Osteoporosis

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Osteoporosis

  1. 1. Osteoporosis
  2. 2. Vertebral column
  3. 3. Vertebrae
  4. 4. Osteoporosis <ul><li>A reduction of bone mass or the presence of a fragility fracture </li></ul><ul><li>WHO osteoporosis: a bone density that fall 2.5 SD below the mean for young healthy adults of the same race and gender </li></ul><ul><li>WHO osteopenia : a bone density that fall 1-2.5 SD below the mean for young healthy adults of the same race and gender </li></ul>
  5. 5. Osteoporosis
  6. 6. Osteoporosis <ul><li>PATHOGENESIS </li></ul><ul><li>1. Peak bone mass : about 20 years old </li></ul><ul><li>- genetic, hormone, nutrition, life style </li></ul><ul><li>2. Rate of bone loss : after age 30-45, bone resorption (osteoclast)> formation (osteoblast) and become exaggerated after menopause </li></ul><ul><li>(50 years old) </li></ul><ul><li>3. Bone remodeling : keep balance at 20-30 years old, after that become negative balance </li></ul>
  7. 7. Osteoporosis <ul><li>Type 1 Type 2 Type 3 </li></ul><ul><li>Postmenopausal Senile secondary </li></ul><ul><li>Age 55 -70 years 70-90 years all </li></ul><ul><li>Sex(F/M) 6:1 2 :1 1:1 </li></ul><ul><li>Fx site vertebrae vertebrae vertebrae </li></ul><ul><li>distal forearm hip hip </li></ul><ul><li>distal forearm </li></ul><ul><li>The threshold for Fx is reduced for osteoporotic bone </li></ul>
  8. 8. Disease associated with increased risk of osteoporosis <ul><li>1. Hypogonadal states : Turner syndrome, Klinefelter syndrome </li></ul><ul><li>2. Endocrine disorder : Cushing’s syndrome, hyper PTH, thyrotoxicosis </li></ul><ul><li>3. Nutritional and GI disorder : malnutrition </li></ul><ul><li>4. Rheumatologic disorder : RA </li></ul><ul><li>5. Hematologic disorder/malignancy : MM, lymphoma, leukemia </li></ul><ul><li>6. Inherited disorder : osteogenesis imperfecta </li></ul><ul><li>7. Other disorder : immobilization, COPD </li></ul>
  9. 9. Drugs associated with increased risk of osteoporosis <ul><li>- Glucocorticoids </li></ul><ul><li>- Cycosporine </li></ul><ul><li>- Cytotoxic drugs </li></ul><ul><li>- Anticonvulsants </li></ul><ul><li>- Excessive alcohol </li></ul><ul><li>- Excessive thyroxine </li></ul><ul><li>- Heparin </li></ul><ul><li>- Lithium </li></ul>
  10. 10. Risk factor for osteoporosis fracture <ul><li>Nonmodifiable </li></ul><ul><ul><li>1. Hx of Fx in first degree relative </li></ul></ul><ul><ul><li>2. Female (lower peak bone mass and menopause) </li></ul></ul><ul><ul><li>3. Advanced age </li></ul></ul><ul><ul><li>4. Caucasian , white </li></ul></ul><ul><ul><li>5. Dementia </li></ul></ul>
  11. 11. Risk factor for osteoporosis fracture <ul><li>Potentially modifiable </li></ul><ul><ul><li>1. Cigarette smoking </li></ul></ul><ul><ul><li>2. Low body weight ( < 58 kg.) </li></ul></ul><ul><ul><li>3. Estrogen deficiency : early menopause </li></ul></ul><ul><ul><li>(<45 years) </li></ul></ul><ul><ul><li>4. Low calcium intake, high salt and protein diet </li></ul></ul><ul><ul><li>5. Alcoholism </li></ul></ul><ul><ul><li>6. Inadequate physical activity </li></ul></ul><ul><ul><li>7. Poor health </li></ul></ul>
