Poudre Valley Internists/Center for Bone Health, Fort Collins, CO.
FG is a 69-yr old white man who presented to establish primary care and requested bone density screening because his father had had severe osteoporosis of unclear cause. He had a past medical history of atrial fibrillation and hypercholesterolemia. His medications included diltiazem, flecainide, simvastatin, and warfarin. A bone density was performed.The L1-L4 BMD was 0.974 g/cm (T-score -1.07), but the L4 BMD was 0.913 g/cm, with a T-score of -2.11. Mild osteopenia was seen at the femoral neck with a BMD of 0.761 g/cm (T-score -1.2). Based on these results, the patient was advised to take 1200 mg of calcium and 800 IU of vitamin D daily.Four months later, the patient presented after a fall with lower back pain radiating around his flanks bilaterally. Workup revealed an acute L4 fracture. Biochemical evaluation for osteoporosis was done and was remarkable for a low testosterone level. Treatment was initiated with alendronate 70 mg po q week, and the patient accepted testosterone replacement to help with erectile dysfunction.I offer this case report as an example of the dilemma of isolated vertebral osteoporosis; under current guidelines, I averaged L4 with the rest of the lumbar spine and so did not start treatment. In retrospect, one may question whether he would have benefited from starting a bisphosphonate earlier.
J Clin Densitom. 2004 Winter;7(4):459-62.