Osteoporosis, Vertebroplasty and the Aging Spine: Chiropractic Considerations

Osteoporosis vertebral fractures are a common cause of pain, disability and increased mortality. Approximately 750,000 new vertebral fractures occur in the United States each year. Among adults over the age of 50, up to a quarter will have at least one vertebral fracture in their lifetime. Every year, about 1.4 million vertebral compression fractures come to clinical attention worldwide.

Numerous case series and several small, unblinded, nonrandomized, controlled studies have suggested the effectiveness of vertebroplasty (VP) in relieving pain from osteoporotic fractures, but data about VP from high-quality randomized, controlled trials are lacking.¹ Furthermore, chiropractic clinical guidelines for the management of vertebroplasty patients are elusive and lack revision frequency and provider education.

Assessment

The patient is a 91-year-old right-handed, retired, caregiver mother of 14 children who presents in a wheelchair on a medical referral for chiropractic. Her chief complaints are biaxial lumbar pain at the beltline, and bilateral lower-extremity pain anterior aspect below the knees and above the ankle. Medications include Reglan 5 mg, Requip 3 mg and Lovastatin. Supplements include fish oils, cal-mag-zinc multivitamin, and vitamin C 1,000 mg. She had a prior lumbar vertebroplasty, multi level.

Physical Examination: She stands 5'2" and weighs 145 lbs. Blood pressure is 120/78. LA RR: 16; P: 56. Distal and proximal pulses are full, regular and strong. No signs for dural tension or nuccal rigidity are exhibited. Gait is normal yet slow. She reports wheelchair use due to alternate physician appointments today; no drop foot or steppage gait observed. Heel and toe rise are intact. Seated deep-tendon reflexes of the upper and lower extremities demonstrate +2 symmetrically using the Wexler Grading Scale with reinforcement maneuvers. Capillary refill less than two seconds distal extremities. Testing sensory discrimination to pain sensation is normal in lower extremities; no pedal or pitting edema. Range of lumbar motion markedly diminished consistent with age, degenerative changes and prior radiographic evidence of multi-level lumbar vertebroplasty.

Diagnosis: Lumbar vertebroplasty, multi-level with moderate complexity lumbosacral neuritis with myofascial and osteoarthrosis components. This individual uses her arms to propel; no foot propel combination. Transfer to and from the wheelchair is by assisted stance. The wheelchair seat is too high; she slides down in the seat in order to rest her feet, creating poor posture. This can cause further long-term damage to the spine. A more immediate problem is shallow breathing as a result of folding the diaphragm in half. She is observed to lean forward repeatedly.

Her osteoarthrosis in the spinal and lower extremity regions is significant and since cartilage itself is not innervated, her pain is presumed to arise from a combination of mechanisms, including osteophytic periosteal elevation; vascular congestion of subchondral bone, leading to increased intraosseous pressure; synovitis with activation of synovial membrane nociceptors; fatigue in muscles that cross the joint; and overall joint contracture.

In addition to the underlying pathophysiologic changes described above, her joints have undergone mechanical deformation, with resultant malalignment and instability and ankylosis. This is easily observed about the medial knee joints and the PIPs and DIPs. Throughout the exam, she repeatedly rubs these areas.

Recommendations

Percutaneous vertebroplasty involves the vertebral injection of polymethylmethacrylate cement. Although there is some indication that this procedure is safe and effective for treating osteoporotic compression fractures, "Medicare promulgated no national coverage policies for this procedure after reviewing the available nonrandomized evidence. Nevertheless, local Medicare contractors in multiple jurisdictions have covered vertebroplasty for various indications since as least 2001."^2-4

Traditionally, osteoporosis has been underdiagnosed and undertreated following a low-energy fracture in an elderly patient. Although treatment rates may be improving through public health initiatives, the majority of patients with osteoporosis remain inadequately treated. Patient intervention programs that focus on patient education about osteoporosis and treatment options can lead to significant increases in intervention and treatment.

Reducing the risk of skeletal fractures in patients susceptible to osteoporosis involves improved chiropractic education on the risk factors and management of osteoporosis, as well as informing patients on the significance of dual-energy X-ray absorptiometry testing and medical treatment so they may serve as their own health care advocates.

Plan of Care

Instruction on the need for wheelchair cushions to provide padding for lumbosacral support. Discussion of home care with a geriatric medicine approach to diet, moist heat and NSAID methods. Moist heat pack for low back use. Discontinue home dry-heat methods, as they worsen condition by dehydrating muscle. Review and implementation of home exercises. Cautionary conditions are recognized but could still be a candidate for mid- or low-back adjustment and could benefit from low-force pressure-point techniques.

Any new developments in chiropractic management of osteoporosis with/or without vertebroplasty should be added to care guidelines at a two-year frequency. Chiropractic care guidelines and updates should be considered mandatory as a part of the provider education process.

References

1. Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med, 2009 Aug 6;361(6):557-68.
2. Alvarez L, Alcaraz M, Perez-Higueras A, et al. Percutaneous vertebroplasty: functional improvement in patients with osteoporotic compression fractures. Spine, 2006;31(10):1113-8.
3. Gray DT, et al. Research Letter: Thoracic and lumbar vertebroplasties performed in U.S. Medicare enrollees, 2001-2005. JAMA, Oct. 17, 2007;298(15).
4. Treatments for Vertebral Body Compression Fractures. Medicare Coverage Advisory Committee Meeting, May 24, 2005. Centers for Medicare & Medicaid Services.