“Osteoporosis” does not mean that your back will break the moment you bend down. It means that the bone has lost substance and copes less well with loads it used to tolerate. In the spine this often shows up first — not as pain, but as a vertebra that quietly gives way. This page explains what osteoporosis does to the spine, how a vertebral fracture is recognised, how the diagnosis is made, and what — besides medicines — protects the spine.
Osteoporosis itself does not hurt. In the spine it only becomes noticeable when a vertebral body gives way. Anyone who knows their risk can often prevent the first fracture — and, after a first fracture, the second.
What is it?
Osteoporosis is a disorder of bone metabolism. Bone is constantly being rebuilt: old substance is broken down, new substance is laid down. If the breakdown predominates over years, the bone loses mass and internal structure — the fine trabeculae inside become thinner and snap. From the outside the bone looks unchanged, but it is more porous and breaks under loads that a healthy bone carries. The vertebral bodies are particularly vulnerable, because they consist largely of this sponge-like inner bone. In advanced osteoporosis it takes no more than lifting a bag of shopping, a hard bout of coughing or a stumble for a vertebral body to collapse — usually at the junction between the thoracic and the lumbar spine, where the load is greatest.
How common this is can be seen in figures from the Institute for Quality and Efficiency in Health Care: at the age of 70, about 10 in 100 men and 20 in 100 women have a diagnosis of osteoporosis; women are affected roughly twice as often as men. Of all bones, the vertebral bodies break most frequently — and about two thirds of these vertebral fractures go unnoticed, because they cause few symptoms or none at all. They come to light only when someone has become shorter or when an X-ray taken for another reason shows a deformed vertebra.
What symptoms occur?
As long as no bone has broken: none. Osteoporosis causes no joint pain, no tiredness and no dragging ache in the back. That is why it is so often recognised only after the first fracture. When a vertebral body does break, there are two courses. One is unmistakable: a sudden, deep-seated back pain, often after a trivial load, which grows worse on standing, walking and straightening up and eases when lying down; the affected spot is tender to tapping and to pressure, and the pain can radiate like a belt along the ribs or into the buttock and the groin. The other course is quiet: the vertebra collapses over weeks, the back becomes rounder, height decreases, clothes fit differently, the abdomen bulges forwards because the trunk is shorter, and the back aches dully on standing for longer periods.
Nerves are rarely involved in osteoporotic vertebral fractures: the guideline of the German Society for Orthopaedics and Trauma puts fracture-related neurological deficits at about 2.5 in 100 of those affected. What belongs to a vertebral fracture in detail — diagnosis, treatment with and without an operation — is on the page Vertebral fracture. This page is about the condition behind it.
Causes
From middle age onwards everyone loses bone mass; in women this accelerates after the menopause, because the oestrogen that slows bone breakdown is missing. Whether this turns into osteoporosis depends on the starting mass built up in younger years and on factors that speed up the breakdown. The DVO guideline sums up the most important ones: higher age, female sex, a fracture already sustained after a minor load — the single strongest pointer —, a hip fracture in one’s father or mother, low body weight, smoking, a lot of alcohol, lack of exercise, frequent falls, and a shortage of calcium and vitamin D.
Added to these are diseases and medicines that attack the bone: treatment with cortisone tablets over months, rheumatic inflammation, diabetes, an overactive thyroid or parathyroid gland, chronic kidney or bowel disease, anti-hormonal treatment for breast or prostate cancer. In men and in younger people, such a second cause lies behind osteoporosis more often, and it has to be looked for specifically. Several of the risk factors can be influenced: being underweight, a lack of calcium, a lack of vitamin D, lack of exercise, smoking, heavy drinking and — as far as it can be avoided or shortened — a longer course of cortisone.
How is it diagnosed?
