Patient 65 years old retired teacher with severe back pain Patient 65 years old retired teacher with severe back pain . Beginning of this pain is associated with yesterday's collapse, when capsized getting out of bed.

Interview The pain appeared suddenly, just after a small fall the pain is severe VAS 7 points increases when moving and changing position is located in the middle of the lumbar spine and radiates to the right and left

Physical examination: RR 140/80 growth 159 cm - previously 161 cm weight 50 kg deepening of thoracic kyphosis, movement increases the pain reduced mobility of the lumbar spine tenderness increased paraspinal muscle tension Th 12 - L5

What is the suspect?

Degenerative disease of the spine, intervertebral discs, sciatica Degenerative disease of the spine, intervertebral discs, sciatica? Compression fracture of the spine ? Inflamed kidney? Metastases to the spine?

How to write data from the interview How to write data from the interview? What is the probability of fracture? Is the patient with normal bone mass will break the spine at such a low trauma?

from the study smoked cigarettes 20 / day * from the study smoked cigarettes 20 / day * at the age of 45 was made ​​ hysterectomy, after HRT applied, but briefly because of intolerance preparations * 2 years earlier wrist fracture * not practiced any sports , had low physical activity * not had any chronic diseases , corticosteroid therapy was not * her mother was ill patients: a broken hip 82 years of age, and soon died of pneumonia

FRAX ® WHO Fracture Risk Assessment Tool The FRAX® tool has been developed by WHO to evaluate fracture risk of patients. It is based on individual patient models that integrate the risks associated with clinical risk factors as well as bone mineral density (BMD) at the femoral neck. The FRAX® algorithms give the 10-year probability of fracture. The output is a 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture).

Secondary osteoporosis Age The model accepts ages between 40 and 90 years. If ages below or above are entered, the programme will compute probabilities at 40 and 90 year, respectively. Sex Male or female. Enter as appropriate. Weight This should be entered in kg. Height This should be entered in cm. Previous fracture A previous fracture denotes more accurately a previous fracture in adult life occurring spontaneously, or a fracture arising from trauma which, in a healthy individual, would not have resulted in a fracture. Enter yes or no (see also notes on risk factors). Parent fractured hip This enquires for a history of hip fracture in the patient's mother or father. Enter yes or no. Current smoking Enter yes or no depending on whether the patient currently smokes tobacco (see also notes on risk factors). Glucocorticoids Enter yes if the patient is currently exposed to oral glucocorticoids or has been exposed to oral glucocorticoids for more than 3 months at a dose of prednisolone of 5mg daily or more (or equivalent doses of other glucocorticoids) (see also notes on risk factors). Rheumatoid arthritis Enter yes where the patient has a confirmed diagnosis of rheumatoid arthritis. Otherwise enter no (see also notes on risk factors). Secondary osteoporosis Enter yes if the patient has a disorder strongly associated with osteoporosis. These include type I (insulin dependent) diabetes, osteogenesis imperfecta in adults, untreated long-standing hyperthyroidism, hypogonadism or premature menopause (<45 years), chronic malnutrition, or malabsorption and chronic liver disease Alcohol 3 or more units/day Enter yes if the patient takes 3 or more units of alcohol daily. A unit of alcohol varies slightly in different countries from 8-10g of alcohol. This is equivalent to a standard glass of beer (285ml), a single measure of spirits (30ml), a medium-sized glass of wine (120ml), or 1 measure of an aperitif (60ml) (see also notes on risk factors). Bone mineral density (BMD) (BMD) Please select the make of DXA scanning equipment used and then enter the actual femoral neck BMD (in g/cm2). Alternatively, enter the T-score based on the NHANES III female reference data. In patients without a BMD test, the field should be left blank (see also notes on risk factors) (provided by Oregon Osteoporosis Center).

In this case… probability is high The ten year probability of fracture (%) Major osteoporotic 19 Hip Fracture 7.5 www.shef.ac.uk/FRAX

X-ray thoracic and lumbar spine Alkaline phosphatase We suspect compression vertebral fractures in the course of osteoporosis. What test should we do? select an answer Ultrasound scan of the lumbar spine X-ray thoracic and lumbar spine Alkaline phosphatase Densitometry of the spine by DEXA Th -L

What will be the procedure in waiting time for test results What will be the procedure in waiting time for test results? - Select an answer analgesics, eg. acetaminophen with tramadol 4 times a day NSAIDs, eg., Diclofenac, ketoprofen rest in bed a few days bisphosphonates

X-ray – spine Th-L

What treatment should be implemented ? Why? What is the purpose of this treatment?

Treatment of osteoporosis The goal of treatment of osteoporosis in this case is to prevent fractures of the proximal femur

What treatment should be implemented What treatment should be implemented ? Vitamin D3 supplementation 800-2000 u/d Supplementation of Ca 1000 mg/d Bisphosphonates,: Alendronate at a dose of 10mg / day or 70 mg / 1x week or desmosumab sc. Refferal to neurosurgeon? Pain control?