Degenerative bone disease

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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The term “degenerative bone disease” is somewhat of a misnomer. There are a few conditions though where the bone does, in a sense, degenerate.

Osteoporosis is a disease in which bones become fragile and more likely to break. If left untreated, osteoporosis can progress, without symptoms, until a bone breaks. These fractures occur most often in the hip, spine, and wrist. Bone is living tissue. They provide structural support for muscles, protect vital organs, and store minerals essential for bone strength.

Bones may be affected by diet and exercise. Until the age of about 30, bone mass is in positive balance. More bone is made than is broken down. After 30, bones begin to break down faster than new bone can be formed. In women, bone loss accelerates after menopause, when ovaries stop producing estrogen - the hormone that protects against bone loss.

The critical years for building bone mass are from youth to about age 30.

Of special concern are fractures of the hip and spine. A hip fracture requires hospitalization and surgery. It can impair a person's ability to walk without help and may cause permanent disability or even death. Spinal fractures also have serious consequences, including loss of height, severe back pain, restriction of the chest and abdomen, and deformity.

While women are four times more likely than men to develop the disease, men also suffer from osteoporosis.

The next type of disease that might be considered a degenerative bone disease is Paget’s disease. Paget’s disease of bone is also known as osteitis deformans.

It is defined as a progressive disorder of bone remodeling where normal bone is removed and replaced with abnormal bone.

The disorder is due to the overly rapid growth of abnormal osteoclasts, which resorb bone at local sites. Resorption is followed by an increase in the formation of new bone that is disorganized in structure.

Paget's disease of bone is estimated to occur in 2 to 3% of persons past the age of 60 in the United States.

The etiology has not been established, but genetic factors and a paramyxovirus infection may be involved.

Pagets disease can involve any part of the skeleton but most commonly the pelvis, femur, spine, skull, and tibia.

Deformities, neurologic impairment, bone pain, hypervascularity, and arthritic changes in joints may be the initial symptoms. Changes in the skull often lead to impaired central nervous system function, particularly hearing loss. Involvement of the base of the skull may produce platybasia and basilar invagination, which can lead to brain stem compression. Vertebral deformity may lead to spinal cord compression. Bones affected by Paget's disease are at increased risk of fracture. The bone deformity can lead to damage to cartilage with osteoarthritis, especially in the knee and hip. The increased blood flow in bone from the condition can cause heart failure. Angioid streaks in the retina may occur but rarely impair vision.

Osteosarcoma in the elderly is often associated with Paget's disease. Fibrosarcoma and chondrosarcoma may also occur. Such tumors may result in pathologic fractures.

Hypercalcemia can occur in immobilized patients with Paget's disease or may be caused by associated hyperparathyroidism. Patients with Paget's disease who require bed rest should be monitored.

Asymptomatic Paget's disease may be detected incidentally by finding elevated levels of serum alkaline phosphatase. Also, Paget's may be found incidentally on x-ray.

Patients who develop osteosarcoma, fibrosarcoma, or chondrosarcoma respond poorly to chemotherapy.

Localized asymptomatic disease requires no treatment. Treatment should be given to those at risk of complications, including those with osteoporosis and those whose disease affects weight-bearing areas (eg, long bones, vertebrae) or sites where neurologic damage is likely to occur.

Patients can be followed with serum alkaline phosphatase measurements but measurements of urinary collagen cross-links may be more sensitive for early diagnosis of relapse. In general, treatment should be continued until a biochemical remission has occurred.

Hearing loss is common in patients with Paget's disease and should be monitored. The process probably cannot be reversed by treatment, but antiresorptive therapy may prevent progression.

Bisphosphonates are the therapy of choice.

Antiarthritic drugs should be used in patients with joint involvement in whom pain often persists despite biochemical remission.

Patients with severe deformities and irreversible osteoarthritic changes in the hip or knee joint may be treated surgically.

A recent article discussed the role of pain in both degenerative bone as well as degenerative joint disease.

Pain. 2003 Oct;105(3):387-92.

Causes of pain in degenerative bone and joint disease: a lesson from vertebroplasty.

Niv D, Gofeld M, Devor M.

Center for Pain Medicine, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 64239, Israel.

Pain in degenerative bone and joint disease is usually attributed to sensitized nociceptors in inflamed periarticular soft tissues. Here we draw attention to the potential contribution of intrinsic bone innervation. The structure and innervation of articular bone ends is analogous to that of teeth. Although some dental pain derives from inflamed periodontal soft tissue, a more important source is the dentine and root canal. By analogy, pain on weight bearing in osteoarthritis and related conditions may be due to compressive forces applied to the innervation of subchondral bone exposed by erosion of the overlying cartilage. Pain relief obtained by injecting acrylic cement into the bone interior during percutaneous vertebroplasty is consistent with this concept. The development of a new family of pain relief options based on "marrow canal treatment" may be a realistic possibility.

Publication Types:

PMID: 14527699 [PubMed - indexed for MEDLINE

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