Osteoporosis: Silent villain can cause major pain

14th September, 2015

It’s amazing how quickly my role switched from physician to patient, thanks to a silent assailant: osteoporosis.

I went to the gym in the morning before work 12 days ago, as I often do now that my children are all grown up and out of the house. First, a couple of light sets of leg exercises served as a warm-up, and then I started a set with a barbell on my shoulders. I’ve been doing weight training for years, since my mother suffered badly from osteoporosis and I knew I was at risk. Weight training, along with calcium and Vitamin D, can help maintain bone density.

The weight was average for me, and I was halfway through my second set of 12 repetitions when suddenly there was a loud noise, like a sharp crack or pop, that people in the gym heard 10 feet away. I felt my mid-spine collapse downward what seemed like an inch, accompanied by sharp pain. The trainer grabbed the weight, helped me lie down, and called my husband.

I did a quick self-assessment.

Can I move everything? Check.

Is anything numb? No.

Can I do a straight leg raise without more pain? Yes.

This confirmed that I didn’t have any spinal cord injury and probably didn’t have a herniated disk. The most likely diagnosis was a spinal compression fracture, which turned out to be exactly what happened.

Off to the emergency room

My husband insisted on driving immediately to the emergency room, which gave me a little time to reflect.

By coincidence, September is “Pain Awareness Month”, and I had been wanting to write a piece in support of the American Chronic Pain Association and the American Society of Anesthesiologists‘ recognition of pain as an endemic problem. Chronic pain ruins lives, and inappropriate treatment of pain with narcotics too often leads to addiction, overdose, and death.

But what to write?? I treat acute pain in my daily work as a physician anesthesiologist looking after patients in the immediate recovery timeframe, right after surgery. Sometimes I take Aleve for a headache, but that’s about it. Now, of course, it seemed much likelier that I would have a story to tell.

Luckily for me, the Cedars-Sinai Medical Center emergency room was relatively quiet at 6 a.m. The staff whisked me off to X-ray, and the technician quickly took supine and lateral films. He said, kindly, “Ma’am, I’m not a doctor, but it looks to me like you have a compression fracture.” He printed out the films for me to see, and of course he was right. A nurse gave me some morphine, which eased the pain considerably, and then it was time to consider next steps.

Conservative treatment or intervention?

My fracture was at the level of the 12th thoracic vertebra or “T12”, the commonest site for compression fractures. This is hardly a rare problem. One in four American women will have a vertebral compression fracture during her lifetime, and men can suffer them too. The most common cause is osteoporosis, a condition in which bone loss over time results in weak, brittle bones.

The emergency room physician ordered a CT scan to see the extent of the fracture in more precise detail, and to see whether or not any bone fragments were endangering the spinal cord. Then he called a neurosurgeon, Dr. Khawar Siddique, to see me.

The neurosurgeon outlined treatment options. Basically, there were three:

Conservative treatment: a back brace, pain medications, and 6-8 weeks of rest, with gradual mobilization;

Surgery: thoracic fusion;

Kyphoplasty: a less invasive procedure to stabilize the fractured vertebra.

Thoracic fusion surgery would be the nuclear option — my spine wasn’t unstable despite the fact that one bone fragment protruded posteriorly toward the spinal cord, and I wasn’t the least bit interested in having metal rods inserted in my back, so we ruled that out quickly.

Conservative treatment?  I really didn’t want to spend 6-8 weeks at home in a back brace. Two of the partners in my anesthesiology practice, who had come to see me in the ER, collared the neurosurgeon in the hall and explained to him that there was no way I would be patient enough or compliant enough to put up with 6-8 weeks of idleness.

Dr. Siddique agreed that early kyphoplasty was probably what he would choose in my situation. It offered the best chance of quick pain relief and early return to work. It also offered the immediate hope of restoring height to the collapsed vertebra, and reducing the risk that I would end up with permanent spine curvature — the “dowager’s hump“.

So I was admitted to the hospital to rest for the night, with a plan for kyphoplasty the next morning. This is a minimally invasive procedure, performed under local anesthesia with sedation.

