Patients with vertebral fragility fractures treated in hospital – could we do better?

Terence Ong is a Research Fellow funded by the Dunhill Medical Trust at the Department for Healthcare of Older People, Nottingham University Hospitals NHS Trust. He discusses his Age and Ageing Paper Characteristics and outcomes of hospitalised patients with vertebral fragility fractures: a systematic review. He tweets @terenceongkk

Vertebral fragility fractures have received much attention lately due to growing research interest and increased awareness driven by high-profile osteoporosis groups such as the International Osteoporosis Foundation (through its vertebral fracture initiative) and the National Osteoporosis Society.

There is growing literature to support how well vertebral fragility fractures predicts future fractures, morbidity and risk of mortality. However, what has been lacking is research exploring the specific cohort of people with vertebral fractures who are admitted to hospital. Most vertebral fractures do not need admission to hospital and it is likely that those who are admitted are more debilitated by their fracture. To date, there is no overall consensus on how these patients should be managed. An increasing number of potential interventions, both medical and surgical, further adds to the complexity of these patients’ hospital treatment. Experts have advocated a multi-professional, multi-disciplinary approach to the care of these patients, similar to the orthogeriatric management of hip fractures. Hence, knowing more about the condition’s ‘natural history’ would provide the first step in helping us better answer if there is a role for such a model of care.

One method of looking at this is systematically reviewing existing scientific literature to describe the characteristics and health outcomes of patients hospitalised for vertebral fractures. Our systematic review of non-randomised studies identified 19 eligible studies. There was geographical variation in the overall incidence of vertebral fracture hospitalisation from 2.9 to 19.3 per 10,000/year. Its incidence peaked in those over the age of 80 years from 10 to 50 per 10,000/year. Patients admitted were between the ages of 70 and 85 years and had multiple comorbidities, with one study reporting that over 75% had at least 5 comorbid diagnoses. At least one-third had either a diagnosis of osteoporosis or had sustained a previous fracture. 59 to 78% presented to hospital after a fall; hence, this group of patients are at risk of further falls and fractures. Access to imaging modalities, such as magnetic resonance imaging (MRI), is needed as some fractures were not detected on plain imaging of the spine. Patients were mostly non-operatively managed and stayed in hospital on average 10 days. Although hospital mortality was low at 0.9 to 3.5%, there were longer term consequences post-fracture. 12 month survival ranged from 20 to 27%. Up to half of the patients were discharged to a care facility and many became more dependent on daily living at discharge. Age and number of comorbidities were associated with worse outcomes.

Patients with these fractures need access to skilled clinicians with the ability to identify those with co-pathologies in order to mitigate their negative effects on poor outcomes. Their hospital care must include access to: the appropriate diagnostic capabilities; a falls and bone health assessment; a consistent approach to ensure that all who might benefit from surgery have access to it; access to rehabilitation and appropriate post-hospital care. This is similar to the orthogeriatric care delivered for hip fracture patients. Hence, a similar multidisciplinary specialist service for vertebral fractures would be able to deliver the care needed for this group of patients with the potential for delivering the same health benefits. Prior to even clinically evaluating the effectiveness of such a service, further research is still needed to inform what this service would practically look like. Local data to scope an appropriately sized service is needed, as well as further development of understanding about why there is increased disability in these patients and what intervention could potentially address this.

Read his his Age and Ageing Paper Characteristics and outcomes of hospitalised patients with vertebral fragility fractures: a systematic review.

One thought on “Patients with vertebral fragility fractures treated in hospital – could we do better?

  1. Great review of the clinical literature – thanks!

    Three points spring to mind from this review.

    Firstly, from the patient’s point of view, the key problem (and usual reason for admission to hospital) is pain. Often, severe pain (fractures hurt!!). This pain is mechanical: both positional, and also triggered by certain movements, usually (but not always) easing as the fracture unites. Powerful opioids either don’t work for this peak pain, if used at doses to control basal pain, or sedate the patient if used to control the peaks of pain. This is an area crying out for research. Nerve block, salmon calcitonin, vertebroplasty? In which patients? For how long? It is so frustrating to treat.

    Secondly, the overall outcome is not that different to patients with femoral neck fractures: about a third institutionalised and a third dead within the first year. This former is a highly vulnerable group of people. It suggests a phenotype of underlying frailty – we should be particularly careful with polypharmacy in these people.

    Thirdly, for those patients discharged to a nursing home, what is the point of prescribing osteoporosis secondary prevention? They must be at a much lower risk of falls – often bed-fast, and the risks of oesophageal damage from bisphosphonates cannot be minimal in this population. Have you seen the advice for using them?

    ‘Tablets should be swallowed whole with plenty of water while sitting or standing; to be taken on an empty stomach at least 30 minutes before breakfast (or another oral medicine); patient should stand or sit upright for at least 30 minutes after taking tablet’
    Source: https://www.evidence.nhs.uk/formulary/bnf/current/6-endocrine-system/66-drugs-affecting-bone-metabolism/662-bisphosphonates-and-other-drugs-affecting-bone-metabolism/bisphosphonates/alendronic-acid

    I suspect this is yet another case of ‘therapeutic mission creep’ – applying data from patients fit enough to be in trials, to those who would never have been included.

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