Osteoanabolic therapy: a non-surgical option of treatment for Kümmell's disease?

Kümmell's disease is the current eponym of avascular osteonecrosis (AVN) of a vertebral body leading to a delayed non-healing vertebral compression fracture (VCF) and thus pseudo-arthrosis. AVN is characterized by production of gas that outlines a radiolucent zone in the vertebral body, called vacuum cleft sign (VCS) or "Kümmell's sign". This sign has been observed in up to one-third of VCFs and is often associated with osteoporosis and never with malignant or inflammatory diseases. Generally, treatment strategies are conservative management and percutaneous vertebroplasty. Teriparatide (rhPTH [1-34]) is an osteoanabolic agent approved for treatment of osteoporosis and helpful in fracture's healing too. Here, we describe the case of an 81-year-old osteoporotic woman presented with a 1-year history of persistent low back pain onset after a trauma. A lumbar spine Computer Tomography (CT) scan performed 2 months after the injury (November 2006) showed the VCS within a VCF of the first lumbar vertebra; a control CT scan 1 year later showed persistence of the finding. After 12 months of treatment with teriparatide 20 mcg/day, symptoms disappeared and vacuum was significantly reduced. In conclusion, Kümmell's disease may be hypothesized in patients with chronic spinal symptoms, especially in the presence of osteoporosis. Moreover in this condition, osteoanabolic treatment may be used in patients with Kümmell's disease to enhance vertebral fracture's healing and contribute to back pain relief.

High weight or body mass index increase the risk of vertebral fractures in postmenopausal osteoporotic women.

In the general population, low body weight and body mass index (BMI) are significant risk factors for any fracture, but the specific association between body weight, BMI, and prevalence of vertebral fractures in osteoporotic women is not fully recognized. Hence, the association between body weight, BMI, and prevalent vertebral fractures was investigated in 362 women with never-treated postmenopausal osteoporosis. All participants underwent measurement of BMI, bone mineral density (BMD), and semiquantitative assessment of vertebral fractures. Thirty percent of participants had > or =1 vertebral fracture. Body weight and BMI were associated with L1-L4 BMD (R = 0.29, P < 0.001 and R = 0.17, P = 0.009, respectively). In logistic regression analysis, BMI was positively associated with the presence of vertebral fractures independent of age and other traditional risk factors for fractures. Including weight and height instead of BMI in the multivariate model, showed weight as a positive and significant covariate of the presence of vertebral fractures (OR = 1.045; P = 0.016; 95% CI 1.008-1.084). BMI was associated with the number of vertebral fractures (rho = 0.18; P = 0.001), this association being confirmed also in the multivariate analysis (beta = 0.14; P = 0.03) after correction for smoking, early menopause, family history of fragility fractures and BMD. In conclusion, among postmenopausal women with osteoporosis, body weight and BMI are associated with a higher likelihood of having a vertebral fracture, irrespective of the positive association between weight and BMD.

Diffuse muscoskeletal pain and proximal myopathy: do not forget hypovitaminosis D.

A 20-year-old vegetarian man was admitted to our hospital complaining of muscle weakness and gait disturbances of 4 years duration. For the past 5 years, he had major depression and had confined himself at home. He exhibited tenderness upon palpation of the chest, sternum and proximal muscles. Hypocalcemia, hypophosphatemia, vitamin D deficiency, increased levels of alkaline phosphatase, and intact parathyroid hormone were noted. An x-ray skeletal survey revealed generalized osteopenia, multiple vertebral and costal fractures, and a pelvis deformed into the shape of a triangle. A diagnosis of osteomalacia secondary to vitamin D deficiency from lack of exposure to sunlight and to inadequacy of the diet was made. The patient was started on a treatment with 20,000 IU of vitamin D3 once a week plus 1 g/d of calcium. Eight months later, gait disturbances have significantly improved and laboratory findings have all normalized.

Cervical spondylodiscitis with spinal epidural abscess caused by Aggregatibacter aphrophilus.

Spondylodiscitis caused by Aggregatibacter aphrophilus, formerly known as Haemophilus paraphrophilus, is an unusual condition and can be very difficult to diagnose. We report a case of cervical spondylodiscitis complicated by spinal epidural abscess in a 63-year-old woman, without underlying predisposing conditions. The source of infection was identified as a periodontal infection. The patient was successfully treated with systemic antibiotics.

Low bone mineral density in institutionalized patients with HIV and psychiatric co-morbidity.

Osteoporosis occurs in HIV-infected patients as well as in common psychiatric conditions and causes significant morbidity. There are no published studies assessing bone mineral density (BMD) in institutionalized HIV patients with associated psychiatric disorders. We analyzed 51 subjects in a case control study: 17 HIV patients (males or pre-menopausal females) with psychiatric co-morbidity and a long-term antipsychotic and antiretroviral therapy; and 34 control healthy subjects, not infected with HIV, matched with patients by age and sex. The results show that the HIV group had significantly higher rates of pathological T-scores, as compared with the controls (71% vs. 9% p<0.001). Chronic mental illness may represent a possible important co-factor influencing BMD in HIV patients. We suggest that fracture risk should be carefully evaluated for institutionalized HIV patients with psychiatric co-morbidity.