At my hospital, kyphoplasty is performed by a radiologist in the interventional radiology suite, though it may also be done by a neurosurgeon in the operating room. Two large-bore needles or “trocars” are inserted into the fractured vertebra, and small balloons are inserted via the trocars. The balloons are inflated to create a space inside the vertebra and restore the height that was lost in the vertebral collapse. The balloons are withdrawn, and then a type of cement is injected to fill up the new space. The trocars are removed and the cement hardens quickly. The entire procedure takes about half an hour. Thanks to the sedation, administered and carefully monitored by a physician anesthesiologist who’s another one of my partners, I dozed from start to finish.

That was the easy part

Armed with a new Jewett back brace and a bottle of pain medication (Norco), I went home the same day. In retrospect, being in the hospital was the easy part. I’m certain that the pain has been considerably less than it would have been without the kyphoplasty procedure to stabilize the bone, but the recovery has turned out to be more challenging than I expected.

The normal response to a back injury is for the muscles on either side of the spine to tighten up and go into spasm. This reflex helps stabilize the spine and avoid further injury. But those back spasms don’t go away instantly, and they’re much more uncomfortable than I would have imagined.

There are huge risks to taking a lot of narcotics — it’s easy to escalate their use and become addicted. All narcotics are chemical derivatives of opium, and are often termed “opioids”. These include standard pain medications like morphine, Demerol, Dilaudid, Norco, Vicodin, and Oxycontin. Once a patient gets used to taking large doses, the body becomes physically dependent and the habit is brutally hard to break.

There are minor side effects too — drowiness, constipation, and nausea, among others. I hated how groggy Norco made me feel, and preferred non-steroidal anti-inflammatory medications (NSAIDs) such as Aleve or Motrin. But I soon learned that NSAIDS weren’t a good option right after a fracture, as they slow down the normal process of bone healing.

I developed my own daily routine over the next week. Tylenol worked fine (though not as effective as Norco), and a prescription medication called Robaxin (methacarbamol) helped with the muscle spasms. I alternated mile-long walks with Milo, my dog — the only exercise allowed — with resting on the sofa with a heating pad.

Osteoporosis was the culprit

After a week at home, I went for a consultation with a specialist in osteoporosis, Dr. Stuart Silverman. He repeated a bone density scan and confirmed what I already suspected to be true. My previous diagnosis of “osteopenia”, or reduced bone mass, had escalated to full-blown osteoporosis in my spine. On that morning in the gym, my T12 vertebra just couldn’t handle the weight and suddenly collapsed. This could happen at any moment — sometimes just a vigorous sneeze can cause a vertebral fracture, or it could easily have happened the next time I picked up one of my grandsons.

Dr. Silverman pointed out one important fact about kyphoplasty. It may increase the risk of fracture in the vertebrae above and below the fracture. Think of a basket of eggs, and imagine that just one of the eggs is filled with hard cement. If the cement-filled egg bumps into another egg, that egg is much more likely to break. That image is a vivid reminder to move smoothly, use good body mechanics, and not lift any object heavier than a cat.

There are several choices of medications to treat osteoporosis. They fall into two types:  antiresorptive medications that slow bone loss, and anabolic drugs that increase the rate of bone formation. The National Osteoporosis Foundation is an excellent resource for facts about osteoporosis and information about the different drugs available. Any decision about treatment of osteoporosis involves a full discussion with your physician of the risks and benefits of medication in your particular situation. I’ve started on the medication that Dr. Silverman and I decided is the best choice in the setting of an acute fracture.

Other than the occasional twinge of muscle pain, I’m fine and ready to go back to work tomorrow. I feel very fortunate that kyphoplasty was immediately available, and that my osteoporosis has been diagnosed and treated sooner rather than later.

Acute pain can be treated thoughtfully with selective opioids as well as non-opioid pain medications — an approach known as “multimodal analgesia”. Acute pain doesn’t need to turn into chronic pain. That’s a message we hope everyone hears during #PainAwarenessMonth.

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