When I was in medical school over 40 years ago, we understood that old bones got soft and crumbled. In the spine that crumbling often took years. The vertebrae grew osteophytes and became sclerotic in a vain attempt to stop this totally natural process. We called it Natural Degenerative Kyphosis of Age. More important, there was nothing we could do to stop progressive kyphosis.
In my orthopedic training I was taught that similar slow crumbling deformities of Paget’s and Osteogenesis Imperfecta were bad and should be treated. Arthritic progressive deformity in knees and hips is treated. Somehow the progressive deformity of kyphosis has been left out when it comes to treatment. We can and should stop progressive kyphosis.
If I see a single Vertebral Compression Fracture Deformity of 25% or more, that is Osteoporosis. I can treat it. If there are multiple Vertebral Compression Fracture Deformities of 25%, the clinical effects are far more serious. To say that multiple vertebral deformities are not osteoporosis because they are progressing slowly and have not visibly crunched recently, does the patient no service. Granny once had a straight spine. Kyphosis looks the same as Paget’s or OI to an orthopod.
I have patients with 4, 5, 6, or more Genant Grade 1 Vertebral Wedge Deformities. The total kyphotic deformity on supine VFA can be 60 or even 90 degrees, but no single vertebra makes it to the magic 25% to be a Grade 2. We need to treat this patient the first time we see her, not have to wait for further progression of this life threatening condition.
Many insurers strongly resist non oral meds, even in patients with severe GERD, unless the diagnosis is Osteoporosis. The 80 year old with GERD, hips at -2.4, and major kyphosis should not have to wait for one vertebra to crunch past 25%. FRAX tells us what to do. Let’s do it.
We as a society need to formally revisit our definitions. We need to treat patients, not numbers.
Jay Ginther, MD, CCD