Crippled by a sharp back pain that took her breath away, barely able to walk or do basic chores, Annette Browne was convinced this wasn’t something that was going to clear up ‘with a few paracetamol’.
When the pain began in May last year, Annette’s GP diagnosed a muscle strain brought on by strenuous gardening, prescribed codeine painkillers and referred her for physiotherapy.
The pain got worse over the next few weeks. Nor was this the first time Annette had had a ‘bad back’.
‘I’d been to see the GP five times over four or five years and was told it was just a muscle strain — but I kept getting the same problem,’ she recalls.
When the pain began in May last year, Annette’s GP diagnosed a muscle strain brought on by strenuous gardening, prescribed codeine painkillers and referred her for physiotherapy
The pain this time was much more intense, and it got worse.
‘Every few weeks, I’d call the GP but all I’d get would be a higher dose of my codeine prescription,’ says Annette, 64, a business strategist who lives with her partner Carolyn Blake, 70, a painter, in Edgbaston, Birmingham.
Annette was unable to walk and barely able in August 2013. Annette called her GP for an MRI. She decided not to wait for months before she could get an NHS appointment. Instead, she went private.
A scan showed that three bones of her spine had fractured. The fourth fracture had suffered for so long, that it was not visible on the scan.
Annette was informed that her bones looked weaker and could fracture without any treatment.
While osteoporosis may cause severe pain, the condition can also lead to hip and spine fractures. This, in turn raises the chance of premature death.
‘I was so shocked,’ says Annette. ‘I had no idea I had fractured bones and no clue that I had osteoporosis. In my mind’s eye I suddenly saw myself ending up in a wheelchair.’
It may sound impossible that a broken back can go undiagnosed, but this happens all the time.
![In August last year, and by then barely able to move, Annette called her GP to ask for an MRI scan. Rather than wait months for an NHS appointment, she paid to go private. The scan revealed the cause of her pain: three of the bones in her spine were fractured [File photo]](https://i.dailymail.co.uk/1s/2021/11/09/01/50233881-10179255-image-a-106_1636421718308.jpg)
Annette was unable to walk and barely able in August 2013. Annette called her GP for an MRI. She decided not to wait for months before she could get an NHS appointment. Instead, she went private. She had three fractures in her spine, which was revealed by her scan. [File photo]
A new report from the Royal Osteoporosis Society (ROS) estimates that 2.2 million spinal fractures go undetected each year — most of them in people with osteoporosis. (Although often thought of as a women’s disease, men get it, too.)
This condition is caused by ageing and an imbalance between the rates at which old bones are broken down and new ones being created. It can lead to loss of bone overall.
All of this happens, however, the consequences are worse for osteoporosis patients (risk factors include postmenopause as estrogen helps to strengthen bone and long-term steroids use, which inactivates bone production, and genetics).
Therefore, it is possible to sustain fractures without causing significant trauma.
These fractures are more common in the spine because of their vulnerability to bone loss. One in 10 women over 50 suffers from one or more spine fractures. For those aged 70 and over, that number is one in five.
Yet as these fractures tend to occur without a traumatic fall or accident, they often get dismissed by patients and medical practitioners as ‘just a bad back’, says Nicola Peel, a consultant in metabolic bone medicine at Sheffield Teaching Hospital.
‘Probably fewer than a third of spinal fractures come to clinical attention,’ says Dr Peel, who is also chair of the clinical committee of the ROS. ‘They happen insidiously in someone with osteoporosis. They can occur when you pick up or twist something, and they may also happen while coughing or wheezing.
‘One common scenario is that someone has a fracture as they pick up a wriggling grandchild.’
While some cause no or little pain, others can cause severe pain.
‘Because back pain is ubiquitous, people and healthcare professionals don’t have the index of suspicion that it might be a vertebral fracture,’ says Dr PeelYou can find out more.
However, there are red flag signs that should set these cases apart — for example, if the patient is over 50 (as the disease becomes increasingly common with age) and has already broken a bone.
‘The nature of the pain can also be suggestive,’ says Dr Peel.
‘It often causes sudden onset pain with no obvious cause, and is often helped by lying down.’