  12. 12. Measurement of bone mass <ul><li>1. Dual energy x-ray absorptiometry (DEXA) </li></ul><ul><ul><ul><li>- standard for measuring bone density </li></ul></ul></ul><ul><ul><ul><li>- hip, spine, wrist </li></ul></ul></ul><ul><li>2. Quantitative computed tomography </li></ul><ul><ul><ul><li>- expensive, greater radiation exposure </li></ul></ul></ul><ul><li>3. Ultrasound </li></ul><ul><ul><ul><li>- low cost, use as screening procedure </li></ul></ul></ul><ul><li>Plain radiography not noticeable until 30 % of bone mineral is lost </li></ul>
  13. 15. Bone mineral density (BMD) should be measured in <ul><li>1. Post menopausal women > 65 years old. </li></ul><ul><li>2. Post menopausal women < 65 years who have 1 or more risk factor. </li></ul><ul><li>3. Post menopausal women with Fx. </li></ul><ul><li>4. Women who considering therapy by using BMD decision. </li></ul><ul><li>5. Women who have been HRT for long time. </li></ul><ul><li>6. Men who experience Fx after minor trauma. </li></ul><ul><li>7. Evidence of osteopenia/osteoporosis on film. </li></ul>
  14. 16. Management of osteoporosis <ul><li>1. Risk factor reduction </li></ul><ul><li>2. Nutritional recommendations </li></ul><ul><ul><li>Calcium, vitamin D </li></ul></ul><ul><ul><li>Avoid salt, caffeine, excessive protein intake </li></ul></ul><ul><li>3. Exercise </li></ul><ul><li>4. Protective pads </li></ul>
  15. 17. Management of osteoporosis <ul><li>5. Pharmacologic therapies </li></ul><ul><ul><li>A. Estrogens (prevention & Rx) </li></ul></ul><ul><ul><li>B. Selective estrogen response modulator (SERMs) prevention & Rx :Tamoxifen, Raloxifene </li></ul></ul><ul><ul><li>C. Biphosphonates (prevention & Rx) : Alendronate, Risedronate </li></ul></ul><ul><ul><li>D. Calcitonin : Rx, pain relief effect, not indicated for prevention </li></ul></ul><ul><ul><li>E. Parathyroid hormone, fluoride </li></ul></ul>
  16. 18. Spine compression fracture in osteoporosis <ul><li>Compression Fx may be caused by trauma, osteoporosis, malignancy, infection </li></ul><ul><li>Found 25 % in women over 50 years old and 40 % in women 80 years old </li></ul><ul><li>Many cases found incidental during CXR </li></ul><ul><li>Causes : - Hx of trauma </li></ul><ul><li>- No Hx of increased force on spine </li></ul><ul><li>- stepping out bathtub, lifting trivial object, bending forward, raising window (in severe osteoporosis) </li></ul>
  17. 19. Spine compression fracture in osteoporosis <ul><li>Fx site : any where ( in trauma usually at T11,12 and L1) </li></ul><ul><li>Symptoms : - 1/3 are symptomatic, sudden back pain </li></ul><ul><li>- sudden injury – severe pain </li></ul><ul><li>- collapse in gradual – </li></ul><ul><li>mild pain </li></ul><ul><li>- chronic pain – change in spine alignment, muscle spasm </li></ul>
  18. 20. Spine compression fracture in osteoporosis <ul><li>Investigation </li></ul><ul><li>1. Plain radiography : may not differentiate between old and recent fracture. </li></ul><ul><li>2. MRI can determine </li></ul><ul><ul><li>Old v.s. recent Fx </li></ul></ul><ul><ul><li>Osteoporosis v.s. malignancy </li></ul></ul>
  19. 21. Spine compression fracture in osteoporosis <ul><li>Investigation </li></ul><ul><li>3. Bone scan : </li></ul><ul><ul><li>help determine acuity of Fx </li></ul></ul>
  20. 22. Spine compression fracture in osteoporosis <ul><li>Management </li></ul><ul><li>1. Rest </li></ul><ul><li>2. Analgesic, NSAID </li></ul><ul><li>3. Calcitonin </li></ul><ul><li>4. Brace </li></ul>
  21. 23. Spine compression fracture in osteoporosis <ul><li>Management </li></ul><ul><li>5. Vertebroplasty </li></ul><ul><li>6. Surgical Rx </li></ul>

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