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The Aging Spine

The Aging Spine. Pathology - Epidemiology - Treatment J.J. Verlaan. Introduction. Aim of lecture Pathological conditions of the aging spine osteoporosis metastatic spinal disease (degenerative conditions) Epidemiology prevalence; risk factors; socioeconomic costs Treatment Conclusions.

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The Aging Spine

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  1. The Aging Spine Pathology - Epidemiology - Treatment J.J. Verlaan

  2. Introduction • Aim of lecture • Pathological conditions of the aging spine • osteoporosis • metastatic spinal disease • (degenerative conditions) • Epidemiology • prevalence; risk factors; socioeconomic costs • Treatment • Conclusions Consensus Conference JAMA 2001;285(6):785-95 / J Bone Miner Res 2008 Jan;23(1):159-65

  3. Aim of Lecture To provide the audience with up-to-date knowledge on the pathology, epidemiology and treatment of the aging spine

  4. Osteoporosis • Definition: A skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture • Bone Strength = Bone Density + Bone Quality • Bone Density: Grams of mineral content per area or volume (BMD) • Bone Quality: Architecture; bone turnover and damage accumulation (these parameters are typically not available) Bone Strength ≠ Bone Density

  5. Osteoporosis • Wolff’s Law: Bone adapts to load • osteocytes (strain transducers, regulatory function) • osteoblasts form bone, osteoclasts resorb bone • unused bone slowly remodelled away

  6. Osteoporosis • Wolff’s Law: Bone adapts to load • osteocytes (strain transducers, regulatory function) • osteoblasts form bone, osteoclasts resorb bone • unused bone slowly remodelled away

  7. Osteoporosis • Central Issue:Peak Bone Mass (≈BMD) • building bone mass during skeletal maturation (max. approx. 35 yrs) • general health; physical exercise; diet; genetic determinants • cave: failure to achieve adequate peak bone mass in adolescence • Decrease in Bone Mass • irreversible decline after 35 years of age (0.6-1.6% decrease yearly) • process can not be stopped, can be slowed down though • may fall below fracture threshold

  8. Osteoporosis INCREASED RISK for FRACTURE

  9. Osteoporosis • How to measure Bone Mineral Density? • Dual Energy X-Ray Absorptiometry (DXA) • currently best validated instrument • used at femoral neck and lumbar spine • low exposure to radiation • reproducible • Quantitative Ultrasound (QUS) • predominantly used at the heel • predictive value for skeletal fractures • validation issues

  10. Osteoporosis • Currently no accurate measure of bone strength • BMD proxy measure (accounts for approx. 70% of bone strength) • BMD only reproducible parameter for estimated bone strength • Definition of osteoporosis by WHO: • BMD 2.5 standard deviations below mean for young white women after DXA scanning of femoral neck • Reference for males, children, ethnic groups? • Controversy using this definition

  11. Osteoporosis

  12. Osteoporosis • T-Score: The number of standard deviations above or below the average BMD for young healthy white women (this score determines osteopenia/osteoporosis) • Z-Score: The number of standard deviations above or below the average BMD for age- and sex-matched controls

  13. Metastatic Spinal Disease • Spine primary location for metastasis • Symptomatic spinal metastasis in approx. 5-10% • Pain and neurological deficit • Vertebral and/or epidural involvement • osteolysis: painful micromotion • compression neural structures / periosteum • can lead to pathological fracture • Deciding between radiotherapy / surgery / both • Diagnosis primary tumor necessary (biopsy)

  14. Metastatic Spinal Disease • Spine Instability Neoplastic Score (SINS) • Location (junction, mobile/rigid segment) • Pain (yes, occasional, no) • Bone lesion (lytic, mixed, blastic) • Alignment (subluxation, deformity, normal) • Vertebral body (% collapse, no collapse) • Posterolateral involvement (bi/unilateral, none) 0-6 points 7-12 points 13-18 points potentially unstable stable unstable Fisher et al. Spine Oncology Study Group, Spine 2010

  15. Epidemiology Osteoporosis • Primary Osteoporosis • idiopathic ( female > 70%; male ≈ 46%) • osteoclastic activity > osteoblastic activity: net decrease in bone mass • occurs in both sexes • risk factors (women after menopause; smoking; ↓BMI; ↓activity) • Secondary Osteoporosis, caused by • medication (glucocorticoids, anticonvulsants, long term heparin) • diseases (celiac disease; diabetes mellitus; hyperthyroidism etc.) • other conditions (prolonged immobilization; alcoholism; anorexia etc.)

  16. Epidemiology Osteoporosis • Osteoporosis in the USA: • prevalence 10.000.000 individuals (3% of total population) • osteopenia 18.000.000 individuals → at risk for osteoporosis • approximately 700.000 vertebral fractures diagnosed annually

  17. Epidemiology Osteoporosis • Burden for individual patient • high mortality rate following hip fractures (≈ 20% within 1 year) • disabling pain following spinal collaps • deformity, postural instability • decrease of pulmonary function • decrease quality of life

  18. Epidemiology Osteoporosis • Socioeconomic consequences for society • estimated cost for treatment of osteoporotic fractures $10-15 billion annually for USA • excluding treatment of patients with osteoporosis but without fractures • probably underestimation due to loss of productivity of patients and caregivers

  19. Epidemiology Metastases • Approximately 60-70% of patients with systemic cancer get spinal metastasis • lung (31%) > breast (24%) > GI tract (9%) • From top-5 malignancies (16.000 deaths in 2010, CBS): • 3 frequently metastasize to spinal column (lung, breast, prostate) • Increased number cases due to improved survival • most notable improvement breast cancer, myeloma • Median survival 10 months

  20. Treatment Osteoporosis • Dietary • vitamin D; important for calcium absorption from gastro-intestinal tract • recommended daily vitamin D intake for adults: 400-600 IU (=10-15μg) • calcium; most important nutrient for attaining peak bone mass • recommended daily calcium intake for adults: 1000-1500 mg • Exercise • regular basis; especially resistance & high impact exercises • Medical • bisphosphonates; decrease osteoclastic activity (↓remodeling!) • hormone replacement therapy; selective estrogen receptor modulators • analgesics in case of vertebral compression fracture Kwek et al. Injury 2008

  21. Treatment Spinal Metastasis • Depending on diagnosis, life expectancy • Radiotherapy • local tumor control, analgesic effect • Medical treatment of pain • dexamethasone • NSAIDS / opioids • Medical treatment of hypercalcemia • rehydration, steroids • bisphosphonates; decrease osteoclastic activity • Surgery if indicated (SINS, neurological deficits) Kwek et al. Injury 2008

  22. Conclusions • As the spine ages, osteoporosis and metastatic spinal disease become more prevalent • An increasing number of patients will be affected • Nonoperative treatment succesful in most cases • New minimal invasive techniques available for cases refractory to nonoperative treatment

  23. Thank You

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