Touching Lives - November 2007
Easing the pain of spinal fractures
Osteoporosis affects one in two women and one in five men over the age of 50 in the UK. It causes a reduction in bone density resulting in an increased risk of bone fractures in anyone suffering from the condition. When the spine is affected, osteoporotic fractures may cause chronic pain and deformity — the characteristic ‘dowager’s hump’ — as the fractured vertebrae change shape, causing the spine to become more curved.
A treatment called vertebroplasty, where cement is injected into fractured vertebrae, has been developed in order to treat osteoporotic fractures of the spine, and an adaptation of this procedure, called kyphoplasty, may help to correct deformity in the spine before cement is injected. Both procedures are being used increasingly in the USA and UK to alleviate the pain associated with spinal fractures. However, little is known about how these procedures relieve pain and how they might influence the spine’s mechanical function.
A team of experts funded by Action Medical Research has just completed a study looking at the mechanical effects of spinal fracture and the impact that vertebroplasty and kyphoplasty have, in an attempt to widen our understanding of the effects of these treatments.The aim was to demonstrate how the mechanical function and loading on the spine are changed following cement injection, and to determine whether the extent of osteoporosis or the severity of fracture has any impact on outcome. The hope was that the research would help to indicate which patients were most likely to benefit from cement injection and whether the type of cement injected or the type of procedure used (vertebroplasty or kyphoplasty) influenced the mechanical changes that resulted.
Team Leader Dr Patricia Dolan explains, “In tests, we found that spinal fracture alters the forces acting on different parts of the spine, and this could suggest why these fractures cause chronic pain. Fractures tend to concentrate stresses in certain tissues of the spine. It’s a bit like having a stone in your shoe; when the weight of your body is concentrated on such a small area, it causes a pain in the foot.
“We found that cement injection following fracture partially reversed these mechanical changes in the spine by smoothing out the stress points.We also found that more osteoporotic and degenerated spines showed the greatest changes after fracture but also the greatest improvement after cement injection.Vertebroplasty and kyphoplasty produced similar mechanical changes, as did the different cements we used. However, some cements achieved good mechanical results even when they were injected in smaller volumes, which may help reduce the risk of cement leaking from the vertebra.We hope that our findings will improve how doctors perform the procedures and help them to identify which people will potentially have the most positive outcome.”
The team, based at the University of Bristol and Queen’s Medical Centre in Nottingham, has published a journal paper on its findings and has also presented at several conferences to ensure that the study findings reach as many people as possible.This research was funded by a generous grant from The HSA Charitable Trust.
Dr Dolan has spent 20 years studying the load mechanisms of the human spine, and her work is set to continue with the award of another grant from Action Medical Research.The new project, which has just begun, will look at how to avoid fractures to adjacent vertebrae following cement injection.
Money from Action Medical Research has been crucial in getting the research team this far. Dr Dolan says, “The tests we do on the spine take a long time and mean very long hours in the laboratory.The grant funded a postdoctorate assistant and a technician, and without it we simply could not have done this work.
“Osteoporosis affects millions of people across the world, and these new treatments have huge potential — perhaps they could one day become as successful as hip replacement, with vertebrae being strengthened even before fractures occur. More randomised trials are needed, but already in the USA the procedures are becoming widely used in the treatment of osteoporosis in the spine.
“There are still some questions to be answered, which is why our research is now moving on to another phase, but the outlook is very exciting indeed and gives hope to the people who suffer the relentless pain and deformity caused by spinal fractures.” TL
Living with osteoporosis
Fifteen years ago Moira Wigglesworth was lifting a settee to replace a broken castor when she heard a tremendous crack. Her grandson said jokingly that she had broken the settee — in fact she had fractured a bone in her back. That incident and a subsequent X-ray led to Moira being diagnosed with osteoporosis, something she admits left her feeling devastated.
“I just didn’t know anything about the condition and had never suspected there was anything seriously wrong,” says Moira, who lives in Lytham, Lancashire. “They told me I had osteoporosis but I’m not the sort of person to accept something without knowing more about it, so I joined the local support group and they were a huge help to me in understanding what was going to happen.”
Moira’s condition has worsened considerably since her initial diagnosis. Bone density scans at hospital confirmed that she was likely to suffer more fractures, and over recent years she has started to suffer a severe curvature in her spine as she loses bone strength in her vertebrae. She has also suffered several rib fractures — sometimes not even knowing they were there.
“The doctors say I must have a very high pain threshold, because I have had cracked ribs and not even known,” she says. “Recently though, things have got worse. Due to my shortened spine, my lower ribs have started to rub against my pelvis when I am sitting down. I use morphine patches and other painkillers, and have to write a list of everything I take each day, but really it is the relentlessness of the pain that gets you down.”
Moira, whose husband died 22 years ago, does not drive and relies on her daughters and friends for getting out and about. A fall early in the summer left her housebound for 13 weeks, something she found particularly difficult.
“The problem with this condition is that your mind is unaffected and it’s so frustrating that you can no longer do the things you want to,” she explains. “Going out in a car can be painful because I feel every bump and hole in the road. I still play bridge, which I can do at home and I have people at the house most days, but I can no longer do so many of the things people take for granted. Everything takes me a long time and I think that you do become afraid of falling, which makes you lose some confidence in going out.”
“When I fell recently I slipped off a step at home and fell part way down the stairs. I was on my own and still don’t know how I managed to get the rest of the way down and get to the phone. I was in shock and could hardly speak. The paramedics came and took me to hospital, but it is a terrible feeling of helplessness having to wait for people to come and pick you up and to not know how much damage you have done.”
The curve in Moira’s spine means that she can no longer lie down properly in bed, and sitting for long periods is also becoming increasingly difficult. She says, “I set the alarm every two hours during the night in case I need to get up to use the bathroom — it takes me so long to get up that I have to plan ahead, but waking up so many times is very disruptive.
“Osteoporosis does leave you feeling bitter sometimes, because you know it is probably only going to get worse as you get older.That’s why research into this condition is important — it may be too late for me, but if they can develop new treatments to stop it or to repair the damage it does, it will help others in the future.” TL