La columna que se fractura

Fracturas vertebrales mal diagnosticadas y mal tratadas

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  • Fracturas leves o moderadas (sin desplazamiento) son frecuentemente mal interpretadas o reportadas en el expediente, como no existentes.
  • El pacientes hospitalizados quienes tienen una radiografía lateral de tórax, poco menos del 50% de las fracturas vertebrales son identificadas más tarde.
  • Sólo cerca del 40% de las mujeres mayores con FV, son detectadas a los rayos X y referidas entonces a la toma de la DXA (densitometría axial de doble fotón) y en los hombres es todavía más baja la cifra apenas un 20%.

Las fracturas vertebrales tienen un impacto importante en las personas y la sociedad.

  • Las FV llevan a una deformidad espinal severa, dolor lumbar, pérdida de altura, inmovilidad, depresión, aumento del número de días-cama, reducen la función pulmonar y la muerte prematura.
  • Las FV clínicas son asociadas con 8 veces aumento de la mortalidad, la cual es similar al aumento en la mortalidad vista en la fracturas de cadera.
  • La carga financiera de la osteoporosis vertebral y asociado a otras fracturas, es significativa y en la vejez, incluye los costos de hospitalización, rehabilitación subsecuente y cuidados.
  • En la población que trabaja, los costos médicos asociados con las FV, son relacionados con el cuidado del paciente ambulatorio y la pérdida de días laborales.
  • En los EU hay dos millones de fracturas por osteoporosis con un costo cercano a los 20 billones de USD. Las FV, contribuyen con costo de 1.5 billón de USD.
  • En Europa, los casos nuevos de FV se estiman en un costo de 730 millones de EUR.
  • En México se calculan cerca de 800 mil fracturas, entre las de cadera y de columna. Desafortunadamente se escapan muchas fracturas por osteoporosis por mal diagnóstico. Con un costo aproximado de $40,000 cada una; algo así como 320 mil millones.

¿Qué podrán hacer los profesionales de la salud?

Los médicos deberán tomar en cuenta y valorar los signos de fracturas vertebrales, como son: pérdida de la altura (más o menos 3cm), dolor lumbar agudo o crónico, aumento de la deformidad espinal o aparición de joroba.

El diagnóstico radiográfico es considerado la mejor forma para identificar y confirmar la presencia de fracturas vertebrales. Aunque también puede valorarse por medio de la densitometría ósea central (DOC). Una Densitometría Periférica (muñeca o talón), sólo nos dará una guía para investigar más.

Los radiólogos y otros profesionales deberán reportar los hallazgos de fracturas vertebrales, como Fractura, para evitar malas interpretaciones, como: “parece, imagen sugestiva, línea imprecisa”, etc.

Las terapias efectivas que reducen el riesgo de FV, puede ser entre el 30% al 70% en mujeres postmenopáusicas; están disponibles, en México.

Introducción

Las fracturas vertebrales por osteoporosis son comunes alrededor del mundo, con una de cada cuatro mujeres con 50 años de edad, teniendo una fractura vertebral en el transcurso de su vida (por lo menos). Estas tienen un impacto mayor en la calidad del vida del individuo, causando dolor, pérdida de altura, depresión e incapacidad. Estas fracturas conllevan un aumento de la mortalidad.

Tienen un impacto en los recursos de la sociedad y los sistemas de salud. Sin embargo, estas fracturas siguen siendo en gran parte poco diagnosticadas y mal tratadas por los profesionales médicos, estimando que dos tercios de todas las fracturas por osteoporosis no reciben atención médica.

Una fractura vertebral lleva a una y a otra, resultando en una cascada de fracturas. Por otra parte, las FV son predictores poderosos de futuras fracturas osteoporóticas de todos los tipos.

Las FV, que son valoradas en atención médica son asociadas con al menos ocho veces más aumento de la mortalidad, similar a las vistas en fracturas de cadera. En individuos quienes tienen una FV, la mortalidad aumenta progresivamente seguida del diagnóstico y suele reflejar comorbilidades coexistentes, tales como mala función pulmonar y problemas gastrointestinales, por compresión abdominal.

