Prevention and treatment of osteoporosis

What is osteoporosis, and why does fracture risk matter?

Osteoporosis reduces bone strength, so a fracture may follow minor trauma. The condition is often identified after a fracture of a vertebra, hip or another bone. Risk assessment helps select prevention and treatment before another fracture occurs.^[1]

A previous low-trauma fracture matters even if the bone density result does not appear very low. We also consider age, falls, other diseases, medicines and family fracture history.

When to check bone health

• After a fracture from minor trauma, particularly a vertebral or hip fracture.
• With loss of height, a change in posture or new back pain, when there is a risk of a compression fracture.
• After menopause and in older age when risk factors are present.
• With prolonged glucocorticoid use or diseases that may affect bone.
• Before fusion or screw insertion, if reduced bone strength is suspected.

We determine the extent of investigation according to the clinical situation. In younger patients, it is especially important to establish possible causes of low bone density rather than automatically applying criteria for older age groups.^[1]

DXA bone densitometry, FRAX and investigations

DXA — measurement of bone mineral density, usually in the lumbar spine and hip. We assess the result alongside imaging, previous fractures and clinical findings. Severe degenerative spinal changes can affect lumbar measurements.

FRAX helps estimate ten-year fracture probability from risk factors, taking bone density into account when suitable data are available. It complements clinical assessment and helps guide management in the appropriate age groups.^[1]

We arrange blood tests to identify causes of osteoporosis and select treatment safely. Kidney function, calcium, vitamin D and other measures may need assessment. If a vertebral fracture is suspected, we separately determine the radiographs, MRI or CT required.

Calcium and vitamin D: the basis of bone support

We first assess diet and dietary calcium intake. Sources may include dairy products and calcium-fortified foods. Supplements are used to address a shortfall, taking diet, kidney health and other medical circumstances into account.^[2]

Vitamin D is needed for calcium absorption and normal bone metabolism. The need for supplements and their dose are determined by deficiency risk, investigation results and the treatment plan. Vitamin D doses are stated in international units — IU — or micrograms, mcg.

At high fracture risk, medicines for osteoporosis are added to calcium and vitamin D support. At the consultation, it is important to review the entire plan, including supplements already prescribed.

Medicines for treating osteoporosis

The choice depends on fracture risk, previous treatment, kidney function, other medical conditions and ability to follow the regimen. At very high risk, particularly after multiple vertebral fractures, the treatment sequence may differ.^[3]

Do not stop or delay denosumab yourself: this can increase the risk of vertebral fractures. Agree any treatment change and the next medicine with your doctor.^[3]

For each medicine, we discuss expected benefits, contraindications, how it is used and monitoring. Hormonal therapy may be an option only for certain women after individual assessment of benefits and risks.

Movement and falls prevention

Regular activity helps maintain strength, balance and safe walking. We select an exercise programme according to age, spinal condition and previous fractures. It may include weight-bearing exercise, muscle strengthening and balance training.^[2]

• A safe home: adequate lighting, clear walkways and stable supports where needed.
• Balance and vision: assessment of unsteadiness and correction of falls risk factors.
• After a fracture: agreed exercises, gradual activity increases and training in safe movement.
• Habits and nutrition: adequate nutrient intake, stopping smoking and limiting alcohol.

After a vertebral fracture, agree exercise intensity, bending and weight training with a specialist familiar with your scans and recovery.

Vertebral compression fracture: when intervention is needed

With new severe back pain, especially after minor loading, it is important to check for a fracture. Imaging and examination assess the affected level, fracture age and healing, nerve function and whether the pain corresponds to the fracture.

Vertebroplasty or balloon kyphoplasty may be considered for severe persistent pain from a recent unhealed fracture despite appropriate pain relief. The painful level must correspond to examination and imaging findings.^[4]

Vertebroplasty strengthens a particular damaged vertebra. A plan to reduce subsequent fracture risk is also needed. Preventive cement injection solely because of low bone density or a high calculated risk is not a standard indication.

Vertebroplasty, balloon kyphoplasty and SpineJack

Osteoporosis before fixation and fusion

Bone strength matters for screw purchase, cage support and fusion. If spinal stabilisation is planned and osteoporosis is suspected, we assess bone before surgery and discuss its preparation.

Confirmed osteoporosis may affect the choice of instrumentation and the treatment plan. When needed, preparation is coordinated with a metabolic bone disease specialist. Preoperative assessment and appropriate treatment are included in the CNS recommendations for patients undergoing spinal instrumentation.^[5]

Pedicle screw fixation and interbody cage placement · Endoscopic lumbar fusion

What to send for a consultation

• DXA result with the complete report and date, if the examination has already been performed.
• Spinal imaging: existing radiographs, MRI or CT; digital series in DICOM format.
• Fracture history: when and under what circumstances fractures occurred, and how they were treated.
• List of medicines and supplements: names, doses and duration of use; for injections, the date of the last administration.
• Existing laboratory results and discharge summaries, including those after surgery or previous consultations.

For preliminary review, send what you already have. Further investigations and monitoring are determined after assessment of the clinical situation.

How to prepare and send digital CT/MRI studies in DICOM format

Questions about osteoporosis

Are calcium and vitamin D enough?

They provide important support for bone metabolism. At high fracture risk, a separate decision on osteoporosis medicines is needed. We make the choice according to fractures, investigations and health status.

Can men develop osteoporosis?

Yes. In men, we also assess fracture risk, bone density and possible secondary causes. A fracture from minor trauma warrants investigation regardless of sex.

Is an ordinary X-ray enough for diagnosis?

A radiograph helps show a fracture and vertebral shape. DXA and other validated methods are used to assess bone mineral density when indicated. Results are assessed together with clinical risk factors.

How is treatment monitored?

New fractures, adherence, side effects and the need for blood tests and repeat bone densitometry are assessed. Monitoring intervals depend on the medicine, risk and previous results.