A new report from the Royal Osteoporosis Society (ROS) estimates that 2.2 million spinal fractures go undetected each year — most of them in people with osteoporosis. (Although often thought of as a women’s disease, men get it, too.)
Yet all too often patients don’t go to their GP.
‘Or they are seen and reassured, and may be given painkillers, but are not sent for that critical X-ray,’ says Dr Peel.
‘I’ve seen patients with fractures to every single bone in the lumbar and thoracic spine [the lower and middle back]. It’s tragic when you can look back and see that there were missed opportunities to diagnose them earlier.’ The right treatment can help to prevent fractures and other knock-on problems.
‘Each time there is a fracture, the bone gets shorter and the spine starts to curve,’ says Dr Peel.
‘The more fractures, the more someone starts to become bent over, and that puts strain on other joints and ligaments and muscles, and arthritis sets in.’
As the height loss continues, this can ‘reduce the space in the ribcage, so people find it harder to breathe, or in the abdomen, which can trigger problems like bloating or incontinence,’ explains Dr Peel.
While any fracture should be taken seriously, ‘the two most likely to be an indicator of osteoporosis are vertebral fractures and hip fractures,’ says Dr Peel.
‘But unlike vertebral fractures, hip fractures don’t get missed.’
Someone with undiagnosed osteoporosis and who has one fracture has — without treatment — a one-in-five chance of having another within 12 months.
‘But if we start treatment, we can reduce their chances of having another spinal fracture by up to 80 per cent,’ says Dr Peel.
However, despite how common the condition is — osteoporosis affects around 3.5 million Britons — all too often, cases appear to be slipping thought the net. One problem is that even when the fractures are spotted, they aren’t always acted on.
An audit last year by the Royal College of Radiologists, involving more than 6,000 patients who’d had a scan for a reason other than back pain, found that where a spinal fracture was present, ‘it was often not mentioned in the report or no advice was given’ — with the result that only 5.5 per cent of the cases were referred on for investigations such as DEXA scans, which determines bones’ density.
Under official guidelines, anyone over 50 with a history of ‘frailty fractures’ (fractures after an incident that wouldn’t normally cause a break) should be referred on.
‘Even when an X-ray or scan shows a vertebral fracture, it’s often dismissed as part of getting older,’ says Dr Peel.
‘The attitude is “Oh, it doesn’t matter, there’s nothing that needs to be done”, when it should be a red flag: this is someone who almost certainly has osteoporosis.’
A result of the audit, Royal College of Radiologists issued updated guidance to their members in January. This included the necessity for an Osteoporosis Lead in every department of radiology.
They are also now raising awareness of the ‘vital need for integrated fracture liaison services and better onward referral for patients,’ said Professor David Howlett, vertebral fracture audit and guidance lead at the RCR.
If people don’t get diagnosed and treated properly, they will suffer more pain and other problems.
A month after her diagnosis in August last year, and still yet to see a specialist and start treatment, Annette was just plumping up a pillow when she was struck by a pain so intense that she ‘almost passed out’.
A paramedic was dispatched to her hospital and they found another spine fracture.
Annette was discharged after 7 days. However, the pain was so bad that Annette had to be on morphine for many weeks.
A patient with a fracture diagnosis should be referred within 12 weeks. If the bone structure and risk factors are compatible, the osteoporosis can be diagnosed without the need for a DEXA scan.
Treatment can then be offered — such as alendronic acid, a type of bisphosphonate drug which helps slow the rate at which old bone is broken down — or drugs that build new bone, such as teriparatide (a daily injection).
But this depends on getting a diagnosis, which is why the ROS is calling for more to be done to spot osteoporosis sooner — for example by encouraging GPs to assess a patient’s risk — as well as improving the quality of care when someone has had a fracture.
Annette now takes zoledronic acids as an annual injection to build her bones, but her pain in the spine is not going away.
‘I don’t feel angry, I’m pragmatic,’ she says. ‘We have to stop thinking this is just something inevitable that happens to old ladies. These fractures are happening to active people like me, and they are life-changing.’
Theros.org.uk