It begins with a conversation about the risk factors named above, earlier fractures and medicines. At the examination we measure your height and compare it with the height you remember from younger years, check the rounding of the back and tap over the spinous processes. Bone density is determined with a bone density measurement (DXA) at the lumbar spine and at both hips. The result is the T-score, a comparison with the bone of young healthy adults: down to −1 normal, between −1 and −2.5 reduced (osteopenia), at −2.5 and below osteoporosis. From bone density, age, sex and the risk factors, the DVO guideline of 2023 calculates the risk of sustaining a vertebral or hip fracture within the next three years — and treatment is guided by that risk, not by the T-score alone.
The spine itself is X-rayed if a new back pain from middle age onwards, a loss of height or an increasing rounded back points to a vertebral fracture — thoracic and lumbar spine in two planes, standing where possible. Whether a fracture is recent the X-ray does not show; an MRI scan can, in which a recent fracture shows bone marrow oedema while an old fracture is “quiet”. The MRI scan also distinguishes an osteoporotic fracture from a fracture caused by a tumour or a metastasis — a question that has to be asked with every vertebral fracture that occurs without an accident. A CT scan shows the back edge of the vertebra and fragments at the spinal canal. To this belongs a blood test that uncovers other causes: calcium, vitamin D, kidney and thyroid values, proteins that point to a disease of the bone marrow. What the terms in your report mean is explained on the page Understanding your MRI report.
Warning signs
Osteoporosis is not an emergency, and a vertebral fracture only rarely. The exceptions: a new severe back pain after a fall accompanied by weakness in the legs, numbness in the area of the buttocks and the perineum, or a problem passing water or opening the bowels — then the examination belongs in an emergency department on the same day. You should have the following assessed within a few days: a new back pain with a known cancer, back pain with fever, and pain that does not ease even when lying down and at night. Everything else on the page Warning signs.
Treatment without an operation
The treatment of osteoporosis is not a surgical one. Its aim is to prevent the next fracture, and it rests on four pillars, none of which replaces the others.
- Exercise and strength training — bone is built up only where it is loaded. Strengthening of the back extensors and the trunk muscles, walking, stairs, balance exercises. Targeted training keeps the bones stable, strengthens the muscles and trains balance — and thereby lowers the risk of falling. To be avoided are jerky forward bending under load and sports carrying a risk of falling, for as long as bone density is markedly reduced.
- Calcium and vitamin D — the DVO guideline recommends a calcium intake of at least 1000 mg daily, through diet where possible, and vitamin D at a dose of at least 800 units daily if sunlight and food do not provide enough.
- Avoiding falls — check your glasses, remove trip hazards in the home, wear firm shoes, review medicines that cause dizziness or drowsiness, and train strength and balance. Many vertebral and hip fractures are the result of falls.
- Medicines — according to the DVO guideline, treatment with medicines comes into consideration if the calculated risk of a vertebral or hip fracture within the next three years is 3 per cent or more, and is recommended from 5 per cent. Between 5 and 10 per cent a bone-building medicine may, and from 10 per cent should, be used first, followed by one that slows the breakdown. The groups of active substances include bisphosphonates, denosumab and raloxifene as brakes on breakdown, and teriparatide and romosozumab as bone-building agents. A recent vertebral fracture after a minor load as a rule indicates a high risk. The choice, prescription and monitoring of these medicines belong with your GP practice or a practice specialising in osteology; we discuss with you which findings in the spine matter for this, and we pass them on.
If a vertebra has already broken, the treatment of the fracture is added: painkillers that allow early getting up, physiotherapy and follow-up images. What that involves, and when cement is injected into the vertebra, is on the page Vertebral fracture.
When an operation is considered
Osteoporosis itself is never operated on. A procedure comes into consideration only for a vertebral fracture — and then only if the fracture hurts so much despite pain treatment that getting up and walking are not possible, if it collapses further on follow-up images, if it is unstable, or if it presses on nerves. For this decision the DGOU/DWG guideline provides a score, the OF score, which takes in the shape of the fracture, bone density, the pain under medication, the ability to get up, neurological deficits and general condition. The score is an aid, not an automatism: the professional association of general practitioners has expressly recorded in the guideline that a recommendation for an operation must not hang on a number of points alone.
