Back Pain, Disability, and Vertebral Fractures in Elderly Women
August 30, 1998 3 minutes read
Back Pain, Disability, and Vertebral Fractures in Elderly Women
ABSTRACT & COMMENTARY
Synopsis: New vertebral fractures, even those unrecognized clinically, are associated with significant back pain and disability in elderly white women, and active treatment of vertebral osteoporosis should reduce this burden of mortality.
Source: Nevitt MC, et al. Ann Intern Med 1998;128:793-800.
Vertebral fractures affect 5% and 25% of women 50 years and 80 years of age, respectively. A hallmark of postmenopausal osteoporosis, such fractures predict an increased risk of additional vertebral and other bone fractures. Two-thirds of new vertebral fractures may go unrecognized, however, suggesting that most vertebral fractures are asymptomatic.1,2 In this study, 7223 white women older than 65 years underwent lateral thoracic and lumbar spine radiographs at baseline and again at follow-up an average of 3.7 years later (range, 1.3-5.1 years) to determine whether new vertebral fractures were associated with back pain and disability in older women. Baseline and annual assessment of back pain and limitation of activity were performed using a standard questionnaire.3 Potential confounding factors were evaluated, including smoking, inactivity, a previous diagnosis of osteoporosis or spine fracture, and estrogen use. Standard t-test and logistic regression techniques were used for statistical analysis.
Twenty percent of the group had a baseline vertebral fracture. During a mean of 3.7 years of follow-up, incident vertebral fractures occurred in 5.1% overall (annual risk, 1.4%), but were four times more frequent among those with a fracture at baseline (13.8% vs 3.0%). In the absence of any fracture at baseline or during the study (23% and 15%, respectively), participants had increased back pain and disability during follow-up. In the absence of any fracture at baseline, those with an incident fracture during follow-up were 2.4 times more likely to have back pain, 2.6 times more likely to have back disability, 6.7 times more likely to require at least one day of bed rest annually due to back pain, and 3.8 times more likely to require seven days of limited activity annually due to back pain. Among women with a fracture at baseline and an incident fracture during the study, back pain was twice more common and back disability was 2.2 times more common. Additionally, at least one annual day of bed rest due to back pain was 7.9 times more common, and seven days of limited activity annually due to back pain were 3.5 times more common. New vertebral fractures, even those unrecognized clinically, are associated with significant back pain and disability in elderly white women, and active treatment of vertebral osteoporosis should reduce this burden of morbidity.
COMMENT BY MICHAEL RUBIN, MD
Vitamin K deficiency is associated with vertebral and other bone fractures,4 raising the possibility that warfarin, a vitamin K inhibitor, may exacerbate osteoporosis. Fortunately, this appears not to be the case. Warfarin and its effects were examined in 6201 women 65 years and older who participated in the fourth clinic visit of the multicenter Study of Osteoporotic Fractures.5 Medication use and dosage were noted, hip and heel densitometry were performed, as well as a survey for bone fractures, and fractures were confirmed by radiographic review. Altogether, warfarin users more often: 1) sustained involuntary weight loss (P < 0.001), 2) were treated with nonthiazide diuretics (P < 0.001), 3) showed frail appearance (P = 0.005), and 4) self-rated themselves as suffering poor health (P = 0.01), no difference was seen in the rate of bone loss or fracture. Age adjusted bone loss was 1.1% and 0.8% in the warfarin users (n = 149) and nonusers (n = 6052), respectively, while among users, 15 (10%) suffered a nontraumatic nonvertebral fracture virtually identical to 561 fractures among nonusers (9.3%). These findings emphasize that in the elderly white female population, warfarin does not increase osteoporosis or fracture rates, and increased vigilance for these complications is unnecessary. (Dr. Rubin is Associate Professor of Clinical Neurology, New York Hospital-Cornell Medical Center.)
References
1. Ann Intern Med 1991;114:919-923.
2. J Bone Miner Res 1992;7:221-227.
3. J Bone Miner Res 1992;7:449-455.
4. Bone 1991;12:387-389.
5. Ann Intern Med 1998;128:829-832.
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