Osteoporosis and back pain

Osteoporosis is a systemic metabolic disease of the skeleton, which is characterized by a decrease in bone mass and a disturbance in the microarchitectonics of bone tissue, which in turn leads to bone fragility and a tendency to fracture (WHO, 1994).

Pathogenetic classification of osteoporosis

• Primary osteoporosis
  • postmenopausal osteoporosis (type 1)
  • senile osteoporosis (type 2)
  • juvenile osteoporosis
  • idiopathic osteoporosis
• Secondary Osteoporosis
  • diseases of the endocrine system
  • rheumatic diseases
  • diseases of the digestive system
  • kidney disease
  • blood diseases
  • genetic disorders
  • other conditions (ovariectomy, COPD, alcoholism, anorexia, eating disorders)
  • medicines (corticosteroids, anticonvulsants, immunosuppressants, antacids containing aluminum, thyroid hormones)

Risk factors for osteoporosis: genetic

• Race (white, asians)
• Elderly age
• Heredity
• Low body weight (<56kg) hormonal
• Female
• Later onset of menstruation
• Amenorrhea
• Infertility
• Early menopause lifestyle
• Smoking
• Alcohol
• Caffeine
• Exercise stress:
  • low
  • redundant
• Deficiency of calcium and vitamin D in food
• Medications
  • Glucocorticoids
  • Heparin
  • Anticonvulsants
  • Thyroid hormones
• Other diseases
  • Endocrine
  • Rheumatic
  • Tumors
  • Hematological
  • The liver
  • Kidneys
• Radiation therapy
• Oophorectomy

Risk factors for fractures:

• internal factors (various diseases or age-related decline of non-pyromagic regulation, decreased stability, muscle weakness, decreased hearing, senile dementia, taking barbiturates, tranquilizers, antidepressants);
• environmental factors (ice, loose mats, slippery floors, poor lighting of public places, lack of railings at the stairs).

Instrumental diagnosis of osteoporosis:

• Radiography of the spine:
  • - late diagnosis (diagnoses loss of more than 30% of bone mass)
  • - detection of X-ray morphometry fractures)

Quantitative Computed Tomography

• Ultrasonic densitometry (screening method)
• Dual-energy X-ray absorptiometry, standard method: early diagnosis (1-2% bone loss)

The main sign of osteoporosis is a decrease in bone mineral density (BMD) that develops in all parts of the osseous-articular system, but more so at earlier stages of development pathological changes affect the vertebral column, which allows us to consider it as a diagnostic "object" through which it is possible to reveal the most initial manifestations of osteoporosis.

One of the characteristic clinical signs of osteoporosis are vertebral fractures. Clinical signs of vertebral fractures (pain in the back and a decrease in growth) are noted only and 1/3 of the patients, the rest - radiographically revealed ostoporegic deformation of the vertebrae without clinical manifestations. Reformation can be most accurately detected when evaluating lateral radiographs at the level of ThlV-ThXII, LII-LIV.

X-ray morphometric examination consists in changing the height of vertebral bodies from ThIV to LIV on the lateral radiograph in three of their sections: anterior (value A), mean (M) and posterior (P). Considering the fact that the size of vertebral bodies can vary depending on sex, age, body size, and patient's growth, it is advisable to analyze not the absolute values of the obtained sizes for greater reliability, but their ratios are indices of vertebral bodies. Accordingly, the three absolute sizes are distinguished by the following indices:

• index A / P - front / rear index (ratio of the height of the anterior margin of the vertebral body to the height of the posterior)
• M / P index - mean / posterior index (ratio of height of middle part of vertebra to height of posterior margin of vertebra)
• index P / P1 - posterior / posterior index (ratio of the height of the posterior edge of the vertebra to the height of the posterior edge of the two overlying and two underlying vertebrae).

Degree of deformation is determined by the Felsenberg method - by the ratio of the height of individual parts of the vertebral bodies in percent. Normally, the index is 100%, that is, all the dimensions of the vertebral body have equal values. Minimal osteoporetic deformation is characterized by an index of 99-85% (provided there are no inflammatory and non-inflammatory diseases of the spine).

[1], [2]

Symptoms of osteoporosis consists of three main groups of symptoms:

• Nebola manifestations associated with structural changes in the vertebrae, bones of the skeleton (changes in posture, decreased growth, etc.)
• Nonspecific, but almost always encountered pain syndrome, from insignificant to intense, different localization and severity.
• Changes in the psychoemotional sphere

Clinically significant of nebolevyh signs of osteoporosis are thoracic kyphosis, often causing shortening, contraction of the trunk of the patient, low position of the ribs, almost on the crests of the iliac bones. The lumbar lordosis is enlarged or flattened. Changes in physiological curves and postures lead to a shortening of the spinal musculature, the appearance of pain from muscle overstrain (preferential localization of such pain is paravertebral, increased pain during prolonged standing in the vertical position, decrease in intensity during walking). An important criterion for diagnosis is a reduction in the patient's growth of more than 2.5 cm per year or 4 cm during life. The head-symphysis and symphysis-stop distance are normally the same, the decrease of the first distance to the second by more than 5 cm is indicative of osteoporosis. With a fat measurement of growth, a decrease of 6 mm can be a pointer to the compression fracture of the vertebral body.