Osteoporosis also plays a part in every other spinal operation: screws hold less well in porous bone. That is why bone quality is assessed before a planned fusion — on CT or by a bone density measurement — and, where bone quality is reduced, screws can additionally be anchored with bone cement. Anyone who knows that they have osteoporosis should mention it before any procedure on the spine.
Surgical options
For a painful, recent osteoporotic vertebral fracture that cannot be controlled without an operation, we perform kyphoplasty: through a needle, and under X-ray guidance, the collapsed vertebral body is raised with a balloon and stabilised from within with bone cement. If the fracture is unstable or has destroyed the back edge of the vertebra, stabilisation with screws and rods comes into consideration — spinal fusion — combined, where there is pressure on nerves or the spinal cord, with a decompression. Both are among the procedures we perform. The course, risks and aftercare of these procedures are described on the page Vertebral fracture. What should happen after an osteoporotic fracture, whatever the procedure, is summed up in the following sequence:
- Classify the fractureX-ray taken standing, MRI for the question of recent or old and to rule out a tumour, CT where needed. Examination of strength, sensation and reflexes. From this it follows whether the fracture is stable and whether it can be treated without an operation — in most people it can.
- Assess the osteoporosisBone density measurement at the lumbar spine and hips, blood tests to rule out other causes, recording of the risk factors and calculation of the fracture risk according to the DVO guideline. A vertebral fracture without an accident is, until proven otherwise, a pointer to osteoporosis.
- Prevent the next fractureExercise, calcium, vitamin D, prevention of falls and — where the risk warrants it — treatment with medicines, prescribed and monitored by your GP practice or a practice specialising in osteology. Measure your height once a year, follow-up images as agreed.
What to expect
Osteoporosis is a lasting condition, but one that can be influenced. A broken vertebra does not regain its old shape; the deformity remains, the pain passes in most cases within weeks. The most important predictor of a further fracture is the first one — which is why the real treatment begins as the acute pain subsides. What you can do yourself: train the back extensors and the trunk muscles for the long term, walk every day, bend your knees when lifting instead of bending your back, avoid falls, do not smoke, cover your calcium through your diet, and do not stop prescribed medicines on your own. Measure your height once a year. A loss of several centimetres or a new, suddenly starting back pain is a reason to get in touch.
Frequently asked questions
May I do sport with osteoporosis?
You should. Strength training, walking, climbing stairs, dancing and balance exercises load the bone in the way it needs, and lower the risk of falling. What you should avoid is jerky bending forwards and twisting under load, and sports with a high risk of falling, for as long as bone density is markedly reduced. Which exercises suit you is best worked out with a physiotherapy practice experienced in osteoporosis.
What does a T-score of −2.8 mean?
That bone density at the measured site lies in the range of osteoporosis — from −2.5 and below. The T-score alone does not decide the treatment, though; according to the DVO guideline what counts is the calculated fracture risk, which takes in age, sex, earlier fractures and further factors.
Does every osteoporotic vertebral fracture have to be stabilised with cement?
No. Most heal within weeks with painkillers, early movement and physiotherapy. A kyphoplasty is considered if the pain prevents getting up despite medication or if the vertebra collapses further. More on the page Vertebral fracture.
How long do I have to take osteoporosis medicines?
That is decided by the practice that prescribes them, and it depends on the substance. For bisphosphonates the IQWiG names a treatment duration of about three to five years; after that it is reviewed whether to continue or pause. Do not stop such a medicine without discussing it — with some substances the fracture risk rises temporarily after stopping.
What should I bring to my first appointment?
The report of your bone density measurement, X-ray, CT and MRI images of the spine on CD together with the reports, your list of medicines — especially cortisone, thyroid and hormone preparations — and, if you know it, your height in younger years. Everything else is on the page Your first appointment.