Generalized Bone Disease
A generalized bone disease characterized by low bone mass, damage to bone microstructure, increased bone fragility, and susceptibility to fracture, mainly manifested by low back pain, spinal deformity, fractures, etc. Pathologies are due to genetics, endocrinology, nutritional factors, medications, and ageing, etc. Main treatments are lifestyle modification and medication, and surgery for severe cases.
Definition
Osteoporosis is a systemic bone disease characterized by decreased bone strength and increased risk of fracture.
The incidence of this disease is increasing yearly with the advent of an aging society.
Classification
There are primary osteoporosis and secondary osteoporosis.
Primary osteoporosis
Primary osteoporosis accounts for 90% of osteoporosis, including postmenopausal osteoporosis (type I), senile osteoporosis (type II) and idiopathic osteoporosis (including juvenile type).
Type I: Postmenopausal osteoporosis (PMOP), which usually occurs within 5 to 10 years after a woman’s menopause.
Type II: senile osteoporosis (SOP).
Senile osteoporosis generally refers to osteoporosis that occurs after the age of 70.
In postmenopausal women, it lasts 5 to 10 years and may be combined with the presence of senile osteoporosis.
Idiopathic osteoporosis: occurs mainly in adolescents and the cause is not yet known.
Secondary osteoporosis
Secondary osteoporosis is defined as osteoporosis caused by any disease that affects bone metabolism, and/or by medications and other clear causes.
Pathogenesis
Primary osteoporosis is a degenerative disease that increases in risk with age.
Osteoporosis can occur at any age, but is most common in postmenopausal women and older men.
The prevalence of osteoporosis in people over 50 years old in China is 20.7% for women and 14.4% for men.
The prevalence of osteoporosis in people over 60 years old is significantly higher, and more prominent in women.
Causes
Causes
The causes of osteoporosis are not clear, but may be related to the following factors:
Endocrine factors
Estrogen deficiency: It is the main cause of postmenopausal osteoporosis in women, and may also be one of the causative factors of osteoporosis in men.
Relative increase in parathyroid hormone: with increasing age, parathyroid hormone levels increase, which can lead to the development of osteoporosis.
Others: Decreased levels of calcitonin and decreased production of 1,25(OH)2D3 can cause osteoporosis.
Nutritional factors
Inadequate intake of dietary calcium or endogenous vitamins (especially vitamin D) can also lead to osteoporosis.
Osteoporosis results from decreased intestinal calcium absorption and increased urinary calcium excretion with advancing age.
Drug Factors
The following drug factors may cause the disease.
Taking adrenocorticotropic hormones for greater than 3 months or using heparin for greater than 4 months.
Taking some antiepileptic drugs.
Thyroid hormone overdose.
Cytotoxic or immunosuppressive drugs: e.g. cyclosporine A, tacrolimus.
Drugs that cause hypogonadism: aromatase inhibitors, gonadotropin-releasing hormone analogs, etc.
Unhealthy lifestyle habits
The following bad living habits may easily lead to osteoporosis.
Lack of exercise, smoking, alcoholism, etc.
Drinking large amounts of strong tea and coffee for a long period of time, etc.
High salt diet, insufficient intake of vitamin D and reduced light exposure, etc.
Other factors
Prolonged bed rest, weightlessness (e.g. astronauts), etc.
Immune diseases, such as rheumatoid arthritis.
Digestive system absorption disorders, motor dysfunction, etc.
Pregnancy or lactation, etc.
Pathogenesis
The pathogenesis of osteoporosis is unknown, and multiple factors contribute to the development of osteoporosis, mainly including:
Inability to obtain appropriate peak bone mass and bone strength
Mainly determined by genetic factors, environmental factors including nutrition and lifestyle also have an impact.
Accelerated bone loss due to increased bone resorption
Mainly caused by estrogen deficiency, calcium and vitamin D deficiency, secondary hyperparathyroidism, and certain cytokines.
Insufficient bone formation during bone reconstruction
Decreased peak bone mass, increased bone resorption and/or insufficient bone formation due to cell renewal defects, decreased growth factors, certain cytokines, etc. due to any cause can cause decreased bone mass and increased bone fragility.