Back pain is the most frequent complaint made by patients with osteoporosis to the doctor. Isolate acute and chronic pain. Acute pain syndrome, as a rule, is associated with the development of a compression fracture of the vertebra due to a minimal trauma (which occurred spontaneously or when it fell from a height not higher than (the person's own growth, which arose on coughing, sneezing, sharp movement) .The pain can radiate along the root type in the chest, the abdomen, along the thigh, severely restrict the motor activity.Intense pain after 1-2 weeks decreases until docking within 3-6 months against the background of lumbar lordosis or thoracic kyphosis, or becomes chronic.

Chronic pain can be episodic, associated with lifting gravity, uncoordinated movement, or constant, aching, accompanied by a feeling of fatigue, heaviness in the back, in the interscapular area. Strengthening of pain in this case. Occurs when walking for a long time, after being forced to stay in one position. The intensity decreases after resting in a prone position. NSAIDs for the most part do not stop the pain syndrome, or reduce its intensity insignificantly. The degree of severity of pain varies from slight to severe in one and the same patient.

In addition to the compression fracture, the cause of pain may be partial break with periosteal hemorrhage, shortening of paravertebral muscles, compression of muscles and ligaments. Dysplasia of the ribs, thoracic kyphosis can lead to pressure on the crests of the iliac bones, intervertebral joints with the appearance of back pain, ribs, pelvic bones, pseudoradical pain in the chest. Less common with osteoporosis is pain in the joints, gait disturbance, and lameness.

Pain often occurs with chest compressions, and diffuse bone pain is less common. There is an indirect load test on the spine: the doctor presses down on the patient's outstretched arms. In osteoporosis, the patient experiences severe pain in the spine. Sometimes patients complain of pain in the chest-lumbar spine with a sharp lowering from the "on tiptoe" position.

There are frequent complaints of a decrease in working capacity, increased fatigue, irritability, excitement, sometimes express complaints of a depressive nature.

A feature of the course of osteoporosis is the absence of a characteristic clinical picture until the development of significant changes in density and architectonics of bone tissue provoking the development of osteoporotic fractures.

Treatment of osteoporosis

The treatment of osteoporosis depends on the value of the t-test, determined with two-energy densitometry. Reflecting the number of standard deviations (SD) above and below the average peak of bone mass in young women aged 30-35 years and the presence of osteoporotic fractures

Treatment of osteoporosis is divided into three aspects:

• etiotropic
• simtomatic
• pathogenetic.

Etiotropic treatment of osteoporosis presupposes treatment of the underlying disease in secondary osteoporosis and correction or abolition of iatrogenic drugs with regard to osteoporosis. Symptomatic methods of therapy are mandatory in the treatment and prevention of osteoporosis. They include conducting various schools, educational programs, maximum impact on modifiable risk factors, rejection of bad habits, physical exercises according to a special program developed for patients with osteoporosis. If necessary, the possibility of wearing thigh protectors for persons with a high risk of developing hip fractures (thin, persons who have had a history of a hip fracture with a high tendency to fall) is considered even if this group of people does not have a reliably confirmed diagnosis of osteoporosis. Also apply to this group is the use of pain medications during periods of exacerbation of pain syndrome, massage, surgical methods of treatment of terelomas. A number of authors refer to symptomatic and therapy with calcium preparations, without denying it from an undeniable prophylactic value, especially in adolescence, during the formation of a peak in bone mass

The task of pathogenetic treatment is to restore the normal process of bone remodeling, including suppression of increased bone resorption and stimulation of reduced bone formation. Osteoporosis therapy is carried out both as a mono-and combination therapy, depending on the etiology, severity of osteoporosis, somatic status.

Pathogenetic therapy involves taking medications:

• slowing bone resorption: bisphosphonates (alendronate, alendronate and vitamin D, zoledronic acid), calcitonin, selective modulators of estrogen receptors, estrogens, estrogen-progestational drugs, strontium ranelate.
• mainly enhancing bone formation: PTH, fluorides, anabolic steroids, androgens, growth hormone, strontium ranelate.
• which have a multilateral effect on bone tissue: vitamin D and its active metabolites, osteogenone, ossein-hydroxyapatite complex
• calcium salts: used in combination therapy, or for the primary prevention of osteoporosis.