Textbook Reading

THE SPINE
Metabolic Bone Disorders of the Spine
Cellular Biology
Bone Cells
◦ The osteoprogenitor cells are components of the bone marrow stromal system, give rise to
either the bone forming.
◦ Osteoblasts synthesize and release unmineralized bone matrix called osteoid.
◦ Osteocytes regulate bone formation is by the secretion of the glycoprotein sclerostin.
◦ Osteoclasts resorb bone.
Cellular Biology
Bone Matrix
◦ The inorganic matrix consists of bone mineral .
◦ The organic matrix consists of collagenous fibers embedded in a ground substance.
Cellular Biology
The organic matrix of bone is primarily composed of proteins, approximately 95% of which is
collagen in adult humans.
The inorganic matrix represents two-thirds of the dry weight of bone and primarily consists of
calcium phosphate which exists in three forms:
◦ (1) crystalline hydroxyapatite [Ca10(PO4)6(OH)2], the most abundant;
◦ (2) octacalcium phosphate [Ca8H2(PO4)6 5H2O)], a rarer form; and
◦ (3) brushite [CaHPO4 2H2O].
 Cellular Biology
Collagen
◦ Type I collagen is found not only in the bones of the spine but also in the intervertebral discs,
where it coexists with type II collagen.
◦ Within the disc, each type of collagen maintains a separate anatomic domain: type I collagen is
more abundant in the anulus fibrosus, whereas type II predominates in the nucleus pulposus.
Skeletal Homeostasis
• Modeling means deposition of new bone in regions which results in changes to the external
shape, mass, or volume of existing bone.
• Remodeling means bone replaces itself by balancing synthesis in some places with lysis in
others, purposed to prevents accumulation of aged or fatigued bone.
Mineral Homeostasis
Calcium
◦ Calcium fulfills its skeletal role, where it provides mechanical strength.
◦ Metabolic function of bone

Phosphate
◦ Participates in the interconversion of the energy of metabolism;
◦ As a constituent of nucleotides, phosphate partakes in the transmission and expression of genetic
information;
◦ It regulates the oxygen affinity of hemoglobin.
Regulator of Bone and Mineral Metabolism
• Parathyroid Hormone
• Restore a normal calcium consentration.
• Vitamin D (Calcitriol)
• Increase intestinal absorption of calcium from the diet.
• Associated with decreased cancer rates, improved muscle function, and a more normal
immune system.
• Fibroblast Growt Factor – 23
• Potent regulator of serum phosphate and contributes to vitamin D and PTH homeostasis.
• Calcintonin
• Response to increased serum calcium concentration.
Osteoporosis
• Osteoporosis is a metabolic bone disease characterized by low bone mass and
microarchitectural deterioration of bone tissue, leading to increased bone fragility and a
consequent increase in fracture risk.
• Osteoporosis is not limited to the spine.
• Approximately 27% of postmenopausal women will develop a vertebral compression fracture,
an additional 15% will experience a hip fracture.
• In the elderly, hip fractures, most caused by osteoporosis, result in death, disability, and
dependency.
Osteoporosis
Osteoporosis is classified as either primary or secondary.
Primary osteoporosis is further subdivided on the basis of its pathogenesis.
◦ Type I, or postmenopausal osteoporosis, is related to the abrupt decline of estrogen levels
that occurs in menopausal women.
◦ Type II osteoporosis, known as senile or age-related osteoporosis, is due to the progressive
decrease of BMD that occurs with aging.
Osteoporosis
 Osteoporosis
Several risk factors for osteoporosis have been identified
◦ Nonmodifiable risk factors include: age greater than 50 years, female sex, family history of fragility
fractures, and white or Asian ethnicity.
◦ history of premature menopause, cigarette or excessive alcohol use, eating disorder (e.g.,
anorexia nervosa), a sedentary lifestyle, use of anticonvulsants, or lifelong low calcium intake.
Osteoporosis
• Secondary osteoporosis results from any medical condition or medication that contributes to
accelerated bone loss.
• The most common causes are glucocorticoid use, hypogonadism, alcohol abuse, and
malnutrition.
• Corticosteroid therapy causes bone loss and fractures because it suppresses bone formation
and inhibits intestinal calcium absorption, which leads to secondary hyperparathyroidism and
increased osteoclastic bone resorption.
Osteoporosis
Bone mass as a function of age in men (blue)
and women (purple).
The images above the graph depict a cross-
section of bone as maturation occurs over
time. Mass is accumulated until peak bone
mass is reached and then decreases and
becomes more porous in advanced age.
Osteoporosis
Multiple studies have shown the importance of estrogen deficiency in the causation of the
accelerated phase. Estrogen is thought to play a critical role in maintaining bone mass in adult
women by suppressing cancellous bone remodeling and maintaining remodeling balance
between osteoblastic and osteoclastic activity.
Osteoporosis
Clinical course
◦ Severely painful, with the pain remaining over the afected area (backache) or radiating across
the thorax.
◦ The pain from a vertebral fracture does not radiate down the legs.
◦ Symptoms such as leg pain suggest involvement of the spinal cord and obligate the physician
to search for another or concomitant process to explain the pain.
Osteoporosis
Osteoporosis
Clinical course
◦ In the thoracic spine, both asymptomatic and painful fractures have a predilection for the
anterior aspect of the bone.
◦ Progressive fracture thus leads to progressive shortening of the anterior height of the
vertebral body relative to the posterior
◦ The resultant shape of the body suggests the name of this process: wedge fracture.
◦ The wedge shape of the body, when summed over two or more vertebrae, causes dorsal
kyphosis.
Osteoporosis
Diagnosis
◦ BMD measured via dual-energy x-ray absorptiometry (DEXA) remains the clinical standard for
diagnosing osteoporosis.
◦ The World Health Organization (WHO) defines osteoporosis by the T score, or number of
standard deviations (SD) below peak bone mass of healthy adults.