case_images: PMC5534275_01
case_images: (a) BMD measurements and Z-scores at lumbar spine, femoral neck, and total hip at initial presentation. (b) Left: sagittal view of spine CT scan showing compression fractures of T12, L1, L3, and L5, with diffuse osteopenia. Right: lateral spine X-ray showing cement in the body of L5 following vertebroplasty (arrowhead) and severe wedging of L1 and L3. (c) Changes in serum levels of osteocalcin (:) and P1NP ( : ) during the course of treatment. Shaded area represents normal reference values. (d) BMD measurements and Z-scores after completing two years of treatment with teriparatide followed by one year of denosumab.
case_images: CRIE2017-6328524.001.jpg
case_images: PMC5534275_01_CRIE2017-6328524.001.jpg
case_images: fig1
case_images: Dual-energy X-ray absorptiometry (DXA) scan of the skeleton reported a Z-score of -6.9 at the lumbar vertebrae (L2-L4), -3.3 at the femoral neck, and -4.1 at the total hip (Figure 1(a)). The T11-L1 fractures remained unchanged (Figure 1(b), left panel). Given that the area of maximal pain was at the L5 level, the patient underwent L5 vertebroplasty with good analgesic response and near complete ambulatory recovery (Figure 1(b), right panel). Skeletal response to the drug was monitored using osteocalcin and procollagen type 1 N-terminal propeptide (P1NP) serum levels as surrogate markers of bone formation (Figure 1(c)). A repeat DXA scan performed on May 2015 (following two doses of denosumab) showed improvement of the bone mineral density at the lumbosacral spine, femoral neck, and total hip [Z score of -5 (from -6.9), -3.3 (from -3.3), and -3.9 (from -4.1)] (Figure 1(d)).