Diagnosing Osteoporosis for the Spine Practitioner

STUDY DESIGN: Literature review. OBJECTIVES: Review updated criteria that categorize patients' bone health for operative and nonoperative patients. SUMMARY OF BACKGROUND DATA: Osteoporosis is common in spine patients including those with fragility fractures and in the elective surgery population. Untreated osteoporosis is associated with secondary spine fractures and increased likelihood of osteoporotic bone-related complications after elective surgery. Recently, the definition of osteoporosis is expanded beyond use of bone mineral density (BMD) to also include fracture history and fracture risk. Most spine practitioners are not aware of this definition. METHODS: Recent clinical guidelines and recommendations for the diagnosis of osteoporosis are reviewed. Included are the use of dual x-ray absorptiometry (DXA), adjuncts such as trabecular bone score and vertebral fracture assessment, and other factors such as comorbidities, fracture history, and opportunistic use of other imaging studies. RESULTS: The use of the clinical diagnosis based on BMD, fracture history, and fracture risk increases the diagnosis of osteoporosis in spine patients. BMD is measured using DXA, which is sensitive and precise, although errors in analysis and interpretation are common. Fracture history is a strong predictor of secondary fracture and poor surgical outcomes. Reducing fracture risk is the goal of medical treatment, but it is rarely performed by spine practitioners. Fracture risk can be stratified into low, high, and very high-risk groups. High and very high-risk patients are candidates for medical management. Other clues to the presence of osteoporosis that should prompt further bone health assessment are based on history, height loss, risk factors, and opportunistic use of plain radiographs, CT, and MRI. CONCLUSIONS: Spine practitioners should be aware of newer concepts in the diagnosis of osteoporosis. Utilizing the clinical diagnosis of osteoporosis based on BMD thresholds, fracture history, and fracture risk will identify patients who should be considered for further health assessment and treatment.