La prevención de fracturas por osteoporosis es un objetivo clave de salud pública. El diagnóstico y la intervención temprana después de la primera fractura llevará a una menor carga de enfermedad, e importantes mejoras en la calidad de vida de las personas que sufren de OP.

Hay avances recientes en la identificación de FV Por medio de la VFV – Valoración de Fracturas Vertebrales, utilizando la densitometría ósea acompañada de radiografías de la columna, y esta VFV podría considerarse por los clínicos para la identificación de dichas fracturas. Y prevenir futuras fracturas iniciando tempranamente el tratamiento y con esto reducir tanto la morbilidad como la mortalidad.

 

La Osteoporosis – OP

Es una enfermedad caracterizada por baja masa ósea y deterioro en la microarquitectura del tejido óseo, que lleva a un aumento del riesgo de fractura. La OP ocurre cuando la masa del hueso disminuye más rápido de lo que el cuerpo puede reemplazarlo, lo que lleva a una pérdida de la resistencia y fuerza ósea. Como resultado el hueso se vuelve frágil y con un ligero golpe o caída puede llevarlo a fracturarse. Esto se conoce como fracturas por fragilidad.

La osteoporosis pudiera no tener signos ni síntomas hasta que la fractura ocurre, es por eso que frecuentemente se le llama la “enfermedad silenciosa”.

La OP afecta todos los huesos del cuerpo, sin embargo, ocurren más frecuentemente en las vértebras, muñeca y cadera. Las fracturas de la pelvis, brazo y pierna son también comunes y están asociadas con incapacidad importante. La fragilidad de los huesos no duele pero los huesos fracturados si que duelen.

 

Fracturas de cadera

Estas se deben considerar como las fracturas a nivel de articulación coxofemoral. Anatómicamente la “cadera” se encuentra atrás de la ingle, sí efectivamente, nosotros decimos cadera, para denominar el ancho o protrusión de la pelvis posterior; pero no. La articulación de la cadera queda a nivel de las ingles.

Estas fracturas son las más devastadoras en términos de morbilidad o mortalidad, tanto como que el 20% de los pacientes que la sufren pueden morir dentro de los primeros seis meses después de la misma. Aunque aquí hay que considerar, edad, hipertensión arterial, diabetes, problemas renales, circulatorios, etc. La mayoría de estas fracturas ocurren después de una caída. Aunque siempre existe el cuestionamiento de “¿qué es primero la fractura y después la caída, o, primero la caída y después la fractura?”. Ahí queda para pensarlo.

Pero ya sea en hombres o mujeres siempre estarán en relación a una disminución de la masa ósea en el fémur proximal (cuello y trocánter) y al número de caídas.

 

Fracturas vertebrales

Son frecuentemente causadas con actividades rutinarias tales como inclinarse hacia adelante, girar y levantar objetos ligeros. La prevalencia (el número de fracturas que ocurren en la comunidad) es igual en hombres que mujeres. En los hombres, se cree que la ocupación que realiza va asociada. Sin embargo la incidencia (número de nuevas fracturas) de FV es un tercio mayor en mujeres que en hombres entre 50-60 años y el doble después de los años 70.

 

Fracturas de muñeca

Suceden en el tercio distal del radio y pueden lesionar también el cúbito, la mayoría ocurre en mujeres, y suceden más tempranamente que la FV o de cadera, pero que aumentan en incidencia con la edad. En hombres esta fractura es baja y no aumenta con la edad

 

Fisiopatología de la Osteoporosis

Hay dos tipos de huesos: el cortical (compacto) y el trabecular (esponjoso). El cortical comprende aproximadamente el 80% del esqueleto y se encuentra en las paredes de los huesos largos (tales como el fémur y la tibia) o por fuera en la superficie de los huesos planos. El hueso trabecular se encuentra principalmente al final de los huesos largos, dentro de los huesos planos y en los huesos de la columna.

El hueso cortical, consiste en hueso compacto estructurado concéntricamente alrededor de los canales centrales, conteniendo vasos sanguíneos y nervios. El hueso trabecular esta compuesto por placas interconectadas y barras en donde se encuentra la médula ósea.

