The jacket that used to sit right now bunches at the wrists. The top shelf of the press has quietly moved out of reach. Your driving licence says 1.68 metres; the practice nurse measured you at 1.63 last week. Somewhere in the past decade five centimetres went missing, and nobody has ever asked where they went.
Height loss on that scale is not simply posture, and it is not “just getting older”. In people over 70 it is one of the most reliable outward signs of a spinal fragility fracture: a vertebra in the mid or lower back that has quietly collapsed because the bone inside it was no longer strong enough to hold its shape. It is the most common fracture caused by osteoporosis. In Ireland it is also the one least likely to be named, referred or treated.
TL;DR
- Spinal (vertebral) fragility fractures make up as much as half of all osteoporotic fractures, and around two-thirds are never diagnosed at the time. They surface by accident on chest X-rays and CT scans done for something else.
- Ireland’s Fracture Liaison Service Database recorded 637 spinal fractures in 2024, roughly 29% of the number expected. One hospital captured 66% of its expected cases; another captured 7%.
- Losing 4cm or more of height, a new rounding of the upper back, or sudden back pain after a trivial strain all justify a fracture risk assessment, not just painkillers.
- A spinal fracture carries up to a 20% risk of another fracture within a year, and it responds better to osteoporosis medication than any other type of fragility fracture.
- Ten of Ireland’s sixteen adult trauma hospitals run a Fracture Liaison Service, so across much of the country the follow-through falls to you and your GP.
What a spinal fragility fracture actually is
This is a break in bone, not a disc problem. The vertebral body, the solid block at the front of each spinal segment, loses height: it wedges at the front, dips at the end plates, or crushes. Radiologists grade the loss by how much of the vertebra’s height has gone.
What makes it a fragility fracture is the amount of force involved, which is to say barely any. Lifting a bag of compost, a hard sneeze, missing the bottom step, hauling a suitcase into the boot. Sometimes there is no event at all that anyone can recall. Each collapsed vertebra takes a few millimetres off your standing height; several of them take centimetres, and pull the upper back into a forward curve that changes how you breathe, how much you can eat in one sitting, and how far forward your head sits over your feet.
The pain is an unreliable signal. It can be severe for six to twelve weeks and then fade, worse standing and easier lying flat, or it can never arrive at all.
Why so many are never named
Roughly two-thirds of vertebral fractures are picked up incidentally, which means neither the person nor the doctor was looking for them. A review from the Department of Radiology at University Hospital Galway set out exactly where they hide in plain sight: on the lateral chest X-ray, on the side-on reconstructions of a CT of the chest or abdomen, on the scout view taken before a CT, on the localiser image at the start of an MRI. The vertebrae are right there in the picture, in people who were scanned for a cough or abdominal pain.
The evidence the Galway authors gathered is sobering. In a study of more than 10,000 postmenopausal women who had a lateral chest X-ray, 41% of radiologists who did identify a fracture did not carry it into the summary of their report, and only 36% of those patients left hospital on bone protection.
Part of the problem is vocabulary. Reports describe “wedging”, “end plate compression” or “loss of vertebral height”, and a busy referring doctor reading that does not necessarily read the word fracture, or hear osteoporosis, or think treatment.
The other part is that nothing in the system picks these patients up. A broken wrist gets a plaster and a fracture clinic appointment. A broken hip gets surgery and an orthogeriatric team. A collapsed vertebra generally gets neither, so services that find their patients by trawling orthopaedic fracture clinic lists will never see them. Ireland’s own national report says it plainly: patients with spine or pelvis fractures do not usually require orthopaedic follow-up, so they will be missed if fracture clinics are the only way of finding people.
The Irish numbers
The fourth Irish Fracture Liaison Service Database annual report, covering 2024, is the clearest picture we have. Ten services between them managed 3,335 people after a fragility fracture, about a third of the caseload expected. Of those, 637 were spinal fractures: 29% of the expected number nationally, ranging from 65.8% at Beaumont and 62.1% at Galway down to 7.2% at the lowest site.
The benchmark is worth understanding, because it reframes the whole topic. The report estimates that the number of spinal fractures presenting clinically in a hospital is roughly equal to its number of hip fractures. Hip fracture in Ireland is audited, resourced, measured in hours to theatre and reported on every year. Its quiet twin in the spine is counted at under a third of expectation, and recommendation seven of that same report asks services to prioritise vertebral fractures for case finding precisely because they carry the greatest risk of the next fracture and gain the most from medication.
The surrounding burden is not small. Ireland recorded around 32,000 new fragility fractures in 2019, projected to reach 51,000 by 2034, an increase of over 58%. Research on national hospital data found fragility fractures accounted for 249,887 public hospital bed days in 2017 among adults over 50, more than chronic obstructive pulmonary disease, six solid cancers, heart attacks and diabetes, and up 43% in a decade while bed days for cancer, heart attack and diabetes fell.
