broccoli, spinach)
- Canned salmon or sardines
- Calcium-fortified cereals and orange juice.
Calcium carbonate and calcium citrate are both good forms of calcium supplements. Some people prefer calcium citrate because it is more easily absorbed, especially in people who take histamine blockers or proton pump inhibitors for acid reflux and heartburn.
Experts recommend taking 600 IU for adults ≥50 years of age and 800 IU for adults ≥70 years.7
In people with vitamin D3 deficiency, a family history of osteoporosis, or who don’t get enough strong sunlight, Dr. Dimar recommends taking 2,000 to 5,000 IU per day. Take vitamin D3 with your calcium supplements as they work together in the body.
Ask your doctor to check your vitamin D3 levels as many people in the United States have vitamin D3 deficiency, placing their bones at risk. While your body makes vitamin D3 from sunlight, year-round exposure to the sun is limited in many areas of the country and many people use SPF, which blocks vitamin D3 productions. A variety of over-the-counter vitamin D3 supplements are available.
Magnesium also works with calcium to maintain healthy bones. Ask your doctor about magnesium supplements if you don’t already take it in your multivitamin. Vitamin C is another good supplement to boost bone health.
Weight-bearing exercises (walking, running, jumping rope, stair climbing) and strength training with weights or resistance bands are great ways to help strengthen bones and prevent osteoporosis. Weight-bearing exercises put stress on the bones, which increases the deposit of calcium into the bone and stimulates new bone growth.
If you already have osteoporosis and a compression fracture, you should select low-impact exercies such as water aerobics, walking, and biking. Jogging, lifting heavy weights, and activities that require twisting or bending (eg, golf, situps) may have too much impact on your bones and should possibly be avoided to avoid another compression fracture. Yoga and tai chi can help improve your balance to prevent falls.
Smoking and Alcohol
If you smoke cigarettes, stopping might be the single best thing you can do for your bones, Dr. Dimar said. “Smoking is incredibly destructive to your health and particularly to bone health as it interferes with bone metabolism and healing,” Dr. Dimar said.
Don’t drink alcohol or limit yourself to one drink per night. Alcohol interferes with vitamin D3 metabolism in the liver and blocks the liver from producing factors you need to produce new bone, Dr. Dimar says.
If you are concerned about bone loss and osteoporosis, talk to your doctor and request a bone density test. If you have osteoporosis or a compression fracture, be proactive in asking your doctor which treatments are best for you.