1. SURACHAI SAE-JUNG, MD, PhD Department of Orthopaedics Khon Kaen University

2. Bone density accounts for 60% to 80% of bone strength in untreated patients 1 One of best early predictors of fracture risk 2 Diagnosis before fractures T-score Relative Risk of Hip Fracture 0 10 20 30 -5-4-3-20 1.Kushida K. Clin Calcium. 2004;14:11-17. 2.Fogelman J, Blake GM. J Nucl Med. 2000;41:2015-2025.

3. 10-Year Probability of Symptomatic Fracture (%) Age is a major risk factor for fracture Permission from Springer Science+Business Media: Kanis JA,et al. Ten year probabilities of osteoporotic fractures according to BMD and diagnostic thresholds. Osteoporos Int.2001;12:989-995. 80 70 60 50 AGE Age 50 T-score -2.5 12% Fx Risk Age 70 T-score -2.5 24% Fx Risk -3-2

4. Most are compression Fx at T7 to L2 Osteoporotic Fx is a signal for subsequent Fx. Woman with spine Fx had 4x risk of further spine Fx Asymptomatic to severe pain/disability Natural history: acute pain  resolve pain (4-6 wk of healing) Persistent pain may be new Fx/delay healing Men Fx pattern: follow women for 10 years Ross PD, Osteoporosis: epidemiology and risk assessment. J Nutr Health Aging. 1998;2(3):178-83

5. Main clinical symptom/sign Pain Height loss: > 6cm spec/sens=94%/30% Kyphosis: 15 o per height loss 4 cm Neurological deficit

6. BMD Women ≥ 65 yrs, men ≥ 70 yrs 50-69 yrs with risk factor(s) All patients with fragility Fx Vertebral imaging Women > 70 yrs, men ≥ 80 yrs Before this ages with BMD ≤ -1.5 Before this ages with fragility Fx, long term steroid uses, height loss ≥ 4 cm

8. ConservativeSurgery Life style/exerciseVertebroplasty Reduce alcoholKyphoplasty Calcium/vitamin DPedicle screw/wiring Anti-resorptive Anabolic Medication: 40-60% (new Fx prevention)

9. Initial: pain control, activity modification Acetaminophen, NSAIDs, COX-2 inhibitors, opioids 2-4 weeks of calcitonin Until the patient can start up to get the more effective drug regimens.

10. PreventionTreatment FDA-Approved Therapeutic Options Estrogen Alendronate Risedronate Ibandronate Zoledronic acid Raloxifene Calcitonin PTH (teriparatide) Denosumab Strontium ranelate

11. Calcitonin Not 1 st line, adjunct to analgesics Some role in reduction of Fx risk Some role for increasing BMD Not for long term use (due to risk of cancer) AAOS recommend 4-wk calcitonin in neurologically intact OVCF patient who had intractable pain

12. Bisphosphonates Limited evidence for acute pain relieving Use as option for long term management Alendronate/risedronate: reduce new Fx (50% ) Strontium ranelate/ PTH/ denosumab are recommended as alternative treatment options

13. Muscle relaxants Limited evidence for short term pain relief in non-specific back pain No RCT to prove benefit in osteoporotic Fx

14. Limited evidence for bracing in osteoporotic spine Fx Not recommend bracing for management of pain

15. Vertebroplasty VS kyphoplasty Timing for these is controversial. **** Most spine Fx can be treated successfully with conservative treatment AAOS/NICE guideline: option for painful Fx Insufficient evidence to select whom would most likely benefit from vertebral augmentation

16. Meta-analysis of observational studies: no difference between these RCTs: no difference between these Kyphoplasty: better in postop in vertebral height (6mm) & kyphosis correction (5 o )

17. VAS difference Shi-ming G, Indian J Orthop 2015; 49:377-87.

18. Kyphotic angle & vertebral height Shi-ming G, Indian J Orthop 2015; 49:377-87.

19. ODI Shi-ming G, Indian J Orthop 2015; 49:377-87.

20. Some evidences: augmentation better than placebo in term of pain, disability Limited evidence: augmentation better than sham operation in term of pain, disability No trials to support long term benefit

21. Adverse events Cement leakage: 11-73% Pulmonary emboli: 5-23% Risk of new Fx: Odds=6.8 (compare to no Tx)

22. Poor bone stock: difficulty in achieving fixation & fusion Longer fixation & fusion (3 upper + 3 lower) Avoid stop fixation at C-T or T-L junction Screw augmentation: cement augment with screw, fenestrated or expandable screw inconclusive evidence to proof the best technique

23. Calcitonin: for pt not response to analgesics (grade 2B) Skeletal muscle relaxants: no benefit for acute pain management (2C) Pt not response to parenteral analgesics: the vertebral augmentation is recommended(2c) Pharmacologic treatment is recommended for long term treatment (1A)

24. PatientTreatment line Treatment OVCF1 st Bed rest plusAnalgesia/ pain clinic consultation plusOrthosis plusLong term osteoporosis drugs With severe un-relieving pain adjunctVertebroplasty/kyphoplasty/ open surgical stabilization >30 o kyphosis Severe collapse plusSurgical stabilization ± vertebroplasty/kyphoplasty

26. DrugsDoseOutcomeComments Ca1-1.2 gmsupplement Vit D800-1000 iusupplement BisphosphonatevariesAnti-resorptiveOral/iv Terriparatide20 µg sc/day +++BMDCramp/ risk of Osteosarcoma EstrogenvariesMaintain BMDMI/DVT/CA Raloxifene60 mg/day- Vertebral FxDVT Calcitonin200 iu/day- Vertebral Fxrhinitis Denosumab60 mg sc/6 mo ++BMDbody pain,ONJ pancreatitis

27. Drugs for osteoporosis with high risk Fx Strontium: *** caution in circulatory disease Terriparatide Denosumab