Symptoms
Bone pain, spinal deformity and fragility fracture are the most typical clinical manifestations of osteoporosis.
However, patients usually have no obvious symptoms in the early stage and are often found to have osteoporosis only after the fracture occurs by X-ray or bone density examination.
Main Symptoms
Osteoporosis is asymptomatic in the early stages and is only detected on X-ray or bone mineral density (BMD) measurements.
Bone pain
As the disease progresses, bone pain can develop.
It is more common to have low back pain or pain in the peripheral bones.
The pain worsens or limits movement with increased loading (e.g., weight bearing or increased resistance), and in severe cases there is difficulty turning over, sitting up, and walking.
The pain spreads along the spine to the sides, decreases when lying on the back or sitting, increases when standing upright or sitting for a long time, and becomes more pronounced when bending, coughing, or straining to defecate.
Deformation of the spine
Severe cases of osteoporosis may have spinal deformities such as shortened height, hunchback, and limited extension.
Compression fracture of thoracic vertebrae can lead to thoracic deformity and affect cardiopulmonary function.
Fractures of the lumbar vertebrae may affect gastrointestinal function, leading to constipation, hiatal hernia, abdominal distension, decreased appetite and premature satiety.
Fractures
Mostly fragility fractures are often induced by minor activities (after bending, weight bearing, crushing or falling) or can be spontaneous.
Common sites for fragility fractures are the thoracic and lumbar vertebrae, the hip, the distal radius and ulna, and the proximal humerus.
Fractures can also occur at other sites.
After one fragility fracture, the risk of another fracture increases significantly.
Secondary symptoms
Muscle weakness.
Symptoms worsen with exertion, activity, etc.
Psychological abnormalities can occur due to the impact of the disease on life, including fear, anxiety, depression, and loss of self-confidence.
Consultation
Department of Medicine
Endocrinology
If symptoms such as hunchback, shortening of height, or fatigue occur during menopause, or if osteoporosis is detected on examination, it is recommended to consult a doctor promptly.
Orthopedics
If you have back pain, bone fracture or fracture, we recommend you to consult the doctor in time.
Preparation for medical treatment
Preparation for consultation: registration, preparation of documents, common problems
Tips for medical consultation
It is helpful to keep track of changes in height and progression of the disease to provide reference for the doctor.
Preparation Checklist
Symptom list
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
Are there any symptoms such as low back pain, hunchback, thoracic deformity, weakness, etc.?
Have you noticed any shortening of height in the last 1 year?
List of medical history
Are there any allergies to drugs, food or other substances?
Any long-term use of drugs such as methylprednisolone, dexamethasone, cyclosporine A, tacrolimus, etc.?
Has there been heavy alcohol consumption or dieting?
Have you ever had a bone crack or fracture from a minor collision or fall?
Any diabetes, hypertension, hyperthyroidism, hypogonadism, etc.?
Is there any menopause (female)?
Checklist
Test results of the last six months, which can be brought to the doctor’s office
Laboratory tests: blood electrolytes, urine electrolytes, alkaline phosphatase, parathyroid hormone, renal function, urine routine, blood routine, liver function, thyroid function, blood cortisol
Imaging Tests: Bone Densitometry, Thoracolumbar Spine X-ray Lateral Imaging, Ultrasound of Liver, Gallbladder, Pancreas, Spleen and Kidneys, Cardiac Ultrasound, Pituitary MRI
Other tests: electrocardiogram
Medication List
Medication used in the last 3 months, if available, bring the box or package to the doctor’s office
Anti-osteoporosis drugs: salmon calcitonin, raloxifene, ibandronate, zoledronic acid, teriparatide, alpha-osteol, osteotriol, calcium carbonate, calcium gluconate
Glucocorticoids: hydrocortisone, prednisone acetate, methylprednisolone, dexamethasone
Cytotoxic or immunosuppressive agents: cyclosporine A, tacrolimus
Diagnosis
Diagnosis is based on
The doctor can make the diagnosis by combining the medical history, clinical manifestations and examination findings.
