ANSWER 31
This woman has vertebral collapse due to osteoporosis. The symptoms of osteoporosis
are deformity, localized pain and fracture. The loss of height is typical, and is usually
noted more by others than the patient. The back pain is due to collapse of the vertebrae.
This can occur spontaneously or in association with a recognized stress such as carrying
a heavy load. Examination confirms loss of trunk height, thoracic kyphosis and proxim-
ity of the ribs to the iliac crest.
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- Multiple myeloma
- Metastatic carcinoma, particularly from the prostate, breast, bronchus, thyroid and
kidney - Osteomalacia
- Hyperparathyroidism
- Steroid therapy or Cushing’s syndrome
The differential diagnoses of osteoporosisThis patient has several risk factors for osteoporosis. Firstly she is aged 75 years, and age-
ing is associated with bone loss. Secondly she has been postmenopausal for over 30 years.
Premenopausal ovarian production of oestrogens help to preserve bone mass. Thirdly she
has been on oral and inhaled corticosteroids for her asthma for years. Finally, excess alco-
hol intake may also be a factor. Her red cells are macrocytic, which is consistent with heavy
alcohol intake. Alcohol can lead to an increased incidence of falls and fractures. She has
no clinical evidence of thyrotoxicosis or hypopituitarism which can cause osteoporosis.
This woman should have blood tests to exclude myeloma, cancer and metabolic bone dis-
ease. Patients with myeloma are anaemic with a raised ESR and a monoclonal paraprotein
on serum protein electrophoresis. In contrast to metabolic bone diseases biochemical meas-
urements (serum calcium, alkaline phosphatase and parathormone (PTH)) in osteoporosis
are normal. She should have plain X-rays of her spine. Collapse of the vertebral body will
manifest as irregular anterior wedging affecting some vertebrae and not others (L1 and L4).
A dual-energy X-ray absorptiometry (DEXA) scan can be performed to assess the severity
of the osteoporosis, but treatment is indicated anyway with a fracture at this age.
She should have her dose of corticosteroids reduced to the minimum required to control her
asthmatic symptoms, using the inhaled routes as far as possible. She should be started on
calcium and vitamin D supplements and a bisphosphonate to try to reduce her bone loss.
Oestrogen-based hormone replacement therapy is only used for symptoms associated with
the menopause because of the increased incidence of thromboembolism and endometrial
carcinoma. Newer treatments for osteoporosis include strontium and parathyroid hormone.
- Osteoporosis is common in the elderly.
- Bone loss is more rapid in women than men.
- DEXA scan is the method of choice of screening for osteoporosis.
- There are increasingly effective treatments available for the treatment of osteoporosis.