One more figure from the 2024 Irish data says most of what needs saying about missed opportunity: 37% of people assessed had already had a previous fragility fracture, and only 30% of them were on any osteoporosis medication when the next one happened.
What is worth bringing to your GP
- Height loss of 4cm or more, measured against your height as a young adult or against a documented reading from a few years ago.
- A new forward curve in the upper back, or the sense that you can no longer stand flat against a wall the way you used to.
- Back pain that started suddenly after lifting, twisting or a stumble, worse upright and easier lying down.
- Back pain plus any osteoporosis risk: a previous fracture after 50, long-term steroid tablets, early menopause, low body weight, rheumatoid arthritis, coeliac disease, diabetes, heavy drinking or smoking.
- Clothes sitting differently, a waistband that has risen, feeling full after a few mouthfuls, or breathlessness that does not fit your heart and lungs.
Some back pain in later life needs same-day assessment rather than a bone conversation: unexplained weight loss, fever or night sweats, constant pain that wakes you, new leg weakness or numbness, numbness around the saddle area, or any change in bladder or bowel control. Those patterns point towards infection, myeloma or secondary cancer, and they are investigated urgently and differently.
What to ask for, in order
Get measured, and get it written down. It takes thirty seconds and it is the single most useful piece of data in this entire topic. Ask for the number to go in your record so next year’s reading means something.
Ask about the scans you have already had. If you had a chest X-ray or a CT of the chest or abdomen in the past few years, the question is simply: did my spine look normal on that? A fracture already recorded in an image you have had does not need to be found again.
Ask for a fracture risk assessment, and ask whether a DXA scan should include vertebral fracture assessment. FRAX, the risk tool used in Irish practice, does not take height loss as an input, but height loss and a rounded upper back are both recognised reasons to run it. Current clinical guidance makes it a strong recommendation for anyone over 50 with 4cm of height loss, visible kyphosis, long-term steroid use, a T-score of -2.5 or below, or acute back pain alongside osteoporosis risk factors. A private scan runs around €120, and HSE access goes through your GP with means-tested cover. Within the fracture liaison services themselves, only a third of people referred for DXA were scanned within three months, so it is reasonable to ask about timelines.
Treatment, and what it is actually for
A confirmed spinal fragility fracture changes the arithmetic. In older adults with a prior fragility fracture, treatment is considered on the strength of the fracture itself, without waiting for a bone density number to give permission. First-line options are weekly alendronate or risedronate tablets, or an annual zoledronate infusion. Where someone is 70 or older, or has already had a hip or spine fracture, the planned course is longer: at least ten years for oral bisphosphonates and at least six for zoledronate, with review along the way.
A spinal fracture within the last two years, or two or more spinal fractures whenever they happened, marks someone out as very high risk, and that is the group where referral to a bone health specialist for injectable or bone-building treatment is worth asking about rather than waiting for.
Alongside that, the Department of Health recommends a 15 microgram vitamin D supplement every day, all year round, for everyone aged 65 and over in Ireland, with calcium coming from food where possible. Medication costs are covered by a medical card, and the Drugs Payment Scheme caps a household at €80 a month.
Pain, movement, and two things that do not help
Pain relief in the acute phase matters because it lets you keep moving, but it needs care: codeine and opioids bring constipation, drowsiness and a higher falls risk with them. Physiotherapist-supervised exercise improves both pain and physical function after a vertebral fracture, and while the back is still sore, exercises for the back extensor muscles are best started unloaded, lying down, rather than upright.
Two interventions that sound logical are not supported for routine use. Back braces have no evidence of helping a vertebral fracture heal, and routine bracing is not recommended. Vertebroplasty and balloon kyphoplasty, where cement is injected into the collapsed vertebra, do not show consistent patient benefit for painful osteoporotic fractures and are not recommended as routine care.
What does hold up is strength and balance training, the leading intervention for reducing falls. It is also the most neglected: in Ireland’s 2024 fracture liaison data, only 20% of people who were followed up had started such a programme within sixteen weeks of their fracture, with some services unable to confirm whether anyone had. If nobody offers, ask your GP or physiotherapist what runs locally.
If there is no fracture liaison service near you
Even where a service exists, a fracture found on an old scan may never reach it, so the sequence often has to be GP-led: height measured and recorded, fracture risk assessed, DXA arranged, treatment started and reviewed, a strength and balance class found, and height measured again in a year. Keep your own note of every fracture you have had since 50, because that list is the strongest predictor anyone has.
The Irish Osteoporosis Society runs a national helpline on (01) 637 5050 for questions about scans, treatment and what to raise with your doctor. At Críonna Health we keep returning to this kind of gap, where the condition is common, the treatment is cheap and effective, and the only thing missing is somebody naming it out loud.
Five centimetres is not vanity and it is not fate. It is a measurement, and measurements can be acted on.
This article is for general information and is not a substitute for individual medical advice. If you have new or severe back pain, or any of the red flag symptoms above, contact your GP or out-of-hours service.
📷 Photo by jason hu on Unsplash