Medical history
The person presenting with the relevant symptoms is an elderly or postmenopausal woman.
There are bad lifestyle habits that can easily lead to osteoporosis, such as insufficient exercise, smoking and alcohol abuse.
Presence of family history of osteoporosis, history of fragility fracture, emaciation, amenorrhea, early menopause, chronic diseases, chronic malnutrition, prolonged bed rest, or prolonged use of drugs that affect bone metabolism.
Clinical manifestations
Sudden onset of unexplained low back pain.
Easily fracture.
Typical manifestations such as height loss or hunchback.
Laboratory Tests
Routine blood tests
Basic laboratory tests include routine blood tests, routine urine tests, liver and kidney functions, blood calcium, phosphorus and alkaline phosphatase levels, urine calcium, sodium and creatinine.
Patients with primary osteoporosis usually have blood calcium, phosphorus and alkaline phosphatase values in the normal range, and blood alkaline phosphatase levels may be mildly elevated when there is a fracture.
Erythrocyte sedimentation rate (sedimentation), C-reactive protein, urine peripheral protein, sex hormones, serum prolactin, parathyroid hormone, thyroid function and other tests may be used as appropriate and are mostly used in the differential diagnosis of etiology.
Bone formation indicators
Bone-derived ALP: synthesized and secreted by osteoblasts, its activity can reflect osteoclast activity.
Osteocalcin: a non-collagenous protein synthesized by osteoblasts, which can represent bone formation function, reflect osteoblast activity, and reflect the level of bone conversion.
Type I precollagen prepeptide: can be used as an indicator of osteoblast activity and bone formation.
Bone resorption indicators
Among the following indicators, the International Osteoporosis Foundation recommends precollagen type I amino-terminal prepeptide (P1NP) and serum collagen type I carboxy-terminal peptide cross-linking (CTX) as biochemical markers of bone turnover with relatively good sensitivity.
Fasting Urine Calcium to Creatinine Ratio: An increased fasting urine calcium to creatinine ratio usually indicates increased bone resorption and may be caused by excessive calcium supplementation.
Blood tartrate-resistant acid phosphatase (TRAP): can reflect the degree of bone resorption.
Blood type I collagen carboxy-terminal peptide cross-linking (CTX) and type I collagen amino-terminal peptide cross-linking (NTX)
are good measures of bone resorption with good sensitivity and specificity.
CTX is more specific and is more commonly used.
Imaging
Dual-energy X-ray absorptiometry (DXA) is currently recognized as the gold standard for the diagnosis of osteoporosis.
Dual Energy X-ray Absorptiometry (DXA)
The DXA measurement is currently recognized as the gold standard for the diagnosis of osteoporosis and is the most widely used method for measuring bone density.
The main measurement site is the mid-shaft bone, including the lumbar vertebrae and the proximal femur. If the measurement of the lumbar vertebrae and the proximal femur is limited, the distal 1/3 of the radius on the non-dominant side can be selected.
The following criteria are used to determine the degree to which the radial bone is
A decrease of less than 1 standard deviation below the peak bone value of a normal adult of the same sex and race is considered normal.
A decrease of 1.0 to 2.5 standard deviations is considered low bone mass (osteopenia).
A decrease of ≥2.5 standard deviations is considered osteoporosis.
A decrease in bone mineral density that meets the diagnostic criteria for osteoporosis and is accompanied by one or more fractures is considered severe osteoporosis.
Quantitative ultrasound measurement
In addition to responding to bone density, it can also analyze bone structure, bone quality, and predict the risk of fracture, and has the advantages of economy and no radiation damage.
The range of application is narrow, only the heel, radius, patella or tibia can be measured.
At present, it is mainly used for the screening of people at risk of osteoporosis and the risk assessment of osteoporotic fracture, but it cannot be used for the diagnosis of osteoporosis and the judgment of drug efficacy.
Quantitative CT
Quantitative CT is a method that measures the bulk density of cancellous and cortical bone separately, and can provide an early indication of the loss of cancellous bone in the early stages of osteoporosis.
