compression fractures of the spine are the bread and butter of radiology. And
for 25 years of viewing these xrays, it was frustrating that many women were
obviously not taking their calcium tablets and instead presented with end stage
disease. Over the years, we witnessed many fashionable procedures which eventually
faded away. One procedure still in vogue is the rather barbaric injection
of glue into the osteoporotic compression fracture under x ray control, called
Invented in 1984 by the French and introduced into the US by Mary Jensen MD, the procedure is not for the light hearted. During injection, the acrylic cement may flow into the epidural venous plexus leading to venous thrombosis or pulmonary embolus. The more refined Kyphoplasty version involves inflation of a balloon device to expand the collapsed vertebral body just prior to injection of cement into the cavity. Pain reduction is the goal and is usually achieved.
On the surface, it
might appear callous for the medical system to wait years until millions of
women develop compression fractures, and then intervene with glue
injections. Perhaps some form of
prevention would make more sense. While
the usual recommendation of calcium tablets didn’t seem to be completely effective,
the best preventive plan can be found in Russell Jaffe’s article, Acid-Alkaline
Balance and its Effect on Bone Health. Russell
Jaffe is a charming and humorous fellow who informed our small group of docs at
his course that in the old days he ran a lab at the NIH was actually appointed
assistant surgeon general for one day, but quit as it wasn’t his cup of tea.
According to him, excess
acid production from the American diet causes the chronic calcium loss of
osteoporosis, because calcium is pulled from the bones and used up to buffer the
urinary acids. With the help of alkaline
food charts, and pH test strips along with the usual calcium and vitamin
supplements, osteoporosis can be arrested and gradually reversed in a process
which may take years. I would add that bio-identical
hormonal supplementation is also useful.
For the impatient ones
who wish to see a prompt increase in bone density, the FDA approved the
biphosphonate drug Fosamax (alondronate) which was first introduced in 1995. Merck made 3.2 Billion on 22 million Fosamax prescriptions last year. The major study, (FIT)
Fracture Intervention Trial, showed lower fracture rates in the drug group.
What could alondronate have in common with Toulouse Lautrec, the famous Impressionist artist? His name came up in conversation at the art studio, and nobody knew the cause of his short stature. It turns out that Toulouse’s parents were first cousins which gave him the autosomal recessive genetic disease called, pycnodysostosis, which means dense bones. I had seen this in radiology board study materials, but never in actual practice. Gelb (link) found this “dense bone disease” to be caused by a genetic defect in cathepsin K, a protease enzyme of the osteoclast cells responsible for removing and remodeling bone. Resultant bone is dense on xrays, yet under the microscopic, there is profound deterioration in trabecular architecture and lamellar arrangement which is presumably the reason for spontaneous fracture and jaw necrosis (link).This osteoclast dysfunction and resulting bone fragility explains why Toulouse had spontaneous fractures of both mid femurs at the age of 12 and 14. The fractures never healed and he attained a height of 4.5 feet (see figure to the right).
Fosamax and Actonel, are taken up by osteoclasts with resulting loss of
osteoclast activity and inhibition of bone resorption, and bone remodeling (link). Although DEXA scanning confirms increased bone
density and studies such as the FIT
suggest reduced fracture rate, Susan Ott, MD raises questions about the long term safety of
bisphosphonates. Although the bisphosphonates appear to have short term
benefits, she speculates that after 5
years of use, there is severe
suppression of bone formation with negative effects such as microdamage and
Jennifer P. Schneider, MD, PhD reports a 59-year old previously healthy woman on long-term alendronate. While on a subway train in New York City one morning, the train jolted, and the woman shifted all her weight to one leg, felt a bone snap, and fell to the floor, suffering a spontaneous mid -femur fracture (see image). In the months following, it became clear that the fracture was not uniting. Schneider speculates that increased bone density from the bisphosphonate drug does not necessarily equate with good bone quality. By decreasing osteoclast activity and bone resorption, and therefore bone formation as well, microdamage, and brittle bone may result in fractures.
on 9 cases of spontanous fracture while on alendonate. Five
of the nine cases were spontaneous mid femur fractures. Two had bilateral mid femur fractures same as
Toulouse. Six cases had delayed or absent fracture healing. Histomorphometric analysis of the
cancellous bone showed markedly suppressed bone formation, and
Odvina raised the possibility that
severe suppression of bone
turnover could develop during long-term alendronate therapy, resulting
in increased susceptibility to, and delayed healing of, nonspinal
Dimitrakopoulos reports on 11 patients presenting with necrosis of the jaw, claiming this to be
a new complication of bisphosphonate
therapy administration, i.e. osteonecrosis of jaws. He advised clinicians to
reconsider the merits of the rampant use of bisphosphonates. Osteonecrosis of
the jaw is a common finding in pycnodysostosis. The bisphosphonates recreate the same
clinical profile of spontaneous mid femur fractures, failure of bone
healing and jaw necrosis which tormented
In spite of this well known information, there are four more drugs in clinical trials which are specifically designed to inhibit cathepsin K, the enzyme defect in Lautrec's genetic bone disease. FDA approval for use in osteoporosis treatment is expected. Excuse me here, but perhaps this thinking needs re-evaluation. In essence we are creating a population of women with Toulouse Lautrec’s bone disease. Ironically, women who sustain fractures while on Fosamax are told by their docs that the fractures are due to the underlying osteoporosis, not the drug. For example, recently a friend’s wife sustained a fractured elbow after minor trauma at home in the kitchen. She claims that, if not for the biphosphate drug, her fracture would have been much worse.
Jeffrey Dach M.D. is board certified in interventional
radiology and a member of the Board of the American Academy of Anti-Aging
Medicine. He retired from radiology two years ago, and is currently in private
practice focusing on bio-identical hormone treatment.