Durante la primera década de la vida, los huesos crecen (se hacen más largos) y más fuertes con lo que aumenta la masa ósea. Aproximadamente el 80% de la masa del hueso adulto se adquiere en la pubertad, y el pico máximo de masa ósea (que se alcanza alrededor de los 30-35 años de edad) depende de una adecuada nutrición, ejercicio y exposición al sol, que se necesita para que el cuerpo produzca vitamina D. Lo cual ayuda al cuerpo a absorber el calcio de nuestra dieta.

Los déficits en la nutrición o ejercicio en este momento crítico puede llevar al esqueleto a una pérdida a lo largo de su vida de la resistencia y fuerza ósea. Después de este tiempo, el esqueleto se somete a un proceso continuo y coordinado de ruptura ósea (reabsorción) y reconstrucción del hueso, denominado: remodelado óseo.

Este remodelado óseo esta dirigido por la necesidad del cuerpo por calcio, está influenciado por un número de hormonas y factores de crecimiento y también posiblemente por la necesidad de reparar regiones del hueso que han sido lastimados debido al uso diario.

Este proceso coordinado de ruptura ósea y reconstrucción permite al esqueleto mantenerse saludable a través de la vida.

Con el aumento de la edad, el balance entre la ruptura ósea (resorción) y la reconstrucción del mismo (formación) tiende a ponerla fuera de balance, con mayor resorción que formación. Esto debido a una serie de factores, que incluyen la declinación de la hormona sexual en mujeres y hombres, insuficiente ingesta de calcio y/o de vitamina D. Este desbalance lleva a una progresiva pérdida de hueso, deterioro de la microestructura del mismo, una declinación en la resistencia y consecuencia un aumento en el riesgo de fractura. En adición, ciertas drogas y enfermedades pueden causar perdida ósea y aumento de la fragilidad esquelética. (corticoides, insuficiencia renal, tiroidea y demás).

Las vértebras consisten principalmente en hueso trabecular con una capa externa de hueso cortical. El hueso trabecular tiene una gran superficie, cerca a las células de la médula ósea que están involucradas en la formación y la eliminación del hueso.

Como la pérdida de masa ósea comienza inicialmente en las superficies óseas, los cambios en la masa del hueso ocurren antes y en mayor medida, en el hueso trabecular como las vértebras, que en las áreas del esqueleto que son principalmente corticales, como el fémur (hueso del muslo).

Las fracturas vertebrales se producen cuando uno de los huesos de la columna vertebral, se colapsa o se fractura. En la población que tiene hueso con poca resistencia, estas fracturas pueden ocurrir durante las actividades cotidianas, como levantar un objeto, o dar la vuelta en la cama, o con trauma mínimo, como bajar la banqueta o escalón, o, por caídas.

Un padecimiento común

A nivel mundial una fractura osteoporótica ocurre cada 3 segundos. A los 50 años de edad, una de cada dos mujeres y uno de cada cinco hombres sufrirán una fractura en el transcurso de su vida. Para las mujeres este riesgo es mayor que el riesgo de cáncer de mama, ovario y útero juntos. Para los hombres el riesgo es mayor que el riesgo de cáncer de próstata.

Aproximadamente el 50% de las personas con una fractura de OP tendrán otra, con el riesgo de nuevas fracturas que aumentarán exponencialmente con cada nueva fractura.

De particular importancia, una fractura vertebral ocurre en el 20-25% de hombres y mujeres caucásicas (blancas) como en Europa, Balcanes, Canadá, EU; a los 50 años. En México, he observado que la frecuencia de aumento de VF va con la edad. 1/10 de las mujeres de 50 años, 1/5 de las mujeres de 60 años. 2/5 de las mujeres de años 70, 2/3 de las mujeres mayores de 80, tienen sus fracturas. Uno podría pensar que debido a la cantidad de días soleados al año, la dieta rica en calcio de leche y sus derivados, bueno hasta las tortillas, podrían ser buenas para evitar este problema. ¡Pues no!

En México, ahora las “fábricas de leche”, las “fábricas de tortillas”, las “fábricas de huevo” y las “fábricas de pan”; les quitan todos los nutrientes que pudieran haber tenido los alimentos comentados; ya que la mayoría de las mujeres mexicanas tienen alergias o son intolerantes a “todo”.