Typically, cancellous bone density is measured in the lumbar spine and/or proximal femur.
It can also be used to monitor the efficacy of osteoporosis medications.
Quantitative CT of peripheral bone can be used to assess the risk of hip fracture in postmenopausal women.
Routine X-rays
A plain x-ray of the hand measures the thickness of the cortical bone in the middle of the second metacarpal stem. Normally, the cortical bone thickness should be at least half the diameter of the area.
Thoracolumbar X-ray lateral images may be the test of choice for determining osteoporotic vertebral compression fractures.
Differential Diagnosis
Myeloma
Similarities: Skeletal x-rays show similarities to osteoporosis.
Differences: Myeloma has an increased concentration of globulin in the blood and elevated light chain proteins in the blood and urine.
Metastatic cancerous bone lesions
Similarities: Both have low back pain and a hunchback.
Difference: Metastatic cancerous bone lesions are usually associated with a primary cancer, such as lung cancer.
Hereditary osteogenesis imperfecta
Similarities: The various manifestations are extremely similar to this disease.
Difference: Hereditary osteogenesis imperfecta is accompanied by other congenital abnormalities, such as deafness. If you have similar symptoms and find it difficult to distinguish between them, you need to go to the hospital in time and the doctor will rule out other diseases through examination.
Treatment
Principles of treatment
The aim of osteoporosis treatment is to relieve bone pain, increase bone mass and reduce the risk of fracture.
Currently, the mainstay of treatment is medication, which can be supplemented by general treatment, physical therapy, and possibly surgery in the event of a fracture.
General treatment
Balanced diet
Eat more calcium-rich foods such as milk and cheese.
Eat high protein foods such as fish and eggs.
Avoid foods high in salt such as salted vegetables and canned food.
Avoid excessive consumption of coffee and carbonated drinks.
Regular exercise
Do more outdoor activities such as jogging and walking.
Include plyometrics and weight training.
Follow your doctor’s instructions for training.
Adequate sunlight
Get plenty of sunshine, and you should also be careful to prevent sunburn.
Choose your medication wisely
Use medication under the guidance of your doctor.
Avoid long-term use of drugs that affect bone metabolism, such as heparin and glucocorticoids.
Take calcium supplements as prescribed by your doctor.
Others
Quit smoking and avoid alcohol.
Prevent falls.
Medications
Medications for osteoporosis are mainly categorized into basic supplements and anti-osteoporosis drugs.
Drug treatment for osteoporosis needs to be fully evaluated and requires individualized long-term treatment under the guidance of a doctor.
Basic supplements for bone health
Calcium supplements
Calcium supplements need to be taken in moderation. Super-dose supplementation may increase the risk of kidney stones and cardiovascular disease.
Calcium should be used in combination with other medications in the management of osteoporosis.
Vitamin D
Adequate vitamin D increases intestinal calcium absorption, promotes bone mineralization, maintains muscle strength, improves balance and reduces the risk of falls.
Simultaneous supplementation of calcium and vitamin D may reduce the risk of osteoporotic fracture.
Anti-Osteoporosis Drugs
Indications for osteoporosis drug therapy:
Primarily includes patients who have been diagnosed with osteoporosis by bone density testing;
Those who have already had fragility fractures in areas such as vertebrae and hips;
Patients with reduced bone mass who are at high risk of fracture.
Calcitonin
Calcitonin prevents acute bone loss, such as that caused by prolonged bed rest after surgery or braking after a fracture.
It promotes calcium absorption into the bones, reduces bone pain and improves quality of life.
The synthetic calcitonin commonly used in clinical practice is salmon calcitonin.
Calcitonin salmon is not used continuously for more than 3 months.
Estrogenic drugs
Estrogenic drugs can inhibit bone resorption, but can only be used in women.
For women with menopausal symptoms such as hot flashes, sweating, etc. and osteoporosis, they can be started early in menopause with greater benefit and less risk.
