Osteoporosis Missed Despite 'Red Flag' of Spinal Fracture

Marlene Busko

March 14, 2019

Older patients who went to the emergency room (ER) for acute back pain from a nontraumatic vertebral compression fracture were rarely screened or treated for osteoporosis in a study at a single center that did not have a fracture liaison service.

"In the absence of a specific local program to improve secondary fracture prevention following minimal trauma spinal fractures," the researchers write, "recognition and treatment of osteoporosis in patients at this institution remained dismal over time despite numerous calls to action on the topic in the [orthopedic] literature and elsewhere."

The study by David W. Barton, a medical student at the Virginia Tech Carilion School of Medicine, Roanoke, and colleagues, including senior investigator Jonathan Carmouche, MD, was published in the March issue of The Spine Journal.

Specifically, Barton and colleagues found that in the year following an incident spinal fracture only 0.6% of patients received dual-energy X-ray absorptiometry (DEXA) to measure bone mineral density (BMD), which is required to see if a patient meets the World Health Organization (WHO) definition of osteoporosis. And only 5% of patients were started on an osteoporosis medication approved by the US Food and Drug Administration (FDA).

However, within 2 years of the incident fracture, 38% of patients developed another osteoporosis fracture — most frequently a vertebral fracture (74%) and less often a hip or femur fracture (14%).

"Because of the size of the treatment gap and that diffusion of responsibility, anybody who can take action on this can really help to improve this treatment gap," Barton stressed to Medscape Medical News.

Douglas P. Kiel, MD, MPH, from the Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School, Boston, Massachusetts, who co-chaired fracture follow-up recommendations recently issued by the American Society for Bone and Mineral Research, agrees. 

"It's still another example, albeit it was only at one tertiary care center," of a lack of recognition of treating underlying osteoporosis, he told Medscape Medical News.  

Almost All Patients Hadn't Received a Work-Up for Osteoporosis

"Vertebral compression fractures are the most common sentinel [osteoporosis] fracture, providing an opportunity to intervene with antiresorptive therapy before more debilitating fractures occur," Barton and colleagues write as background.

However, no large US studies have determined the size of the "osteoporosis care gap" following a nontraumatic vertebral compression fracture in institutions where there is no systematic approach to diagnosis and treatment.

To investigate this, the researchers identified 2933 patients age 50 years or older who visited the ER of a tertiary care hospital — or its six affiliated community hospitals — for a minimal trauma vertebral fracture for the first time in 2008 to 2014, when these institutions did not have a fracture liaison service.

Patients were a mean age of 74 years, 60% were women, and 95% were white.

In the 2 years before the ER visit for back pain, only 1.5% of patients received a DEXA scan — which would rule in or rule out osteoporosis using the WHO definition — and only 0.6% of the remaining patients received a DEXA scan in the following year. 

However, the DEXA scan requirement to diagnose osteoporosis is a gray area, Barton said.

In 2014, the National Bone Health Alliance suggested that osteoporosis guidelines be changed to allow diagnosis based solely on the presence of characteristic fracture patterns, including vertebral compression fractures — although their suggestion has not yet been widely accepted.  

In the meantime, "the low rate of DEXA scanning in this population despite institutional control of most local DEXA scanners suggests nearly 98% of patients presenting with a vertebral fracture did not receive an appropriate workup for osteoporosis," the researchers write.

The patients were also unlikely to be taking osteoporosis medications approved by the FDA at the time: an antiresorptive — bisphosphonate or denosumab — or teriparatide, raloxifene, denosumab, or calcitonin.

Before their ER visit, 21% of patients had been prescribed one of these osteoporosis medications.

However, 73% of patients were never prescribed osteoporosis therapy in the 2 years before or after the finding of an incident vertebral fracture.

Similarly, 75% of patients did not have a record of taking calcium or vitamin D supplements.   

"This study demonstrates a profound post vertebral fracture osteoporosis care gap," the researchers conclude.

Possible Reasons for Osteoporosis Care Gap

The main reason for the osteoporosis care gap is a "diffusion of responsibility" after a patient goes to the ER with a vertebral fracture, according to Barton.

Patients typically develop acute back pain after a relatively minor activity, such as picking up a box.

In the ER, the patient has an X-ray that identifies a vertebral fracture.

When the patient sees their primary care physician, the physician is "not necessarily emphasizing bone health," or when the patient sees an orthopedic surgeon, the surgeon "is focused on surgical management of any surgical problems but not on general bone health management."

Most patients are not getting endocrinology referrals and the emergency department is focused on what is currently life threatening.

"So nobody is really 'owning' bone health management" for a lot of patients, Barton explained. 

Similarly, Kiel said that clinicians tell patients they have a vertebral fracture and "send them out with something for the pain, but they don't treat the underlying reason the bone got compressed or broken, which is weakness of the bone. They don't prescribe medications."

"The only way to prevent fractures in a woman or man who has had one of these vertebral fractures is to prescribe an FDA-approved osteoporosis drug," he said, "and they all work quite well."

Having a spinal fracture is "a red flag that you're very vulnerable to more fractures," he stressed, and if you are older and have a hip fracture "you have a chance of dying; you may not be able to get around anymore and be on your own."

Fracture Liaison Service Can Help

The concept of a fracture liaison service to follow patients who have had a recent fragility fracture has been around for about a decade, Barton said.

The service has been shown to improve the rate of post-fracture treatment and thereby reduce the risk of future fractures.

He noted that his institution set up a fracture liaison service about 16 months ago and a nurse practitioner is part of the orthopedic trauma group.

Under the supervision of an orthopedic trauma physician, the nurse practitioner sees patients who have had a fracture, prescribes medications, follows patients for about a year, and then transitions them to primary care.

Spine J. Published online March 6, 2019. Abstract 

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