En lugar de que desde pequeños todos tomáramos “leche bronca” que se llama (bien hervida), evitaríamos toda esa serie de problemas gastrointestinales, de alergias, intolerancias, que actualmente sufren miles de personas nada más en México. Y lo peor, es que cientos de mujeres-madres mexicanas están provocando mayores problemas a sus hijos por el tipo de alimentación que les dan, no los dejan tomar leche, o carne, o hierbas, que durante siglos tomaron nuestros antepasados y que no tenían estos problemas. Sí, de infección por las malas medidas de higiene, pero nada más. Ahora hasta les flamean cada plato en donde comen, ¿Cómo, carambas, van a formar anticuerpos?

Estamos mal educando a nuestro hijos, en el saber comer, no se necesita que coman pechugas de ángel, caviar o jamón ibérico acompañados por vino francés o español. ¡No!

Solamente bien comer, de todo. Las famosas leches “nutritivas”, no son leche, son derivados lácteos o formulaciones de soya, que no sirven para nada.

La Osteoporosis es un problema de salud pública, que aumenta cada día.

 

Con la edad avanzada, el hueso disminuye la densidad mineral (DMO) y la prevalencia de OP aumenta.

Cada día, el mayor segmento de la población son las personas mayores. Si la esperanza de vida aumenta en la mayoría de la población mundial, el costo financiero y humano asociado con las fracturas por OP aumentará exponencialmente.

En Europa la población de mujeres mayores de 70-80 años aumentará un 170%, en hombres hasta un 240% entre 2010 y 2050. Mientras que la mitad de las fracturas de cadera entre la gente mayor, que están ocurriendo sobre todo en Europa y EU, se verá reducida a una cuarta parte alrededor del 2050; pero, cada día estarán aumentando en Oriente Medio, Asia y en Latinoamérica (que incluye México, obviamente), regiones en donde se considera mejorará la expectativa de vida. En Asia por ejemplo, se espera que se eleve la cifra de población hasta 7 veces más y esta predicción se considera entre 2010 y 2050. Por lo que las fracturas de cadera aumentarán hasta 5 veces más en el mismo periodo.

En México, salvo algunos grupos organizados, o médicos investigadores sobre esta problemática, no han logrado permear estas cifras y situaciones clínicas (que se van a presentar en poco tiempo) sobre las autoridades sanitarias, que se suponen cuidan de la salud y bienestar de la población. Y por lo que se ve, en este nuevo gobierno que empieza, la situación no va a cambiar.

Están más preocupados (creo) por la obesidad, la hipertensión y problemas cardiovasculares, que por algo que va a costar cada día más, como la osteoporosis y sus secuelas que pueden ser fatales.

Poca detección, pobre diagnóstico y mal tratamiento

Los estudios muestran que las FV son frecuentemente no diagnosticadas, y que sólo el 30% de las mismas tienen atención médica. La mayoría de estas (un 85%) son detectadas durante una exploración de rutina de dolor lumbar y 15% son fracturas no recientes detectadas incidentalmente durante algún estudio clínico por otro padecimiento.

Hay varias razones por las cuales la FV no son atendidas por los médicos.

En el caso de una FV generalmente no requiere cuidado de emergencia, salvo que exista el antecedente de un accidente automovilístico, caída, contusión directa por trauma. Esto aplica para la cadera y otras fracturas osteoporóticas. El la fractura de cadera, sin embargo, la incapacidad para levantarse, apoyar, la desviación del miembro pélvico hacia fuera, son signos inequívocos de fractura. Sin embargo, hay fracturas de cadera, no desplazadas, en las cuales la paciente puede seguir caminando, estas son las más difíciles de diagnosticar.

El paciente que de pronto presenta un dolor en su columna lumbar, puede ser debido a artrosis, esguince lumbar, infección renal, etc.

En la exploración no hay pérdida de estatura, deformidad de la curva espinal, y no hay signos de que haya ocurrido alguna fractura.

Las FV no son necesariamente dolorosas, y en México, las pacientes por lo general, le achacan el dolor diversas actividades de la vida diaria, lavar la ropa, cargar bolsas pesadas del súper, subir escaleras a la azotea para colgar la ropa, ir al mercado ambulante, etc.

A veces las fracturas llegan a ser apenas pequeñas fisuras difíciles de detectar; por eso es que la Densitometría Ósea Central (DOC) es de gran ayuda.