Estrogenic drugs are not recommended if you have breast cancer, endometrial cancer, thrombophilia, unexplained vaginal bleeding and active liver or connective tissue disease.
Selective estrogen receptor modulator class
These drugs bind to estrogen receptors in the bone and exert estrogen-like effects, inhibiting bone resorption, increasing bone density, and reducing the risk of vertebral fractures.
Commonly used drugs include raloxifene drug, but raloxifene is not suitable for men with osteoporosis.
Bisphosphonates
Bisphosphonates can effectively inhibit bone resorption, increase bone density and reduce the risk of fracture.
Bisphosphonates are one of the most widely used and effective anti-bone resorption drugs.
Commonly used bisphosphonates include alendronate, zoledronic acid, ibandronate, etidronate disodium and clodronate disodium.
Parathyroid hormone analogs
Intermittent use of small doses of parathyroid hormone analogs stimulates osteoblast activity, promotes bone formation, increases bone density, and reduces the risk of vertebral and nonvertebral fractures.
Representative drugs include teriparatide, and treatment should not exceed 24 months.
Strontium salt
Strontium salt has the dual effects of inhibiting bone resorption and promoting bone formation, which can reduce the risk of vertebral and non-vertebral fractures.
Representative drugs include strontium ranelate. However, they should be used with caution in individuals with a high risk of venous thrombosis, a previous history of venous thrombosis, and a history of drug allergy.
Active Vitamin D and its analogs
This class of drugs is indicated for the elderly, patients with reduced renal function, and patients with 1 alpha hydroxylase deficiency or reduction to increase bone mineral density, reduce falls, and decrease the risk of fracture.
Commonly used drugs include alpha-osteol and osteotriol.
When using these drugs, it is not advisable to supplement with larger doses of calcium at the same time, and it is recommended that patients’ blood and urine calcium levels be monitored regularly.
Vitamin K
Have the effect of increasing bone mass.
Commonly used drugs include tetraenylmenaquinone.
RANKL inhibitors
Can reduce osteoclast formation, function and survival, thus reducing bone resorption, increasing bone mass and improving the strength of cortical or cancellous bone.
Commonly used drugs include dinosemide.
Physical Therapy
Physical therapy can be used to treat osteoporosis by relieving pain, improving blood circulation and increasing bone density.
Pulsed electromagnetic fields, extracorporeal shock waves, whole-body vibration, ultraviolet light and other physical factor treatments can increase bone mass.
Treatments such as ultrashort wave, microwave, transcutaneous electrical nerve stimulation, and intermediate frequency pulse can reduce pain.
Surgery
Surgical treatment is required when fractures occur due to osteoporosis. Depending on the location and degree of the fracture, minimally invasive surgery or traditional surgery can be chosen.
Minimally invasive surgery
Percutaneous vertebroplasty and kyphoplasty are one of the new advances in minimally invasive spine treatment.
It is suitable for fresh vertebral compression fractures without spinal cord or nerve root symptoms and severe pain.
It has better pain relief effect.
Treatment of comminuted fracture
Elderly osteoporotic distal radial ulna fracture is mostly comminuted fracture, and involves the articular surface, the fracture is easy to residual deformity after healing, often resulting in wrist and finger dysfunction.
The treatment generally adopts manipulation and reduction, and can be fixed by splint or plaster, or external fixator.
For a few unstable fractures, surgery can be considered.
Treatment of hip fracture
Hip fracture has the following characteristics:
High mortality rate, prone to complications such as pneumonia, urinary tract infection, decubitus ulcer, lower extremity venous thrombosis.
High rate of osteonecrosis and non-union.
High rate of deformity and disability.
Slow recovery.
Surgical treatment includes internal fixation, artificial joint replacement and external fixator.
Non-surgical treatment is also available.
Precautions after treatment
Some people taking bisphosphonates may experience adverse reactions such as fever, vomiting, dizziness, abdominal pain, ulcerative stomatitis, indigestion, etc. Antiemetic drugs and gastric mucosal protectants can be taken under the guidance of the doctor to relieve the symptoms.
If serious conditions such as gastrointestinal bleeding occur, the medication needs to be stopped promptly and hospitalization is required.
