The dilemma of isolated vertebral osteoporosis

FG is a 69-yr old white man who presented to establish primary care and requested bone density screening because his father had had severe osteoporosis of unclear cause. He had a past medical history of atrial fibrillation and hypercholesterolemia. His medications included diltiazem, flecainide, simvastatin, and warfarin.

A bone density was performed.The L1-L4 BMD was 0.974 g/cm (T-score -1.07), but the L4 BMD was 0.913 g/cm, with a T-score of -2.11. Mild osteopenia was seen at the femoral neck with a BMD of 0.761 g/cm (T-score -1.2). Based on these results, the patient was advised to take 1200 mg of calcium and 800 IU of vitamin D daily.Four months later, the patient presented after a fall with lower back pain radiating around his flanks bilaterally. Workup revealed an acute L4 fracture. Biochemical evaluation for osteoporosis was done and was remarkable for a low testosterone level. Treatment was initiated with alendronate 70 mg po q week, and the patient accepted testosterone replacement to help with erectile dysfunction.The researcher offers this case report as an example of the dilemma of isolated vertebral osteoporosis; under current guidelines, the researcher averaged L4 with the rest of the lumbar spine and so did not start treatment. In retrospect, one may question whether he would have benefited from starting a bisphosphonate earlier.(Source: PMID: 15618609 [PubMed – in process])