En pacientes mayores que están hospitalizados quienes tenían radiografías laterales de columna menos del 50% de ellos le fue diagnosticada una fractura vertebral retrospectivamente y fueron reportados muy pocos en los expedientes; los consideraron de poca importancia.

Cerca del 40% fueron enviadas a que les tomaran su DOC, en los hombres apenas en el 20% de los casos se efectuó este estudio. Y solamente el 5% de los pacientes con fracturas vertebrales recibieron tratamiento adecuado para su osteoporosis.

Esto hace muy importante de que tanto médicos como pacientes recibamos los conocimientos adecuados para detectar la OP y después las fracturas vertebrales.

Más o menos entre el 30 al 50% de las FV fueron mal diagnosticadas o no mencionadas en los reportes radiográfico (falsos negativos) atribuibles en parte a la falla de detección o el uso de terminología ambigua en el reporte.

Y de la otra mano, solo el 5% de las FV fueron equivocadamente diagnosticadas (falsos positivos).

Manejo y tratamiento

Terapia medicamentosa

Las terapias efectivas, como son anti/resortivos y agentes anabólicos están ampliamente disponibles y pueden reducir nuevas fracturas vertebrales desde un 30% a un 70% en pacientes postmenopáusicas. Eficacia similar es observada en hombres. Estos tratamientos deben ser tomados con la adecuada suplementación de calcio y de vitamina D.

Los siguientes medicamentos han probado ser efectivos en el tratamiento de las fracturas por osteoporosis. Considerar que “vamos a evitar la aparición de la osteoporosis, es un error; lo que trataremos de hacer es de evitar las fracturas por osteoporosis”.

Los escribiré en orden alfabético, para evitar predilecciones, cada médico estudioso de la OP, sabrá cual le da mejores resultados a sus pacientes.

  • Alendronato
  • Calcitonina (utilizado más como analgésico óseo)
  • Denosumab
  • Hormona paratiroidea
  • Hormonas (estrógenos)
  • Ibandronato
  • Raloxifeno
  • Ranelato de estroncio
  • Risedronato
  • Zoledronato

 

La disponibilidad de estos medicamentos puede variar entre los diferentes países; en México los tenemos todos.
Cualquier terapia (anti/resortiva) para tratar la osteoporosis deberá acompañarse siempre de: Calcio más vitamina D

Calcio

La mujer postmenopáusica debería ingerir suplementos adecuados de calcio elemento (generalmente 1.000-1.500 mg/día) con las comidas, de tal manera que la ingesta total de calcio, incluida la aportada por los alimentos, se aproxime a los 1500 mg/día. Un adecuado aporte de calcio reduce la pérdida de masa ósea en adultos. La mayor fuente de calcio se encuentra en los productos lácteos; un litro de leche contiene aproximadamente un gramo de calcio elemento (un yogur aproximadamente 225 mg). La cantidad de calcio aportada en la dieta, fuera de los productos lácteos, no supera los 300 mg por día.

Vitamina D

Una de las funciones de la vitamina D es estimular la absorción intestinal de calcio. Los déficit subclínicos de vitamina D son frecuentes y pueden contribuir al desarrollo de osteoporosis, los depósitos de vitamina D dependen de dos factores, la producción endógena derivada de la síntesis cutánea inducida por la exposición a la luz solar y la ingesta de vitamina D en la dieta.

En personas mayores es frecuente encontrar un déficit de ambos factores, de manera que es fundamental asegurar un aporte adecuado de esta vitamina.

La ingesta diaria de vitamina D debería ser al menos de 800 UI (unidades internacionales). La leche constituye la mayor fuente de vitamina D, aportada por la dieta, un litro de leche contiene aproximadamente 400 UI de vitamina D. En los pacientes con OP se recomiendan suplementos de vitamina D generalmente a razón de 800 UI diarias. En el mercado mexicano existen preparados combinados de calcio y vitamina D, lo cual facilita su administración

Espero que esta artículo, sea de utilidad, para mis cuatro lectores, y sirva de guía clínica para evitar fracturas por osteoporosis a muchas personas.

Dr. José Luis Sánchez Mejía
Ortopedia y Traumatología

IOF- The breaking spine. Octubre 2010

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