Some people using calcitonin will experience adverse reactions such as rash, itchy skin, angina, arrhythmia, abdominal cramps and dizziness.
Prognosis
Cure
It is difficult to generalize about the cure of osteoporosis, as it is influenced by the primary disease and the degree of control of risk factors.
The determinants of cure are as follows:
Whether the primary disease causing osteoporosis is cured or controlled.
Whether the patient’s risk factors for having osteoporosis are minimized.
Whether initial and recurrent fractures can be prevented.
Hazards.
A serious consequence of osteoporosis is the development of osteoporotic fractures (fragility fractures), i.e., fractures that can occur in response to minor trauma or daily activities.
Common sites for fractures to occur are the spine, hip and distal forearm.
Daily
Daily Management
Diet
Consume calcium-rich foods
Eat a balanced diet.
Eat enough calcium-rich foods and consume 300 ml of milk or an equivalent amount of dairy products daily.
Vitamin D supplementation
Vitamin D helps in the absorption of calcium.
Animal livers, egg yolks, marine fish, cod liver oil and mushrooms are all rich in vitamin D.
Eat meat in moderation
Eat about 200 grams of lean meat and fish every day.
Adequate protein can promote the absorption and storage of calcium.
Reduce salt intake
Try to eat less salty food, preserved food, canned food and other high-salt food.
Avoid alcohol
Alcohol accelerates bone loss and aggravates osteoporosis, people suffering from osteoporosis must avoid alcohol.
Lifestyle Habits
Exercise
More outdoor exercise such as jogging and walking is not only conducive to calcium absorption, but also strengthens muscle power, which helps improve the ability to resist fractures.
Exercise helps improve blood circulation and bone density.
Avoid hiking, ball games, etc. to avoid falling and causing fractures.
Improve the living environment
Keep the room clean.
Avoid excessive clutter on the floor and the floor should be non-slip.
Keep the room bright.
Maintain sufficient sunshine
Sun exposure is good for vitamin D synthesis, but care should be taken to protect sensitive areas such as the eyes from the sun.
Maintain a good mood
Maintain a good mood, do not have too much psychological pressure.
Follow-up and review
In general, osteoporosis patients should follow the doctor’s instructions for medication and regular checkups.
For those who have bone fracture and other complications, follow the doctor’s instructions to review on time, so that the doctor can understand the condition and formulate a follow-up treatment plan.
If symptoms such as rash, itchy skin, abdominal pain, fever, vomiting, etc. appear, you need to consult a doctor promptly.
Prevention
Primary prevention means that people who do not yet have osteoporosis but have risk factors for osteoporosis should prevent or delay the onset of osteoporosis and avoid the first fracture.
Secondary prevention refers to those who already have osteoporosis or have had a fragility fracture, where the ultimate goal of prevention and treatment is to avoid a fracture or re-fracture.
Adolescence
Enhance exercise and ensure sufficient calcium intake.
At the same time, prevent and actively treat various diseases, especially chronic wasting disease and malnutrition, malabsorption and so on.
Prevent and treat various gonadal dysfunction diseases and growth and development diseases.
Avoid long-term use of drugs that affect bone metabolism to reduce the risk of osteoporosis.
Adulthood
Try to slow down the rate and extent of bone loss. For postmenopausal women, early supplementation of estrogen, or estrogen and progesterone combination should be taken.
Preventing fractures in osteoporotic patients and avoiding risk factors for fractures can significantly reduce the incidence of fractures.
Special Reminder
Once an osteoporotic fracture occurs in osteoporotic patients, it will lead to various complications and even cause disability or death, so the prevention of osteoporosis is more important than the treatment.
Osteoporosis can be prevented or treated, and early prevention can avoid osteoporosis and its fractures.
Even if a fracture has occurred, as long as appropriate and reasonable treatment is taken, the risk of another fracture can still be effectively reduced.
Taking the initiative to learn about osteoporosis, striving for early diagnosis, and predicting the risk of fracture in time are all important measures to prevent osteoporosis.